philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 special announcement 6 philippine journal of otolaryngology-head and neck surgery we, the participants in the asia pacific association of medical journal editors (apame) convention 2012, gathered in kuala lumpur, malaysia, from 31 august to 3 september 2012; considering that scholarly, scientific and technical health information is an invaluable resource for universal health promotion and policy development, disease prevention, diagnosis and treatment, habilitation and rehabilitation, support and palliation; that this health information must be reliable, comprehensible and available to health care providers and beneficiaries within the asia pacific region and the rest of the world; that the western pacific and southeast asian regions of the world health organization together represent over 50% of the global population, who both generate and need an enormous amount of health information; that the asia pacific association of medical journal editors (apame) is an important catalyst for the promotion of scholarly writing skills and standards that will increase the reliability, comprehensibility and availability of health information generated within the region; confirm our commitment to promoting quality scholarly writing skills and standards that will ensure greater access to publication by authors and researchers, especially for developing countries in the asia-pacific region, elevating loco-regional research and publishing to the global arena; our commitment to the continuing education of researchers, authors, reviewers and editors, to empower them to write, review and edit scholarly manuscripts for publication and dissemination, thereby promoting health and well-being in the region and the world; kuala lumpur declaration on promotion of scholarly writing skills and standards in the asia pacific region our commitment to collaboration with academic societies, universities, government and non-government organisations to promote research and publication to support evidence-based policies for the betterment of health and societal development in the region and globally; commit ourselves, to improving our scholarly writing skills and standards, setting the example for our peers, authors, reviewers, editors and librarians in the region; our publications, to attaining increasing scholarly quality worthy of continued production and dissemination through analog and digital library services including, but not limited to, the western pacific region index medicus (wprim), asia pacific medical journal articles central archives (apamed central) and global health library; our organization, the asia pacific association of medical journal editors, to building further networks, convening conferences, and organizing events to educate and empower editors, peer reviewers and authors to achieve and maintain internationally acceptable, but regionally appropriate, scholarly skills and standards. kuala lumpur, malaysia 2 september 2012 this declaration was launched at the 2012 convention of the asia pacific association of medical journal editors (apame) held in kuala lumpur from 31 august to 3 september 2012. it is concurrently published by journals linked to apame and listed in the western pacific region index medicus (wprim). copyright © apame. www.wpro.who.int/apame philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 philippine journal of otolaryngology-head and neck surgery 45 letters to the editor philipp j otolaryngol head neck surg 2014; 29 (2): 45 c philippine society of otolaryngology – head and neck surgery, inc. dear sir: i greatly enjoyed reading the paper by david and lim on “congenital bilateral vocal fold paralysis”1 and complement the authors on their excellent surgical outcome. they also very appropriately underscored the primacy of careful clinical assessment over costly investigations, particularly in an environment of scarce resources. we have previously reported on the mri findings in 23 children with bilateral vocal fold dysfunction (bvfd) as an isolated abnormality that was present at birth. we found mri abnormalities in 35%, but these were all non-specific.2 this study indicated that mri was of research and clinical value but did not identify any major cns structural abnormalities in this patient group. however, the case reported by david and lim involved the delayed onset of symptoms at two years of age that may have increased over the next three years. this acquired and possibly progressive disease process differs from that of congenital bvfd. the likelihood of arnoldchiari malformation or another significant structural cns abnormality being present would appear to be higher when symptoms of bvfd are acquired later in life compared to when they are present at birth. anecdotally, i have been involved with a case of acquired bvfd presenting at a similar age where the underlying cause was found to be a posterior fossa tumour. the 3-year history of symptoms in the child in the case report would very likely preclude this diagnosis but certainly another cns cause needs to be considered to explain the development of delayed-onset brainstem dysfunction and this would require mri. best wishes, robert g. berkowitz, md department of otolaryngology royal children’s hospital 50 flemington road parkville victoria 3052 australia cns imaging is essential in acquired bilateral vocal fold dysfunction in children references 1. david rb, lim wl. congenital bilateral vocal fold paralysis in a two-year-old girl. philipp j otolaryngol head neck surg 2014, 29(1):30-32. 2. steiner ji, fink am, berkowitz rg. magnetic resonance imaging findings in pediatric bilateral vocal fold dysfunction. ann of otol rhinol laryngol 2013, 122:417-420. dear sir: we would like to express appreciation for the comments given as well as for sharing your research findings in relation to the case. we agree that a neurological problem must be properly ruled out most especially when there is a delayed onset of neurological symptoms with progression over time. indeed, the presence of vocal fold dysfunction in children should make one consider cns pathologies most common of which is the arnoldchiari malformation. however, the following are our reasons for concurring with the pediatric neurology service in not requesting imaging: aside from vocal fold paralysis, no other neurological 1. symptom or finding was noted such as presence of swallowing and feeding difficulties, dizziness or uncoordination usually present in brainstem pathologies manifesting with vocal fold paralysis such as chiari type i.1,2 previous and subsequent neurological examinations showed 2. a bilaterally intact gag reflex which somewhat made the possibility of a cns lesion affecting the vagus unlikely. furthermore, no findings indicative of cerebellar dysfunction (such as dysdiadokinesia) were noted. thank you very much. reylan b. david, md william l. lim, md department of otorhinolaryngology head and neck surgery saint luke’s medical center 279 e. rodriguez ave., quezon city 1102 philippines response from the authors references 1. greenlee jd, donovan ka, hasan dm, menezes ah. chiari i malformation in the very young child: the spectrum of presentations and experience in 31 children under age 6 years. pediatrics. 2002 dec;110(6):1212-9. 2. aitken la, lindan ce, sidney s, gupta n, barkovich aj, sorel m, wu yw.chiari type i malformation in a pediatric population. pediatr neurol. 2009 jun;40(6):449-54. doi: 10.1016/j. pediatrneurol.2009.01.003. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 the traditional thirtieth anniversary symbol is the pearl. pearls are calcareous concretions of nacre formed through a biomineralization process incited by an irritant in the tissue of bivalve mollusks, producing concentric layers of crystal-form cac0 3 (aragonite or calcite) and an organic binding agent, conchiolin.2,3 interestingly, the modern thirtieth anniversary symbol is the diamond. whether it is reflective of the fast-food generation penchant for instant gratification, or a commentary on their transient perspective on relations to fast-track the traditional diamond jubilee, the pearl teaches a lesson all its own. in contrast to the fiery metamorphosis of carbon to brilliant diamond, pearls are examples of slower creative processes overcoming potential destruction, or patiently making the best of a bad situation, demonstrated by the lowly oyster. as federico fellini put it, “all art is autobiographical; the pearl is the oyster’s autobiography.”4 there is great value in painstakingly producing a work of art or craft, science or technology. the mentifacts and artifacts conceived and created by our minds and hands arise from our interactions with the geosphere, biosphere and sociosphere. our research in these spheres reciprocally affects them in a continuing spiral of experience, reflection and expression as our findings are published and disseminated to others. moreover, the elements that make up the components of our research and publication activity, including the materials we use and the methods by which they are sourced, used and disposed of, also affect these spheres of our existence, and affect us in return.5 editorial 4 philippine journal of otolaryngology-head and neck surgery creative concretions, pearls and publication: the philippine journal of otolaryngology head and neck surgery on its thirtieth year 1revised standard version of the bible, copyright 1952 [2nd edition, 1971] by the division of christian education of the national council of the churches of christ in the united states of america. 2saruwatari k, matsui t, mukai h, nagasawa h, kogure t. nucleation and growth of aragonite crystals at the growth front of nacres in pearl oyster, pinctada fucata. biomaterials. 2009 jun;30(16):3028-34. 3rousseau m, meibom a, gèze m, bourrat x, angellier m, lopez e. dynamics of sheet nacre formation in bivalves. j struct biol. 2009 mar;165(3):190-5. 4walter e. “federico fellini: wizard of film.” atlantic monthly.1965 dec;216(6): 62. 5goleman d. ecological intelligence: how knowing the hidden impacts of what we buy can change everything. 2009. new york: macmillan. “who, on finding one pearl of great value, went and sold all that he had and bought it.”1 matthew 13:46 our journal is itself the product of countless hours of writing, editing and review by our authors, editors and reviewers. from initial manuscript submission, through research design and methodological evaluation and reference checks, repeated form and content editing and revision, to external review and more revisions, each manuscript is painstakingly shepherded through the editing and review process, to final copyediting, galley proofing and approval of accepted manuscripts. the entire process can take anywhere from two weeks (for wellwritten manuscripts compliant with instructions to authors and excellent reviewers) to two years (for more challenging manuscripts, with equally challenged authors or reviewers). the online editorial management system has increased the number of overseas submissions, reflected in our growing international contributions. our publication is disseminated electronically and in print to subscribers and medical libraries and indexed on multiple databases. it is a pearl of great value to many who benefit from the knowledge and wisdom contained in its pages, and who in turn use their learning for the good of their colleagues, trainees, students, patients, families and communities. it would not have been possible without the contributions of our authors, the dedication of our editors, the zeal of our reviewers, the support of our specialty society and the patronage of our readers. thank you. we especially thank our editorial assistant (weng) and our layout (virgie) and artistic (erika) producers and copywriter (patti) for their strong, silent background support. another milestone has been achieved. we are now thirty years old. maraming salamat po! prof. josé florencio f. lapeña, jr., m.a.,m.d. editor-in-chief philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 philippine journal of otolaryngology-head and neck surgery 65 from the viewbox this 57 year-old woman presented with a seizure. she had a history of attending the ent and neurosurgical departments for more than a decade. at the time of her initial presentation many years prior, her main complaint was of nasal congestion. a nasopharyngeal biopsy confirmed an olfactory neuroblastoma. (figure 1) olfactory neuroblastoma correspondence: dr. ian c. bickle consultant radiologist department of radiology ripas hospital bandar seri begawan ba1710 negara brunei darussalam phone: + 00 673 224 2424 fax: + 00 673 224 2690 email: firbeckkona@gmail.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2016; 31 (1): 65-66 c philippine society of otolaryngology – head and neck surgery, inc. ian c. bickle, mb, bch, bao, frcr department of radiology ripas hospital bandar seri begawan brunei figure 1. coronal ct brain (non-contrast) olfactory neuroblastoma is an uncommon slow growing tumour of the nasal cavity with no established etiological basis. with a neuroectodermal origin, it arises from the olfactory epithelium of the upper nasal cavity.1 most cases arise from the cribriform plate, upper third of the nasal septum, superior turbinates or anterior ethmoidal air cells. however, it typically presents late when multiple structures are involved, which may include the orbits and intracranial compartments.2 accounting for approximately 2% of sinonasal tumors, although often late to present, ironically only a minority of patients experience anosmia.3 the commonest complaint at initial presentation is nasal blockage accounting for nearly a quarter of cases, with headache and epistaxis the next most frequent symptoms.1 multi-modality imaging is essential in that the most recognized management of this infrequent tumor is a combination of craniofacial surgery and radiotherapy. the imaging pathway in this case was typical, with ct and mri complementing each other in maximizing tumor delineation. computed tomography has superior definition is reviewing bony involvement which is a typical finding, whereas mri has superiority in evaluating the extent of soft tissue invasion and establishing tumor boundaries against post obstruction fluid in the paranasal sinuses.3 in this case the ct illustrates the gross destruction of the skull base, orbital and sinus margins. (figure 2-5) the mri outlines the extension of disease involving the pituitary fossa, brainstem and frontal sinus invasion. (figures 6 and 7) creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 from the viewbox 66 philippine journal of otolaryngology-head and neck surgery references 1. diaz em, johnigan rh, pero c, el-naggar ak, roberts db, barker jl, demonte f. olfactory neuroblastoma: the 22-year experience at one comprehensive cancer center. head neck. 2005 feb;27(2):138-49. 2. li c, yousem dm, hayden re, doty rl. olfactory neuroblastoma: mr evaluation. anjr. 1993 sept/oct;14:1167-1171. 3. thompson, ldr. olfactory neuroblastoma. head neck pathol. 2009 sep;3(3): 252-259. figure 3. sagittal ct brain (non-contrast): the tumor has replaced the sphenoid sinus and sella (*) with destruction of the floor of the anterior cranial fossa and frontal sinus invasion (black arrow). figure 6. axial mri brain (post contrast): enhancing soft tissue in both frontal sinuses indicating this is complete tumor invasion (*) without obstructed secretions. figure 7. axial t2 fs brain: the huge tumor involves the ethmoid sinuses (*), cavernous sinus (white arrow) and compresses the pons (black arrow). figure 4. axial ct brain (non-contrast): tumor contiguous with the ethmoid and sphenoid sinuses (black arrow) and extension into the pre-pontine space (*) with bilateral proptosis due to mass effect. figure 5. axial ct brain (bone windows): extensive bony destruction of the base of skull: involving the walls of the spenoid sinus, (white arrows), carotid canals and petrous ridge. figure 2. coronal ct brain (non-contrast): tumor in the midline involving the nasal septum (*), with destruction of the cribriform plate (black arrow) and destruction of both superior orbital margins (white arrow). philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 philippine journal of otolaryngology-head and neck surgery 67 from the viewbox this middle-aged woman presented for the first time to ent clinic with a complaint of nasal stuffiness. computed tomography (ct) of the paranasal sinuses was performed following clinical review that revealed a left intranasal mass. 3d stereolithographic modeling of an inverted papilloma correspondence: dr. ian c bickle consultant radiologist department of radiology ripas hospital bandar seri begawan ba1710 brunei darussalam phone: + 00 673 8 612182 fax: + 00 673 224 2690 email: firbeckkona@gmail.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2015; 30 (1): 67-68 c philippine society of otolaryngology – head and neck surgery, inc. ian c. bickle, mb, bch, bao, frcr department of radiology ripas hospital bandar seri begawan brunei figure 1a. coronal ct paranasal sinuses (bone widows) showing complete opacification of the left maxillary sinus and left ethmoidal air cells with widening (*) of the osteomeatal complex b. axial ct paranasal sinuses (bone windows) showing opacification of both frontal sinuses with destruction of the posterior wall of the right frontal sinus (arrow). figure 2a. coronal mri paranasal sinuses (t2 fat sat) showing mass (p) in the left ethmoid sinuses widening the osteomeatal complex with post-obstructive fluid in the maxillary sinus (f) b axial mri paranasal sinuses (t2 fat sat) showing mass (wide arrow) occupying most of the frontal sinuses with only a slither of sinusoidal fluid (thin arrow). due to a radiological suspicion of an inverted papilloma, magnetic resonance imaging (mri) of the paranasal sinuses was performed. a b a b philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 from the viewbox 68 philippine journal of otolaryngology-head and neck surgery references 1. rengier f, mehndiratta a, von tengg-kobligk h, zechmann cm, unterhinninghofen r, kauczor hu, giesel fl. 3d printing based on imaging data: review of medical applications. int j comput assist radiol surg. 2010 jul;5(4):335-41. 2. esses sj, berman p, bloom ai, sosna j. clinical applications of physical 3d models derived from mdct data and created by rapid prototyping. ajr am j roentgenol. 2011 jun;196(6):w683-8. 3. d’urso ps, barker, tm, earwaker wj et al. stereolithographic bimodelling in cranio-maxillofacial surgery: a prospective trial. j craniomaxillofac surg 1999; 27: 30-37. in this illustrative case a mass occupies the left ethmoidal and frontal sinuses with destruction of the floor of the anterior cranial fossa (figure 1 a,b) with further delineation on mri (figure 2 a,b). this case of an inverted papilloma illustrates the tremendous assistance that 3d modelling offers to the surgeon in examining the anatomical extent of the tumor, visualising their surgical approach and planning the operative procedure. (figure 3) for example, in this case a combined procedure between the omf and the neurosurgery departments was undertaken with a bifrontal craniotomy and maxillectomy. operating times have also been shown to improve following the use of 3d models as preparation prior to surgery is more robust.3 figure 3. 3d stereolithographic model: the papilloma (shaded) is exquisitely illustrated on a 1:1 scale model (materialise, belgium) with destruction of the left medial orbital, anterior cranial fossa and detailing its extension across the midline. this, combined with endoscopic biopsy confirmed an inverted papilloma. following referral to oral maxillofacial surgery (omf), 3d modelling was performed using the original ct data to aid surgical planning. discussion dramatic technological advancements in the fields of medical imaging and computer aided design (cad) in the past decade have enabled sterolithographic 3d modelling to evolve from a research aspiration to everyday reality. the widespread availability of high-resolution volumetric data sets, providing isotropic imaging from cross-sectional imaging studies allows for exquisite 3d model production using rapid prototyping techniques.1 although its domains are ever widening, its use is most established in the fields of oral maxillofacial (omf) surgery and otolaryngology enabling surgical planning in anatomically complex areas which often require lengthy and complex surgery.2 similarly, in these fields the 3d modelling assists in prosthesis design and production with additional professional advantages such as teaching aids and aiding patient consent. philippine journal of otolaryngology-head and neck surgery 35 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 from the viewbox a 10-year-old boy with bilateral moderate sensorineural hearing loss underwent computerized tomographic (ct) imaging (ge brightspeed, wisconsin, usa) of the temporal bone as part of the work-up to determine the etiology of his condition. the formal radiologic interpretation of the scan stated that the vestibular aqueducts were not enlarged. however, independent review of the axial ct images appeared to indicate the presence of enlarged vestibular aqueducts. (figure 1) this can be contrasted with a scan from another patient with no evidence of sensorineural hearing loss. (figure 2) when is a vestibular aqueduct enlarged? correspondence: dr. nathaniel w. yang department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 philippines phone: (632) 526 4360 email: <nwyang@gmx.net> reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2012; 27 (2): 35-36 c philippine society of otolaryngology – head and neck surgery, inc. figure 1. axial ct image of the patient’s right temporal bone showing an apparently enlarged vestibular aqueduct (white arrowhead) figure 2. axial ct image showing a normal-sized vestibular aqueduct (black arrowhead) nathaniel w. yang, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila philippine national ear institute national institutes of health university of the philippines manila department of otolaryngology head and neck surgery far eastern university – nicanor reyes memorial foundation institute of medicine philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 from the viewbox 36 philippine journal of otolaryngology-head and neck surgery figure 3. clinically measured vestibular aqueduct dimensions on axial ct the vestibular aqueduct opercular (op) width is measured from the edge of the operculum to the posterior surface of the petrous bone, using a line perpendicular to the posterior surface of the petrous bone. the vestibular aqueduct midpoint (mp) width is measured halfway between the origin of the vestibular aqueduct or posterior wall of the vestibule and the point at which the opercular width is measured. what can explain the discrepancy between the two? if simple visual inspection of the vestibular aqueduct (va) can lead to conflicting interpretations, then what radiographic parameters can be used to resolve the issue? is there a more objective means of determining the presence of a clinically significant vestibular aqueduct enlargement? in 1978, valvasorri and clemis1 first described an association between congenital sensorineural hearing loss and an abnormality in vestibular aqueduct anatomy which they labelled as the “large vestibular aqueduct syndrome.” in this landmark study that utilized hypocycloidal polytomographic temporal bone studies, they proposed that a vestibular aqueduct is enlarged when its midpoint diameter is greater than 1.5 mm. although this parameter is generally considered to be the defining characteristic of the condition, one must realize that this measurement was based on less accurate imaging technology and measurement tools. contemporary studies utilize highresolution ct imaging with digital workstation measurement software to evaluate vestibular aqueduct anatomy. currently, the two most commonly used radiographic parameters are the va midpoint (mp) width and the va opercular (op) width. (figure 3) more recently, boston et al.2 in 2007 published normative values for these parameters based on a study population of 73 children without known sensorineural hearing loss. they considered a vestibular aqueduct enlarged when one or both of the measured widths were above the 95th percentile of the normal study group measurements. on this basis, a va midpoint width of >0.9 mm and/or a va opercular width of >1.9 mm was the criteria established to define an enlarged vestibular aqueduct. figure 4. measurement of the patient’s right vestibular aqueduct on axial ct using radiologic workstation software (syngo ct, siemens ag, berlin and münchen). the vestibular aqueduct opercular width (2d 1) measured 0.29 cm. the vestibular aqueduct midpoint width (2d 2) measured 0.21 cm. the patient’s measured vestibular aqueduct midpoint width on the right was 2.1 mm, while the vestibular aqueduct opercular width was 2.9 mm. (figure 4) these measurements, when evaluated against either the original valvassori criteria or the newer criteria of boston et al., confirm what was visually apparent– the presence of a clinically significant enlargement of the vestibular aqueduct as the etiology of the patient’s sensorineural hearing loss. references valvassori ge, clemis jd. the large vestibular aqueduct syndrome. 1. laryngoscope 1978 may; 88(5): 723-728. boston m, halstead m, meinzen-derr j, bean j, vijavasekaran s, arjmand e, et al. the 2. large vestibular aqueduct: a new definition based on audiologic and computed tomography correlation. otolaryngol head neck surg 2007 jun; 136(6): 972-977. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 editorial 4 philippine journal of otolaryngology-head and neck surgery like the alma ata declaration1 of “health for all by the year 2000,” the dakar framework for action2 and “education for all by 2015” will not be achieved as envisioned. of the many determinants and barriers to universal access to health and education, the intersection of health with education itself represents a major barrier. the social determinants of health3 can themselves pose barriers to education. maternal and infant mortality and morbidity, homelessness, hunger and malnutrition, poor sanitation, lack of security and life-sustaining resources impact on both health and education, and “damaged brains and bodies” cannot learn optimally. health education aims to address these barriers in a special manner and on several levels, beginning with pre-school formal and non-formal community-based health education of children, their parents and community health workers, through formal kindergarten to grade 12 education of schoolchildren (the philippine government k-12 implementation) as well as nonformal education of out-of-school youth (cf: the “kareton klassroom” concept of 2011 cnn hero of the year efren peñaflorida). tertiary undergraduate, graduate and postgraduate education in health professions and allied medical professions is the unique mission of the university of the philippines manila, as the national health sciences center. together with other public and private institutions, government and non-government organizations and the private sector (including the philippine society of otolaryngology head and neck surgery, the philippine college of surgeons, and the philippine medical association), tertiary health education should aim to make an impact on all other levels of health education in particular, and education in general. this effect should happen during the process of education, and not just after — a synchronous multilevel model that is well-entrenched in the medical and health care professions. consultants teach residents and medical students, residents teach medical students and health workers, medical students teach health workers, and so on, as all teach patients and their care-givers also. inequitable access to health is a major barrier to educational access (and vice versa), and solutions to lower or eliminate this barrier will hinge on acquiring adequate and accurate information on universal health coverage, people-centered/point-of-care services, public policy, leadership and governance.4 moreover, information on psychosocial, socio-cultural, economic, ecological-environmental and political contexts and realities, especially in such a geolinguistically diverse country as the philippines is of utmost importance to any leader in health, in education and in health education. the quality of information, as reflective of reality rather correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft ave., ermita, manila 1000 philippines phone (632) 526 4360 telefax (632) 524 4455 email lapenajf@upm.edu.ph reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author has no relevant financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. josé florencio f. lapeña, jr., m.a., m.d. department of otorhinolaryngology college of medicine, university of the philippines manila department of otorhinolaryngology head and neck surgery east avenue medical center, diliman, quezon city from alma ata to dakar: health for all, education for all philipp j otolaryngol head neck surg 2012; 27 (1): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 5 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 editorial references who & unicef (1978). 1. declaration of alma-ata. geneva, world health organization. available from http://www.who.int/hpr/nph/docs/declaration_almaata.pdf accessed march 17, 2012. unesco (2000). 2. the dakar framework for action. education for all: meeting our collective commitments. paris, united nations educational, scientific and cultural organization. available from http://unesdoc.unesco.org/images/0012/001211/121147e.pdf accessed march 15, 2012. csdh (2008). 3. closing the gap in a generation: health equity through action on the social determinants of health. final report of the commission on social determinants of health. geneva, world health organization. available from http://www.who.int/social_determinants/ thecommission/finalreport/en/index.html accessed march 17, 2012. who (2008). the world health report 2008primary health care (now more than ever). geneva, 4. world health organization. available from http://www.who.int/whr/2008/en/index.html accessed february 17, 2012. than merely representative of rhetoric, is just as important (but even more difficult to acquire). otherwise, any solutions conceived of and developed will fall far short of their targets or entirely miss the mark. the interpretation of such information should likewise remain faithful to the original contexts. therefore, the acquisition and utilization of such information should involve a cooperative, participatory, inter-disciplinary and multi-level effort among various stakeholders, including the people (beneficiaries) themselves. our research efforts should take these into consideration, as should the dissemination of these efforts, primarily (in our case) through the philippine journal of otolaryngology head and neck surgery. many of us perform multiple educational roles in academic and training institutions, and in our respective subspecialty interest and study groups. our teaching and training programs, as well as our advocacies, should benefit health, education, and health education in the philippines, and the people that we ultimately serve. let us learn from the past, so that we can move into the future. as educational leaders, it is of paramount importance to be well informed of what has transpired, so that being inspired, leaders and stakeholders together can positively transform their situations in life and their realities. a tribute to dr. ariston g. bautista (1921-2014) “ the ent man” rebecca chung-santos, md one can never really say all that is in one’s heart about a person who has passed on, in a given limited time. but from my experience, such endearing memories come in patches, when you’re alone, when you hear a particular strain of music or when you visit a certain place – glimpses of memories. and so this afternoon, i stand here before you in behalf of the ent department, the department that dr. ariston gella bautista spearheaded and formed in 1982. the department has trained and since then graduated 30 or so doctors who benefited from his strict but fatherly training until the day he fell ill. now these same doctors after having examined their frontals and hearts have these to say of dr. ariston, all their experiences, funny, naughty and professional as a fitting tribute to dr. bautista-the doctor, the mentor, the man, our mmc father. boss, papang, tito, as he was fondly called by us, was a reserved person – very professional in his interaction and relationship with patients and doctors. he was gentlemanly and good-looking. if ladies fell for his charms, it was not his fault but he was totally rañing’s man. in the ‘60s when he was with uerm, he was “crush ng bayan,” i was told, “pinag-fantasyahan si doc titong naming mga nurses noon dahil malumanay siya magsalita” by one of them. he had an engaging wit. when a young patient asked him what agb meant, he told the boy with a glint in his eyes, agb is ariston good boy. we learned the proper etiquette of patient care from him. he treated every ear and nostril that he examined and cleaned like they were eggshells, so gently lest they break. we never heard him make a comment on how icky or how big and dirty these crevices were. we as ariston’s angels emulated this. and proud to say we learned it from him. but it was also in the out-patient clinic that we discovered the naughty side of agb, ariston good boy. residents had to do preceptorials with him. the females of course were his angels but the male residents were otherwise. they were the “promotors ng mga kalokohan,” adding color to boss papang’s daily clinic routine and i believe adding more years to his life, they were his wellspring, his fountain of youth. about maybe 5-or-so years ago (he must have been 87 then), these residents who are now board-certified ents were once caught by agb in the clinic watching a video of an actress caught in a compromising situation: “ano yan?” “eh boss si ano, andito sa ipad.” “patingin, pero bantay ka sa pinto” (saying to one of the boys), “at baka dumating si rañing.” so as these naughty doctors watched, “eh biglang boss, boss, si ma’am padating.” naku, they immediately closed the ipad at si doctor, sat in front of his tv, looking like an angel when ma’am rañing entered. (sorry, no more secrets, our lips are sealed.) i had a patient two days ago who requested me to add his memory of dr. bautista. he was an old patient of agb and when he consulted around 1994 for a sore throat. he was told his tonsils were surgically removed, perfectly. he was then asked who did the surgery. sagot nya “doc pinagawa ko ito sa ue nung 1964, e talagang magaling yung doctor, kayo po doc ang nagopera sa akin.” “ah, ganun ba?” and he smiled. his patients were loyal to him, following him all the way to mmc. as a surgeon, he was composed, quiet, unfazed in the or. his surgical skills were beyond reproach. he taught us everything that we should know, step by step. we watched and we learned. those of us who were lucky enough to have scrubbed for him learned surgery the papang’s way. “turo ni papang yan” we always say when we do surgeries. he motivated us to do our very best in our patient care. he was the best, and in turn we will try our very best to train the future mmc ent the papang’s way, kasi kung ano ang puno, siya ang bunga. lalayo pa ba kami? as for us, the most precious gift that boss papang left us, his ent children, is this: he treated us as his very own and made us one family. he taught us how to iron out all our differences, to love each other unconditionally, to accept each other’s fault, swallow the bitter pill. and so, if you notice the camaraderie we often have, it’s because we are a family. and personally, what have i learned in the 32 years with him? humility. by his example, i learned the meaning of humility, for despite his being unequalled in the field, he was never boastful, never heard him ridicule or insult those who are lesser than him in ability and intelligence-rather he taught them how to do it the right way, helped them correct surgical errors without any insulting words. never heard him talk maliciously about a person behind his back. he knew how to count his blessings. this december will be our first christmas celebration as a department without boss papang. though feeling orphaned, we will always remember him, for he lives in each one of us, in our hearts and our minds, in our work, in our skills and lessons learned. who and what we are now, we owe to dear boss papang ariston good boy. thank you. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 passages 48 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 editorial 4 philippine journal of otolaryngology-head and neck surgery the world health organization constitution “enshrines the highest attainable standard of health as a fundamental right of every human being. the right to health includes access to timely, acceptable and affordable health care of appropriate quality... as well as the underlying determinants of health, such as ...access to health-related education and information.”1 on the other hand, “social determinants of health can themselves pose barriers to education... and ‘damaged brains and bodies’ cannot learn optimally.”2 while there are no clear-cut solutions to such multifactorial issues involving complex-systems, the sustainable developmental goals of the united nations development agenda beyond 2015 address both health and education.3 health research fundamentally underpins the key aspiration of the sustainable development goals to realize universal health coverage.3 it is the responsibility of researchers and publishers to make this research available and accessible to all those who need it in order to assist policymakers and practitioners to progressively realize the right to health of every global citizen. it would seem that the speed and reach of present-day information and communication technology would have facilitated the dissemination of health information. “however, despite the promises of the information revolution and some successful initiatives, there is little if any evidence that the majority of health professionals in the developing world are any better informed than they were 10 years ago.”4 this observation made over a decade ago still holds true today. how can we advance access to health information and publication in our current “glocal” situation? how can the health information produced by research conducted by our students, residents and fellows, be shared with all those who may need and use the information? the philipp j otolaryngol head neck surg has been actively pursuing multiple means of ensuring the availability of our research and innovation through traditional means including indexing on various index medici and databases. while our visibility has increased dramatically in the 10 years of our editorship, we need to explore new paradigms, trends and innovations especially with regard the social media. this includes using facebook, twitter, linkedin and rss feeds, to name a few. it also calls us to consider the transition to a full open access model and adopting creative commons licenses. it is timely that the asia pacific association of medical journal editors (apame) will explore this very theme of shifting paradigms, trends and innovations in advancing access to health information and publication in the forthcoming apame2015 annual convention and joint meeting with the western pacific region index medicus at the sofitel philippine plaza and who correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone (632) 554 8467 telefax (632) 524 4455 email lapenajf@upm.edu.ph reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines advancing access to health information and publication: shifting paradigms, trends and innovations philipp j otolaryngol head neck surg 2015; 30 (1): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 5 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 editorial western pacific region office from august 24-26 (http://apame2015. healthresearch.ph) in conjunction with the global health forum 2015 at the philippine international convention center (http://www.forum2015. org). close to a thousand editors, reviewers, authors, researchers, librarians, and publishers of medical journals from asia pacific states, local delegates representing various institutions and organizations, including the department of science and technology philippine council for health research and development (pchrd), department of health, university of the philippines manila, medical and health librarians association of the philippines (mahlap), the philippine medical association, the philippine nursing association, the philippine dental association and others will exchange ideas in three days of meetings, scientific sessions and workshops. at the same time, the over 70 conjoint forum 2015 sessions across 2 tracks covering 6 themes will provide “a platform where several other thousand key global actors in health gather to learn, debate and shape the global agenda on research and innovation for health, to arrive at new solutions that are driving health equity and socio-economic development.” whether you are a beginning researcher or a seasoned scientist, a novice trainee or senior subspecialist, a community-based health worker or health policy-maker, there will be something for you to learn and share at these meetings that recognize “people (are) at the center of health research and innovation.” medical and health professions students, orl-hns residents and consultants of all training and academic institutions are particularly enjoined to participate in this rare opportunity that will benefit us as well as the people we serve. meet me at the forum! references 1. world health organization. “the right to health” fact sheet no323 reviewed november 2013. cited 10 may 2015. available at: http://www.who.int/mediacentre/factsheets/fs323/en/. 2. lapeña jf. “from alma ata to dakar: health for all, education for all” philipp j otolaryngol head neck surg. 2012 jan – jun; 27(1):4-5. 3. open working group of the general assembly on sustainable developmental goals. document a/68/970, united nations department of economic and social affairs. cited 22 april 2015. available at http://undocs.org/a/68/970. 4. godlee f, pakenham-walsh n, ncayiyana d, cohen b, packer a. “can we achieve health information for all by 2015?” lancet 2004 jul; 364(9430):295-300. doi: http://dx.doi.org/10.1016/ s0140-6736(04)16681-6. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 philippine journal of otolaryngology-head and neck surgery 33 from the viewbox a 14-year-old lass with down syndrome presented with a 3-year history of recurrent purulent left otorrhea. the discharge had become more frequently blood-tinged. otologic examination revealed a stenotic ear canal with polypoid granulation obstructing the view of the tympanic membrane. high resolution computerized tomographic (hrct) imaging of the temporal bone was performed to assess the status of the middle ear and mastoid. particular attention was given to assess for bony erosion associated with cholesteatoma formation. comparison of the scutum on coronal view (figure 1) did not show a marked visual difference in the sharpness of the scutum edge. as erosion of the scutum edge is the hallmark radiological finding in the diagnosis of a pars flaccida or attic retraction-based acquired cholesteatoma, a confident radiologic diagnosis of cholesteatoma via this pathophysiologic mechanism could not be given. ossicular erosion from a posterior pars tensa retraction cholesteatoma correspondence: dr. nathaniel w. yang department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 philippines phone: (632) 526 4360 email: nwyang@gmx.net reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2013; 28 (2): 33-34 c philippine society of otolaryngology – head and neck surgery, inc. nathaniel w. yang, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila philippine national ear institute national institutes of health university of the philippines manila department of otolaryngology head & neck surgery far eastern university – nicanor reyes memorial foundation institute of medicine figure 1. coronal hrct images of the scutum. the top scutum (white arrow) does not appear to be blunted when compared to the bottom scutum, which is known to be intact. the left middle ear space is entirely filled with a soft tissue lesion, whilst there is only soft tissue in the right epitympanum lateral and superior to the ossicles. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 from the viewbox 34 philippine journal of otolaryngology-head and neck surgery references pappas dg, flexer c, shackelford l. otological and habilitative management of children 1. with down syndrome. laryngoscope 1994 sep; 104(9): 1065–1070. doi: 10.1288/00005537199409000-00003. bacciu a, pasanisi e, vincenti v, giordano d, caruso a, lauda l, bacciu s. surgical treatment of 2. middle ear cholesteatoma in children with down syndrome. otol neurotol 2005 sep; 26(5):10071010. baráth k, huber am, stämpfli p, varga z, kollias s. neuroradiology of cholesteatomas. 3. ajnr am j neuroradiol 2011 feb; 32(2):221-229. doi 10.3174/ajnr.a2052. exploratory surgery via an initial external end-aural approach revealed the presence of a posterior pars tensa retraction cholesteatoma underneath the granulation polyp. the cholesteatoma had extended medial to the ossicular chain causing erosion of the long process and medial portion of the short process of the incus, as well as the entire stapes superstructure. definitive surgery consisting of a canal-wall down mastoidectomy via a post-auricular approach, cartilage graft figure 2. axial hrct images at the level of the epitympanum showing the ‘ice-cream cone’ appearance of the malleus head and incus body. the white arrow is pointing to the short process of the top incus, which appears to be subtly thinned from the medial side with increased concavity when compared to the bottom incus. tympanoplasty without ossicular chain reconstruction, meatoplasty and partial mastoid obliteration was performed. this case is particularly instructive regarding two issues: otologic disease in down syndrome and radiological evidence of erosive middle ear disease. an increased incidence of otologic conditions in down syndrome is well established in the medical literature. these include external auditory canal stenosis, ossicular chain abnormalities and otitis media with effusion (ome).1,2 cholesteatoma as a sequelae of undiagnosed or untreated ome has to be suspected in children with down syndrome, especially in those with recurrent otorrhea and persistent hearing loss. unfortunately, the identification of a cholesteatoma may be difficult due to stenosis of the external auditory canal or a sub-optimal otologic examination due to behavioral problems in children with down syndrome.2 these factors were both present in this particular case, as the cholesteatoma remained undiagnosed for several years despite regular consultations with an otolaryngologist. radiologic evaluation with high-resolution computerized tomographic (hrct) imaging is extremely important in these situations. as described by barath et al., the “typical findings associated with cholesteatoma include a sharply marginated expansile soft-tissue lesion, retraction of the tympanic membrane, scutum blunting, and erosion of the tympanic tegmen and ossicles. holotympanic absence of bony changes is suggestive of otitis media without cholesteatoma formation, whereas presence of bony erosions (along with clinical suspicion) indicates cholesteatoma.”3 in this particular case, the presence of soft tissue within the epitympanum and antrum accompanied by the subtle evidence of ossicular erosion were crucial in the decision to advise and perform surgery. although it may be argued that a high clinical suspicion based on the suggestive otological history in a child with down syndrome may be enough to warrant surgical exploration, it cannot be disputed that the radiological findings help in advising patients preoperatively about the indications for and expected outcomes of surgical management. in this case, it also impacted on the surgical approach – a transmeatal procedure appropriate for a limited middle ear exploration was initially performed with conversion to a standard post-auricular approach appropriate for more extensive mastoid surgery once the presence and extent of the cholesteatomatous disease was confirmed intra-operatively. meticulous examination of the ossicles on axial view (figure 2) showed a subtle thinning of the short process of the incus by sharply marginated, seemingly expansile soft tissue medially located between the incus and the tympanic segment of the facial nerve. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 philippine journal of otolaryngology-head and neck surgery 39 under the microscope abstract primary sinonasal ameloblastoma is an extremely rare odontogenic epithelial tumor histomorphologically identical to its gnathic counterparts but with distinct epidemiologic and clinicopathologic characteristics. we present a case of a 46-year-old female with a one year history of recurrent epistaxis, nasal obstruction and frontonasal headache. clinical examination, ct scan and subsequent surgical excsion revealed an intranasal mass attached to the lateral nasal cavity with histomorphologic features of ameloblastoma and was signed out as extragnathic soft tissue ameloblastoma of the sinonasal area. extraosseous extragnathic primary sinonasal ameloblastoma are rare but do occur and should be distinguished from infrasellar craniopharyngiomas. keywords: extraosseous, extragnathic, sinonasal, ameloblastoma ameloblastomas are slow growing locally aggressive odontogenic epithelial tumors of the jaw and are classified into solid/multicystic, unicystic, desmoplastic, and peripheral subtypes.1,2,3 they involve the mandible 80% of the time and are often associated with an unerrupted molar tooth. extraosseous extragnathic ameloblastomas are very rare, occurring less than 1.3 to 10% of all ameloblastomas with all cases reported so far arising from the sinonasal region.1,2,4 we present a case of primary sinonasal ameloblastoma in a filipino female. case report a 46-year-old female consulted at the university of the philippines philippine general hospital department of otorhinolayngology with a one-year history of recurrent, spontaneous epistaxis from the right nose, associated with ipsilateral nasal obstruction, thin-brown rhinorrhea, and frontonasal headache relieved by oral paracetamol. nasal endoscopy revealed a pale pink irregularly shaped polypoid mass attached to the lateral nasal wall almost completely obstructing the nasal cavity. plain coronal and sagittal ct images of the nasal cavity and paranasal sinuses showed opacification of the right nasal chamber by soft tissue densities with obstruction of the ipsilateral ostiomeatal unit and sphenoethmoidal recess (figure 1). the sphenoid, frontal and contralateral paranasal sinuses and nasal vault were uninvolved. incision biopsy was read as sinonasal exophytic papilloma and the mass was excised via endoscopic sinus surgery under general anesthesia. primary sinonasal ameloblastoma in a filipino female correspondence: dr. mark angelo c. ang department of laboratories philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone (632) 554 8400 local 3208 email: mark.ang.2010@gmail.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all authors, that the requirements for authorship have been met by each author, and that the authors believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (2): 39-41 c philippine society of otolaryngology – head and neck surgery, inc. mark angelo c. ang, md1 ariel m. vergel de dios, md2 jose m. carnate, jr. md2 1department of laboratories philippine general hospital university of the philippines manila 2department of pathology college of medicine university of the philippines manila philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 under the microscope 40 philippine journal of otolaryngology-head and neck surgery figure 1. computed tomography scan of the head, plain, coronal cut at the level of the nasal cavity and paranasal sinuses. there is opacification of the right nasal chamber by soft tissue densities with obstruction of the ostiomeatal unit and sphenoethmoidal recess. figure 3. image from another area showing the same epithelial trabecula and the edematous, myxoid stroma (hematoxylin and eosin, 10x). inset: a typical epithelial island with the classic reverse polarization of the peripheral columnar cells (hematoxylin and eosin, 40x). (hematoxylin-eosin, 10x) (hematoxylin-eosin, 40x) at the center of the epithelial islands, loose collections of stellate and spindly cells similar to the stellate reticulum of the embryonic enamel organ are found. acanthomatous changes are present in the superficial layers. there is no atypia and no mitosis (figures 2 and 3). this case was signed out as extragnathic soft tissue ameloblastoma. discussion most reported cases of ameloblastoma in the sinonasal cavity actually describe tumors that originated from the maxilla and have only secondarily involved the sinonasal area.4 to date, the 26-year review by schafer et al. of 24 primary sinonasal tract ameloblastomas at the armed forces institute of pathology remains the single largest series describing this entity.4 although three additional case reports were recently published, to the best of our knowledge, this is the first case of primary sinonasal ameloblastoma in the philippines.5,6,7 unlike our patient, primary sinonasal ameloblastomas more commonly affect males with mean age at presentation of 59.7 years.1,4 patients usually present with an intranasal mass, nasal obstruction, sinusitis and epistaxis of one month to several years duration.1,4 radiologically, sinonasal ameloblastomas are solid masses or opacifications rather than multilocular and radiolucent as those that arise within the jaws.1 the submitted specimen consisted of a 2 cm by 0.8 cm cream white solid, soft to rubbery mass. on histologic examination, trabecula and islands of cytologically benign odontogenic epithelium permeate an edematous, myxoid, hypocellular stroma. columnar cells that display palisading and reverse polarity, line the periphery of the epithelium. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 philippine journal of otolaryngology-head and neck surgery 41 under the microscope the histomorphologic features of primary sinonasal ameloblastomas are identical to their gnathic counterparts and include unencapsulated proliferating nests, islands or sheets of odontogenic epithelium resembling the embryonic enamel organ. the epithelium is composed of a central area of loosely arranged cells similar to the stellate reticulum of the enamel organ and a peripheral layer of palisading columnar or cuboidal cells with hyperchromatic small nuclei oriented away from the basement membrane, the so called reverse polarity.1 experts believe that primary sinonasal ameloblastomas arise from remnants of odontogenic epithelium, lining of odontogenic cysts, basal layer of the overlying oral mucosa or heterotopic embryonic organ epithelium.1,4 this is supported by the observation that the ameloblastomatous epithelial proliferations are often seen in continuity with native sinonasal (schneiderian) epithelium.1,4 this entity should be distinguished from an infrasellar craniopharyngioma which is an important differential diagnosis that is often difficult and often virtually impossible to differentiate from a primary sinonasal ameloblastoma solely on histomorphologic grounds. in most cases, however, clinicopathologic correlation guides the diagnosis8 and special stains are of limited utility.1 surgical excision is the treatment of choice, the type and extent of references 1. wenig bm. “sinonasal ameloblastoma.” atlas of head and neck pathology. 2nd ed. philadelphia: elsevier saunders; 2008. 95-97. 2. international agency for research on cancer. pathology and genetics of head and neck tumours. lyon: iarc press; 2005. 3. gnepp dr. diagnostic surgical pathology of the head and neck. 2nd ed. philadelphia, pa: saunders; 2009. 4. schafer dr, thompson ldr, smith bc, wenig bm. primary ameloblastoma of the sinonasal tract. cancer 1998 feb; 82(4):667-674. 5. leong sc, karkos pd, krajacevic j, islam r, kent se. ameloblastoma of the sinonasal tract: a case report. ear nose throat j 2010 feb;89(2):70-71. 6. ereño c, etxegarai l, corral m, basurko jm, bilbao fj, lópez ji. primary sinonasal ameloblastoma. apmis 2005 feb;113(2):148-150. 7. guilemany jm, ballesteros f, alós l, alobid i, prades e, menéndez lm, cardesa a. plexiform ameloblastoma presenting as a sinonasal tumor. eur arch otorhinolaryngol 2004 jul;261(6):304306. 8. deutsch h, kothbauer k, persky m, epstein fj, jallo gi. infrasellar craniopharyngiomas: case report and review of the literature. skull base 2001 may;11(2):121-128. figure 2. interconnecting trabecula and islands of benign odontogenic epithelium in an edematous, myxoid, hypocellular stroma (hematoxylin and eosin, 10x). inset: an epithelial island with peripheral columnar cells that display palisading and reverse polarity. the center shows a loose collection of stellate and spindly cells, similar to the stellate reticulum of the embryonic enamel organ (hematoxylin and eosin, 40x). (hematoxylin-eosin, 10x)(hematoxylin-eosin, 40x) which is dictated by the size and localization of the lesion. recurrence can occur, generally within two years but overall treatment success depends on complete surgical eradication. no deaths, metastases or malignant transformation have so far been reported1,4 and our patient is free of disease, 15 months post surgery. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 featured grand rounds 34 philippine journal of otolaryngology-head and neck surgery diffuse idiopathic skeletal hyperostosis (dish) is a disease characterized by massive, noninflammatory ossification with intensive formation of osteophytes affecting ligaments, tendons and fascia of the anterior part of the spinal column mostly in the middle and lower thoracic regions. however, isolated and predominant cervical spinal involvement may occur. it has predilection for men (65%) over 50 years of age and a prevalence of approximately 15-20% in elderly patients.1 a ct scan is one of the diagnostic tools. the radiographic diagnostic criteria in the spine include: 1) osseous bridging along the anterolateral aspect of at least four vertebral bodies; 2) relative sparing of intervertebral disc heights with minimal or absent disc degeneration; and 3) absence of apophyseal joint ankylosis and sacroiliac sclerosis.2 we present a rare case of dysphagia over two years duration due to dish. case report a 55-year-old malay man presented with intermittent dysphagia for two years duration. he denied foreign body ingestion, globus sensation or any laryngeal trauma, shortness of breath, hoarseness or any neurological deficits. a solitary smooth mass on the right posterolateral pharyngeal wall that was hard in consistency was appreciated on oropharyngeal examination. (figure 1) there was no significant cervical lymphadenopathy and the neurological examination was unremarkable. cervical radiographs and ct scan showed marked ossification at the right anterolateral aspect of cervical vertebral bodies c2 to c7 most probably representing a diffuse idiopathic skeletal hyperostosis. (figures 2, 3) he was treated conservatively with 6-monthly follow up. discussion diffuse idiopathic skeletal hyperostosis (dish) is an ossifying diasthesis characterized by the thickening and calcification of soft tissue (ligaments, tendons and joint capsule) resulting in secondary formation of osteophytes. most commonly it affects the paraspinal ligaments, predominantly the anterior longitudinal ligament and occasionally the posterior longitudinal ligament.2 it was first described as senile ankylosing hyperostosis of the spine by forestier and rodes querol in 1950.3 in 1970 resnick et al. coined the term dish for this systemic entity. radiologically, they established 3-diagnostic criteria which include: 1) presence of flowing diffuse idiopathic skeletal hyperostosis: a rare cause of dysphagia correspondence: dr. khairullah anuar department of otorhinolaryngology-head & neck surgery, faculty of medicine and health sciences, universiti sains islam malaysia tingkat 13, menara b pesiaran mpaj jalan pandan utama, pandan indah 55100 kuala lumpur malaysia phone: (03) 4289 2400 fax: (03) 4289 2408 email: drkhairul@usim.edu.my khairullah4195@yahoo.co.nz reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. anuar khairullah, mbchb, ms (orl-hns)1 hitam shahrul, mbbs, mmed (orl)2 sushil brito –mutuyanagam, mbbs, ms (orl-hns)2 1department of otorhinolaryngology head & neck surgery faculty of medicine and health sciences universiti sains islam malaysia 2 department of otorhinolaryngology ampang hospital philipp j otolaryngol head neck surg 2014; 29 (2): 34-36 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 philippine journal of otolaryngology-head and neck surgery 35 featured grand rounds figure 1. right posterolateral oropharyngeal mass figure 3a. ct scan, axial section showing large anterior osteophyte at c2 level ossification of anterior longitudinal ligament of at least four contiguous vertebral bodies; 2) preservation of intervertebral disc height; and 3) absence of apophyseal joint ankylosis or sacroiliac joint erosion, sclerosis or fusion.4 cervical anterior osteophytes accompanying dish are mostly asymptomatic. they may present with cervical pain and stiffness. large osteophytes however do cause dysphagia and it is the most common presenting complaint, affecting 17 – 28% of patients.5 many different mechanisms have been suggested as the cause of the dysphagia including mass effect on the esophagus by the osteophytes and neuropathy due to recurrent laryngeal nerve impingement.5,6 according to lin et al., in addition to distortion of laryngoesophageal anatomy and functions, osteophytes of cervical vertebrae can alter the mechanics of pharyngeal swallowing leading to secondary inflammation and edema of mucosa and soft tissue.6 although airway symptoms in patients with dish appear to be rare, clinicians should be aware of this condition and its potential for acute respiratory complications. the etiology of dish is still unclear, however according to calisanellerr et al. it may be associated with excessive mechanical stress, hyperlipidaemia, increased levels of insulin with or without diabetes mellitus, increased levels of insulin-like growth factor-1 and hyperuricaemia.7 a positive hla–b8 has also been reported and hypervascularity may also play a role in the etiopathogenesis of dish.7,8,9 differential diagnosis of dish includes ankylosing spondylitis, spondylosis deformans, osteoarthritis and esophageal malignancies where it should be considered when the dysphagia cannot be explained by small anterior osteophytes.5 figure 3b. ct scan, bone window at same level, showing the large anterior osteophytes figure 2. lateral neck x-ray showing the osteophytes philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 featured grand rounds 36 philippine journal of otolaryngology-head and neck surgery references 1. weinfeld rm, olson pn, maki dd, griffiths hj. the prevalence of diffuse idiopathic skeletal hyperostosis (dish) in two large american midwest metropolitan hospital populations. skeletal radiol 1997 apr; 26(4):222–225. 2. goh py, dobson m, iseli t, maartens nf. forestier’s disease presenting with dysphagia and dysphonia. j clin neurosci. 2010 oct; 17(10):1336-1338. 3. forestier j, rotes-querol j. senile ankylosing hyperostosis of the spine. ann rheum dis 1950 dec; 9(4 ):321–330. 4. resnick d, niwayama g. radiographic and pathologic features of spinal involvement in diffuse idiopathic skeletal hyperostosis (dish). radiology 1976 jun; 119(3): 559–568. 5. kos mp, van royen bj, david ef, mahieu hf. anterior cervical osteophytes resulting in severe dysphagia and aspiration: two case reports and literature review. j laryngol otol. 2009 oct; 123(10):1169-1173. 6. lin hw, quesnel am, holman as, curry wt jr., rho mb. hypertrophic anterior cervical osteophytes causing dysphagia and airway obstruction. ann otol rhinol laryngol 2009 oct; 118(10);703-707. 7. calisaneller t, ozdemir o, tosun e, altinors n. dysphagia due to diffuse idiopathic skeletal hyperostosis. acta neurochir 2005; 147: 1203–1206. 8. denko cw, boja b, moskowitz rw. growth promoting peptides in osteoarthritis and diffuse idiopathic skeletal hyperostosis – insulin, insulin-like growth factor-i, growth hormone . j rheumatol 1994; 21(9): 725–730. 9. miedany ym, wassif g, baddini m. diffuse idiopathic skeletal hyperostosis (dish): is it of vascular etiology? clin exp rheumatol 2000; 18(2): 193–200. 10. troyanovich sj, buettner m. a structural chiropractic approach to the management of diffuse idiopathic skeletal hyperostosis. j manipulative physiol ther.2003 mar-apr; 26(3):202-206. 11. carlson ml, archibald dj, graner de, kasperbauer jl. surgical management of dysphagia and airway obstruction in patients with prominent ventral cervical osteophytes. dysphagia. 2011 mar; 26(1): 34-40. treatment can be divided into conservative treatment with dietary modification, swallowing therapy sessions and analgesia for early stages of mild dysphagia. chiropractic treatment and acupuncture are popular alternatives among patients. the benefit of chiropractic therapy may lie in its role in increasing range of movement of the spine and providing pain relief.10 when conservative treatment fails, surgical interventions such as osteophytectomy, tracheotomy and feeding tube insertion are indicted. surgical excision via perioral transpharyngeal route for c1 and c2 vertebrae or anterior cervical approach for c3 to c7 vertebrae is preferred.6,11 the aim of the surgery is to provide satisfactory decompression of the esophagus.6 recent studies have shown that patients treated surgically with osteophytectomy had marked improvement if not complete resolution of their upper aerodigestive disturbances.11 it should be remembered that surgical interventions harbor the risk of recurrent laryngeal nerve injury, horner’s syndrome, cervical instability, persistent symptoms and recurrence.11 dysphagia caused by diffuse idiopathic skeletal hyperostosis is an uncommon entity. radiological evaluation specifically ct scans are diagnostic and can rule out other possible causes of oropharygeal mass. surgical decompression may relieve the dysphagia when conservative treatments fail. 22 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 case reports philipp j otolaryngol head neck surg 2014; 29 (2): 22-24 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to present a case of rosai-dorfman disease in an individual with a 14-year history of recurrent nasal polyposis and discuss its clinical presentation, physical examination, radiologic findings, histopathologic characteristics and available treatment. methods: design: case report setting: tertiary government hospital patient: one results: a 26-year-old filipino diagnosed and repeatedly treated medically and surgically for recurrent nasal polyposis underwent repeat endoscopic sinus surgery. a histopathologic impression of rosai-dorfman disease was confirmed by positive s-100 and cd1a negative immunochemistry in conjunction with the morphologic findings. conclusion: rosai-dorfman disease is a rare entity which should be considered when dealing with recurrent nasal polyposis that is intractable to initial medical and surgical therapies. histopathologic findings of emperipolesis and immunohistochemical s-100 stains play a key role in the diagnosis but there is yet no definite treatment for this disease. keywords: recurrent nasal polyposis, rosai-dorfman disease, emperipolesis, s-100 stain nasal polyps are common pathology of unknown etiology with a high rate of recurrence after surgery.1 a study of 148 patients to determine the rate and reasons for polyp recurrence after functional endoscopic sinus surgery showed recurrence in 74 patients (49.3%) in the first two years after surgery and 17 patients (12.2%) in the next 3-4 years. there were no associations noted between allergy, infection and recurrence of polyps.1 another study that analyzed 10 variables (age, gender, history of purulent nasal discharge, facial pain, anosmia, post nasal drip, headache, nasal allergy, asthma and ct scan staging using the lund-mckay scoring system) for association with polyp recurrence found a 19% recurrence rate and no association with the variables analyzed except for ct staging which was significantly higher among the group with recurrence compared to the group without recurrence (p<0.00).2 recurrent polyposis which is unresponsive to the standard therapy is associated with hyperplastic chronic sinusitis, allergy, cystic fibrosis and acetylsalicylic (asa) sensitivity. patients with asa sensitivity typically have adult onset asthma with nasal polyps and chronic sinusitis.2 another disease entity associated with recurrent nasal polyposis is inverting papilloma which is a benign but locally aggressive tumor of the nasal cavity. it is similar in appearance but is fleshier than nasal polyp. histopathology can distinguish the one from the other.2 we present a case of recurrent nasal polyposis not responding to repeated medical and surgical treatments diagnosed with rosai-dorfman disease. rosai-dorfman disease presenting as recurrent nasal polyposisneil louis l. apale, mdjoel a. romualdez, md rodolfo e. rivera, md department of otolaryngology head and neck surgery st. luke’s medical center correspondence: dr. joel a. romualdez department of otolaryngology-head and neck surgery st. luke’s medical center – quezon city #279 e. rodriguez sr. boulevard, quezon city metro manila 1112 philippines phone: (632) 723 0101 local 5543 email: slmcearnosethroat@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest presented at the philippine society of otolaryngology head and neck surgery interesting case contest (1st place) held on april 28, 2012 during the 2012 midyear convention: “old time hits: a tribute to the aging ent patient” in iloilo city. philippine journal of otolaryngology-head and neck surgery 23 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 case reports case report a 26-year-old man with recurrent nasal obstruction and nasal discharge for the past 14 years underwent 12 functional endoscopic sinus surgeries in 12 years for chronic rhinosinusitis with nasal polyposis. although his past medical and social histories were unremarkable, he had a family history of bronchial asthma (mother), hypertension (father), and skin malignancy (aunt). he presented to us due to recurrence of nasal symptoms. physical examination showed nasal polyps appearing as non-translucent, coarse and pinkish polypoid masses. paranasal sinus ct scans revealed erosive changes in the posterior wall of the right maxillary antrum with bone thinning and erosive changes in the ethmoids with nodular densities in the nasal cavity. (figure 1) flexible nasal endoscopy showed the extent of the nasal polyps. (figure 2) endoscopic sinus surgery was performed and histopathologic evaluation of the extracted nasal polyps revealed “eosinophilic granularity within the histiocytes and occasional lymphocytes present within the histiocytic cytoplasm with no malignant neoplastic tissue detected.” (figure 3) with an impression of rosai-dorfman disease, immunohistochemical stains for confirmation were positive for s100 and negative for cd1a, which, coupled with the morphology favored the diagnosis. post-operative endoscopicallyguided nasal douches of isotonic nasal saline powder (flo) sachet, 1 sachet/200ml distilled water and budesonide (pulmicort) 1mg/2ml per nebule, 1 nebule/200ml distilled water were started every other day during the first post-operative month and gradually reduced in frequency with resolution of the black crusting admixed with whitish to yellowish mucoid secretions in the nasal cavity. at present, the patient is symptom-free on regular nasal douching twice a week. (figure 4) figure 1. coronal contrast ct scan showing complete opacification of the left maxillary and bilateral ethmoid sinuses. the nasal septum is moderately deviated to the right figure 2. translucent coarse pinkish lesion in the nasal cavity seen on flexible nasal endoscopy figure 3. microscopic view showing engulfment of lymphocytes by histiocytes (emperipolesis) figure 4. frontal sinus with polypoid mucosa and good mucosal healing 6 weeks post-surgery and regular nasal douching 24 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 case reports discussion rosai-dorfman disease (rdd) is a rare non-neoplastic lymphoproliferative histiocytic disorder.3 it is more frequently seen in children and young adults but may occur in any age group and is more common in males and those of african descent.4 the classical clinical presentation of rdd is sinus histiocytosis with massive and painless cervical lymphadenopathy.5 however, extranodal disease occurs in up to 43% of patients and among these, 75% of cases occur in the head and neck region. involvement of the nasal cavity presents with recurrent nasal obstruction and discomfort and on examination reveals small red-wine colored tumor masses.6 ct scan findings in rosai-dorfman disease with involvement of the paranasal sinuses shows diffuse mucoperiosteal thickening of the sinuses with nodular densities in the nasal cavity which are similar findings found in chronic rhinosinusitis with nasal polyposis.5 imaging by ct scan demonstrates the extent of the disease but histopathology and immunostaining are needed for definite diagnosis. histological features of the disease include marked proliferation of sinus histiocytes which often contain phagocytosed lymphocytes (emperipolesis).6 the presence of emperipolesis or the engulfment of lymphocytes and erythrocytes by histiocytes that express s-100 is considered diagnostic of rosai-dorfman disease. references 1. eitan y, jacob s, tamara d, rami t, tuvia h. recurrence of nasal polyps after functional endoscopic sinus surgery. conexiuni medicale 2009 dec; 16: 27-9. 2. akhtar s, ikram m, azam i, dahri t. factors associated with recurrent nasal polyps: a tertiary care experience. j pak med assoc, 2010 feb; 60(2) : 102-4. 3. rosai j, dorfman rf. sinus histiocytosis with massive lymphadenopathy: a newly recognized benign clinicopathological entity. arch pathol 1969 jan; 87(1) : 63-70. 4. komp dm. the treatment of sinus histiocytosis with massive lymphadenopathy (rosai dorfman disease). semin diagn pathol 1990 feb; 7(1): 83-6. 5. la barge dv, salzman kl, harnsberger hr, ginsberg le, hamilton be, wiggins rh, hudgins pa. sinus histiocytosis with massive lymphadenopathy (rosai-dorfman disease): imaging manifestations in the head and neck. ajr 2008 dec; 191(6): w299-w306. 10.2214/ajr.08.1114 6. hagemann m, zbaren p, stauffer e, caversaccio m. nasal and paranasal sinus manifestation of rosai-dorfman disease. rhinology 2005 sep; 43(3):229-32. 7. huang yt, ng sh, ko sf, wong hf, chen yl, huang mc, toh ch, wai yy. extranodal rosai– dorfman disease with paranasal sinuses and intracranial involvement: a case report. chin j radiol 2009; 34:191-96. 8. suh j, kennedy d. treatment options for chronic rhinosinusitis. proc am thorac soc 2011.8:132140 at present, there is still no definite treatment for this disease. systemic corticosteroids are usually helpful in decreasing nodal size and symptoms, however they can be quite immunosuppressive and recurrence of lesions can occur after a short period of interruption. surgical management may be required if there are obstructive or compressive symptoms as in our patient with nasal obstruction.7 in this case, rosai-dorfman disease presented as recurrent nasal polyposis. surgical removal of the lesions is the primary treatment and nasal douching is advocated as an adjunct therapy for recurrent nasal polyposis. saline nasal irrigation demonstrates improvement in symptoms and quality of life. it promotes mucociliary clearance by flushing out mucus, crusts and irritants. adding budesonide respules to nasal douching has been observed to decrease mucosal inflammation, shortening the stage of epithelialisation and accelerating recovery of mucosa after fess.8 rosai-dorfman disease is a rare entity which should be considered when dealing with recurrent nasal polyposis that is intractable to initial medical and surgical therapies. histopathologic findings of emperipolesis and immunohistochemical s-100 stains play a key role in the diagnosis, but there is yet no definite treatment for this disease. philippine journal of otolaryngology-head and neck surgery 31 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports abstract objective: to report two cases of cardiovocal syndrome (or ortner’s syndrome) due to cardiovascular disease. methods: design: case report setting: tertiary university hospital subjects: two results: two patients with cardiovocal syndrome, one due to an aortic saccular aneurysm and the other due to severe mitral stenosis underwent surgery to correct the underlying cardiovascular disease. post-operatively, the hoarseness resolved completely in the patient with mitral stenosis but persisted in the patient with aortic saccular aneurysm. conclusion: cardivascular disease should be considered as a differential diagnosis in a patient with hoarseness. a high index of suspicion is needed to make an early diagnosis which can lead to surgical correction of the potentially life-threatening, underlying cardiovascular disease. keywords: cardiovocal hoarseness, ortner’s syndrome, cardiovascular disease, aortic aneurysm, mitral stenosis hoarseness caused by damage to the recurrent laryngeal nerve as a result of cardiovascular causes is known as cardiovocal syndrome (or ortner’s syndrome). this rare syndrome was first described in 1897 by nobert ortner, an austrian physician.1 although ortner originally described this syndrome in association with mitral stenosis, it is now recognized as a complication of a number of cardiovascular diseases. cardiovocal syndrome remains rare but occurs at a higher prevalence (0.6-5%) in patients with mitral stenosis than in the general population.2 cardiovocal syndrome usually resolves if detected early and the underlying cardiovascular etiology is corrected or treated. we report two cases of the syndrome: one is due to an aortic saccular aneurysm and the other due to severe mitral stenosis. case reports case 1 a 51-year-old malay male with a history of end stage renal failure secondary to hypertension was admitted to the hospital for aspiration pneumonia. he had been having bouts of cough for four months associated with progressive hoarseness and worsening of choking and coughing on swallowing liquid. on examination, the patient was comfortable at rest. he had no stridor or respiratory distress but had hoarseness. there was no palpable cervical lymphadenopathy. hoarseness due to cardiovascular disease: two cases of cardiovocal syndrome khairullah anuar, mbchb1 marina mat baki, md, msurg (orl-hns)1 abdullah sani, md, msurg (orl-hns)1 primuharsa putra sabir husin athar, md, msurg (orl-hns)2 1department of otorhinolaryngology head and neck surgery universiti kebangsaan malaysia medical center cheras, kuala lumpur, malaysia 2ear, nose & throat-head & neck consultant clinic kpj seremban specialist hospital, seremban, negeri sembilan, malaysia correspondence: dr. primuharsa putra sabir husin athar consultant ent-head & neck surgeon kpj seremban specialist hospital jalan toman 1, kemayan square, 70200 seremban, negeri sembilan malaysia fax : (606) 765 3406 e-mail : putrani@yahoo.co.uk the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the 30th mso-hns annual general meeting & second malaysian international otorhinolaryngology head & neck conference, nexus resort & spa, karambunai, kota kinabalu, sabah, malaysia, 3-5 june 2010. philipp j otolaryngol head neck surg 2011; 26 (2): 31-33 c philippine society of otolaryngology – head and neck surgery, inc. 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports a rigid indirect 70°-laryngoscopy showed left vocal cord palsy with a phonatory gap. no other lesions were seen in the larynx. bibasilar crepitations were present over the lungs. a ct scan showed a saccular aneurysm just distal to the origin of the left subclavian artery, pushing the trachea to the right. this aneurysm measured 6.74 cm in diameter. (figure1) flexible endoscopic evaluation of swallowing (fees) showed a delayed swallowing response triggered at the base of tongue. laryngeal sensation and pharyngeal contraction were also reduced. the thickened liquids given during the fees were cleared only after a third swallow. the patient was placed on an oral diet with thickened liquids and advised on techniques for safer swallowing. the clinical diagnosis was left unilateral vocal cord palsy secondary to saccular aneurysm. he was referred to cardiothoracic surgery and underwent an elective aneurysmectomy. post-operatively, the patient was well but the hoarseness persisted. he was advised to follow-up six months later but was not seen again. the patient’s hemoglobin was 14/1g/dl, total white cell count 12.0 103/µl and platelet count 432,103/µl. sodium was 136 mmol/l, potassium 4.4 mmol/l, blood urea was 8.6 mmol/l and serum creatinine 88 µmol/l. an electrocardiogram showed atrial fibrillation at a rate of 80/min. a chest radiograph showed mild cardiac enlargement without pleural effusion. a thoracic computed tomography (ct) scan showed left atrial enlargement with prominent pulmonary veins. echocardiography showed dilation of the left atrium and a thickened mitral valve. (figure 2) the mitral valve area was 0.6 cm2 based on the calculation from pressure half-time. left ventricular systolic function was good with an ejection fraction of 70%. a coronary angiogram showed normal coronary arteries. a diagnosis of severe mitral stenosis with heart failure was made. pre-operatively the patient was stabilized and referred for dental clearance. he then underwent surgery for mitral and aortic valve replacement. post-operatively, he recovered uneventfully. his hoarseness resolved completely after three months of speech therapy and repeat rigid laryngoscopy showed complete recovery of left vocal cord function. discussion cardiovocal syndrome is a clinical entity manifested by hoarseness caused by an impaired ability of the left recurrent laryngeal nerve to transmit impulses to laryngeal musculature because of stretching or impingement of the nerve from disease-induced changes in cardiac or great vessel anatomy. hoarseness due to paralysis of the left recurrent laryngeal nerve caused by a dilated left atrium in mitral stenosis as discussed by ortner is a subject of controversy. different authors have cited different mechanisms for the syndrome and a variety of cardiac problems can lead to paralysis of the left recurrent laryngeal nerve. these include thoracic aortic aneurysms, patent ductus arteriosus, primary pulmonary hypertension, atrial and ventricular septal defects, eisenmenger’s syndrome and recurrent pulmonary embolism.3 to understand how cardiovocal syndrome arises, one has to consider the anatomical position of the recurrent laryngeal nerve and the left atrium. on the right, the recurrent laryngeal nerve crosses around the first part of the subclavian artery and travels in the groove between the trachea and esophagus. on the left, the vagus nerve gives off the recurrent laryngeal nerve at the aortic arch. this nerve hooks around the lateral aspect of the ligamentum arteriosum, passes up the right side of the aortic arch and ascends in the groove between the esophagus and trachea. the lengthy course of the recurrent laryngeal nerve in the thoracic cavity especially around the aortic arch makes it vulnerable to compression, traction and erosion by enlarged or displaced cardiac chambers, dilated pulmonary arteries and a dilated aorta.4,5 contrary to its name, the left atrium does not lie on the left side but forms the most posterior chamber of the heart. it is closely related to the esophagus, spine, left recurrent laryngeal nerve, pulmonary vessels, lung parenchyma and bronchi. therefore, when the left atrium enlarges, it figure 1. transverse computed tomographic scan of the chest showing aortic aneurysm (aa). case 2 a 44-year-old malay man presented with a 4-day history of hoarseness, shortness of breath and symptoms of mild orthopnea and aspiration. he denied any history of dysphagia, chronic cough, sore throat, chest pain, palpitations or decreased tolerance of exertion. he had no history of hypertension, diabetes, asthma or recurrent fever with sore throat during childhood. on examination, the patient appeared well. his blood pressure was 100/60 mm hg and his pulse was irregular with a rate of 78/min. he had no peripheral edema, cyanosis or clubbing. the head and neck examinations were normal. cardiovascular examination revealed no displacement of the apex beat. on auscultation, the first heart sound was loud and a grade 3/6 long rumbling diastolic murmur was heard in the mitral area. bilateral basal crepitations were heard over the lungs. a rigid indirect laryngoscopy using a 70°-laryngoscope showed left vocal cord palsy with the cord in the paramedian position and a phonatory gap. philippine journal of otolaryngology-head and neck surgery 33 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports references 1. ortner ni. recurrenslähmung bei mitralstenose. [article in german] wien klin wochenschr. 1897;10:753-5. 2. solanki sv, yajnik vh. ortner’s syndrome. indian heart j. 1972 jan; 24(1): 43-6. 3. sengupta a, dubey sp, chaudhuri d, sinha ak, chakravarti p. ortner’s syndrome revisited. j laryngol otol. 1998 apr; 112: 377-9. 4. thirlwall as. ortner’s syndrome: a centenary review of unilateral recurrent laryngeal nerve palsy secondary to cardiothoracic disease. j laryngol otol. 1997 sept;111:869-71. 5. mulpuru sk, vasavada bc, punukollu gk, patel ag. cardiovocal syndrome: a systematic review. heart lung cir. 2008 feb;17(1): 1-4. 6. phua gc, eng pc, lim sl, chua yl. beyond ortners’s syndrome-unusual pulmonary complications of the giant left atrium. ann acad med singapore. 2005 nov; 34 (10): 642-5. 7. lee si, pyun sb, jang dh. dysphagia and hoarseness associated with painless aortic dissection: a rare case of cardiovocal syndrome. dysphagia. 2006 apr; 21(2):129-32. 8. loughran s, alves c, macgregor fb. current aetiology of unilateral vocal fold paralysis in teaching hospital in the west of scotland. j laryngol otol. 2002 nov; 116(11): 907–10. 9. de bakey me, mccollum ch, graham jm. surgical treatment of aneuryms of descending thoracic aorta: long-term result in 500 patients. j cardiovasc surg (torino).1978 nov-dec;19(6): 571-6. 10. teixido mt, leonetti jp. recurrent laryngeal nerve paralysis associated with thoracic aortic aneurysm.otolaryngol head neck surg. 1990 feb;102(2): 140-4. 11. bower tc, pairolero pc, hallett jw jr, toomey bj, gloviczki p, cherry kj jr. brachiocephalic aneurysm: the case for early recognition and repair. ann vasc surg.1991 mar; 5(2): 125-32. causes complications by compressing these adjacent structures.6 most authors believe that pressure in the pulmonary artery causes the nerve compression. however, the dilated left atrium found in mitral stenosis or patent ductus arteriosus may compress the vagus nerve.7 cardiovascular pathology is a rare cause of left vocal cord palsy. the incidence of mitral stenosis causing this syndrome ranges from 0.6 to 5% .8 de bakey et al. reported that 8.6% of their patients complained of hoarseness caused by stretching or compression of left recurrent laryngeal nerve, 9 leonetti reported that 8 of 168 patients (4.8%) with thoracic aortic aneurysms (taa) presented with hoarseness and all of these had type i aneurysms (de bakey classification) involving the ascending root and aortic arch.10 the treatment of and prognosis for this syndrome depends on the possibilities of managing the underlying cause. if detected early, the syndrome is usually reversible. both of our patients required surgical intervention. patients who can tolerate mitral valve surgery have a good chance of recovering the voice as a result of the reduction in pulmonary artery pressure as shown in our second case. early surgical treatment for all symptomatic and asymptomatic aneurysms has been recommended to avoid complications such as thrombosis, rupture, dissection or peripheral embolization. 11 the treatment of unilateral vocal cord palsies (uvcp) depends on the degree of vocal cord paralysis and whether the opposite, normal side can compensate for this atrophy. early rehabilitation is essential. it is not necessary to perform any additional surgical procedures on the vocal folds if the patient shows sufficient improvement during speech therapy as shown in our second case. definitive treatment should be considered if aspiration is severe or if no improvement is visible after alleviation of the cardiac problem,7 depending on the patient’s need for better vocalization for occupational or social reasons.5 patients with underlying lung disease, a high risk of aspiration or persistent symptoms after one year should also be considered for surgery. studies have found that uvcp increases the risk of aspiration by impairing various airway protection mechanisms such as laryngeal elevation, epiglottic tilting, closure of both the true and false vocal cords and effective coughing. previous studies reported that 40% of patients with uvcp had symptoms of aspiration and 50% had laryngeal penetration of aspiration .7 various surgical options are available to medialize the paralyzed vocal cord. the options range from thyroplasty to injection augmentation or injection laryngoplasty. cardiovocal syndrome is rare in the general population but associated with causes such as aneurysms and mitral valve stenosis. a high index of suspicion is needed to make an early diagnosis which can lead to surgical correction of the potentially life-threatening, underlying cardiovascular disease. following such treatment, the cardiovocal syndrome usually resolves spontaneously as vocal cord function returns, often without a need for additional invasive treatment. figure 2. (a) transthoracic echocardiography showing a huge left atrium. la indicates left atrium; lv, left ventricle; and ao, aorta. (b) transverse computed tomographic scan of the chest showing left atrial enlargement. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 38 philippine journal of otolaryngology-head and neck surgery under the microscope abstract eight cases of primary thyroid lymphoma were reported in a tertiary government hospital from january 2005 to august 2011. all patients presented with a diffuse enlargement of both thyroid lobes with associated obstructive symptoms. five of these cases were extranodal marginal zone lymphoma and three were diffuse large b-cell lymphoma. clinical features that would favor a thyroid lymphoma include tumor size of greater than 7 cm, obstructive symptoms, clinical hypothyroidism or history of hashimoto thyroiditis. thus, these features must be considered in evaluating thyroid nodules during fine-needle aspiration biopsy. histologically, extranodal marginal zone b-cell lymphoma shows vaguely nodular to diffuse infiltrates of small to intermediate size atypical lymphoid cells infiltrating the thyroid follicles while diffuse large b-cell lymphoma shows sheets of large atypical lymphoid cells infiltrating the thyroid follicular epithelium. keywords: primary thyroid lymphoma, extranodal marginal zone b-cell lymphoma, diffuse large b-cell lymphoma primary thyroid lymphoma is a rare neoplasm that comprises 1-5% of all thyroid malignancy and 1-7% of all extranodal lymphomas.1-4 it usually occurs in older individuals with a mean age of 65.1-2 it is more common in females with a ratio of 3-6:1.1,4 a total of eight patients were diagnosed to have a primary thyroid lymphoma among 1,008 malignant thyroidectomy specimens seen by our department from january 2005 to august 2011 with an incidence rate of 0.8% of all thyroid malignancies in our institution. we review these cases. cases there was one male and seven females with a ratio of 1:7. their ages ranged from 37-86 years old with a median age of 56 years. of the eight patients, only five had available clinical data. all five had a 1-3 year history of diffuse anterior neck mass and all had obstructive symptoms such as dyspnea and dysphagia. one patient each had weight loss and regional lymph node enlargement. pre-operative thyroid function tests of 4/5 patients revealed hypothyroidism in one while three were euthyroid. primary thyroid lymphoma correspondence: dr. claudine ann musngi-paras department of pathology college of medicine university of the philippines manila 547 pedro gil st., ermita, manila 1000 philippines phone (632) 526 4450 fax (632) 400 3638 email: claudineparas@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the case report poster contest (finalist), philippine society of pathologists annual convention, dusit hotel, makati city, philippines, april 26-28, 2012. philipp j otolaryngol head neck surg 2012; 27 (1): 38-40 c philippine society of otolaryngology – head and neck surgery, inc. claudine ann musngi-paras, md1 ansarie p. salpin, md1 januario d. veloso, md1, 2 1department of laboratories philippine general hospital university of the philippines manila 2department of pathology college of medicine university of the philippines manila philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 philippine journal of otolaryngology-head and neck surgery 39 under the microscope macroscopic examinations of all eight thyroidectomy specimens showed diffuse enlargement of both thyroid lobes with sizes ranging from 11 to 15 cm in widest diameter. histopathologic diagnosis revealed diffuse large b-cell lymphoma (figure 1, a-d) in three patients and extranodal marginal zone b-cell lymphoma in five patients. (figure 2, a-e) immunohistochemical staining with cd3, cd5 and cd20 confirmed the diagnosis. of patients younger than 60 years old, comparable with the previous study done in the philippines. the tumor size is usually large at the time of diagnosis between 8-14 cm according to the previous philippine study between 11-15 cm in our series and between 2-15 cm with a median size of 7 cm in other studies.3,7 due to the rapid growth of the tumor, compression of the adjacent organs causes obstructive symptoms such as dyspnea and dysphagia. derringer et al. reviewed 108 cases of primary thyroid lymphoma with 72% having obstructive symptoms.7 hypothyroidism is seen in up to 67% of cases of primary thyroid lymphoma.3 a history of hashimoto thyroiditis has a relative risk of figure 1. diffuse large b-cell lymphoma. a. h and e stain shows large atypical lymphocytes infiltrating the thyroid follicles (10x). b. large atypical lymphocytes (40x). figure 2. a. extranodal marginal zone b-cell lymphoma (10x). there were nodular and diffuse proliferation of small to medium size lymphocytes infiltrating the thyroid follicle. in here, we can also appreciate the remnants of hashimoto thyroiditis characterized by oncocytic changes of the follicular cells (arrow). figure 2. b. extranodal marginal zone b-cell lymphoma (40x). lymphoepithelial lesion showing neoplastic cells within the follicle (arrow). figure 1. c,d. immunohistochemical staining showed diffuse and strong cytoplasmic membrane staining for cd20 and negative for cd3. a b thyroid follicles (h & e stain lymphocytes infiltrating the thyroid follicles (10x) large atypical lymphocytes (40x) cd 20 cd 3 discussion the clinical features that would favour primary thyroid lymphoma include women in the sixth decade, a history of hashimoto thyroiditis and rapid growth of a firm diffuse thyroid mass.1,2,6 a study in the philippines (1994-1998) showed a lower mean age than foreign data with 55% of cases occurring in the less than 60-year-olds (range= 49-69 years) with a male to female ratio of 1:1.25.6 the present series had 60% extranodal marginal zone b-cell lymphoma (10x). extranodal marginal zone b-cell lymphoma (40x) c d philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 under the microscope 40 philippine journal of otolaryngology-head and neck surgery references abbondanzo s, aozasa k, boerner s, thompson ldr. primary lymphoma and plasmacytoma. 1. in: delellis ra, lloyd rv, heitz pu, eng c, editors. world health organization classification of tumours: tumours of endocrine organs. lyon (france): iarc press; 2004. p. 109-110 niitsu n, okamoto m, nakamura n, nakamine h, bessho m, hirano m. clinicopathologic 2. correlations of stage ie/iie primary thyroid diffuse large b-cell lymphoma. ann oncol. 2007 jul; 18(7): 1203-8. thieblemont c, mayer a, dumontet c, barbier y, callet-bauchu e, felman p, berger f, ducottet x, 3. martin c, salles g, orgiazzi j, coiffier b. primary thyroid lymphoma is a heterogenous disease. j clin endocrinol metab. 2002 jan; 87(1): 105-11. ansell sm, grant cs, habermann tm. primary thyroid lymphoma. 4. semin oncol. 1999 jun;26(3):316-23. pasieka jl. anaplastic cancer, lymphoma, and metastases of the thyroid gland. 5. surg oncol clin n am. 1998 oct;7(4):707-720. liwag aa, sedurante mb. a case of primary thyroid lymphoma seen at the university of the 6. philippines-philippine general hospital. philipp j int med. 2004 jan-feb; 42(1): 45-49. derringer ga, thompson ldr, frommelt ra, bijwaard ke, heffess cs, abbondanzo sl. malignant 7. lymphoma of the thyroid gland: a clinicopathologic study of 108 cases. am j surg pathol 2000 may; 24(5):623-39. matsuzuka f, miyauchi a, katayama s, narabayashi i, ikeda h, kuma k, sugawara m. clinical 8. aspects of primary thyroid lymphoma: diagnosis and treatment based on our experience of 119 cases. thyroid. 1993 summer ; 3(2): 93-9. das dk, gupta sk, francis im, ahmed, ms. fine needle aspiration cytology diagnosis of non-9. hodgkin lymphoma of thyroid: a report of four cases. diagn cytopathol 1993 dec; 9(6.): 639-45. klyachkin ml, schwartz rw, cibull m, munn rk, regine wf, kenady de, et al. thyroid lymphoma: 10. is there a role for surgery? am surg 1998 mar; 64(3): 234-8. up to 80x compared to the general population in developing primary thyroid lymphoma.4 extranodal marginal zone b-cell lymphoma is the morphologic variant associated with hashimoto thyroiditis. in our series, only one patient was hypothyroid out of four for whom clinical data was available. fine needle aspiration has become the procedure of choice for the initial pathological diagnosis of thyroid nodules. in one series, a correct diagnosis with fnab was made in 70-80% of patients with thyroid lymphoma,8 but in others, fnab was suggestive but not diagnostic in only 50-60% of patients.9-10 in the present series, only one out of five cases of ptl was correctly diagnosed by fnab. data was not available for the three other cases. the sensitivity of fnab in the diagnosis of primary thyroid lymphoma in our institution is lower compared to the foreign literature. ancillary procedures such as immunohistochemical staining and molecular genetic testing can increase diagnostic accuracy, especially in cases of extranodal marginal zone b-cell lymphoma since it resembles a reactive lymph node in cytology specimens. cytologically, diffuse large b-cell lymphoma shows a cellular aspirate which consists of large atypical lymphoid cells (2-3x larger than mature small lymphocyte) with scattered small cytoplasmic fragments of lymphocytes in the background. there are scanty to absent follicular cells. extranodal marginal zone b-cell lymphoma shows cellular aspirate which consists of small to intermediate-size lymphoid cells. some cells show abundant, pale cytoplasm (monocytoid appearance). this cytologic features overlap with chronic lymphocytic thyroiditis. however, the absence of tangible body macrophages, activated follicle-center cells and spectrum of lymphocytes in all stages of maturation favor extranodal marginal zone b-cell lymphoma. immunophenotyping is often required to aid in the definitive diagnosis. clinical features that would favor a thyroid lymphoma include tumor size of greater than 7 cm, obstructive symptoms, clinical hypothyroidism or a history of hashimoto thyroiditis. thus, these features must be considered in evaluating thyroid nodules during fnab. immunohistochemistry and molecular techniques can be used as adjunct in these cases when cytology specimens are equivocal for lymphoid malignancy. cd 20 cd 3 cd 5 figure 2, c-e. extranodal marginal zone b-cell lymphoma. diffuse and strong cytoplasmic membrane expression of cd20 (20x). negative for cd3 (10x). negative for cd5 (10x). diffuse and strong cytoplasmic membrane expression of cd20 (20x) negative for cd3 (10x) negative for cd5 (10x) c d e philippine journal of otolaryngology-head and neck surgery 43 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports philipp j otolaryngol head neck surg 2015; 30 (2): 43-46 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to report the possible malignant transformation of primary sinonasal ameloblastoma into sinonasal ameloblastic carcinoma. methods: design: case report setting: tertiary public university hospital patient: one result: a 50-year-old woman with a previous diagnosis of sinonasal ameloblastoma reported recurrence of symptoms of right-sided nasal obstruction and epistaxis two years after endoscopic sinus surgery. clinical examination, ct scans and subsequent total maxillectomy with orbital exenteration revealed a left intranasal mass with maxillary, ethmoid and orbital floor extension and pulmonary and hepatic metastases. histopathologic findings of palisading columnar epithelium with reverse polarity with malignant features were consistent with ameloblastic carcinoma. despite subsequent cycles of chemotherapy, the patient died two years after surgery. to the best of our knowledge, there have been no published reports of a primary sinonasal ameloblastoma with malignant transformation in the english literature. conclusion: ameloblastic carcinoma is a rare neoplasm which may arise de novo or from malignant transformation of an ameloblastoma. because ameloblastoma is commonly encountered in our setting, clinicians should be aware of this possibility and closely follow their patients accordingly. keywords: sinonasal, maxillary, ameloblastic carcinoma, malignant transformation an endoscopically excised exophytic papilloma turned out to be a primary sinonasal ameloblastoma for which “no deaths, metastases and malignant transformation has been reported.”1 unaware that she was the subject of this prior publication, we encountered the same patient with recurrence of symptoms of right-sided nasal obstruction and epistaxis two years later. unfortunately, we now have to report possible malignant transformation, metastasis and death. here is her continuing story. sinonasal ameloblastic carcinoma in a 50-year-old filipino female: continuing tale of the unexpected daryl anne a. del mundo, md department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: dr. daryl anne a. del mundo department of otorhinolaryngology ward 10 philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 554 8467 email: darylannedelmundo@gmail.com reprints will not be available from the author the author declares that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, and that the manuscript represents honest work. disclosures: the author signed a statement that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest in the writing of this manuscript. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports 44 philippine journal of otolaryngology-head and neck surgery case report a 50-year-old woman initially presented at the age of 46 in july 2009 with recurrent right-sided nasal obstruction and ipsilateral “spontaneous epistaxis”, “thin brown” rhinorrhea and frontonasal throbbing headache.1 examination then revealed a “pale, pink irregularly shaped polypoid mass attached to the lateral nasal wall almost completely obstructing the nasal cavity.”1 plain paranasal sinus ct scans “showed opacification of the right nasal chamber by soft tissue densities with obstruction of the ipsilateral ostiomeatal unit and sphenoethmoidal recess.”1 (figure 1) an intranasal biopsy obtained an aggregate of 2.5 cm soft, friable, fleshy tissue that was histopathologically diagnosed as “sinonasal exophytic papilloma.”1 heterogeneously enhancing soft tissue component filling the right nasal antrum, maxillary, ethmoid and sphenoid sinuses and obstructing the ostiomeatal unit. (figure 3) histopathology of an intranasal punch biopsy specimen revealed odontogenic carcinoma. figure 1. pre-operative paranasal sinus screening ct scan, 2010, representative coronal cut (a similar figure has been previously published in this journal).1 figure 3. contrast-enhanced paranasal sinus ct scan, 2013, representative coronal cut, taken after recurrence of symptoms two years after endoscopic sinus surgery. endoscopic sinus surgery was performed in july 2010. the mass was followed up to the lateral nasal wall, the uncinate process was opened and a cuff of normal tissue was excised around the root of the papilloma. there were no remnant masses noted in the maxillary sinus, anterior ethmoids and frontal sinus (which only contained mucus). histopathologic diagnosis was extragnathic soft tissue ameloblastoma1 with positive tumor tissue in the specimen labelled “ethmoid.” (figure 2) despite being advised on the possibility of recurrence and importance of regular monitoring, the patient only followed up for a month. unilateral, right-sided epistaxis recurred 2 years later in october 2012 and by december that year, she experienced right-sided gradually worsening nasal obstruction with occasional difficulty of breathing. she finally consulted in march 2013 with a fleshy mass in the right nostril. paranasal sinus ct scan revealed an expansile lytic lesion with osseous matrix and sunburst periostitis involving the medial wall of the right maxillary sinus extending superiorly to involve the anterior portion of the inferior orbital wall and anteriorly to involve the medial portion of the anterior maxillary wall and nasolacrimal duct opening; with a figure 2. histopathology, s/p endoscopic sinus surgery, july 2010, hematoxylin-eosin, 10x, showing interconnecting trabecula and islands of benign odontogenic epithelium in an edematous, myxoid, hypocellular stroma. inset (hematoxylin-eosin 40x): an epithelial island showing peripheral palisading columnar or cuboidal cells with reverse polarity consistent with ameloblastoma (a similar figure has been previously published in this journal).1 (hematoxylin and eosin, 10x) (hematoxylin and eosin, 40x) the patient underwent total maxillectomy with right orbital exenteration and prosthetic reconstruction under general anesthesia in july 2013. intraoperative tumor extension to the anterior maxillary wall, orbital floor and beyond the orbital periosteum was seen. (figure 4) histopathologic diagnosis was “odontogenic carcinoma consistent with ameloblastic carcinoma, maxilla, 5 cm in greatest dimension (specimen consists of a right maxilla with mass and scanty soft tissue measuring 7 x 5 x 2 cm, with the irregularly shaped mass measuring 5 x 3 x 3 cm in the center of the bone); positive for tumor at its superior philippine journal of otolaryngology-head and neck surgery 45 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports and inferior margins; also positive for tumor in the specimen labeled ‘ethmoid’ (consists of a 2 x 1.5 x 0.3cm soft to rubbery, tan brown, irregularly-shaped tissue fragment) and ‘inferior orbital wall’ (consists of brown, gritty, irregularly-shaped tissue fragments with an aggregate diameter of 1 cm).” (figure 5a-c) discussion we only learned that our patient was the same woman described in the previous report1 while reviewing the literature for this paper. the initial diagnosis of exophytic papilloma and subsequent postoperative histopathologic diagnosis of extragnathic soft tissue ameloblastoma with possible malignant transformation to sinonasal ameloblastic carcinoma, metastasis and death need to be reported and the literature reviewed. ameloblastic carcinoma designates lesions that exhibit histologic features of both ameloblastoma and carcinoma with or without metastasis. as shown in the representative slides of the patient, while the classic stellate reticulum-like interior of the enamel organ consistent with ameloblastoma is not as obvious (figure 5a), features of malignancy including variability of nuclear staining, prominent nucleoli and mitoses were demonstrated (figure 5b). the peripheral layer of palisading columnar or cuboidal cells with hyperchromatic small nuclei oriented away from the basement membrane— so called reverse polarity can also be seen. (figure 5c). a b c figure 4. intra-operative photos, 2013, showing extensions a. to the anterior maxillary wall (arrow), b. beyond orbital floor and periosteum (arrow), and c. to the ethmoids (arrow). figure 6. contrast-enhanced ct scan, representative axial cuts, 2013 october, showing a. multiple bilateral pulmonary nodules, and b. a hypodense liver focus. figure 5. final histopathology, ameloblastic carcinoma. a. hematoxylin-eosin, low power showing epithelial islands and trabecula and a myxoid stroma b. hematoxylin-eosin, 40x, an area showing malignant features including variability of nuclear staining, prominent nucleoli, and mitoses; c. hematoxylin-eosin, 40x, an area showing palisading columnar epithelium with reverse polarity consistent with ameloblastoma. (hematoxylin and eosin) (hematoxylin and eosin, 40x) (hematoxylin and eosin, 40x) a c b further surgery was performed in october 2013 to address the positive margins. intra-operatively, tumor in the superior ethmoid area was positive for ameloblastic carcinoma on frozen section. bare bone excision was attempted with tumor noted in the area of the cribriform plate. ct scans revealed pulmonary (figure 6a) and hepatic (figure 6b) metastases, and several cycles of chemotherapy were administered. the patient died after two years of treatment. a b philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports 46 philippine journal of otolaryngology-head and neck surgery acknowledgements i would like to thank my advisers, drs. anna pamela dela cruz and ramon lopa, and drs. ryner jose carrillo and jose florencio lapeña for their guidance in conceptualizing the interesting case and writing the manuscript; dr. cesar villafuerte iii who handled the case with me; drs. mark angelo ang and jenny atun from the department of pathology; and all the consultants of the department of otorhinolaryngology, philippine general hospital for their comments during the interesting case presentation at the department. references 1. ang ma, vergel de dios am, carnate jm. primary sinonasal ameloblastoma in a filipino female. philipp j otolaryngol head neck surg. 2011 jul–dec; 26(2):39-41. 2. kruse ald, zwahlen ra, grätz kw. new classification of maxillary ameloblastic carcinoma based on an evidence-based literature review over the last 60 years. head neck oncol. 2009 aug; 1: 31. doi: 10.1186/1758-3284-1-31. 3. perumal c. ameloblastic carcinoma of the maxilla with extension into the ethmoidal air cells and close proximity to the anterior skull base: a rare case presentation. craniomaxillofac trauma reconstr. 2012 sep; 5(3): 169–174. 4. bedi rs, chugh a, pasricha n. ameloblastic carcinoma of maxilla. natl j maxillofac surg. 2012 jan-jun; 3(1): 70–74. doi: 10.4103/0975-5950.102169. 5. martinez s, schmidt r, moses r, loggi d, puzzi j, malhotra r, et al. unusual otolaryngologic presentations of ameloblastoma. otolaryngol head neck surg. 1999 sep;121(3):285-289. 6. baker b, matukas v. ameloblastoma presenting as an intranasal mass. laryngoscope. 1977 aug; 87(8):1369-1372. doi: 10.1288/00005537-197708000-00015. 7. morrison ej, wei bpc, galloway s, de alwis n, lyons b, baker t. a rare case of sinonasal ameloblastoma presenting with complete nasal obstruction. anz j surg. 2011 dec; 81(12): 931–932. doi: 10.1111/j.1445-2197.2011.05904.x 8. kwartler ja, labagnara j jr., mirani n. ameloblastoma presenting as a unilateral nasal obstruction. j oral maxillofac med oral pathol 1972 april; 34(4):95–7. 9. terada t. malignant transformation of exophytic schneiderian papilloma of the nasal cavity. pathol int. 2012 mar; 62(3):199-203. 10. terada t. malignant transformation of exophytic schneiderian papilloma of the nasal cavity. pathol int. 2012 mar; 62(3):199-203. 11. schafer dr, thompson ldr, smith bc, wenig bm. primary ameloblastoma of the sinonasal tract. cancer 1998 feb; 82(4):667-674. 12. karakida k, aoki t, sakamoto h, takahashi m, akamatsu t, ogura g, sekido y, ota y. ameloblastic carcinoma, secondary type: a case report. oral surg oral med oral pathol oral radiol endod. 2010 dec; 110(6):e33-7. doi: 10.1016/j.tripleo.2010.08.018. 13. ram h, mohammad s, husain n, gupta pn. ameloblastic carcinoma. j maxillofac oral surg. 2010 dec;9(4):415-9. doi: 10.1007/s12663-010-0169-6. epub 2011 mar 17. 14. avon s, mccomb j, clokie c. ameloblastic case report and literature review. j can dent assoc. 2003 oct 69(9):573–6. 15. akrish s, buchner a, shoshani y, vered m, dayan d. ameloblastic carcinoma: report of a new case, literature review, and comparison to ameloblastoma. j oral maxillofac surg. 2007 apr; 65(4):777–783. 16. benlyazid a, lacroix-triki m, aziza r, gomez-brouchet a, guichard m, sarini j. ameloblastic carcinoma of the maxilla: case report and review of the literature. oral surg oral med oral pathol oral radiol endod. 2007 dec;104(6):e17-24. epub 2007 oct. swelling of the involved site is the primary clinical manifestation of maxillary involvement of an ameloblastic carcinoma.2-4 our patient unusually presented with an intranasal mass, right-sided nasal obstruction and epistaxis but not swelling. although reports of nasal obstruction pertain to ameloblastoma rather than maxillary ameloblastoma,5,6 there are reports of sinonasal ameloblastoma presenting with complete nasal obstruction.7,8 indeed, an uncommon neoplasm such as ameloblastic carcinoma may present unusually and mimic more common disease processes or a benign counterpart. the relationship between the histopathologic diagnoses from exophytic papilloma to extragnathic soft tissue ameloblastoma may be explained by the ectodermally-derived ciliated respiratory mucosa that lines the nasal cavity and paranasal sinuses, called the schneiderian membrane which may give rise to schneiderian papillomas—exophytic papillomas being one morphological type.9,10 ameloblastomatous epithelial proliferations are also often seen in continuity with native sinonasal schneiderian epithelium.6,9,10 the largest comprehensive study of primary sinonasal ameloblastoma by schafer et al. reported no malignant transformation published in the literature11 and only one case report by karakida, et al. subsequently discussed a secondary type which may have arisen from an untreated ameloblastoma of the maxilla.12 to the best of our knowledge, no published reports of a primary sinonasal ameloblastoma with malignant transformation are available in the english literature and this may be the first reported death from a sinonasal ameloblastic carcinoma two years after diagnosis. the advanced disease of our patient manifested by tumor in the area of the cribriform plate and possible pulmonary and hepatic metastases contributed to the difficulty in management. after total maxillectomy with orbital extenteration, subsequent cycles of chemotherapy were given despite the limited available data for the best treatment option.13-16 this case has demonstrated that malignant transformation and death previously unreported for ameloblastoma of the maxilla is possible. ameloblastic carcinoma is a rare neoplasm that may arise de novo or from malignant transformation of an ameloblastoma. because ameloblastoma is commonly encountered in our setting, clinicians should be aware of this possibility and closely follow their patients accordingly. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports philippine journal of otolaryngology-head and neck surgery 39 philipp j otolaryngol head neck surg 2015; 30 (1):39-42 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to present a case of type 1 glomus tympanicum, its clinical presentations, surgical management and outcome. methods: design: case report setting: tertiary government hospital patient: one results: a 44-year-old woman with pulsatile tinnitus, vertigo, headache, ear fullness and decreased hearing on the right had a pulsatile reddish mass behind the tympanic membrane and brown sign. weber test lateralized to the right with mild conductive hearing loss on pure tone audiometry. contrast ct scan demonstrated a 5x6 mm welldefined enhancing mass in the mesoand hypotympanum. internal auditory canal mri showed an avidly enhancing 5x3x4 mm nodule within the right middle ear adjacent to the cochlear promontory and anterior to the lateral semicircular canal. impression was glomus tympanicum, type 1. the mass was excised via transcanal approach with postoperative resolution of tinnitus, headache, vertigo and improvement of hearing. final histopathology was consistent with glomus tumor. conclusion: glomus tympanicum tumors are rare, benign middle ear paragangliomas that arise from jacobson’s nerve are slow-growing and locally destructive. ct scan and mri may detect involvement of other structures. surgical resection is the primary treatment modality. type 1 glomus tympanicum tumors are small and limited to the promontory and a less-invasive transcanal approach may be employed. keywords: glomus, tympanicum, paraganglioma, transcanal approach glomus tympanicum tumors are middle ear paragangliomas that arise from jacobson’s nerve. these are tumors of middle age, found two to five times more frequently in women than in men.1 they are benign, slow growing tumors which are locally destructive.2 glomus tumors are rare with an estimated annual incidence of one case per 1.3 million people.3 patients with these tumors present with pulsatile tinnitus and hearing loss. this case report will discuss a 44-yearold woman with glomus tympanicum type 1, highlight its manifestations, imaging, management and histopathologic correlates. transcanal resection of a type 1 glomus tympanicum anna carlissa p. arriola, mdthanh vu t. de guzman, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. anna carlissa p. arriola department of otorhinolaryngology head and neck surgery 4th floor, jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 743 6921 ; (632) 711 9491 local 320 email: carlyarriola@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each authorbelieves that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectualpassion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery, free paper presentation, sofitel philippine plaza, ccp complex roxas boulevard, pasay city, december 3, 2013. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports 40 philippine journal of otolaryngology-head and neck surgery case report a 44-year-old woman came to our outpatient department complaining of pulsatile tinnitus. four months prior to consult, she started to have occasional pulsatile tinnitus on the right ear, the longest episode lasting 15 minutes. this was accompanied by vertigo described as movement of surroundings, lasting about 30 minutes which would spontaneously resolve. she noted the tinnitus to be accompanied by ipsilateral headache and right ear fullness. headache was described as squeezing in character. three months prior to consult, she noted decreased hearing of about 10% on the right. she had hypertension with highest blood pressure of 150/90 and took losartan as maintenance medication. on review of systems, there were no palpitations, anxiety, diaphoresis, weight loss or flank pain. on otoscopy, a pulsatile reddish mass was seen behind the tympanic membrane and brown sign was elicited. (figure 1) weber test lateralized to the right ear where pure tone audiometry detected a mild conductive hearing loss with average of 30 db. cranial nerve vii was intact. blood pressure taken in supine and upright positions showed no significant difference. the systemic examination was normal. our clinical impression was glomus tympanicum tumor. contrast-enhanced temporal bone ct (figures 2 and 3) demonstrated a 5x6 mm well-defined enhancing mass in the meso and hypotympanum which slightly bulged the tympanic membrane. the ossicles were intact and there was no evidence of bony erosion. the vestibule, cochlea and semicircular canals had normal configuration. the carotid canal was intact and no high riding jugular vein or dehiscence was noted. no abnormalities were seen along course of the facial nerve canal. magnetic resonance imaging of the internal auditory canal (figures 4 and 5) showed an avidly enhancing nodule within the right middle ear measuring 5x3x4 mm in ap, transverse and craniocaudal dimensions. the nodule was adjacent to the cochlear promontory and anterior to the lateral semicircular canal. the seventh and eighth nerve complexes were normal. the cerebellopontine angles were unremarkable. the patient underwent excision of the glomus tumor via a transcanal approach. elevation of the tympanic membrane flap revealed a smooth, ovoid pinkish mass that covered approximately 50% of the middle ear. (figure 6) the malleus, a portion of the incus and stapes and round window were still visible. the mass was bluntly dissected from the promontory. (figure 7) bleeding was controlled with epinephrinesoaked gelfoam. the flap was returned to its original position and the ear was packed with gelfoam and ofloxacin otic drops. after the operation, the patient noted absence of tinnitus, headache and vertigo and improvement of hearing. histopathologic examination showed small figure 1. pulsatile reddish mass behind the tympanic membrane figure 2. contrast enhanced temporal bone ct scan, axial view, at the level of the external auditory canal, showing enhancing mass in the right middle ear. figure 3. contrast enhanced temporal bone ct scan, coronal view, at the level of the external auditory canal, showing enhancing mass in the right meso and hypotympanum. round cells infiltrating the entire stroma on low-power magnification, with prominent nuclei and eosinophilic cytoplasm on high-power magnification. (figure 8) final histopathology was consistent with glomus tumor. philippine journal of otolaryngology-head and neck surgery 41 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports discussion paragangliomas are benign, slow growing tumors that arise from neuroectodermal tissues. cervical paragangliomas and temporal bone (jugulotympanic) paragangliomas comprise paragangliomas of the head and neck. 2 paraganglia of the temporal bone are usually found in the mesotympanum and accompanying the inferior tympanic branch of the glossopharyngeal nerve.4 they serve as baroreceptors that sense and regulate oxygen pressure in the middle ear and mastoid cavity.5 these are well-vascularised lesions usually supplied by the inferior tympanic branch of the ascending pharyngeal artery. paraganglions are composed of type i (zellballen) chief cells which are clusters of neural crest origin and are components of the diffuse neuroendocrine system, and type ii or sustentacular cells (modified schwann cells), intimately figure 5. gadolinium-dtpa enhanced t1-weighted internal auditory canal mri, axial view, showing enhancing nodule in the right middle ear. figure 8. hematoxylin and eosin (40x) round cells with eosinophilic cytoplasm surrounding blood vessels. (hematoxylin and eosin, 40x) figure 4. gadolinium-dtpa enhanced t1-weighted internal auditory canal mri, coronal view, showing enhancing nodule in the right middle ear. figure 6. pinkish ovoid mass in transcanal view figure 7. excised glomus philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports 42 philippine journal of otolaryngology-head and neck surgery references 1. barnes l, peel rl, verbin rs.tumors of the nervous system. in: barnes l, ed. surgical pathology of the head and neck. new york, ny: marcel dekker; 1985. p. 659 –724. 2. o’leary mj, shelton c, giddings na, kwartler j, brackmann de. glomus tympanicum tumours: a clinical perspective. laryngoscope. 1991 oct; 101(10): 1038-43. 3. moffat da, hardy dg. surgical management of large glomus jugulare tumours: infraand transtemporal approach. j laryngol otol. 1989 dec; 103(12):1167-80. 4. rohit jain y, caruso a, russo a, sanna m. glomus tympanicum tumour: an alternative surgical technique. j laryngol otol. 2003 jun; 117(6):462-6. 5. manolidis s, shohet ja, jackson cg, glasscock me. malignant glomus tumours. laryngoscope. 1999 jan; 109(1):30-4. 6. glasscock me, shambaugh g. surgery for benign tumors of the temporal bone. in: surgery of the ear usa: people’s medical publishing house; 2010. p.730-739. 7. jackson cg, glasscock me, harris pf. glomus tumours: diagnosis, classification and management of large lesions. otolaryngol. 1982 jul; 08(7):401-6. 8. schwaber mk, glasscock me, jackson cg, nissen aj, smith pg. diagnosis and management of catecholamine secreting tumors. laryngoscope. 1984 aug; 94(8):1008-15. 9. noujaim se, pattekar ma. paraganglioma of the temporal bone: role of magnetic resonance imaging versus computed tomography. top magn reson imaging. 2000; 11:108-22. 10. vogl tj, mack mg, juergens m, bergman c, grevers g, jacobsen tl, et al. skull base tumours gadodiamide injection-enhanced mr imaging. radiology. 1993 aug; 188(2):339-46. 11. sen c, hague k, kacchara r, jenkins a, das s, catalano p. jugular foramen : microscopic anatomic features and implications for neural preservation with reference to glomus tumours involving the temporal bone. neurosurgery. 2001apr; 48(4): 838-47. 12. forest ja 3rd, jackson cg, mcgrew bm. long-term control of surgically treated glomus tympanicum tumours. otol neurotol. 2001 mar; 22(2):232–6. interlaced with a rich network of capillaries and venules.6 there are two commonly used classifications of glomus tympanicum tumors-oldring and fisch and glasscock and jackson’s. glasscock and jackson’s system classifies glomus tympanicum by area and degree of involvement. type 1 tumors are small and limited to the promontory, type 2 tumors completely fill the middle ear. type 3 tumors extend further into the mastoid while type 4 tumors spread into the external auditory canal and may have intracranial extension.7 in this patient, the margins were visible 360 degrees around the circumference of the mesotympanic mass which qualified as a type 1 glomus tympanicum. patients with glomus tympanicum tumor present with pulsatile tinnitus and conductive hearing loss. conductive hearing loss occurs when the tumor impairs normal vibration of the ossicles. rarely, dizziness and sensorineural hearing loss may occur if the tumor has invaded the inner ear.2 this patient presented with pulsatile tinnitus and conductive hearing loss which was consistent with a glomus tympanicum. vertigo and headache are red flags of tumor spread that may warrant further imaging. on ct and mri, the glomus has not infiltrated the labyrinths. every patient with a glomus tympanicum, except those with small type 1 glomus tumor should have serum catecholamine and urinary metabolite determination to rule out the probability of a functioning tumor.6 functioning tumors may present with hypertension, tachycardia, orthostatic hypotension, excessive perspiration, tremor or vascular headaches.8 although this patient had hypertension and headache, the size of the tumor and the absence of other signs and symptoms of a functioning tumor did not warrant catecholamine and urinary metabolite determination. on physical examination, the hallmark of a jugulotympanic glomus tumor is a reddish-blue mass seen behind the tympanic membrane. brown sign described as the pulsation elicited by pneumatic compression that is abolished with further compression was present in the patient. on ct scan, glomus tympanicum appears as a soft tissue mass abutting the promontory of the middle ear.9 imaging with ct also allows visualization of ossicular displacement or bony erosion of the tympanic cavity and is best for evaluating bony destruction and erosion which is a hallmark of jugulotympanic glomus tumors. the patient initially had a ct scan but an mri of the internal auditory canal was requested to visualize whether there was involvement of other structures such as major blood vessels. mri is more advantageous than ct in delineating tumor edges and intracranial extent. it evaluates the relationship of the tumor to vascular structures such as the jugular vein and carotid artery and neck structures such as cranial nerves.10 the treatment of glomus tympanicum depends on the patient’s age, site, size, extent of the tumor, rate of symptom progression, preoperative cranial nerve status, possibility of multicentricity, neurosecretory status and patient preference.11 surgical resection is still considered the primary treatment modality. depending on the type and extent of the tumor, surgical approaches based on the glasscock-jackson classification system include transmeatal, extended facial recess or canal wall-down mastoidectomy.12 the less invasive transcanal route may be employed for complete excision of type 1 glomus tympanicum tumors, as in our case. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles 16 philippine journal of otolaryngology-head and neck surgery abstract objective: to determine the mean distance of the main trunk of the facial nerve from two commonly employed surgical landmarks (tragal pointer and tympanomastoid suture line) among a sample of filipino adults undergoing parotidectomy. methods: design: prospective descriptive study setting: tertiary government training hospital subjects: 22 patients without facial paralysis undergoing surgery for parotid neoplasms were evaluated intraoperatively. results: the main trunk of the facial nerve was found to be 9.0mm (standard deviation of 2.8mm) from the tragal pointer and 6.1mm (standard deviation of 2.0mm) from the tympanomastoid suture line. conclusion: the mean distance from the main trunk of the facial nerve to two of the most commonly utilized landmarks in identification of the nerve during parotidectomy was 9.0mm (standard deviation of 2.8mm) from the tragal pointer and 6.1mm (standard deviation of 2.0mm) from the tympanomastoid suture line. these may serve as reference values for surgeons in safer identification and preservation of the facial nerve during parotidectomy. keywords: facial nerve, parotidectomy, tragal pointer, tympanomastoid suture line, anatomic landmarks the facial nerve and the parotid gland share an intimate anatomic relationship. the gland is divided into superficial and deep lobes by a sagittal plane defined by the branches of the nerve. however, the gland is actually unilobar and the plane created by the fanning branches of the facial nerve is not a true anatomic separation into two distinct and discrete lobes.1 during parotidectomy, several anatomical landmarks may be used to locate the facial nerve. one of the most commonly employed is the tragal pointer. the facial nerve is approximately 1 to 1.5 cm deep and inferior to it.2 another landmark used is the tympanomastoid suture line. it is about 6 to 8mm deep or medial to the nerve.3 this is considered to be the most reliable landmark.4 other landmarks may be used such as tip of the mastoid process and the central point of the transverse process of the atlas which are bony projections.5 to the best of our knowledge, there are limited if any local studies on the use of these landmarks during parotid surgery on filipinos. this study aims to determine the mean distances intraoperative distance between the main trunk of the facial nerve and surgical landmarks used in parotidectomy: a prospective study daniel jose c. mendoza, md samantha s. castaneda, md antonio h. chua, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. daniel jose c. mendoza department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 743 6921; (632) 711 9491 local 320 email: wapi_21@hotmail.com reprints will not be available from the author the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at philippine society of otolaryngology-head and neck surgery, descriptive research contest (1st place), september 19, 2013, natrapharm, the patriot bldg., km 18 slex, paranaque city. philipp j otolaryngol head neck surg 2014; 29 (1): 16-19 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles philippine journal of otolaryngology-head and neck surgery 17 of the two most commonly used landmarks, the tragal pointer and the tympanomastoid suture line from the main trunk of facial nerve during parotidectomy. methods study design: prospective descriptive study from april 2012 may 2013 setting: tertiary government hospital subjects: twenty-two patients aged 18 and above with parotid neoplasms and no facial paralysis and who gave informed consent were included in the study. procedure: under general anesthesia and endotracheal intubation, patients were placed in supine position with the head rotated to the contralateral side of the parotid tumor. a modified blair incision was carried out, skin flaps were developed and the parotid gland was exposed. the tragal pointer, a downward-protruding cartilaginous portion of the tragus was identified. this was followed by identifying the tympanomastoid suture line, a v-shaped sulcus between the antero – inferior margin of the external auditory canal and the anterior margin of the mastoid process of the temporal bone. dissection was done to identify the main trunk of the facial nerve as shown in figure 1. measurements from the two landmarks (figure 2) were taken once the main trunk of the facial nerve was identified prior to excision of the mass using a surgical legged caliper (huco vision sa, switzerland) as follows: • tragal pointer: the shortest distance from the main trunk of the facial nerve to the most inferior and anterior portion of the tragal pointer; • tympanomastoid suture line: the shortest distance from the main trunk of the facial nerve to the most anterior aspect of the palpable v-shaped sulcus; and figure 2. actual intra – operative measurement of the distance of the main trunk of facial nerve from the tragal pointer (a) and tympanomastoid suture line (b) a b c figure 1. identification of tragal pointer (a), tympanomastoid suture line (b), and main trunk of facial nerve (c) philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles 18 philippine journal of otolaryngology-head and neck surgery table 2. distance of the main trunk of the facial nerve to tragal pointer and tympanomastoid suture line among males and females. (n=22; males=8; females=14) tragal pointer males malesfemales females tympanomastoid suture line mean (mm) standard deviation (mm) mode (mm) min (mm) max (mm) 8.5 2.1 7.0 6.0 12.0 9.4 3.1 8.0 5.0 18.0 6.0 1.9 4.0 4.0 9.0 6.1 2.2 6.0 4.0 10.0 table 3. comparison of the mean distance of the main trunk of facial nerve to tragal pointer and tympanomastoid suture line among males and females tragal pointer males malesfemales females tympanomastoid suture line our result (mm) rea, et al6 (mm) pather, et al11 (mm) 8.5 6.7 39.4 9.4 7.1 40.6 6.0 2.3 9.9 6.1 2.6 10.1 • main trunk of the facial nerve: the extracranial segment of the facial nerve as it enters the parotid tissue excision of the mass was completed which involved either superficial or total parotidectomy. standard hemostasis and closure were performed. data and statistical analysis: data taken were recorded and tabulated. the mean and standard deviation of the measurements from the two landmarks of interest were obtained using ms excel (microsoft corporation, redmond, wa, usa). table 1. distance of the main trunk of the facial nerve to tragal pointer and tympanomastoid suture line. (n=22) tragal pointer tympanomastoid suture line mean (mm) standard deviation (mm) mode (mm) min (mm) max (mm) 9.0 2.8 8.0 5.0 18.0 6.1 2.0 4.0 4.0 10.0 results there were 22 patients included in the study, 8 males and 14 females with ages ranging from 22 to 71 years old. of the 22 patients, 1 underwent total parotidectomy while the remaining 21 had superficial parotidectomy. the mean distance of the main trunk of the facial nerve to the tragal pointer was 9.0 mm with standard deviation of 2.8 mm. on the other hand, the mean distance of the tympanomastoid suture line from the main trunk of facial nerve was 6.1 mm with standard deviation of 2.0 mm. (table 1) the mean distances of the main trunk of facial nerve from the tragal pointer and tympanomastoid suture line were 8.5 mm and 6.0 mm for males, respectively. for females, the tragal pointer and tympanomastoid suture line were 9.5 mm and 6.1 mm away from the main trunk of facial nerve, respectively. (table 2) discussion this study aimed to measure the mean distance of the main trunk of the facial nerve from commonly employed surgical landmarks in parotidectomy, the tragal pointer and the tympanomastoid suture line. similar studies comparing the distances of tragal pointer and tympanomastoid suture line from the main trunk of the facial nerve have varying results as seen in figure 3. since many filipinos have relatively smaller stature than caucasians, it may be postulated that the distance of the main trunk of facial nerve to the landmarks should also be shorter. however, studies by rea et al. and de ru et al. showed shorter distances than our results, which may be explained by their use of cadavers as subjects. the cadavers were preserved and fixed using formaldehyde. embalming may have desiccated the tissues altering texture and pliability.4 thus, the measurements obtained would be shorter due to volume loss as compared to our subjects. rea et al. also reflected the ears and removed the sternocleidomastoid muscles, both not representative of the intraoperative situation.6 cadavers also have limited head rotation compared to living subjects. these factors may all contribute to differences in the results. another possible reason may be the presence of parotid tumors in our subjects compared to the subjects used in similar studies which did not have parotid tumors. the tumor may displace the facial nerve either toward or away from the landmarks of interest. we evaluated the measurements according to gender. the mean distances of the facial nerve trunk of male subjects from the tragal pointer and tympanomastoid suture line were 8.5mm and 6.0mm, respectively. females had mean distances of 9.5mm from the tragal pointer and 6.1mm from the tympanomastoid suture line to the main trunk of the facial nerve. our results are consistent with the literature, which shows that the facial nerve in males had a shorter distance from the two operative landmarks in comparison to females. rea et al. postulated that the difference is mainly due to the philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles philippine journal of otolaryngology-head and neck surgery 19 references 1. sunwoo j, lewis j, mcjunkin j, sequeira s. malignant neoplasms of the salivary glands. in: flint p, haughey b, lund v, niparko j, richardson m, robbins kt et al, editors. cummings otolaryngology head and neck surgery. 5th ed. philadelphia: mosby elsevier. 2010. p.1194-5. 2. caldaza g, hanna e. benign neoplasms of the salivary glands. in: flint p, haughey b, lund v, niparko j, richardson m, robbins kt et al, editors. cummings otolaryngology head and neck surgery. 5th ed. philadelphia: mosby elsevier. 2010. p.1172-3. 3. hogg sp, kratz rc. surgical exposure of the facial nerve. arch otolaryngol. 1958. 67: 560-1. 4. de ru ja, van benthem pp, bleys rl, lubsen h, hordijk gj. landmarks for parotid surgery. j laryngol otol. 2001 feb; 115(2): 122-5. 5. greyling lm, glanvill r, boon jm, schabort d, meiring jh, pretorius jp, et al. bony landmarks as an aid for inraoperative facial nerve identification. clin anat. 2007 oct; 20(7): 739-44. 6. rea pm, mcgarry g, shaw-dunn j. the precision of four commonly used surgical landmarks for locating the facial nerve in anterograde parotidectomy in humans. ann anat. 2010 feb 20; 192(1): 27-32. 7. ali ns, nawaz a, rajput s, ikram m. parotidectomy: a review of 112 patients treated at a teaching hospital in pakistan. asian pacific j cancer prev. 2010; 11:1113-5. 8. rahman ma, alam mm, joarder ah. study of nerve injury in parotid surgery. nepalese j ent head neck surg. 2011; 2(1): 17-9. 9. eng cy, evans as, quraishi ms, harkness pa. a comparison of the incidence of facial palsy following parotidectomy performed by ent and non – ent surgeons. j laryngol otol. 2007 jan; 121(1): 40-3. 10. dimitrov sa. our experience with surgical dissection of the facial nerve in parotid gland tumours. (a preliminary report). folia med (plovdiv). 2000; 42(1): 37-40. 11. pather n, osman m. landmarks of the facial nerve: implications for parotidectomy. surg radiol anat. 2006 may; 28(2): 170-5. 12. conley j. search for and identification of the facial nerve. laryngoscope. 1978 jan; 88(1 pt 1): 172-5. 13. reid ap. surgical approach to the parotid gland. ear nose throat j. 1989 feb; 68(2): 151-4. 14. tabb h, scalco a, fraser sf. exposure of the facial nerve in parotid surgery. laryngoscope. 1970 apr; 80(4): 559-77. 15. witt rl. facial nerve function after partial superficial parotidectomy: an 11 – year review (1987 – 1997). otolaryngol head and neck surg. 1999 sep; 121(3): 210-3. 16. pereira, ja, meri a, potau jm, prats – galino a, sancho jj, sitges – serra a. a simple method for safe identification of the facial nerve using palpable landmarks. arch surg. 2004 jul; 139(7): 745-7. anatomic variation of the skulls of males and females. the male skull is more robust with larger mastoid process, deeper mandibular ramus, larger nuchal crest rigidity and rugose muscle attachments.6 further studies may need to be done to determine such discrepancies in the measurements. the use of landmarks and their relative distances to the facial nerve should be applied to minimize one of the complications during parotidectomy which is facial paralysis. studies show that the prevalence rate of facial paralysis is variable ranging from 18.7%7 to 26.08%8 and can be as high as 57% for transient facial paralysis.9 permanent facial paralysis is reported from about 2 to 7%.9 the risk for facial paralysis increases with total parotidectomy.10 a study by dimitrov on 37 patients with parotid tumors who underwent conservative or lateral parotidectomy using the insertion of the posterior belly of the digastric muscle on the mastoid tip process and tympanomastoid fissure as anatomic landmarks in identifying the facial nerve found that these landmarks are easily recognizable and reliable start-points in facial nerve dissection that reduce the risk of traumatic injury of the nerve during parotid surgery.10 to prevent transient or even permanent facial nerve paralysis, it is a must for the surgeon to be knowledgeable of the surgical anatomy and exercise utmost care during surgery. we hope the distances we measured in our study may serve as reference values for surgeons in safer identification and preservation of the facial nerve during parotidectomy. figure 3. comparison of the mean and range of distance of the tragal pointer and tympanomastoid suture line from the main trunk of facial nerve in different studies. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 featured grand rounds 30 philippine journal of otolaryngology-head and neck surgery vocal fold paralysis is an otolaryngologic disorder that is more prevalent in the adult population. its occurrence in children has been documented in the literature. we report a case of congenital bilateral vocal fold paralysis and discuss the issues surrounding its ultimate diagnosis and management. case report three months prior to consult, a five–year-old girl started to have noisy (whistling), difficult breathing lasting throughout the day and becoming louder if she cried. she had no cough, colds, fever, or voice changes. suspecting asthma, an attending pediatrician at a private tertiary hospital emergency room administered salbutamol nebulization affording temporary relief of dyspnea, but the noisy breathing persisted. the girl was discharged on salbutamol syrup to be taken for episodes of difficulty breathing, without any laboratory work-ups. two months before consult, another pediatrician prescribed co-amoxiclav and bromhexine for the persistent noisy breathing, without any improvement. still no work-ups were requested. a month later, the noisy breathing was louder and associated with difficulty breathing, alar flaring and dynamic chest movements. suspecting foreign-body aspiration, a tertiary government hospital pediatrician requested chest radiographs that showed minimal infiltrates and no hyperinflation, inconsistent with the working impression. she was referred to our institution for bronchoscopy and possible foreign body extraction. at our institution, further review of history revealed a caesarian section for premature rupture of membranes, with cord coil noted on delivery. the perinatal history was otherwise unremarkable. the girl had been diagnosed with bronchial asthma at two years of age when the noisy breathing was first noted, and had been given salbutamol syrup as needed for episodes of difficulty breathing. there had been no feeding difficulties and her developmental milestones were at par with age. immunizations were also complete. physical examination revealed respiratory distress with biphasic stridorous breath sounds (heard louder over the neck) with bilateral alar flaring and subcostal and chest wall retractions. examination of the throat, ears and nose was unremarkable, as was the neurological exam. a repeat chest x-ray (figure 1) showed confluent opacities in both lower lobes and shouldering of the subglottic trachea in the frontal projection. no foreign body was appreciated, and a subglottic stenosis and/or tracheomalacia were considered. awake flexible laryngoscopy (figure 2) revealed bilateral immobile vocal folds fixed in paramedian position. tracheobronchoscopy under general anesthesia showed no hypopharyngeal or tracheal lesions up to the level of the carina. a tracheotomy was performed and a shiley size 4.5 tracheostomy tube was inserted. after much consultation with her relatives, it was decided to follow her closely due to the possibility of spontaneous resolution of bilateral vocal fold paralysis. congenital bilateral vocal fold paralysis in a two-year-old girl correspondence: dr. reylan b. david department of otorhinolaryngology head and neck surgery saint luke’s medical center 279 e. rodriguez ave., quezon city 1102 philippines phone: (632) 727 5543 telefax:(632) 723 1199 (h) email: reylandavid@gmail.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believes that the manuscript represent honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to conflict of interest. reylan b. david, md william l. lim, md department of otorhinolaryngology head and neck surgery saint luke’s medical center philipp j otolaryngol head neck surg 2014; 29 (1): 30-32 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 philippine journal of otolaryngology-head and neck surgery 31 featured grand rounds after two years of regular follow-up, repeat awake flexible laryngocopy revealed no change in vocal fold status. direct laryngoscopy with cordotomy and arytenoidectomy were then performed. (figure 3) two weeks post-operatively, the patient was successfully decannulated. discussion stridor represents one of the most common complaints of children presenting with upper airway pathologies. it is defined as an “abnormal sound produced by air passing through an airway lumen of decreased caliber.”1 despite the abundance of literature describing and differentiating this symptom, it would not be uncommon for physicians to mistake this for a wheeze2 – an adventitious lung sound. one important point in determining whether a certain breath sound is stridorous or not is the location where the sound is heard loudest: stridorous sounds being heard louder in the neck and wheezing sounds heard best in the lungs.3 stridor may be classified based on timing -whether it is expiratory, inspiratory or biphasic4,5 determining the timing of stridor allows one to narrow a multitude of differentials. (table 1) figure 1. chest x-ray showing confluent opacities in both lower lobes. note shouldering at subglottic area (indicated by arrow) figure 3. post-operative view if the larynx of the patient figure 2. awake flexible laryngoscopy stills showing closed (top) and open (bottom) phase with absent arytenoid movement table 1. types of stridor and associated pathology4* stridor site of obstruction pathology inspiratory expiratory biphasic above the vocal folds below the vocal folds at and/or below vocal fold level supraglottic mass, croup, epiglotitis foreign body, tracheomalacia foreign body, bacterial tracheitis *adapted with permission from maloney e, meakin g. acute stridor in children. contin educ anaesth crit care pain 2007; 7(6):183-186. doi:10.1093/bjaceaccp/ mkm041 however, the co-existence of upper and lower airway pathologies in a patient with stridor may complicate the diagnosis. hence, further workups may be required. there are no hard and fast indications of what imaging or modality to request in the assessment of a child with stridor. in this case, a chest x-ray showed equivocal findings. flexible endoscopy followed, and revealed the disorder. rigid tracheobronchoscopy ruled out philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 featured grand rounds 32 philippine journal of otolaryngology-head and neck surgery concomitant tracheal lesions such as laryngomalacia, which is the most common associated anomaly.6 congenital bilateral vocal fold paralysis, defined as reduced or absent mobility of both vocal folds in children is an uncommon disorder. a study by ahmad et al. estimated the incidence of congenital bilateral vocal fold paralysis to about 0.9% of all cases of vocal fold paralysis.7 the causes of this rare disorder include central nervous system diseases (most common of which is arnold-chiari malformation), muscular dystrophies, autoimmune disorders and trauma (arytenoid dislocation). most cases however are idiopathic.8 in our case, trauma (cord coil) seems to be the only positive event that may actually be the precipitating factor. however, even after repeated histories, there is a significant disparity between the presumed cause (cord coil) and the start of symptoms at about 2 years of age. labeling this case as idiopathic may also be quite premature since an underlying neuromuscular disorder, though rare may present later in life between 4 months to 7 years.9 case reports of bilateral vocal fold paralysis in the local literature are scarce.10-12 the most common complaint of this airway pathology is stridor with 32% presenting after one year of age.8 one of the most controversial issues regarding this problem is the value of laryngeal electromyography in diagnosis. while its value in adults with vocal fold immobility is recognized, its role in children is questionable. a study by berkowitz showed that a normal emg may be a finding in children with bilateral vocal fold paralysis.13 these reasons, aside from the fact that the patient had no other history of neck trauma and that the procedure is technically difficult with the potential for more damaging complications on account of the smaller laryngeal apparatus of the child compared to an adult precluded the application of laryngeal electromyography in this case. another controversy is the use of imaging modalities such as ct scan and mri. the role of these ancillaries is supposedly to rule out central nervous system and peripheral nerve lesions. but while neurological and thoracic pathologies must be considered in the assessment of vocal fold paralysis, in the face of a normal neurological and chest examination, such exams are unnecessary and may in fact cause untoward and needless stress on the patient. our patient had a normal neurological and developmental exam as well as a normal chest and lung exam. in case of idiopathic bilateral vocal fold paralysis, berkowitz et al.14 opined that “blockade of glycinergic inhibitory neurotransmission by strychnine acts pre-synaptically on postinspiratory laryngeal constrictor motorneurons to induce firing during inspiration” as a suggested mechanism and perhaps the reason why emg findings may be normal in this condition. but the decision and timing to perform definitive surgery or observe (maintain tracheostomy tube) is perhaps the most significant issue to consider. factors to consider include impact on language, emotional, and intellectual development, tracheostomy complications, capacity of caregivers to provide home care and possibility of spontaneous recovery.15 each of these factors must be taken into consideration and weighed prior to decision making. parents must also be informed and included in this process. the rationale for observation has been emphasized in a study by acknowledgements we would like to thank dr. joel romualdez and dr. ray casile for their suggestions and encouragement that have made the writing of this manuscript possible. references mitchell rb, pereira kd.1. pediatric otolaryngology for the clinician. in: brown dj. stridor. humana press; 2009 p. 137 downing et, braman ss, fox mj, corrao wm.2. factitious asthma. physiological approach to diagnosis. jama. 1982 dec 3; 248(21):2878-81. hollingsworth hm. wheezing and stridor. 3. clin chest med. 1987 jun; 8(2):231-40. maloney e, meakin g. acute stridor in children. 4. contin educ anaesth crit care pain 2007; 7(6):183186. doi:10.1093/bjaceaccp/mkm041 cotton rt, reilly js. stridor and airway obstruction. in: bluestone c, stool s, kenna m, 5. editors. pediatric otolaryngology. 3rd ed. philadelphia, pa: wb saunders co; 1995 p275-86. tan hkk, holinger ld. how to evaluate and manage stridor in children. 6. j respir dis. 1994; 15(3):245-260. ahmad s, muzamil a, lateef m. a study of incidence and etiopathology of vocal cord paralysis. 7. indian j otolaryngol head neck surg. 2002 oct; 54(4):294-6. daya h, hosni a, bejar-solar i, evans jn, bailey cm.8. pediatric vocal fold paralysis: a long-term retrospective study. arch otolaryngol head neck surg. 2000 jan; 126(1):21-25. lapena jf jr, berkowitz rg. neuromuscular disorders presenting as congenital bilateral vocal 9. fold paralysis. ann otol rhinol laryngol. 2001 oct; 110(10):952-5. saludo rc, bautista m. bilateral midline abductor paralysis of the vocal folds. 10. sto tomas j med 1997 [abstract only] available from: http://herdin.ph/index.php?option=com_herdin&controll er=research&task=view&cid[0]=21029 alonzo d, de leon a. etiology of bilateral vocal fold paralysis: a pin in a haystack. 11. philipp j otolaryngol head neck surg. 1991:86-88. vinco v, pio f, feliciano r. tracheotomy versus watchful waiting for neonatal bilateral midline 12. vocal fold paralysis: a case report. far eastern university dr. nicanor reyes medical foundation medical journal 2006; 12(1):15-19. berkowitz rg. laryngeal electromyography findings in idiopathic congenital bilateral vocal 13. cord paralysis. ann otol rhinol laryngol. 1996 mar; 105(3):207-12. berkowitz rg, sun qj, pilowsky pm.14. congenital bilateral vocal fold paralysis and the role of glycine. ann otol rhinol laryngol. 2005 jun; 114(6):494-8. graham jm, scadding gk, bull pd. pediatric ent. in: shine n, prescott c, editors. acquired 15. disorders of the larynx in children. united kingdom: springer 2007 p.208 gupta ak, mann sb, nagarkar n. surgical management of bilateral immobile vocal folds and 16. long term follow up. j laryngol otol. 1997 may; 111(5):474-7. daya et al.8 wherein some children showed recovery after age 5 with the longest time of recovery at age 11 years old. in case of non-resolution, a variety of surgical techniques can be done – none showing a clear advantage over the other.16 after two years of regular follow-up, observing no significant change in vocal fold status, the parents decided to opt for surgery. laser arytenoidectomy and cordotomy were chosen because studies have shown it to be superior to other surgical techniques in terms of decannulation rate16 and voice preservation and it was a familiar procedure in our institution. in this procedure, in which an accupulse lumenis 40 st (yokneam, israel distributed by spectromed) carbon dioxide laser machine was used, the posterior one-third of the left vocal fold along with a portion of the left vocal process was ablated. (figure 3) no major complications were noted during the procedure. two weeks postoperatively, the patient was successfully decannulated. four months after the procedure, the mother reported no further episodes of difficulty of breathing and very minimal speech deficiencies. she also noted increased confidence and cheerfulness. this case demonstrates how a careful history and physical examination (with minimal diagnostic studies) allows for precise diagnosis without the use of costly interventions such as a ct scan, mri or electromyography and enumerates the factors that must be considered in choosing the best management for the patient. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports 18 philippine journal of otolaryngology-head and neck surgery abstract objective: to describe a case of mandibular metastasis from nasopharyngeal carcinoma and review the literature. methods: design: case report setting: tertiary public university hospital patient: one result: a 42-year-old malay gentleman underwent concurrent chemoradiotherapy (ccrt) for t4n2m0 (stage iva) nasopharyngeal carcinoma (npc) non-keratinizing type (who ii). upon completion of ccrt, he developed metastasis to the left body of the mandible that increased in size despite three cycles of adjuvant intravenous chemotherapy. hemi-mandibulectomy was deferred due to recent irradiation and a further 15 fractions of boost radiotherapy reduced the mandibular metastasis in size but it has remained the same after six months follow up. conclusion: nasopharyngeal carcinoma (npc) is a common malignancy in oriental asia and the south east asian regions. it has the highest rates of nodal and distant metastases among all head and neck cancers. distant metastasis to bone is common but we could find no previous report of mandibular bone involvement in the literature. radiotherapy remains the main treatment modality and combination with chemotherapy has been shown to improve survival of patients. there are studies on nasopharyngeal carcinoma tumour markers for diagnosis and disease process follow up but these are still inconclusive. keywords: nasopharyngeal carcinoma, bones, mandible, metastasis. case report a 42-year-old malay gentleman first presented to the ent clinic with a five-month history of recurrent headache and a three-month history of recurrent epitaxis. the symptoms were associated with progressive neck swelling and pain and reduced hearing in the left ear with tinnitus. clinical examination showed bilateral multiple cervical lymphadenopathies at level ii, the largest being 2 x 2 cm in dimension. there was no significant cranial nerve involvement noted. nasoendoscopy revealed a large mass occupying the left fossa of rosenmuller extending anteriorly to the left nasal choana. biopsy revealed non-keratinizing nasopharyngeal carcinoma (who ii). staging was t4n2m0 (stage iva) with left middle cranial fossa extension of the primary tumour evidenced by ct scan. mandibular metastasis from nasopharyngeal carcinoma hon syn chong, mbbs1 mohd razif mohd yunus mbbs, ms (orl-hns)1 chee lun lum, mbbs, ms (orl-hns)2 1department of otorhinolaryngology head and neck surgery universiti kebangsaan malaysia medical center cheras, kuala lumpur, malaysia 2department of otorhinolaryngology hospital queen elizabeth, sabah, malaysia correspondence: dr. hon syn chong universiti kebangsaan malaysia medical center department of otorhinolaryngology 9th floor clinical block, jalan yaacob latif bandar tun razak 56000 cheras, kuala lumpur malaysia phone : +60168361901 e-mail : nickchs@hotmail.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (2): 18-20 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports philippine journal of otolaryngology-head and neck surgery 19 the patient underwent concurrent chemoradiotherapy (ccrt) consisting of 35 sessions of fractionated radical radiotherapy (total of 60 gy) with weekly intravenous (iv) cisplatin 30mg/m2. upon completion of the ccrt, he developed a slightly tender swelling of the left mandible. examination revealed a firm, diffuse 3 x 3 cm swelling in the labial sulcus of the left body of the mandible with reddish overlying mucosa. there was no bleeding or purulent discharge noted. fine needle aspiration cytology revealed metastatic carcinoma. he then proceeded with 3 cycles of adjuvant intravenous chemotherapy (5-flourouracil and cisplatin). upon completion of the adjuvant chemotherapy, the mandibular swelling increased in size and was bony-hard and moderately tender on intraand extra-oral palpation. orthopantomogram (opg) showed multiple lytic lesions with fracture of the left body of the mandible (figure 1). the consensus among oncologists, ent, plastic & reconstructive and maxillofacial surgeons was to defer hemi-mandibulectomy due to recent irradiation to the area as this may lead to poor prognosis for healing and reconstructive surgical outcome. discussion npc has one of the highest rates of nodal and distant metastases among head and neck cancers. about 75% of npc patients have enlarged nodes at presentation.1 the clinically important commonly involved lymph nodes are the retropharyngeal (82%), cervical level ii (95.5%), iii (60.7%) and iv (34.8%).2 the common distant metastatic sites are bones, lungs and liver in descending order of frequency.3 distant metastases usually develop within a 3-year period and there is an association between distant metastases and the nodal (n) staging.4 there are also case reports of rare sites of distant metastases to the thyroid glands,5 choroid of the eye6 and skin.7 skeletal involvement usually affects the spine (59.6%) and pelvis (16.3%), followed by femur (9.9%), ribs and sternum (7.8%) and humerus (5.0%).8 on x-ray, lesions are mostly lytic (66%), sclerotic (21%) and mixed lytic and sclerotic (12.8%).8 this unusually high incidence of mixed and sclerotic bony secondaries is unique in head and neck cancer. the role of bone scanning of asymptomatic skeletal metastases on presentation of npc patients is limited by its low sensitivity and specificity.9 thus, bone scintigraphy is not recommended as part of a routine staging investigation for npc on top of its low cost-effectiveness. however, it should be an option for npc patients with higher risk for distant metastasis (advanced t or n staging, male and older age).3 10 chua et al.11 compared 4 diagnostic panels for distant metastasis staging (1. chest x-ray, liver ultrasound, and skeletal scintigraphy; 2. ct of the thorax, abdomen and skeletal scintigraphy; 3. (18)f-fluorodeoxyglucose positron emission tomography (fdg-pet) and 4. integrated fdg-pet/ ct). results showed that integrated fdg-pet/ct was the most specific (83.3%), sensitive (97.2%) and accurate (96.2%) modality to detect distant metastasis. however, this investigation is limited also by its cost and availability. even though distant metastasis to bone from npc is common, we could find no previous report of mandibular involvement in the literature based on a pubmed search of medline as well as ovid and google. intrathoracic metastases incidence has been reported as high as 8-13%.4 12 about 64% of all patients with lung metastasis have thoracic lymphadenopathy especially involving the hilar nodes.13 it is also interesting to note that instead of solitary deposits, there is a 12% incidence of lung lesions of the cavitary type (usually associated with squamous cell carcinoma).13 liver metastasis is also common in npc patients (36% of distant metastases).14 like other cancers, the metastasis of nasopharyngeal carcinoma involves several theoretical sequential steps. metastatic tumour cells must separate from other cells by losing the function of e-cadherin and beta-catenin. then the cells migrate through the basement membrane into the circulation (blood or lymphatic). although these tumour cells are vulnerable to the host immune system, some may escape and adhere to vascular endothelium and invade the susceptible organ parenchyma. figure 1. orthopantogram showing multiple lytic lesions especially on the left mandibular body with associated soft tissue swelling. the lytic lesions are fairly well-defined and permeative with some illdefined margins. the left body of the mandible appears reduced in size compared to the right side. the mandible generally appears osteopenic. a fracture line is noted on the superior margin of the left mandible, extending downward but not involving the inferior margin. there is no periosteal reaction and no sclerosis or calcification of the soft tissue. he was prescribed a further 15 fractions of boost radiotherapy (total of 20 gy) localized to the affected mandible. the swelling reduced in size to 1 x 1cm upon completion of the boost radiotherapy. six months after the boost rt, the swelling on the mandible remained the same but there was no local recurrence at the primary site. surgery remains an option if the swelling increases in size again. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports 20 philippine journal of otolaryngology-head and neck surgery acknowledgements we are grateful to prof. prepageran narayanan (frcs) from the university malaya of kuala lumpur for reviewing this paper. references 1. sham jst, choy d, wei w. nasopharyngeal carcinoma: orderly neck node spread. int j radiat oncol biol phys. 1990;19(4):929-33. 2. ng sh, chang jtc, chan sc, ko sf, wang hm, liao ct, et al. nodal metastases of nasopharyngeal carcinoma: patterns of disease on mri and fdg pet. eur j nucl med mol imaging. 2004;31(8):107380. 3. hui ep, leung sf, au jsk, zee b, tung s, chua d, et al. lung metastasis alone in nasopharyngeal carcinoma: a relatively favorable prognostic group. cancer. 2004;101(2):300-6. 4. sham jst, choy d, choi p. nasopharyngeal carcinoma: the significance of neck node involvement in relation to the pattern of distant failure. br j radiol. 1990;63(746):108. 5. jalaludin ma, rajadurai p, umapati prasad rv. thyroid metastasis from nasopharyngeal carcinoma: a case report. j laryngol otol. 1994;108(10):886-8. 6. özyar e, kiratli h, akbulut s, uzal d, atahan il. choroid metastasis of undifferentiated nasopharyngeal carcinoma. j laryngol otol. 1998;112(07):666-9. 7. luk n, yu k, choi c, yeung w. skin metastasis from nasopharyngeal carcinoma in four chinese patients. clin exp dermatol. 2004;29(1):28-31. 8. sham jst, cheung y, chan f, choy d. nasopharyngeal carcinoma: pattern of skeletal metastases. br j radiol. 1990;63(747):202. 9. sham jst, tong c, choy d, yeung dwc. role of bone scanning in detection of subclinical bone metastasis in nasopharyngeal carcinoma. clin nucl med. 1991;16(1):27. 10. mo l, weng j, zeng f, li x, liu b, li z, et al. the relationship between extend types and distant metastasis of nasopharyngeal carcinoma. lin chung er bi yan hou tou jing wai ke za zhi. 2010;24(12):554. 11. chua mlk, ong sc, wee jts, ng dce, gao f, tan twk, et al. comparison of 4 modalities for distant metastasis staging in endemic nasopharyngeal carcinoma. head neck. 2009;31(3):34654. 12. leung s, teo p, shiu w, tsao s, leung t. clinical features and management of distant metastases of nasopharyngeal carcinoma. j otolaryngol. 1991;20(1):27. 13. daly b, leung s, cheung h, metreweli c. thoracic metastases from carcinoma of the nasopharynx: high frequency of hilar and mediastinal lymphadenopathy. ajr am j roentgenol. 1993;160(2):241. 14. yi j, gao l, huang x, li s, luo j, cai w, et al. nasopharyngeal carcinoma treated by radical radiotherapy alone: ten-year experience of a single institution int j radiat oncol biol phys. 2006;65(1):161-8. 15. thiery jp, sleeman jp. complex networks orchestrate epithelial–mesenchymal transitions. nature rev mol cell biol. 2006;7(2):131-42. 16. pegtel dm, subramanian a, sheen ts, tsai ch, golub tr, thorley-lawson da. epstein-barrvirus-encoded lmp2a induces primary epithelial cell migration and invasion: possible role in nasopharyngeal carcinoma metastasis. j virol. 2005;79(24):15430. 17. lee jk, tsai sc, hsieh jf, ho yj, sun ss, kao ch. beta-2-microglobulin ( 2m) as a tumor marker in nasopharyngeal carcinoma. anticancer res. 2000;20(6c):4765-8. 18. zhi l, yi r. association of e-cadherin and -catenin with metastasis in nasopharyngeal carcinoma. zhonghua yi xue za zhi (taipei). 2004;117(8):1232-9. 19. zheng z, pan j, chu b, wong yc, cheung alm, tsao sw. downregulation and abnormal expression of e-cadherin and [beta]-catenin in nasopharyngeal carcinoma: close association with advanced disease stage and lymph node metastasis. hum pathol. 1999;30(4):458-66. 20. liu t, ding y, xie w, li z, bai x, li x, et al. an imageable metastatic treatment model of nasopharyngeal carcinoma. clin cancer res. 2007;13(13):3960. organ metastases usually could be predicted by the location of the primary tumour and its vascular and lymphatic drainage. however, as seen in this case, the natural drainage pathways do not always explain the site of metastasis. probable mechanisms include expression of adhesion molecules on cell membranes by the metastatic tumour cells whose ligands are expressed on the endothelium of target organs or the use of chemokines by tumour cells to reach specific organs.15 many different npc tumour markers (e-cadherin, β-catenin, β 2-microglobulin, lmp2a)16-19 and npc cell lines (5-8fgfp and 6-10b-gfp)20 for npc have been studied but their clinical relevance still remains inconclusive. rare distant metastases may happen in patients with npc. a study by pegtel et al.16 on epstein-barr virus (ebv) and non-keratinizing npc showed that there was a link between lmp2a expression (latent protein expressed on ebv-infected epithelial cells), itg alpha6 expression (cellular protein associated with cellular migration in vitro and metastasis in vivo), epithelial cell migration and npc metastasis. the results suggest that ebv infection may contribute to higher incidence of metastasis in npc progression. there is further need for laboratory research in this relevant topic for definite treatment regarding ebv infection in humans. nevertheless, ebv serology was not available prior to treatment of our patient as it is not a routine test in our clinical setting. philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2018; 33 (1): 47-50 c philippine society of otolaryngology – head and neck surgery, inc. double ectopic thyroid gland in a 10-year-old filipino boy tomas joaquin c. mendez, md cecilia gretchen s. navarro-locsin, md department of otolaryngology head and neck surgery st. luke’s medical center, quezon city correspondence: dr. cecilia gretchen s. navarro-locsin department of otolaryngology, head and neck surgery 2nd floor, st. luke’s medical center, quezon city eulogio rodriguez sr., avenue, quezon city 1112 philippines phone: (632) 723-0101 local 6530 email: slmcenthns@gmail.com the authors declare that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery interesting case contest (2nd place). june 30, 2016. jy campos hall b unilab bayanihan center, pasig city. abstract objective: to present a case of a double ectopic thyroid gland in a 10-year-old boy and discuss the pros and cons of the different management options that were available. methods: design: case report setting: tertiary private hospital patient: one results: a 10-year-old boy presented with hoarseness and easy fatigability for 6 years. rigid endoscopy and ct scan showed an infraglottic mass originating from the anterior tracheal wall causing obstruction. biopsy revealed thyroid tissue with atypia. thyroid scintigraphy showed uptake in the submental and midline anterior neck. thyroid hormone levels were consistent with hypothyroidism. levothyroxine returned hormone levels to normal and resulted in complete regression of the mass with no symptoms of dyspnea, stridor or bleeding. conclusion: the management of ectopic thyroid presents a challenge as there are no guidelines for optimal treatment. thyroid hormone insufficiency is a frequent occurrence and emphasis must be given to its monitoring. surgery in a critical airway lesion such as this may be reserved for cases where the patient experiences dyspnea and stridor or lack of response to thyroid hormone treatment. keywords: ectopic thyroid, direct laryngoscopy, thyroid hormone, levothyroxine ectopic thyroid results from an aberrancy in the normal migration pathway of the thyroid gland due to an arrest in the descent and/or an interruption in the pathway causing maturation and development in other locations other than the true final anatomic position.1 although a lingual thyroid is the most frequent location of ectopic thyroid tissue, other locations such as the sublingual region, tracheal, submandibular, lateral neck, palatine tonsils, and axilla also exist,2 and ectopic thyroid tissue in distant sites such as the ovary and gi tract have also been reported.2 intratracheal thyroid tissue represents only 7% of all intraluminal tracheal masses.3 dual ectopic thyroid is extremely rare especially when no thyroid gland is seen in the normal anatomic position with very few cases reported in the literature.4 we report one such case. case report our patient presented at birth with a weak, breathy cry and an incidental finding of a submental mass. he was generally stable with no episodes of cyanosis and no need for intubation or admission into intensive care. as the boy grew older, his hoarseness persisted, described as breathy in quality with associated easy fatigability. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery case reports four years prior to consult, an ear, nose and throat (ent) specialist evaluated the submental mass and hoarseness, discovering a reddish, vascular, infraglottic mass on flexible nasopharyngolaryngoscopy. partial excision of the submental mass yielded histopathologic results consistent with nodular colloid goiter. the mother was advised that thyroid hormone levels and further biopsy of the infraglottic mass were needed but they did not follow-up. there was no interim progression of symptoms. due to persistence of hoarseness, a second opinion was sought four months before consult and flexible nasopharyngolaryngoscopy still showed an infraglottic mass. non-contrast neck computed tomography (ct) scan showed a 0.8 x 0.8 cm homogenously enhancing nodule in the anterior commissure of the vocal folds and infraglottic area originating from the anterior tracheal wall, extending downwards and causing infraglottic obstruction, as well as another focus in the region of the floor of the mouth, anterior to the hyoid bone at the level of the anterior belly of the digastric muscle. there was no visible thyroid gland at the level of the thoracic inlet. (figure 1 a, b) the mother was advised excision of the infraglottic mass due to impending upper airway obstruction. the boy was brought to us for a third opinion by now complaining of easy fatigability, hoarseness and difficulty catching up in school. on examination, there was no palpable thyroid gland in the anterior neck, but there was a 3 cm submental surgical scar. rigid endoscopy showed a reddish brown vascular mass originating from the anterior tracheal wall occupying around 2/3 of the trachea at the infraglottic level with a posterior airway patency of around 20-25%. there was good bilateral vocal fold movement but the mass prevented apposition of the vocal folds. (figure 2 a, b) an ultrasonogram to confirm ct scan figure 1. non-contrast neck ct scan prior to hormonal therapy, a. representative axial cut at the subglottic level showing homogenously enhancing nodule; and b. representative axial cut at the level of the hyoid bone showing remnant thyroid tissue anterior to the hyoid body. a b figure 2. flexible nasopharyngolaryngoscopy a. abduction, showing the infraglottic mass occupying around 75% of the tracheal lumen; and b. compensatory adduction of the false vocal folds on phonation. a b philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery case reports figure 3. thyroid scintigraphy scan (i-131) prior to hormonal therapy showing the two foci of avid radiotracer uptake. figure 5. flexible nasopharyngolaryngoscopy showing complete regression of the infraglottic mass after normalization of thyroid hormones. mass in multiple quadrants yielded histopathologic results consistent with thyroid tissue with atypia after staining with pax-8. (figures 4 a, b) hormone replacement was initiated with levothyroxine 100mcg/day with no episodes of stridor, dyspnea or upper airway bleed. the voice improved in four months with good phonation and no apparent hoarseness or easy fatigability. the infraglottic mass regressed completely. (figure 5) figure 4. a. histopathologic slide (hematoxylin – eosin), low power view (100x), infraglottic biopsy. the arrow points to eosinophilic staining of colloid material seen in the tissue sample; b. pax-8 tissue stain confirming the presence of thyroid tissue. the arrow points to colloid material with avid stain uptake. a (hematoxylin – eosin , 100x) b (hematoxylin – eosin , 100x) findings revealed no thyroid gland in the normal anatomic location. thyroid function tests were consistent with hypothyroidism. iodine131 thyroid scintigraphy showed two foci of increased tracer uptake, arranged in vertical configuration in the anterior neck. the superior 2.1 x 2.1 cm focus appearing submental in location on lateral view was suggestive of ectopic thyroid tissue. the inferior 2.3 x 1.6 cm focus in the midline anterior neck most likely represented functioning thyroid tissue. (figure 3) direct laryngoscopy punch biopsies of the infraglottic philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery case reports discussion the thyroid gland is the first endocrine organ to develop in the human body, beginning 3-4 weeks aog.2 dual ectopic thyroid development occurs during the descent and formation of the thyroid gland, which according to two predominating theories of development allow the implantation or invasion of thyroid tissue in other locations.5 the prevalence of ectopic thyroid in other countries ranges from 1/100,000 to 1/300,000 births being more common in females of asian origin.6 dual ectopic thyroid tissue is even rarer especially with no orthotopic thyroid gland.4 studies also suggest that up to 11% of intratracheal thyroidal tissue may undergo malignant transformation if left untreated most commonly papillary thyroid carcinoma.4 our patient presented with submental and infraglottic double ectopic thyroid glands. infraglottic intraluminal involvement may be explained by two theories of development. according to the malformation theory of zierussen,5 developing tracheal cartilage splits the thyroid gland, allowing intraluminal development of an ectopic rest of thyroid tissue. in the ingrowth theory of paltauf, thyroid tissue develops intratracheally through direct invasion of thyroid tissue through the trachea.5 our case is interesting because our patient had an intratracheal component that did not appear to originate from any normal thyroid tissue. moreover, he presented unusually with hoarseness and easy fatigability only, as patients with upper airway obstruction often have biphasic stridor, dyspnea and cough.6 migration control as well as normal thyroid development and differentiation are controlled by gene expression. control and regulation of thyroid migration are a function of the foxe1 gene.2 further studies are needed to elucidate the relationship of foxe1 allele mutations and thyroid ectopy7 including studies of other genes such as titf1/nkx2-1, pax8 and hhex that are involved in intrinsic thyroid development and maturation.8 the most important diagnostic tests include a neck ultrasonogram and thyroid scan preferably a technetium 99m pertechnetate scan.6 the thyroid scan provides valuable information on the presence of a normal anatomic thyroid gland and offers more information to differentiate a suspicious ectopic thyroid mass from other differential diagnoses.6 a ct or mri are helpful for pre-operative evaluation since these evaluate presence of cartilage invasion and/or position of the intratracheal lesion.9 flexible endoscopy should be done in cases of airway involvement such as with our patient. unlike our patient, intratracheal thyroid tissue commonly presents as a reddish-brown submucosal mass in the posterolateral trachea.6 the management of ectopic thyroid with or without an orthotopic thyroid gland is a challenge as there are currently no established guidelines for treatment.6 hypothyroidism further complicates treatment. the treatment strategy centers on the patient’s presentation and symptoms depends on the location of the ectopic thyroid and its biochemical characteristics, age and the qualitative characteristics of references 1. singh gb, kumar d, ranjan s, tomer s. a rare case of double ectopic thyroid without orthotopic thyroid gland. int j pediatr otorhinolaryngol extra. 2015 mar; 10(2): 28-30. doi: http://dx.doi. org/10.1016/j.pedex.2015.01.003. 2. ibrahim na, fadeyibi io. ectopic thyroid: etiology, pathology and management. hormones (athens). 2011 oct-dec; 10(4): 261-269. pubmed pmid: 22281882. 3. oliver vj, rico rr, morillo ad, ruiz ef, ruiz jm, arcos jap, baro gr. tejido tiroideo ectopico intralaringeo. presentacion de un caso clinic y revision de la lieratura. acta otorrinolaringologia. 2001; (53): 54-59. 4. kumar choudhury b, kaimal saikia, u, sarma d, saikia m, dutta choudhury s, barua s, dewri s. dual ectopic thyroid with normally located thyroid: a case report. j thyroid res. 2011; 2011: 159703. doi: 10.4061/2011/159703; pubmed pmid: 21765986; pubmed central pmcid: pmc3134180. 5. ramalingam kk, ramalingam r, dhote k, murthy s. ectopic thyroid: a rare cause of tracheal obstruction. indian j otolaryngol head neck surg. 2005 jul; 57(3): 252-5. doi: 10.1007/ bf03008026; pubmed pmid: 23120184 pmcid: pmc3451353. 6. noussios g, anagnostis p, goulis dg, lappas d, natsis k. ectopic thyroid tissue: anatomical, clinical, and surgical implications of a rare entity. eur j endocrinol. 2011 sep; 165(3); 375-382. doi: 10.1530/eje-11-0461; pubmed pmid: 21715415. 7. van vliet g, deladoey j. sublinguel thyroid ectopy: similarities and differences with kallmann syndrome. f1000 prime rep. 2015 feb 3; 7:20. doi: 10.12703/p7-20; pubmed pmid: 25750738; pubmed central pmcid: pmc4335790. 8. de felice m, di lauro r. thyroid development and its disorders: genetics and molecular mechanisms. endocr rev. 2004 oct; 25(5): 722-746. doi: 10.1210/er.2003-0028; pubmed pmid: 15466939. 9. zander da, smoker wr. imaging of ectopic thyroid tissue and thyroglossal duct cysts. radiographics. 2014 jan-feb; 34(1): 37-50. doi: 10.1148/rg.341135055; pmid: 24428281. the mass itself.6 some studies support the efficacy of tsh suppression alone for asymptomatic/mild obstructive symptom patients with or without thyroid hormone derangements, as tsh suppression alone is proven to significantly decrease the size of the ectopic thyroid masses and stabilize the thyroid hormones.2 tsh suppression also decreases the risk for malignant transformation and prevents further growth of the mass.2 surgical excision is recommended for masses with severe obstructive symptoms, bleeding, ulceration, degeneration, or biopsy proven malignancy.6 an infraglottic thyroid, as found in our patient, may be removed using an open cricoid approach, co 2 laser, or harmonic scalpel if there are severe obstructive symptoms.2 radioactive iodine is reserved for those who are unstable to undergo surgery.6 management revolves around the patient as a whole in cases like these. children are especially sensitive to the effects of hypothyroidism and the importance of thyroid hormone stabilization cannot be overemphasized. surgery may be reserved for critical airway compromise, and watchful waiting with close follow up is currently the best option. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 case reports 18 philippine journal of otolaryngology-head and neck surgery abstract objective: to report a case of ectopic brain tissue in the nasopharynx; discuss the differential diagnoses for and management of, this unilateral nasal mass in a pediatric patient, and describe the diagnostic difficulties and eventual treatment. methods: study design: case report setting: tertiary government hospital participant: one results: a 13-year-old boy consulted with an obstructing mass in the nasopharynx and severe muscle wasting, weight below his age and concurrent anemia. ct-scan revealed a soft-tissue mass occupying a maxillary sinus and nasopharynx consistent with an antrochoanal polyp. initial biopsy revealed a papilloma, but the clinical picture warranted preoperative preparations for a possible vascular tumor such as juvenile angiofibroma. transpalatal excision and final histopathology yielded nasal glial heterotopia. conclusion: when confronted with a unilateral nasal mass in a pediatric patient, aside from the usual considerations, embryologic anomalies particularly those of the intracranial protrusion variety should be strongly considered. scrupulous preoperative evaluation and sufficient diagnostic modalities must be pursued in order to arrive at a correct diagnosis, treatment plan and prevent possible complications especially those related to intracranial communication. keywords: nasal glioma, glial heterotopia, congenital nasal masses tumors in the nasal cavity are rare in the pediatric age group. althought most are benign, they can cause serious problems in children. these lesions may arise from an inflammatory cause, neoplastic process or alteration during embryonic development. usually evident during infancy, some may remain unrecognized until late childhood. the diversity of presentation may not point to a specific cause, making it cumbersome for clinicians to diagnose. we report the case of a teenage boy who was diagnosed with, and managed for, a vascular tumor that later turned out a totally different entity. nasal glial heterotopia: unsuspected brain tissue in the nasopharynx dan valeriano f. daffon, md alberto f. calderon, md francisco a. victoria, md department of otorhinolaryngology head and neck surgery ospital ng maynila medical center correspondence: dr. dan valeriano f. daffon department of otolaryngology-head and neck surgery ospital ng maynila medical center quirino ave. corner roxas blvd., malate, manila 1004 philippines phone: (632) 524-6061 local 220 email: ommc_enthns@yahoo.com reprints will not be available from the author the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2013; 28 (2): 18-21 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 case reports philippine journal of otolaryngology-head and neck surgery 19 case report a 13-year-old boy was brought to us due to nasal obstruction of two years’ duration diagnosed as rhinosinusitis. he was prescribed unrecalled medications affording little relief. he tolerated the condition for another year as it progressed to a right unilateral nasal obstruction with associated episodes of epistaxis. his mother also noted a bulge in the soft palate but they did not consult at this time. a few months later, the mother noted hyponasal speech and a fleshy mass protruding into the oropharynx. the mass rapidly increased in size until it occupied half of the oropharynx, making it visible upon mere mouth-opening. marked weight loss with episodes of loud irregular snoring and subsequent nocturnal apneic episodes frequently disrupting sleep ensued. the boy exhibited a typical “skin and bone” appearance and increasingly became a mouth breather. persistent weakness prompted the family to finally consult at our institution. on physical examination, the boy was noted to be cachectic (figure 1a) with body mass index of 10.5kg/m2, severe muscle wasting and weight below his average age group. he also had a resting open-mouth facies and dull facial appearance. otolaryngologic examination was unremarkable except for peeled-grape-like mass in the right nostril on anterior rhinoscopy. there was also bulging of the soft palate and a fleshy mass protruding into the oropharynx. (figure 2a) with an impression of antrochoanal polyp, a ct-scan revealed a soft-tissue density filling the right maxillary sinus with complete obstruction and widening of the osteomeatal unit, consistent with a large polyp. (figure 3) the boy also developed anemia with haemoglobin at 8mg/dl, prompting admission and transfusion of 1 unit of packed red blood cells. on biopsy of the intranasal and oropharyngeal mass, the latter bled easily on minimal manipulation. fearing a vascular tumor, punch biopsy of the oropharyngeal mass was deferred. histopathologic figure 1. profile picture of the patient: a. at initial consult b. 6 months post-operatively figure 2. a. pre-operative oropharyngeal view revealing firm, solid nasopharyngeal mass protruding into oropharynx (left); and b. excised mass with gel-like consistency (right) examination of the intranasal specimen revealed an edematous stroma infiltrated with chronic inflammation lined with ciliated columnar epithelial cells exhibiting mild dysplastic and koilocytic changes consistent with a nasopharyngeal papilloma. because the clinical picture was inconsistent with this result, juvenile angiofibroma was presumptively diagnosed and a definitive plan for excision begun. a contrast ct-scan was deferred due to history of allergy. following caloric augmentation and with four units of fresh whole blood prepared, transpalatal excision was performed. intraoperatively, the mass was noted to be attached to the superior aspect of the posterior border of the septum. blunt dissection easily freed it from surrounding structures. grossly it measured 5 x 6cm, was firm, whitish and well encapsulated with a gel-like consistency. (figure 2b) estimated blood loss was 500cc. final histopathologic report revealed a mixture of mature astrocytes, glial fibers and fibrovascular connective tissue with a mild to moderate degree of fibrosis. there was no evidence of malignancy in all sections. (figure 4) the final diagnosis was nasal glial heterotopia. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 case reports 20 philippine journal of otolaryngology-head and neck surgery discussion a unilateral nasal mass in a pediatric patient should be regarded with a high level of suspicion even if it presents like a mere polyp (peeled-grape appearance). differential diagnoses should include vascular neoplasm (specifically juvenile angiofibroma), papilloma and even malignancy-and because of the age of the patient, embryologic anomalies. the rarity of nasal glial heterotopia as an embryologic anomaly is interesting but the twists and turns that followed the several changing impressions in managing this case made it even more interesting. the marked weight loss of this patient could be attributed to dysphagia from oropharyngeal obstruction, decreased appetite from anosmia of nasal obstruction, biopsychophysiologic consequences of chroinic illness (including the despair of isolation from friends, school absences and altered activities of daily living) as well as malignancy. with the peeled-grape appearance of this unilateral mass and the plain ct-scan results, it would have been easy to dismiss this as an antrochoanal polyp and proceed with endoscopic polypectomy. in hindsight, this would have been successful considering the narrow attachment to the posterior aspect of the nasal septum. with age, unilaterality and size of the mass factored in, prudence overcame the initial plan in favor of a biopsy of the anterior and oropharyngeal components. however, bleeding forestalled biopsy of figure 3: pns ct-scan: a. axial view (bone window) b. soft tissue density in the right maxillary sinus, mid to posterior aspect of the right nasal cavity and completely obstructing the nasopharyngeal airway c. sagittal view showing bony destruction of the right medial maxillary wall d. coronal view with completely obstructed and widened right osteaomeatal unit and patent left osteomeatal complex. figure 4: final histopathologic slides a. low power view (10x) b. high power view (100x), hematoxylin and eosin stain showing a mixture of mature astrocytes, glial fibers (arrow) and fibrovascular connective tissue with a mild to moderate degree of fibrosis. (hematoxylin and eosin, low power view10x) (hematoxylin and eosin, high power view100x) philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 case reports philippine journal of otolaryngology-head and neck surgery 21 references 1. kindblom lg, angervall l, haglid k. an immunohistochemical analysis of s-100 protein and glial fibrillary acidic protein in nasal glioma. acta pathol microbiol immunol scand a. 1984 sep; 92(5): 387-389. hirsh lf, stool se, langfitt rw, schut l. nasal glioma. 1. j neurosurg. 1977 jan; 46(1): 85-91, burkey b, koopmann cf, brunberg j. the use of biopsy in the evaluation of pediatric na-2. sopharyngeal masses. int j pediatr otorhinolaryngol. 1990 nov; 20(2): 169-179. ajose popoola o, lin hw, silvera vm, teot la, madsen jr, meara jg, rahbar r. nasal glioma: 3. prenatal diagnosis and multidisciplinary surgical approach. skull base rep. 2011 nov; 1(2): 8388. hodges fj. clinical evaluation and diagnosis of tumors of the paranasal sinuses and nasal cavity. 4. in: thawley s, panje w, batsakis j, lindberg r, editors. comprehensive management of head and neck tumors. philadelphia, pa: wb saunders; 1999. p. 511-18. magit ae. tumors of the nose, sinuses and nasopharynx. in: bluestone cd, stool se, alper c, 5. arjmand e, casselbrant m, dohar j, yellon r, editors. pediatric otolaryngology. 4th ed. philadelphia, pa: wb saunders; 2003. p. 1053-64. the latter. the histopathologic reading of “nasopharyngeal papilloma” for the former was incongruent with the nature and behavior of the mass. the thought of a male teen with a bleeding unilateral nasal mass made it extremely difficult not to consider a juvenile angiofibroma. after all was said and done, the mass turned out to be an embryologic nasal glial heterotopia. nasal glial heterotopia or “nasal glioma” represents heterotopic or “ectopic” mature glial tissue found in or around the nose.1 although the term implies a neoplasm, it is not a true neoplasm but a collection of normal tissue found in an abnormal location, or “choristoma.” in essence it is a congenital malformation with a male to female predominance of 3:1. this rare congenital anomaly is estimated to occur in 1:20,000 to 40,000 births.1 how can brain tissue present in the nasal cavity with an intact skull base? this results from alterations in embryologic events that produce the nose, frontal-basal skull and intracranial contents. such alterations include faulty closure of the anterior neuropore with defects in the fonticulus frontalis, foramen caecum, cribiform plate or sphenoid and ethmoid bones. gliomas or rests of neuroglial tissue result when brain tissue is isolated extracranially by the fusion of cranial sutures without the inclusion of meninges although a fibrous stalk may persist. hence, they remain unsuspected in the nasal cavity.2 about 30% of nasal gliomas are found intranasally, 60% extranasally, and only 10% in both locations.3 intranasal lesions usually present with nasal obstruction or nasal deformity,1 or may present as mass protruding from a nostril, or more frequently, as a pale, glistening, polypoid mass within the nasal cavity or nasopharynx as seen in this patient.2 rarely, there is epistaxis or spontaneous cerebrospinal fluid leakage.2 extranasal gliomas are firm, incompressible masses that often occur along the nasomaxillary suture or near the glabella. they do not transilluminate or expand with valsalva or crying (furstenberg test).4 the overlying skin may have telangiectasia and they may easily be confused with haemangiomas. the nasal bridge may be broadened and the space between the eyes may be widened.2 they are differentiated from nasal encephaloceles which always have a dural connection, transilluminate and have a positive furstenberg test.5 although rare, these are clinically important because of the potential for intracranial connection. overall, only 10 to 15% of gliomas have a connection to dura. intranasal gliomas are two to three times as likely to have such a connection compared to their external counterparts.5 therefore, office biopsies should be withheld without prior imaging studies and incisional biopsies should be performed with caution, if at all, under controlled circumstances in the operating room due to the risk of serious cerebrospinal fluid leak with subsequent intracranial infection risk.3 histologic examination reveals neuroglial tissue (astrocytes and connective tissue) without a true capsule.5 neurons are usually absent. rarely, choroid plexus, ependyma-lined clefts and pigmented retinal epithelium are seen especially those of the palate and nasopharynx. the glial tissue can be confirmed by immunoreactivity for glial fibrillary acidic protein (gfap) or s100 protein.1 the possibility of nasal glioma may be entertained based upon clinical evaluation and the use of adjunctive studies such as radiographic imaging scans (ct and mri). these may also reveal a soft tissue mass without an intracranial component or bony defect in the floor of the anterior cranial fossa tissue. even with high-resolution computed tomography and magnetic resonance imaging, the connection may be very small and unapparent.3 definitive diagnosis is often only possible after complete surgical excision.3 the preferred management for nasal glioma is surgical excision. if there is no evidence of intracranial communication external/ transfacial approaches are adequate. neurosurgical consultation may still be necessary if a previously unrecognizable tract is identified intraoperatively to be coursing to the skull base.2 intranasal gliomas, if small and lacking intracranial communication may be excised endoscopically. though this lesion has a slow growth rate and is benign without any potential for malignant degeneration, delays in treatment may lead to distortion of the septum and nasal bone, or infection. overall, recurrence rates of 4 to 10% have been reported.6 our patient had an uneventful recovery and regained an adequate body mass index with normal physical examination findings and no noted recurrence at six months. (figure 1b) when confronted with a unilateral nasal mass in a pediatric patient aside from the usual considerations, embryologic anomalies particularly those of the intracranial protrusion variety should be strongly considered. scrupulous preoperative evaluation and sufficient diagnostic modalities must be pursued in order to arrive at a correct diagnosis, treatment plan and prevent possible complications especially those related to intracranial communication. philippine journal of otolaryngology-head and neck surgery 7 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 original articles abstract objective: determine the frequency-specific thresholds of auditory steady state response (assr) of filipino children with absent auditory brainstem response (click-abr) results. methods: this is a cross-sectional study analyzing the frequency-specific thresholds of auditory steady state response (assr) of filipino children with absent auditory brainstem response (click-abr) results. the study population comprised of 99 pediatric patients referred for hearing assessment using electrophysiologic techniques at the ear unit of the philippine general hospital. the subjects underwent hearing threshold evaluation using both evoked-potential techniques (click abr and assr) within a one-month period from january 2009 to march 2014. the assr results of patients with absent click-abr were collected and analyzed. results: there were 99 patients who underwent both abr and assr. of the 65 patients with absent abr thresholds results, 13 patients had unilateral absent abr while 52 had bilateral absent abr results. the data of hearing tests from the combined 117 ears with absent abr hearing tests were collected. the proportion of children with assr thresholds with absent abr per frequency were: • 500 hz 45/117 (38.5 %); • 1000 hz 76/117 (64.0 %); • 2000 hz 63/117 (53.8 %); and • 4000 hz 41/117 (35.0 %). the proportion of children with assr thresholds with absent abr per number of frequencies were: • 4 frequencies 19/117 (16.2 %); • 3 frequencies 32/117 (27.4 %); • 2 frequencies 22/117 (18.8 %); and • 1 frequency 44/117 (37.6%) conclusion: in the absence of clickabr response, assr may provide information about the levels of severe to profound hearing loss among children. the criteria of selection of candidates for intervention (hearing aids or cochlear implantation) should include results from hearing evaluation not only from behavioral and abr thresholds but also from assr thresholds. this may ensure that exclusion of some children with severe and profound hearing loss who may benefit from the intervention will be minimized. keywords: profound sensorineural deafness, evoked response audiometry, hearing thresholds with the implementation of universal newborn hearing screening in the world including the philippines, more children will be identified at birth with hearing loss and subsequently evaluated for intervention. for young children, early diagnosis of hearing loss and early intervention with amplification or cochlear implantation allow access to sound and the potential to develop speech, language and listening skills needed for oral communication.1,2 however, for a subset of hearing-impaired children with severe to profound hearing loss, current evaluation for auditory steady state response (assr) frequency-specific thresholds with absent auditory brainstem response (click-abr) test results among filipino children romeo l. villarta jr., md, mph1 maria luz m. san agustin, rn, mclinaudio2 1department of epidemiology and biostatistics college of public health university of the philippines manila 2ear unit philippine general hospital university of the philippines manila correspondence: dr. romeo l. villarta jr. department of epidemiology and biostatistics college of public health university of the philippines manila 625 pedro gil st., ermita, manila 1000 philippines phone: (632) 526 0784 telefax.: (632) 525 4239 email: rvillartajr@upm.edu.ph reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2014; 29 (2): 7-9 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 original articles 8 philippine journal of otolaryngology-head and neck surgery fitting of hearing aids or cochlear implants presents a special problem. estimates of profound, early-onset deafness are around 4–11 per 10,000 children in the united states.3 current testing for children with severe to profound hearing using click-abr (auditory brainstem response) and behavioral test methods is limited by the inability to obtain frequencyspecific thresholds.4 an absent auditory brainstem response does not allow meaningful conclusions about the amount of residual hearing. the estimation of residual hearing is relevant to the selection of a right habilitation strategy particularly in children with severe or profound hearing loss where the loss is overestimated by abr.5 however, auditory steady-state response (assr), an evoked potential test, can accurately measure auditory sensitivity beyond the limits of other test methods.4 the assr system’s primary advantage over the standard evoked potential test is the ability to differentiate between severe and profound hearing loss as well as distinguishing between levels of profound hearing losses, e.g. the difference between a 90db and a 110db hearing loss. this ability to differentiate is crucial in instances where a cochlear implant is being considered as well as accurately fitted amplification. unlike abr testing which does not differentiate the severe and profound levels, the assr evaluation in combination with the behavioral methods currently used will make earlier identification of hearing loss even more accurate and this is essential for the management of infants with severe to profound hearing loss.6,7 to the best of our knowledge, there are no published philippine studies that quantify the assr frequency-specific thresholds of children with severe and profound hearing loss diagnosed with negative or absent response to click-abr. this study would provide an estimate of the numbers of possible children with residual hearing who may be excluded from hearing intervention if the decision is based only on behavioral and abr hearing thresholds. the objective of this study was to determine the frequency-specific thresholds of auditory steady state response (assr) of filipino children with absent auditory brainstem response (click-abr) results. methods the cross-sectional study involved analysis of the frequency-specific thresholds of auditory steady state response (assr) of filipino children with absent auditory brainstem response (click-abr) results. sample population: children referred for hearing assessment at the ear unit of the philippine national ear institute and philippine general hospital because of the inability of conducted behavioral tests to provide reliable estimates of hearing sensitivity were included in the study. the children who participated in this study underwent hearing threshold evaluation using both evoked-potential techniques (click abr and assr). data collection: medical and audiologic records containing the abr and assr results of children seen from january 2009 to march 2014 were reviewed. only the records of children who underwent both abr and assr testing within a 1-month interval period were included in the study. a written informed consent of the parents or legal guardian of each child was solicited. the university of the philippines manila ethics review board approved the research protocol. all patients were tested using the standard testing protocol for abr and assr of the ear unit of the philippine general hospital.8 if deemed necessary using standard clinical procedure, the patient was sedated using chloral hydrate. audiologic testing made use of the biologic® master® ii multiple auditory steady-state evoked response machine (natus medical incorporated, san carlos, ca, usa). the first test performed was the click-abr. the results were recorded using biologic navigator® evoked potential system. surface electrodes were applied to the high forehead (active), the ipsilateral mastoid process (ground) and the contralateral mastoid process (reference). electrode impedances never exceeded 3kohms. the click rarefaction polarity stimulus consisting of 100µs pulses of a maximum of 95db nhl at a rate of 13.3/sec and a filter of 30 -1500hz bandwidth with an amplifier gain of 10,000. time window of 20msec were used to record the click-abr. at each presentation level, a minimum of 1500 sweeps was averaged. a 10db increment or decrement was used to determine the threshold. threshold was defined by visual inspection of the waveform displayed on the computer screen. assr testing immediately followed while the patient was still asleep or sedated. patients were tested at 10db above the previously determined abr thresholds when available. increments of 10db and decrements of 10db were used depending on the required number of sweeps per frequency and threshold. patients tested for thresholds of 80db hl and above were tested mono-aurally, one frequency at a time. data analysis: the results were codified as shown in tables 1 and 2. a retrospective review of the records of patients with absent abr results was performed and the data inputted in an excel® spreadsheet (microsoft corporation, usa) containing among others, the hospital record number, name, age, abr thresholds and assr thresholds (for right and left ear). descriptive statistical data analysis was performed using stata 11® statistical software (statacorp lp, texas, usa). results there were 99 patients who underwent both abr and assr within a 1-month period from january 2009 to march 2014. there were 47 males (52.5%) and 52 females (47.5%) with mean age of 3.6 years (sd=1.9 and range: 0.6 10). of the 99 patients, 65 patients had absent abr thresholds results: 13 patients with unilaterally absent abr results and 52 with bilaterally absent abr results. the data of hearing tests from the combined 117 abr hearing tests were collected. the proportion of children with assr frequency-specific thresholds with absent abr per frequency is shown in table 3. more than half of the patients with absent click-abr had assr thresholds in the 1000 hz (64%) and 2000 hz (54%) levels. more than a third of patients had assr philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 original articles philippine journal of otolaryngology-head and neck surgery 9 thresholds in the 500 hz (38%) and 5000 hz (35%) levels. the proportion of children with assr frequency-specific thresholds with absent abr per number of frequencies is shown in table 4. less than half (44%) of the patients had assr thresholds in three or more frequencies. for those with other frequencies of assr thresholds, the results were still significant (1 frequency – 38%; 2 frequencies – 19%). discussion relying on the evidence provided by click-abr alone as basis for intervention planning for hearing loss such as prescription for hearing aid amplification and cochlear implantation would underestimate the number of children who may benefit from intervention. the results of the study show that around 35 – 64 % of children with absent abr results have residual hearing shown in the assr thresholds in each references 1. yoshinaga-itano c, sedey a, coulter dk, mehl al. language of early and later identified children with hearing loss. pediatrics. 1998;102:1161-1171. 2. moeller mp. early intervention and language development in children who are deaf and hard of hearing. pediatrics. 2000 sep;106(3):e43. 3. marazita ml, ploughman lm, rawlings b, remington e, arnos ks, nance we. genetic epidemiological studies of early-onset deafness in the u.s. school-age population. am j med genet. 993 jun; 46(5): 486–491. 4. stueve mp, o’rourke ca. comparison of auditory steady-state response, auditory brainstem response, and behavioral test method. am j audiol. 2003 dec;12(2): 125-136. 5. marttila ti, karikoski jo. comparison between audiometric and abr thresholds in children. contradictory findings. eur arch otorhinolaryngol. 2006 may; 263(5): 399–403. 6. firszt jb, gaggl w, runge-samuelson cl, burg ls, wackym pa. auditory sensitivity in children using the auditory steady-state response. arch otolaryngol head neck surg. 2004 may; 130(5): 536-40. 7. lee hs, ahn jh, chung jw, yoon th, lee ks. clinical comparison of the auditory steady-state response with the click auditory brainstem response in infants. clin exp otorhinolaryngol. 2008 dec; 1(4): 184–188. 8. tan lc, reyes-quintos mr, tantoco mc, chiong cm. comparative study of the auditory steadystate response (assr) and click auditory brainstem-evoked response (click abr) thresholds among filipino infants and young children. philipp j otolaryngol head neck surg. 2009 jan-jun; 24 (1): 9-12. 9. kandogan t, dalgic a. reliability of auditory steady-state response (assr): comparing thresholds of auditory steady-state response (assr) with auditory brainstem response (abr) in children with severe hearing loss. indian j otolaryngol head neck surg. 2013 dec; 65(suppl 3):604-7. 10. swanepoel d, hugo r. estimations of auditory sensitivity for young cochlear implant candidates using the assr: preliminary results. int j audiol 2004 jul-aug; 43(7): 377–382. 11. joint committee on infant hearing. year 2007 position statement: principles and guidelines for early hearing detection and intervention programs. pediatrics. 2007 oct; 120(4): 898-921. table 1. coding manual for data entry for abr thresholds ear (left or right) data entry for abr thresholdspatient id 30 db to 95 db or absent response table 2. coding manual for data entry for assr thresholds ear (left or right) assr thresholds (frequency) data entrypatient id 20 db to 114 db or absent response 20 db to 120 db or absent response 20 db to 120 db or absent response 20 db to 120 db or absent response 500 hz 1000 hz 2000 hz 4000 hz table 3. proportion of children with assr thresholds and absent click-abr results: assr thresholds (frequency) proportion 45/117 (38.5 %) 76/117 (64.0 %) 63/117 (53.8 %) 41/117 (35.0 %) 500 hz 1000 hz 2000 hz 4000 hz table 4. proportion of children with multiple assr thresholds frequencies and absent click-abr results: number of assr thresholds frequencies proportion 19/117 (16.2 %) 32/117 (27.4 %) 22/117 (18.8 %) 44/117 (37.6 %) 4 3 2 1 tested frequency. furthermore, around 16% exhibit assr thresholds in 4 frequencies. clearly these numbers are significant. these findings confirm the conclusions of several studies that in children with no response abr, additional electrophysiologic testing be conducted to acquire a more complete assessment of the child’s hearing.6,9 the study results also support the contention of swanepoel and hugo that preliminary results indicate that absent abr and behavioral thresholds do not preclude the possibility of residual hearing, making the assr a primary source of information regarding profound levels of hearing loss.10 health personnel involved in planning intervention for children with severe to profound hearing loss should consider that evidence based on behavioral and abr hearing thresholds alone may exclude children with possible residual hearing. the benefit of the assr is that the results may provide more frequency-specific threshold information for children who have severe to profound hearing losses. this information would provide more precise data to proceed with hearing aid fittings or determining cochlear implant candidacy. it should be noted however that the joint committee on infant hearing (jcih) 2007 position statement does not recommend assr as the sole measure of auditory status in newborn and infant populations.11 reliance on click-abr alone for hearing evaluation may result in overestimation of the prevalence of hearing loss. even in the absence of results of clickabr thresholds, assr may provide information about the residual hearing of children with profound hearing loss. the criteria used in selection of candidates for intervention (hearing aids or cochlear implantation) should include results from hearing evaluation not only from behavioral and abr thresholds but also from assr thresholds. this may minimize the exclusion of some children with profound hearing loss who may benefit from the intervention. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery case reports abstract objective: to present a rare case of inverted papilloma of the middle ear in a 77-year-old man presenting with an external auditory canal polyp of the right ear. methods: design: case report setting: tertiary private hospital patient: one results: a 77-year-old man presenting with external auditory canal mass underwent tympanoplasty with canal wall down mastoidectomy. histopathologic examination revealed inverted papilloma. conclusion: with only 30 cases reported in the literature, inverted papilloma of the middle ear is a rare disease entity that may mimic other benign conditions such as cholesteatoma. it requires further investigation to devise a rational approach to diagnosis and management. regular postoperative monitoring is essential due to high recurrence and malignant transformation rate while post-operative radiotherapy remains controversial and requires further investigation. keywords: inverted papilloma, cholesteatoma, middle ear middle ear infection and its symptoms are quite common in our setting such that consultation and management (mostly surgical) are often delayed. mastoidectomy with or without tympanoplasty usually suffices for straightforward aural polyps and cholesteatoma but what if a presumed common condition turns out to be something unexpected and rare? we report one such case. inverted papilloma of the middle ear presenting as an aural polyp dann joel c. caro, md department of otorhinolaryngology head and neck surgery university of santo tomas hospital correspondence: dr. dann joel c. caro department of otorhinolaryngology head and neck surgery university of santo tomas hospital españa blvd., sampaloc, manila 1015 philippines phone: +63 917 562 2786 email: dann.caro@gmail.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery interesting case contest. june 30, 2016. unilab bayanihan center, pasig city. philipp j otolaryngol head neck surg 2018; 33 (1): 34-38 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery case reports case report a 77-year-old hypertensive man consulted due to progressive hearing loss in his right ear. since childhood, he experienced recurrent episodes of right aural discharge that persisted until adulthood. there were no consults or medications. four years prior, he noticed decrease in hearing acuity in the right ear with otorrhea and ear pain. his hearing progressively worsened prompting consult in our institution. on physical examination, there was no gross deformity of the auricle and no tragal tenderness noted on both ears. video otoscopy showed a pinkish, fleshy, mass with smooth surface and irregular borders in the right ear, characteristic of an aural polyp. (figure 1) the mass obstructed 70% of the external auditory canal limiting the view of the tympanic membrane. minimal whitish discharge was also noted. the left middle ear appeared normal. figure 1. a. video otoscopy (still image) shows the polypoid mass occupying the right external auditory canal; b. normal otoscopy of the left ear a b a b figure 2. plain ct scan, a. axial view showing a soft tissue density occupying the antrum (*) extending to the external auditory canal (**); b. coronal view shows blunting of the scutum (***) plain computed tomography scan of the temporal bone showed a soft tissue density in the antrum and epitympanum extending to the external auditory canal of the right ear on axial view and blunting of the right scutum on coronal view. the middle ear ossicles were not identified in the right ear. (figure 2) pure tone audiometry revealed mild sensorineural hearing loss on the left and profound mixed hearing loss on the right ear. tympanometry revealed a type a tympanogram on the left and a type c tympanogram on the right ear. with an impression of chronic otitis media as, active with cholesteatoma formation, a canal wall down mastoidectomy with tympanoplasty via post auricular approach with temporalis fascia underlay graft, ossiculoplasty and meatoplasty was performed on the philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery case reports figure 3. histopathologic sections (hematoxylin – eosin), a. scanning view showing tissue fragments lined by hyperplastic respiratory epithelium; and b. low power view [10x magnification] showing epithelial surface inversion inside the stroma characteristic of inverted papilloma (hematoxylin – eosin , 10x) (hematoxylin – eosin , 10x) figure 4. a. video otoscopy (still image) 3 months post-operatively showing no recurrence of otorrhea and aural mass in the right external auditory canal; b. normal otoscopy of the left ear a b a b right. intraoperatively, a firm, fleshy, polypoid mass in the middle ear cavity extending to the mastoid antrum was completely removed. whitish epithelial debris was also noted in the middle ear cavity. significantly, there was no mass observed in the eustachian tube opening. surgical specimens submitted for histopathology consisted of the aural polyp, cholesteatoma and middle ear mass. the cholesteatoma was confirmed as such but the aural polyp and middle ear tissue were diagnosed as consistent with inverted papilloma. (figure 3) the post-operative course was uneventful with unremarkable twoweek and three-month follow ups. there was no ear canal mass and the tympanoplasty graft was intact. (figure 4) repeat pure tone audiometry showed profound mixed hearing loss in the right ear. discussion “the presence of an aural polyp in a chronically infected ear should be considered to be a cholesteatoma until proven otherwise.”1 our patient presented with a polypoid external auditory canal mass on the background of a 20-year history of chronic otorrhea with imaging findings suggestive of cholesteatoma. hence, the patient was managed as an aural polyp. biopsy of the ear canal mass was not done preoperatively and we proceeded directly with mastoidectomy as it is the definitive management for cholesteatoma. however, an unexpected result of inverted papilloma was the final histopathologic finding of the middle ear mass. aural polyps are granulation tissues usually found at the junction philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery case reports between an eroding cholesteatoma and bone.1 like the tip of an iceberg, an aural polyp may contain significant clues to a serious underlying infection or benign lesions such as cholesteatoma. grossly, an aural polyp may be described as a solitary, polypoid, hyperemic mass, often friable, obstructing the view of the tympanic membrane as seen in our patient.2 other benign lesions such as inverted papilloma of the middle ear may also present as an external auditory canal mass. however, it is not surprising that inverted papilloma was not initially considered due to the extreme rarity of the case.3 ear canal malignancies may also present as such. however, clinical course and radiologic evidences may differ from a simple condition of cholesteatoma. shuang et al. described the radiologic findings of malignant ear canal and middle ear conditions. both squamous cell carcinoma and adenocarcinoma present radiologically as a hypodensity on ct imaging signifying necrosis and involvement of the deep structures such as subcutaneous tissues, petrous bone and carotid artery wall in both conditions on mri.4 these findings were not present in our patient. inverted papilloma, also called “schneiderian papilloma” is a common tumor arising from schneiderian epithelium of the nasal cavity and paranasal sinuses.5 it is the second most common benign tumor of the nose and paranasal sinuses and is the most common surgical indication for benign sinonasal tumor.5 inverted papilloma can also be found in other areas of the body such as the urinary tract specifically the urinary bladder and in extremely rare conditions, it could also arise in the middle ear. as of 2012, rubin et al. 3 reported there were only less than 20 cases of inverted papilloma in the literature. however, our search of the english literature on medline (pubmed), embase and google scholar using the keywords “inverted papilloma,” “inverting papilloma,” “ear canal,” “middle ear,” “aural,” yielded a total of 31 cases as of may 2018. inverted papilloma of the nose and paranasal sinuses may arise due to several factors. occupational hazards such as outdoor and industrial occupations and exposure to different smokes, dust and aerosols, may all be considered potential risk factors.6,7 however, for inverted papilloma in the middle ear, no research has been published to our knowledge that associates occupational hazards with middle ear papilloma. while it seems interesting that this patient worked as a traffic enforcer for five years exposing himself to various pollutants encountered in the streets, we can only conjecture that the background underlying chronic otitis media with a persistent tympanic membrane perforation may have exposed the middle ear to environmental pollutants that may have predisposed to developing a middle ear papilloma. another etiology of sinonasal papillomas include infection with human papilloma virus (hpv) specifically strains 6 and 11. however, this concept remains controversial for the middle ear.4,8 of the three hypotheses proposed by rubin et al., the first is migration of paranasal sinus inverted papilloma cells via the eustachian tube, as suggested by the considerable percentage of patients with an ipsilateral paranasal sinus inverted papilloma.4 in our patient, imaging showed no signs of nose and paranasal sinus involvement. post-operative nasal endoscopy showed no signs of an intranasal mass either. thus, development of papilloma in our patient may be explained by the second (an abnormality of embryonic migration of ectopic schneiderian membrane into the mucosa of the middle ear) or third hypothesis (chronic otitis media stimulating the development of schneiderian mucosa).4 otorrhea and hearing loss are the main symptoms associated with inverted papilloma of the middle ear.3,8 additionally, pou et al. reported its frequent association with persistent middle ear effusion and ipsilateral sinonasal tumors.11 although middle ear papilloma may be different from sinonasal papilloma in terms of epidemiology and pathology, both are locally aggressive, have a high tendency to recur and are associated with malignancy.4,9,10 the malignant transformation rate for middle ear papilloma is 35.3%, higher than that observed in paranasal sinus inverted papilloma and the recurrence rate is 56.25%.4 the difference may be attributed to the difficulty of complete resection of inverted papilloma in the complex middle ear and mastoid cavity compared to the large paranasal sinuses.4 it is also worth noting that recurrence and malignant transformation is usually observed in cases with which sinonasal inverted papilloma was initially diagnosed and managed prior to middle ear involvement. in the summary of case reports by kainuma et al., recurrence is almost always noted in cases of simultaneous sinonasal and middle ear papilloma.11 on the other hand, primary inverted papilloma of the middle ear showed no recurrence except for two cases wherein the surgeon did conservative surgeries prior to radical mastoidectomy.11 hence, we can only assume that middle ear papilloma with sinonasal involvement has more aggressive features compared to primary middle ear inverted papilloma and requires more meticulous follow-up surveillance. still, its similarities to cholesteatoma in terms of presentation, clinical course, local aggressiveness and morphology makes the diagnosis difficult and is only confirmed on final histopathology after the surgery. one dilemma in middle ear papilloma is the management. although all would agree that surgery is the mainstay of treatment, it is difficult to define a standard surgical strategy based on limited data available in the literature.4 current recommendations include complete surgical excision followed by long term surveillance for newly diagnosed cases, while post-operative radiotherapy is reserved for recurrent disease philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery acknowledgements i would like to express my gratitude to the following, whose contributions were of utmost significance in the accomplishment of this report. dr. marichu florence ciceron-gloria, who performed the surgery and shared this case; dr. cristopher ed gloria, who assisted in the surgery, for sharing valuable inputs on the case and contributing to its presentation; and dr. emmanuel dela cruz, who assisted in the surgery, for his accurate description of the intraoperative findings that were included in the report. references 1. chole r. chronic otitis media, mastoiditis, and petrositis, in: flint pw, haughey bh, lund vj, niparko jk, robbins kt, thomas jr, et al. cumming’s principles of otolaryngology. 6th edition, volume 2. philadelphia pa 19103-2899: elsevier saunders. 2015.p. 2141. 2. friedmann i. pathological lesions of the external auditory meatus: a review. j r soc med. 1990 jan; 83(1): 34–37. pmcid: pmc1292463 pmid: 2406442. 3. rubin f, badoual c, moya-plana a, malinvaud d, laccourreye o, bonfils p. inverted papilloma of the middle ear. eur ann otorhinolaryngol. 2012 aug; 129(4);207-10. doi: 10.1016/j. anorl.2012.02.002; pmid: 22921721. 4. xia s, yan s, zhang m, cheng y, noel j, chong v, et al. radiological findings of malignant tumors of external auditory canal: a cross-sectional study between squamous cell carcinoma and adenocarcinoma. medicine (baltimore). 2015 sep; 94(35): e1452. doi: 10.1097/ md.0000000000001452; pmid: 26334907 pmcid: pmc4616505. 5. nicolai p, castelnuovo p. benign tumors of the sinonasal tract. in: flint pw, haughey bh, lund vj, niparko jk, robbins kt, thomas jr, et. al, cumming’s principles of otolaryngology. 6th edition, volume 1, philadelphia pa 19103-2899: elsevier saunders. 2015. p. 741. 6. d’errico a, zajacova j, cacciatore a, baratti a, zanelli r, alfonzo s, et al. occupational risk factors for sinonasal inverted papilloma: a case-control study. occup environ med. 2013 oct; 70(10):703-8. doi: 10.1136/oemed-2013-101384; pmid: 23739491. 7. deitmer t, wiener c. is there an occupational etiology of inverted papilloma of the nose and sinuses? acta otolaryngol. 1996 sep; 116(5):762-5. pmid: 8908257. 8. acevedo-henao cm, talagas m, marianowski r, pradier o. recurrent inverted papilloma with intracranial and temporal fossa involvement: a case report and review of the literature. cancer radiothér. 2010 jun; 14(3): 202-5. doi: 10.1016/j.canrad.2010.01.012; pmid: 20418144. 9. blandamura s, marioni g, de fillippis c, giacomelli l, segato p, staffieri a. temporal bone and sinonasal inverted papilloma: the same pathological entity? arch otolaryngol head neck surg. 2003 may; 129(5):553-6. doi: 10.1001/archotol.129.5.553; pmid: 12759269. 10. pou am, vrabec jt. inverting papilloma of the temporal bone. laryngoscope. 2002 jan; 112(1):140-2. doi: 10.1097/00005537-200201000-00024; pmid: 11802052. 11. kainuma k, kitoh r, kenji s, usami s. inverted papilloma of the middle ear: a case report and review of the literature. acta oto-laryngologica. 2011; 131:216-220. doi: 10.3109/00016489.2010.498025. and tumors with malignant transformation.4,8,10,11 however, it is still necessary to conduct further investigations to come up with a rational and standard approach in the management of this rare condition. in summary, middle ear inverted papilloma is a rare disease entity. awareness of this rare disease makes us more careful in the management of benign conditions such as cholesteatoma of the middle ear that may present similarly. further investigations are required to identify the risk factors and its etiology and to come up with a rational approach to its management. complete excision is necessary but performing extensive surgery such as temporal bone resection or postoperative radiotherapy are still controversial. post-operatively, its high recurrence rate and possibility of malignant transformation require close monitoring and should include repeated otoscopic examination and imaging procedures such as ct scan or mri. case reports philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports philippine journal of otolaryngology-head and neck surgery 23 abstract objective: to present a rare case of facial schwannoma manifesting as a parotid mass and discuss its diagnosis and treatment. methods: design: case report setting: tertiary government hospital patient: one results: a 48-year-old female was seen for a 2-year progressive left hemifacial paralysis and a 5-month gradually enlarging left infraauricular mass with episodes of tinnitus but intact hearing and balance. physical examination showed a left-sided house-brackmann grade vi facial paralysis and a 5 x 4 x 3 cm soft, ill-defined, slightly movable, nontender, left infraauricular mass. gadolinium-enhanced magnetic resonance imaging revealed a 5 cm heterogeneouslyenhancing lobulated mass centered within the deep lobe of the left parotid gland extending to the left mastoid, with facial nerve involvement. a diagnosis of a facial nerve tumor, probably a schwannoma, was entertained. pure tone audiometry revealed normal hearing thresholds for both ears with dips at 6-8 khz on the left. the patient underwent total parotidectomy with facial nerve tumor resection via transmastoid approach, with simultaneous facial – hypoglossal nerve anastomosis reconstruction. histopathologic findings confirmed the diagnosis of a schwannoma. postoperative facial function was grade vi. hearing and hypoglossal nerve function were preserved. conclusion: a progressive hemifacial paralysis of chronic duration with or without the presence of an infra-auricular mass should raise the suspicion of a facial nerve tumor. gadolinium-enhanced magnetic resonance imaging is valuable since intraparotid facial nerve schwannomas are mostly diagnosed intraoperatively when the neoplasm and the nerve are exposed and determined to be contiguous. the clinician should be aware that not all parotid masses are salivary gland in origin. keywords: intraparotid facial nerve schwannoma, facial nerve paralysis, parotid mass intraparotid facial nerve schwannoma with temporal bone extension alexander t. laoag, m.d.1 antonio h. chua, m.d.1, 2 thanh vu t. de guzman, m.d.1 samantha s. castañeda, m.d.1, 3, 4 jose a. malanyaon, jr., m.d.1,5 1department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center 2department of otorhinolaryngology head and neck surgery university of the east – ramon magsaysay memorial medical center 3department of otorhinolaryngology head and neck surgery the medical city 4department of otorhinolaryngology head and neck surgery rizal medical center 5department of otorhinolaryngology head and neck surgery east avenue medical center correspondence: dr. alexander t. laoag department of otorhinolaryngology jose r. reyes memorial medical center san lazaro compound, rizal ave., sta. cruz, manila 1003 philippines phone: (632) 711 9491 local 320 fax: (632) 743 6921 e-mail: alexanderlaoag_md@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the clinical case report contest, philippine society of otolaryngology – head and neck surgery, taal vista hotel, tagaytay city philippines april 24, 2010 philipp j otolaryngol head neck surg 2012; 27 (1): 23-27 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 24 philippine journal of otolaryngology-head and neck surgery case reports gradual facial paralysis in a patient with infra-auricular mass most often indicates a parotid malignancy.1 however, if the tumor grows toward the facial canal, facial nerve schwannoma should be suspected.2 schwannomas are benign, slow growing neoplasms of ectodermal origin that arise from schwann cells. these tumors are usually solitary, well encapsulated and tend to splay the nerve of origin. although approximately one third of all of these lesions occur in the head and neck, facial nerve schwannomas are rare with less than 500 cases reported in literature — mostly intratemporal and less than 70 with parotid involvement. 3 the estimated frequency of parotid tumors originating in the facial nerve ranges from 0.2% to 1.5%. preoperative diagnosis of this tumor in the parotid gland is usually difficult because of the low occurrence of the disease and few distinctive signs associated with it. 1, 2 patients may present with a painless facial mass, progressive facial weakness or paralysis and audiovestibular symptoms (hearing loss, tinnitus, and instability). despite a characteristic microscopic appearance, the firmly attached cells in tumors of neurogenic origin make obtaining positive cytology difficult; therefore, fine needle aspiration may not be a useful diagnostic modality in the evaluation of parotid schwannoma. a gadolinium-enhanced magnetic resonance imaging might only be indicative but not pathognomonic. therefore, intraparotid facial nerve schwannomas are mostly diagnosed intraoperatively when the neoplasm and the nerve are exposed and directly visualized.4 management is quite difficult considering the possible need for resection resulting in severe facial nerve paralysis with important aesthetic and functional consequences. the aim of this article is to discuss a rare case of a facial nerve schwannoma initially presenting as an infraauricular mass preceded by a long-standing facial nerve paralysis. case report a 48-year-old female consulted with a 2-year history of progressive left hemifacial paralysis and a 5-month history of a gradually enlarging left infraauricular mass. she complained of episodes of tinnitus but hearing and balance were intact. she was initially treated by a general practitioner for acute cerebrovascular infarct versus bell’s palsy. gadolinium-enhanced magnetic resonance imaging (mri) of the brain revealed a 5 cm heterogeneously-enhancing lobulated mass centered within the deep lobe of the left parotid gland extending to the left mastoid with facial nerve involvement. (figure1) she was referred to our department. physical examination findings a figure 1. t2-weighted magnetic resonance images showing the 5 cm heterogeneously enhancing lobulated mass centered within the deep lobe of the left parotid gland a. extending to the left mastoid with facial nerve involvement b. arrowhead. b s showed a left-sided house-brackmann grade vi facial paralysis and a 5 x 4 x 3 cm soft, ill-defined, slightly movable, nontender, left infraauricular mass. otoscopy was unremarkable. tympanic membranes were both intact. there was no bulging or medialization of the left tonsillar area. a parotid malignancy was initially suspected. upon review of the mri, a facial nerve tumor, probably a schwannoma was entertained. pure tone audiometry (pta) revealed normal hearing threshold in both ears, with philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports philippine journal of otolaryngology-head and neck surgery 25 dips at 6000-8000hz on the left. the patient underwent total parotidectomy with facial nerve resection. a well-encapsulated, slightly-adherent, tan-brown mass was seen continuous with the facial nerve at the pes anserinus. the capsule contained yellowish, caseous material with light-brown, slightly-turbid fluid amounting to 3 ml. the mass, which seemed more like a dilated trunk of the facial nerve was followed as it passed through the stylomastoid foramen through the mastoid area with minimal erosion of the posterior canal wall. (figure 2a) the nerve was resected via transmastoid figure 2. intraoperative findings a. the dilated nerve trunk was followed as it passed through the stylomastoid foramen. involved segments were resected and access to the intratemporal segment was done via transmastoid approach (top photo). b. a schematic diagram showing the tumor. c. primary anastomosis of the facial and section of half of cn xii using interrupted epineural sutures with 9-0 monofilament nylon was performed (left). d. a schematic diagram of the procedure (right). b d a c approach from the pes anserinus up to the vertical segment before it entered the middle ear at the level of the tympanic membrane. (figure 2b) the frozen section margins of resection of both proximal and distal ends of cn vii were void of tumor. a primary anastomosis of the facial nerve trunk and section of half of cranial nerve xii was performed using interrupted epineural sutures with 9-0 monofilament nylon. (figure 2c) the use of a hemihypoglossal – facial nerve anastomosis instead of the classic technique prevented total denervation of the tongue to avoid post-operative hemi-tongue atrophy. histopathologic findings were 26 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports consistent with schwannoma. postoperative facial function was housebrackmann grade vi. speech and hearing remained intact. (figure 3) discussion parotid masses are commonly seen in the practice of head and neck surgery and almost 80% of them are benign. the presence of facial nerve paralysis may indicate compression and/or raise the suspicion of malignancy that warrants radiographic imaging and fineneedle aspiration biopsy. however, not all cases point to parotid tissue pathology. our patient initially presented with non-specific, gradual onset facial nerve paralysis. it was only after some time that an infra-auricular mass was noted warranting referral to an ent specialist. we initially suspected a parotid malignancy most probably an adenoid cystic carcinoma due to its tendency for perineural invasion. however, the peculiar presentation of paralysis preceding a parotid mass was a cause for concern. was it really a parotid malignancy invading the facial nerve causing the facial paralysis? did the neoplasm eventually spread via the nerve, through the stylomastoid foramen, hence the mastoid involvement? if so, the parotid mass had manifested quite late – two years after the facial paralysis. parotid malignancies such as adenoid cystic carcinoma typically present with skip lesions and would not involve the entire facial nerve on imaging.2 moreover, malignancies tend to contiguously spread to areas of least resistance. if it were a primary parotid lesion, a softtissue or parapharyngeal extension would have been more probable. the mri findings in our patient of an intraparotid mass with temporal bone extension following the course of a well-delineated and enlarged facial nerve led to a seemingly more logical impression of a facial nerve schwannoma. if this were the case, then the lesion may have primarily occurred on the main trunk and followed a proximal course. a highresolution temporal bone ct-scan together with a facial nerve mri would have been beneficial for surgical planning but the financial resources for these were not available. the surgical management of schwannomas is challenging. the aim of surgery is complete tumor excision with preservation of the facial and hearing nerve functions.4 many authors insist that it is beneficial to operate as early as possible but some prefer to delay surgery until the facial nerve function deteriorates to at least a hb grade iii. resection is favored in nearly all cases and nerve decompression for a selected few. the final decision of whether to resect facial nerve schwannomas remains contentious because of the benign and slow growing nature of the tumor.3 intraparotid facial nerve schwannomas are classified for management options. type a (41.3%) and b neoplasms can be resected without apparent aesthetic and functional compromise. type c neoplasms involve the main trunk of the nerve and type d involve both the main trunk and its main divisions. in type c and d tumors, patients with hb < 3 warrant biopsy and physicians may adopt conservative management and follow-up after ruling-out malignancy. patients with hb > 4 require resection +/reconstruction. reconstruction options include end-to-end anastomosis, nerve grafting and facial – hypoglossal nerve anastomosis.5 our case involved three issues: first was the timing and extent of surgery. resection of the affected segment of the facial nerve was based on the extent of the lesion and preoperative facial function. the lesion was classified as type d and facial function was hb vi. the gradualonset facial paralysis of chronic duration should have triggered a higher index of suspicion for a tumor, and additional diagnostic procedures such as imaging could have been done earlier.6 early identification and intervention would have provided a higher chance of recovering satisfactory facial nerve function.1 second was the type of facial reanimation surgery. a temporalis muscle facial sling could have been appropriate.7 however, the decision for hemihypoglossal – facial nerve anastomosis was a consensus of the surgical team lead by a neurootologist and a microvascular surgeon. (figure 2) casas1 and roland8 report satisfactory outcomes for facial to hypoglossal nerve anastomosis even for patients with longstanding paralysis of more than two years. there is no advantage for any particular type of reconstruction, with the best recovery being hb grade iii function.5 the impact of a facial nerve disorder can be dramatic. disabilities encountered include corneal exposure of the affected figure 3. post-operative audiogram: philippine journal of otolaryngology-head and neck surgery 27 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports acknowledgements we would like to acknowledge dr. elias t. reala for assisting in the surgery; and dr. rolando a. lopez for reading the specimen slides. references 1. casas p, lassaletta l, sarriá mj, gavilán j. facial nerve schwannomas: management and facial function results. turk arch otolaryngol. 2007 jan; 45(1): 26-32. 2. shimizu k, iwai h, ikeda k, sakaida n, sawada s. intraparotid facial nerve schwannoma: a report of five cases and an analysis of mr imaging results. ajnr am j neuroradiol. 2005 jun-jul; 26(6): 1328–1330. 3. caughey rj, may m, and schaitkin bm. intraparotid facial nerve schwannoma: diagnosis and management. otolaryngol head neck surg. 2004 may; 130 (5): 586 – 592. 4. chung jw, ahn jh, kim jh, nam sy, kim cj, lee ks. facial nerve schwannomas: different manifestations and outcomes. surg neurol. 2004 sep; 62(3): 245–52. 5. alicandri-ciufelli m, marchioni d, mattioli f, trani m, presutti l. critical literature review on the management of intraparotid facial nerve schwannoma and proposed decision-making algorithm. eur arch otorhinolaryngol. 2008 dec 19; 266(4): 475-479. 6. lapeña jf, chiong cm. the tip of the iceberg: not all that palsies is bell’s: a series of five facial nerve neurilemmomas in the philippines. first place. philippine society of otolaryngology – head and neck surgery descriptive research contest, 1997 sep 26 and presented at the 8th asean orl-hns congress, davao city. 1998 oct 5-9,. (e-publication on the web) cited in: litre cf, gourg gp, tamura m, mdarhri d, touzani a, roche ph, régis j. gamma knife surgery for facial nerve schwannomas. neurosurgery. 2007 may; 60(5): 853-859. 7. hadlock ta, cheney ml, mckenna mj. facial reanimation surgery. in: nadol jb jr, mckenna mj, editors. surgery of the ear and temporal bone. philadelphia (pa): lippincott williams and wilkins; 2005. 461-472. 8. roland jt jr, lin k, klausner lm, miller pj. direct facial-to-hypoglossal neurorrhaphy with parotid release. skull base: an interdisciplinary approach: 2006 apr; 16: 101–108 (cited 2012 feb 10). available from:http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1502037/pdf/ sbs16101.pdf. 9. levine, re. modern management and rehabilitation of the eye in facial paralysis. acoustic neuroma association notes: 2002 sep; 83 (cited 2012 jan 30). available from: http://www. levine-eyesurgery.com/[ub/modern.pdf. eye, oral incompetence and articulation difficulties, and functional nasal obstruction. it would have been better if we had incorporated adjunctive reanimation techniques to augment the results of our facial to hemihypoglossal neurorraphy. eyelid gold weights, tarsorraphy, endoscopic browlift and facial sling could have been offered as interim therapies in conjunction with the nerve anastomosis.7 during the six or more month waiting period for nerve regeneration/ recovery, eye rehabilitation should be instituted to prevent excessive corneal exposure leading to ophthalmologic complications. the patient was advised to apply lubricating ophthalmic drops, occlusive dressing and cross taping of the eyelids to narrow the lid fissure and decrease drying. if incomplete lid closure persists, surgical reanimation can be performed.9 the third issue concerned the surgical approach and preservation of hearing. pre-operatively, the patient did not complain of audiovestibular symptoms other than infrequent episodes of tinnitus. most of the surgical approaches to the intratemporal segment of the facial nerve may result in a sensorineural or conductive hearing loss. it is therefore prudent to inform the patient of the risks and possible consequences of surgery. fortunately, our patient’s lesion was sufficiently exposed via a transmastoid approach. because the ossicular and labyrinthine structures were virtually untouched, our patient’s hearing and balance remained intact. (figure 3) a progressive hemifacial paralysis of chronic duration with or without the presence of an infra-auricular mass should raise the suspicion of a facial nerve tumor. gadolinium-enhanced magnetic resonance imaging is valuable since intraparotid facial nerve schwannomas are mostly diagnosed intraoperatively when the neoplasm and the nerve are exposed and determined to be contiguous. the clinician should be aware that not all parotid masses are salivary gland in origin. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 letter to the editor 38 philippine journal of otolaryngology-head and neck surgery dear editor, reconstruction of mandibular defects resulting from ablative surgery for benign and malignant tumors remains a reconstructive challenge. for the past decade, the fibular free flap has been the workhorse for large mandibular defects because of its length, versatility and ability to be harvested with a skin paddle for soft tissue closure. although its success rate has continuously improved to almost 95%, donor site morbidity remains a matter of concern.1,2 bone grafts are already widely used in dental surgery but only as fillers for chipped or marginal defects and not for large segmental mandibular defects. we present a new technique of reconstructing segmental mandibular defects using bone grafts combined with autologous platelet-rich fibrin (prf), a biomaterial derived intra-operatively from the patient that incorporates leukocytes, platelets, growth factors, and a wide range of glycoproteins in a dense fibrin matrix. moreover, we describe the essential role of prf in bone healing and regeneration that offers an invaluable reconstructive option that is free of donor site morbidity without sacrificing the main goal of reconstruction in restoring both form and function. keywords: mandibular reconstruction, segmental mandibular defect, bone graft, autologous platelet-rich fibrin (prf) materials and methods subject and indications a 23-year-old male underwent reconstruction with allogenic bone graft in combination with autologous platelet-rich fibrin (prf) for a large segmental angle to parasymphyseal mandibular defect. (figure 1) in this example, the authors’ technique for segmental mandibular defect reconstruction using bone grafts with prf was best performed as a second stage procedure following tumor ablation to prevent contamination from oral cavity secretions. as with any elective procedure, a thorough review of the medical history, control of systemic disease and informed consent were necessary. patients with contraindications for fibular free flaps, such as history of peripheral vascular disease, unfavorable imaging of the lower extremity, venous insufficiency, and anomalous lower extremity vasculature may benefit from this technique.3 patients who had failed mandibular reconstruction with other methods such as those reconstructed with single alloplastic material, titanium plate, non-vascularized autologous bone graft or free flaps are likewise candidates for this option. combination of autologous platelet-rich fibrin and bone graft: an invaluable option for reconstruction of segmental mandibular defects correspondence: dr. adrian f. fernando the head & neck reconstructive surgery fellowship consortium department of otorhinolaryngology head & neck surgery 4/f jose r. reyes memorial medical center san lazaro compound, rizal avenue, manila 1003 philippines phone: (632) 711 9491 local 320 fax: (632) 7436921 e-mail: ianfernando_md@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2013; 28 (1): 38-42 c philippine society of otolaryngology – head and neck surgery, inc. adrian f. fernando, md1 joselito f. david, md1,2,3,4 1the head & neck reconstructive surgery fellowship consortium, department of otorhinolaryngology head & neck surgery jose r. reyes memorial medical center manila, philippines 2 department of otorhinolaryngology head & neck surgery east avenue medical center quezon city, philippines 3 department of otorhinolaryngology head & neck surgery jose r. reyes memorial medical center manila, philippines 4 department of otorhinolaryngology head & neck surgery university of sto. tomas hospital manila, philippines philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 philippine journal of otolaryngology-head and neck surgery 39 letter to the editor procedure a submandibular incision was made and a sub-platysmal flap was raised to expose the entire length of the mandibular defect. apart from the preservation of vital structures in the area, it was important not to violate the oral mucosa to prevent contamination of the reconstruction site. a cortico-cancellous allogenic bone graft (maxgraft®, botiss medical ag, berlin, germany) was fitted to the mandibular defect and anchored with bicortical screws (2.5; 2.8 mm, lengths 14-20 mm) to a pre-bended 2.5 mm reconstruction titanium plate (modus reco 2.5, medartis, hochbergerstrasse basel switzerland). the remaining gaps between the inlaid grafts were filled with the remaining cancellous bone and biomimetic composite materials. (figure 2) although allogenic bone grafts with cortical and cancellous components are recommended for mandibular ramus and condylar reconstruction as these regions are composed of nearly 100% cortical bone, xenogenic (cerabone®, botiss medical ag , berlin, germany) or combined alloplastic material(maxresorb®, botiss medical ag , berlin, germany) bone grafts may be used in other regions. (figure 3) figure 1. ameloblastoma. (a) panoramic radiograph of a 23-year old male who underwent segmental mandibuletomy (broken lines) for ameloblastoma. (b) 10 days post-resection imaging of the mandible. figure 3. different bone graft materials. (a) human or allogenic cortico-cancellous bone graft (broken arrow); (b) xenogenic bone graft; (c&d) biomimetic composites xenogenic bones that may be crushed or injected. figure 4. blood centrifugation. (a) intra-operatively extracted venous blood are placed in (b) plain 10 cc collecting tubes for centrifuge with the (c&d) the pc-o2 unit (pc-o2, process, nice, france) for prf processing. figure 2. anchoring of bone grafts. mandibular reconstruction with cortico-cancellous bone grafts (open arrow) anchored to reconstruction plate and covered with a collagen membrane material (bold arrow). meanwhile, venous blood was simultaneously drawn from the patient and placed in a 10 cc glass collecting tube for single centrifuge processing using a pc-o2 centrifuge (pc-o2, process, nice, france). the specific centrifuge processes eight uncoated tubes using a standard protocol specially manufactured for processing prf using 33° tube angulation at 2700 rpm’s, soft spin for 12 minutes.4 (figure 4) at the end of the centrifugation process, three distinct fractions of blood components were produced where the intermediate fraction composed of dense prf clot was used. the other blood components separated by the centrifugation process serum or platelet-poor plasma (ppp) philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 letter to the editor 40 philippine journal of otolaryngology-head and neck surgery and red blood cell concentrates, were respectively situated in the superficial and bottom layers of the collecting tube. the prf clots were then transferred to a prf processing box (prf box®, process, nice, france) to prepare standardized membranes and harvest the prf exudates in a sterile environment.5 (figure 5) collagen material of native pericardium (gtr/gbr) membrane (jason® membrane, botiss medical ag, berlin, germany) was placed underneath the graft recipient site and the processed prf membranes were layered over the graft recipient site to stimulate osteoblastic differentiation and neoangiogenesis.6 the neomandible and allowing osteogenesis and angiogenesis.7 commercially available collagen biomaterials vary from native collagen membrane to enhanced ca/p collagen composite materials such as the 3d-stable collagen graft (mucoderm®, botiss medical ag, berlin, germany) with larger available sizes for long mandibular defect coverage. the skin was closed in the usual manner and the patient was initially maintained on a liquid diet, progressing to a soft diet over 2-4 weeks. plain panoramic radiographs after a week confirmed proper alignment of the bone grafts and monthly radiographic series was recommended for the first 6 months after reconstruction. results monthly panoramic radiographs for the first six months after reconstruction showed absence of bone resorption. a 3d reconstruction ct imaging of the mandible was done after 10 months for placement of three osteo-integrated dental implants. (figure 7) bone biopsies were also taken in conjunction with placement of dental implants, and sent to the university of bonn, germany for histologic evaluation. (figure 8) the trichromestained specimens showed new mineralized tissues consisting of woven bone characterized by high numbers of distributed osteocytes and irregularly arranged fiber bundles within the new bone matrix confirming bone regeneration. (figure 9) the latest panoramic radiograph of the patient at 26 months after surgery showed absence of gaps between the bone grafts and their junction with the normal mandible, evincing complete bone regeneration and a successful mandibular reconstruction. (figure 10) a total of 14 cases of segmental mandibular defects have been reconstructed by the authors using the particular technique from january 2011 to february 2013 with 100% success rate and will be reported as a series in the near future. figure 5. processing of prf. (a) diagram of a harvested blood after centrifugation using the pc-o2 protocol wherein the intermediate fibrin clot layer (*) is processed in a sterile environment (b) to separate the fibrin clot and other blood components to produce (c) leukocyte-rich prf membranes. figure 6. establishing a membrane barrier. the entire recipient site is enveloped with native pericardium membranes (bold arrow) to mechanically secure the autologous prf (blank arrow) in contact with the bone grafts. figure 7. radiographic series. (a) plain panoramic radiograph 10 days after the procedure showing proper alignment of biomaterials. plain radiograph (b) and 3d ct imaging (c) of the neomandible 4 and 9 months after respectively shows absence of bone resorption. the entire recipient site was then enveloped with the collagen material, mechanically securing the autologous prf in contact with the bone grafts. (figure 6) this established a membrane barrier for guided bone regeneration (gbr) and guided tissue regeneration (gtr) by preventing growth of undesired cells inside philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 philippine journal of otolaryngology-head and neck surgery 41 letter to the editor figure 8. bone biopsy & placement of osteo-integrated implants. (a) biopsy of the neomandible for histologic evaluation at 9 months post-reconstruction in conjunction to the sites of dental implants. figure 10. latest radiographic series. (a) gaps between the graft and the remaining mandible (arrows) 10 months after the procedure . (b) after 36 months, absence of previously noted gaps confirms continuous bone regeneration (circles). figure 9. histologic evaluation. (a&b) bone graft/matrix (nb-new bone, bg-bone graft) stained with trichrome showed presence of new mineralized tissues consisting of woven bone characterized by high number of distributed osteocytes and irregularly arranged fiber bundles within the new bone matrix osteocytes (arrow) evident of bone regeneration. (by dr. daniel rothamel, university of bonn, germany, october 2011) discussion advancements in mandibular reconstruction have continued to develop over the past decades. the use of alloplastic materials like titanium plating implants for repairing mandibular defects provided patients with rapid rigid mandibular restoration but was limited by numerous complications such as infection, plate extrusion, and subsequent failure. recently, the concept of distraction osteogenesis, involving bone distraction with an external mechanical device and progressive lengthening of the bone to allow a gap of new bone during the consolidation phase has also been used for mandibular reconstruction but has been limited by poor scar formation, delayed return to function, and inadequate formation of desired bone length.8 the advent of microvascular reconstructive surgery enabled the transfer of vascularized osseous flaps with the most commonly used fibular free flap showing superior results over non-vascularized bone transfer and better quality of life outcome. however, it did not remain free of donor-site morbidities.9 tissue engineering led to the development and use of bone grafts that hold promise for the future of head and neck repair.10 numerous clinical studies demonstrated the utility of tissue engineering in developing bone grafts for mandibular defect reconstruction.11 such have already been widely used over the past decades in oro-maxillary and dental reconstruction, including the recombinant bone morphogenetic protein (rhbmp-2) that is now used with great success in cleft palate repair, alveolar ridge augmentation, and sinus lift procedures.12 autogenous bone grafts derived from the patient work through osteogenesis, osteoinduction and osteoconduction. however, such are not recommended because apart from enabling a philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 letter to the editor 42 philippine journal of otolaryngology-head and neck surgery references 1. spiegel jh, derosa j. mandibular reconstruction. in: lalwani ak, ed. current diagnosis & treatment in otolaryngology-head & neck surgery. 2nd ed. new york, new york: mcgraw-hill medical; 2008:367-373. 2. hidalgo da, rekow a. a review of 60 consecutive fibula free flap mandible reconstructions. plast reconstr surg. 1995 sep;96(3):585-96; discussion 597-602. 3. lohan dg, tomasian a, krishnam m, jonnala p, blackwell ke, finn jp. mr angiography of lower extremities at 3 t: presurgical planning of fibular free flap transfer for facial reconstruction. ajr am j roentgenol. 2008 mar;190(3):770-6. 4. del corso m, vervelle a, simonpieri a, jimbo r, inchingolo f, sammartino g, et al. current knowledge and perspectives for the use of platelet-rich plasma (prp) and platelet-rich fibrin (prf) in oral and maxillofacial surgery part 1: periodontal and dentoalveolar surgery. curr pharm biotechnol. 2012 jun;13(7):1207-30. 5. dohan dm, choukroun j, diss a, dohan sl, dohan aj, mouhyi j, gogly b. platelet-rich fibrin (prf): a second-generation platelet concentrate. part iii: leucocyte activation: a new feature for platelet concentrates? oral surg oral med oral pathol oral radiol endod. 2006 mar;101(3):e51-5. 6. choukroun ji, braccini f, diss a, giordano g, doglioli p, dohan dm. nfluence of platelet rich fibrin (prf) on proliferation of human preadipocytes and tympanic keratinocytes: a new opportunity in facial lipostructure (coleman’s technique) and tympanoplasty?. rev laryngol otol rhinol (bord). 2007;128(1-2):27-32. 7. schwarz f, rothamel d, herten m, sager m, becker j. angiogenesis pattern of native and crosslinked collagen membranes: an immunohistochemical study in the rat. clin oral implants res. 2006 aug;17(4):403-9. 8. mehta rp, deschler dg. mandibular reconstruction in 2004: an analysis of different techniques. curr opin otolaryngol head neck surg. 2004 aug;12(4):288-93. 9. bozec a, poissonnet g, chamorey e, casanova c, vallicioni j, demard f, et al. free-flap head and neck reconstruction and quality of life: a 2-year prospective study. laryngoscope. 2008 may;118(5):874-80. 10. torroni, a. engineered bone grafts and bone flaps for maxillofacial defects: state of the art. j oral maxillofac surg. 2009 may;67(5):1121-7. 11. von wilmowsky c, schwarz s, kerl jm, srour s, lell m, felszeghy e, et al. reconstruction of a mandibular defect with autogenous, autoclaved bone grafts and tissue engineering: an in vivo pilot study. j biomed mater res a. 2010 jun 15;93(4):1510-8. 12. herford as, boyne pj. reconstruction of mandibular continuity defects with bone morphogenetic protein-2 (rhbmp-2). j oral maxillofac surg. 2008 apr;66(4):616-24. 13. dohan dm, choukroun j. prp, cprp, prf, prg, prgf, fc. how to find your way in the jungle of platelet concentrates? oral surg oral med oral pathol oral radiol endod. 2007; 103(3): 305306. 14. dohan ehrenfest dm, de peppo gm, doglioli p, sammartino g. slow release growth factors and thrombospondin-1 in choukroun’s platelet-rich fibrin (prf): a gold standard to achieve for all surgical platelet concentrates technologies. growth factors. 2009 feb;27(1):63-9. 15. hämmerle ch, lang np. single stage surgery combining transmucosal implant placement with guided bone regeneration and bioresorbable materials. clin oral implants res. 2001 feb;12(1):9-18. donor site morbidity-free technique, they are best harvested as microvascular flaps. allogenic bone grafts on the other hand are cadaveric processed grafts that may be cortical, trabecular, or combined in composition and have both osteoconductive and osteinductive properties. xenografts or processed animal bone graft are a subgroup of the synthetically manufactured alloplasts known to form new bones from their osteoconductive activities. the use of autologous prf is already widely used in combination with bone grafts for dental surgeries but not for large mandibular defects.13 our reconstructive technique using bone grafts for large segmental mandibular defects emphasizes the important role of prf with its intrinsic factors and leukocyte contents that release high amounts of growth factors such as tgbß1, pdgf-ab, vegf and matrix glycoproteins.14 collagen membrane used to envelop the entire recipient site creates a membrane barrier to prevent the growth of soft tissues and allow angiogenesis within the neomandible.15 fascia lata may be used as a membrane barrier but defeats the authors’ goal of an absolute donor site morbidity-free procedure. overall, this particular technique along with gentle tissue handling and avoidance of oral cavity contamination for reconstructing large mandibular defects has been found to enhance bone regeneration capable for osteo-integrated dental implantation. generally, the harvesting and processing of autologous prf is simple and inexpensive. its use with bone grafts is a good substitute for segmental mandibular reconstruction in patients with contraindications to free flap procedures or in cases where patients simply wish to be free from any donor-site morbidity. however, this technique is limited to defects secondary to trauma and ablation of benign conditions as bone regeneration is expected in approximately 6 to 9 months. mandibular defects following resection of malignant oral neoplasms are still best reconstructed with fibular free flaps as radiation therapy is warranted at the soonest possible time. histologic validation of bone regeneration and osteoblastic activity index for the 13 other cases performed by the authors using this particular technique necessitates bone research centers that are capable of advanced bone analysis, and none are locally-available at this time. meanwhile, this technique of combining autologous prf in bone grafting remains an innovative and invaluable option for mandibular reconstruction today. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 original articles 10 philippine journal of otolaryngology-head and neck surgery abstract objective: to describe the clinical presentation and course of seven ectopic thyroid patients. methods: design: retrospective chart review setting: tertiary government teaching hospital patient: seven patients results: five patients were female and two were male (ratio of 5:2). three belonged to the 20 to 30 year-old age group, whereas two were below 10 years of age. all seven were biochemically hypothyroid and ectopic thyroid was found to be the only functioning thyroid tissue.three patients were managed medically with levothyroxine, while ectopic thyroid was excised in four. ectopic thyroid tissue was autotransplanted in two cases following excision. conclusion: the ages of presentation in the present series correspond with the increased physiological demand of thyroid hormone. thyroid substitution therapy is a must in the presence of clinical and/or biochemical hypothyroidism. surgical excision should be avoided as far as possible especially if the ectopic tissue is the only functioning thyroid in the body. surgery is required in selected cases presenting with obstructive symptoms or hemorrhage which are unresponsive to substitution therapy. auto transplantation of the ectopic thyroid may not provide significant benefit to the patient and more research is warranted in this aspect. keywords: ectopic thyroid, lingual thyroid, thyroid replacement therapy, ectopic thyroid surgery when thyroid tissue is not in its normal anatomical location, it is called an ectopic thyroid. ectopic thyroid tissue can be found anywhere between the foramen caecum and the normal position of the thyroid gland, and may be the sole functioning thyroid tissue of the body. it is most frequently found in the region of the foramen caecum in patients where the gland fails to descend. extralingual thyroid tissue is most commonly located in the anterior cervical area in the region of thyroglossal duct.1 sometimes, ectopic thyroid may be found in unusual anatomic locations like the heart, gall bladder and in the trachea.2,3,4 we describe the clinical presentation, location, functional status, course and management of seven patients with ectopic thyroid. ectopic thyroid tissue – a case series somnath saha, ms1 anirban ghosh, ms1 sudipta pal, ms1 v padmini saha, mch2 1department of ent & hns r. g. kar medical college & hospital kolkota, west bengal, india 2department of plastic & reconstructive surgery r. g. kar medical college & hospital kolkota, west bengal, india correspondence: dr. sudipta pal 223, lane no.-3, jhilparj j.c. khan road, p.o: mankundu dist: hoogly, west bengal pin: 712139 india phone: +919051757391/ +919231535309 email: drsudiptapal@gmail.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2013; 28 (1): 10-14 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 original articles philippine journal of otolaryngology-head and neck surgery 11 methods a retrospective chart review was conducted in a tertiary care institution, medical college hospital, kolkata after obtaining institutional ethical board clearance. all patients who were clinically suspected to have an ectopic thyroid tissue and were subjected to radiotracer scanning along with conventional radiological and biochemical investigations between january 1999 and december 2007 were included in our search protocol. among these cases, those patients where documentary proof of ectopic thyroid was present were included in the study. patients having any malignant change in the ectopic tissue demonstrated by fine-needle aspiration cytology (fnac) were excluded from the study. demographic data, clinical presentation and location of ectopic thyroid, thyroid function status (free t3, free t4 and tsh) and results of iodine 131 thyroid scans and ct scans were recorded. medical and surgical treatments as well as follow ups were also obtained and analyzed. results of the 13 patients suspected to have ectopic thyroid within the study period, five patients were excluded (one with tongue base leiomyoma, two with secondarily-infected vallecular cysts, two with cervical lymphadenitis masquerading as ectopic thyroid tissue). eight patients were confirmed to have ectopic thyroid, but one of the eight had follicular neoplasm reported by fnac and was further excluded from the study. thus a total of seven patients were included in the review, of whom five patients were female and two were male (ratio of 5:2). three belonged to the 20to 30-year-old age group, whereas two were below 10 years of age. (table 1) four of these seven patients presented with lingual masses and three had midline neck masses. all four patients presenting with lingual thyroid complained of dysphagia. (figure 1) in addition, two of these patients also had bleeding from the mouth and one had respiratory difficulty. the patients with midline neck masses usually complained of a cosmetic problem. (figure 2) biochemically, all patients were hypothyroid and thyroid scans showed ectopic thyroid as the only functioning thyroid tissue in each patient. midline-neck ectopic thyroids were diagnosed by fnac, whereas lingual thyroids were diagnosed by clinical and radiological examination. thyroid scintigraphy was performed in all cases. (figure 3) ct scans were only performed in the cases of lingual thyroid. three out of four lingual thyroids were excised because of obstructive symptoms. of these, one had auto-transplantation of excised thyroid tissue. only one patient with midline-neck ectopic thyroid was surgically treated and received auto-transplantation. younger patients with little or no compressive table 1. no sex age presentation/ symptoms site treatment 1 2 3 4 5 6 7 f f m f m f f 7 22 18 23 8 26 17 midline neck swelling midline neck swelling; pain lingual mass, dysphagia, bleeding, respiratory difficulty. lingual mass, dysphagia midline neck swelling lingual mass, dysphagia lingual mass dysphagia, bleeding suprahyoid subhyoid base of tongue base of tongue subhyoid base of tongue base of tongue thyroid substitution therapy excision & autotransplantation excision & autotransplantation excision followed by thyroid substitution therapy thyroid substitution therapy excision followed by thyroid substitution therapy thyroid substitution therapy or other symptoms were treated with thyroxin suppression therapy only. regardless of treatment modality all patients received life-long levothyroxine replacement therapy. figure 1. clinical photograph showing ectopic thyroid tissue at the base of tongue in subject number 6, who presented with dysphagia. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 original articles 12 philippine journal of otolaryngology-head and neck surgery discussion a medline search through pubmed using the keywords “ectopic” and ”thyroid” yielded 1603 results. most of the available literature featured case reports with one or two cases each. only four case series or reviews were found with more than five cases.4, 5, 6,7 apart from this, two case series of congenital hypothyroidism were found with more than five cases each of ectopic thyroid.8,9 late in the first month of life the anlage of the thyroid gland descends from the posterior dorsal midline of the tongue (actually the floor of the pharyngeal gut) to its final position in the lower neck. the developing thyroid gland descends ventral to the hyoid bone and laryngeal cartilages. the initial site of descent eventually becomes the foramen caecum, located in the midline at the junction of the dorsum of tongue and the tongue base. if the embryonic gland does not descend normally, ectopic or residual thyroid tissue (technically eit a choristoma) may be found between the foramen caecum and the epiglottis.10 kaplan et al. studied 30 children with ectopic thyroid gland with a female: male ratio of 2:1. nine children were diagnosed within their first year of life.5 in the kem hospital study comprised of 36 patients, female preponderence was also noticed (female: male ratio of 11:7). age of presentation was from five months to 40 years (mean age 14.3 years) in the same study.6 yoon et al. reviewed 30 cases of ectopic thyroid reported in the korean medical literature and added 19 cases from their institution. in this review, most cases of ectopic thyroid were diagnosed in patients aged between 1 and 29 years; it was also found to be more common in females (43 patients).4 in the present series, most of the patients were under 30 years of age with definite female preponderance. lingual thyroid tissue in the region of the tongue base adjoining the foramen caecum is the most common site in all the case series. okstad et al. reviewed cases of thyroid ectopia over a period of 10 years. there were five cases of total ectopia; three of these were lingual thyroid, one was situated in the perihyoid region which had been clinically diagnosed as a thyroglossal cyst, while the fifth presented as a tumor in the lateral neck.11 in the korean study, lingual thyroid was found in 23 patients, a sublingual thyroid in 17 patients, combined type in seven patients, a prelaryngeal thyroid in one patient, and an intratracheal thyroid in one patient. only in four cases was the thyroid gland in the normal position.4 in the kem hospital study, 17 patients (47%) presented with lingual thyroid and 19 patients (53%) had sublingual thyroid, which mainly presented as an anterior neck swelling.6 in this study, most of the cases were lingual thyroid followed by subhyoid midline neck mass. ectopic thyroid may present with symptoms from infancy to adulthood. depending on the patient’s age, the symptoms may be drastic: infants and young children, whose lingual thyroid is detected figure 2. axial contrast enhanced ct scan at the level of the oropharynx showing the location of ectopic thyroid in the tongue base in subject number 6. figure 3. i131 scan showing uptake of the radiotracer superior to the normal location of the thyroid without any uptake at the normal site. the + sign in the picture denotes the suprasternal notch which proves absence of normal thyroid tissue. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 original articles philippine journal of otolaryngology-head and neck surgery 13 via routine screening may suffer from failure to thrive and mental retardation or may present with respiratory or feeding difficulty.12 growth retardation was the most common clinical finding at the time of diagnosis in kaplan’s series.5 in the neck, it may present as a midline neck mass mimicking thyroglossal cyst in early childhood. in the kem series 53% of patients presented with an anterior neck swelling.6 some cases may present with slowly progressing dysphagia and other symptoms of oropharyngeal obstruction before or during puberty, or even during pregnancy. this occurs as a response to the increased demand for thyroid hormone in these hypermetabolic states. in the korean study, chief complaints at presentation were palpable mass in 20 patients, growth retardation in 10 patients and a sensation of lump in the throat in six patients.4 carcinomatous changes may occur in median ectopic thyroid and in lingual thyroid.13,14 nodal metastasis in lingual thyroid is also reported.14 in our series, dysphagia, sensation of lump in the throat, midline neck mass and bleeding per mouth were the presenting symptoms. clinical examination of ectopic thyroid includes a thorough head and neck examination with palpation of the thyroid gland to detect its location in the normal site. indirect laryngoscopy usually detects lingual thyroid and flexible laryngoscopy is required to document the size of the mass. functionally 30-70% of the reported cases were hypothyroid and 70% had cervical athyrosis.15 in the korean study, 26 of 42 patients (61.9%) had hypothyroidism, and 16 patients (38.1%) were euthyroid.4 in the kem study, 83% had hypothyroidism.6 in this series, all cases were biochemically hypothyroid. functioning at marginal levels, they are subject to excessive thyroid stimulating hormone (tsh) stimulation, with resulting hyperplasia and compensatory enlargement. occasionally, ectopic thyroid may present with features of hyperthyroidism likes graves’ disease and graves’ ophthalmopathy.16 regarding investigations, i131 and tc99 scanning are useful to detect the presence of ectopic thyroid tissue in the neck or in the base of the tongue. i131 scanning also alleviates the need for fine needle aspiration biopsy in lingual thyroid. however fnab is still used in ectopic thyroid in the neck. on ct scans, ectopic thyroid tissue appears to be hyperdense and shows contrast enhancement.7 jaromír et al. classified heterotopic thyroid tissue into three groups. group 1 is named the ectopy dystopy group. arrest of descent presenting as lingual, sublingual or subhyoid thyroid hypertrophy belongs to the ectopic subgroup. simultaneous descent with the foetal basis of heart results in intrathoracic or primary retrosternal goiter (dystopy). group 2 consists of accessory thyroid tissue & aberrant thyroid tissue. accessory thyroid tissue develops in the midline in the presence of normal thyroid tissue in its physiological position. descent of thyroid outside the midline results in aberrant thyroid; however it has to be differentiated from metastasis of well differentiated thyroid cancer. group 3 or heterotopic thyroid tissue consists of teratogenic development of thyroid tissue. struma ovarii or abdominal thyroid tissue are examples of teratogenic development of thyroid.17 the management of ectopic thyroid is still a controversial issue. the primary factor to be considered in management planning is the high incidence of absence of normal thyroid gland. long et al. reviewed first 10 described cases of ectopic thyroid, where five of the cases underwent excision. all the five cases developed myxedema. the rest of the five cases that underwent auto transplantation of excised tissue remained clinically euthyroid.18 surgical excision and auto-transplantation of thyroid tissue followed by lifelong thyroid substitution therapy provides results similar to excision of the tissue alone followed by thyroid replacement therapy. however auto-transplantation is associated with more surgical time and auto-transplantation without a vascular pedicle may lead to failure. moreover, malignant changes may occur in autotransplanted ectopic thyroid tissue.13,14 in the kem series, 86% were treated medically, and surgery was performed in only 14% of cases with either recurrent bleeding or dysphagia.6 rahbar et al. reviewed four cases of lingual thyroid from the children’s hospital boston that underwent surgical excision of the mass followed by lifelong hormonal replacement. they observed that majority of patients with lingual thyroid require surgical excision of the symptomatic mass, and in case of absence of orthotopic thyroid tissue, long-term thyroid hormone replacement is needed.12 in the korean series, 22 patients received thyroid supplement whereas 11 patients underwent surgical excision.4 in the present series, symptomatic lingual thyroid and midline neck mass needed surgical excision with or without auto-transplantation. the rest of the patients were treated with thyroxin suppression therapy. while many authors advocate surgical excision of all ectopic thyroid tissue for fear of malignant changes, the risk of malignant changes in ectopic thyroid tissue may not be significantly greater than in colloid goitre or thyroid nodule – therefore vigilant follow up of the patient may be an acceptable management of choice rather than aggressive surgical removal.18,19 in summary, ectopic thyroid is an uncommon entity that is more common in females. the age ranges and symptoms of presentation of ectopic thyroid vary from series to series and depend on two factors: 1) presence of normal thyroid gland along with ectopic thyroid; and 2) thyroid hormone secreting capacity of the ectopic thyroid tissue. thyroid scintigraphy and ct scans remain the radiological investigations of choice. thyroid status must be assessed in all cases of midline neck swelling and in base of tongue swelling, as the majority of these philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 original articles 14 philippine journal of otolaryngology-head and neck surgery references 1. damiano a, glickman ab, rubin js, cohen af. ectopic thyroid tissue presenting as a midline neck mass. int j pediatr otorhinolaryngol. 1996;34(1-2):141-8. 2. comajuan sm, ayerbe jl, ferrer br, quer c, camazón nv, sistach ef, capllonch fg, baliarda xr, tudela vv. an intracardiac ectopic thyroid mass. eur j echocardiogr. 2009 jul; 10(5):704-6. 3. liang k, liu jf, wang yh, tang gc, teng lh, li f. ectopic thyroid presenting as a gallbladder mass. ann r coll surg engl. 2010;92(4):w4-6. 4. yoon js, won kc, cho ih, lee jt, lee hw. clinical characteristics of ectopic thyroid in korea. thyroid. 2007;17(11):1117-21. 5. kaplan m, kauli r, lubin e, grunebaum m, laron z . ectopic thyroid gland. a clinical study of 30 children & review. j pediatr. 1978;92(2):205-209. 6. gopal ra, acharya sv, bandgar t, menon ps, marfatia h, shah sn. clinical profile of ectopic thyroid in asian indians: a single-center experience. endocrine practice 2009; 15(4):322-325. 7. aktolun c, demir h, berk f, metin kir k. diagnosis of complete ectopic lingual thyroid with tc99m pertechnetate scintigraphy. clin nucl med 2001nov; 26(11): 933-5. 8. beltrão cb, juliano ag, chammas mc, watanabe t, sapienza mt, marui s. etiology of congenital hypothyroidism using thyroglobulin and ultrasound combination. endocr j. 2010;57(7):587-93. 9. tamam m, adalet i, bakir b, türkmen c, darendeliler f, baş f, sanli y, kuyumcu s. diagnostic spectrum of congenital hypothyroidism in turkish children. pediatr int. 2009;51(4):464-8 10. bahçeci s, tuzcu a, kemeç z, tuzcu s. lingual thyroid, a rare embryological aberration of thyroid gland and primary hypothyroidism . turk jem. 2007;11:98-100. 11. okstad s, mair iw, sundsfjord ja, eide tj, nordrum i. ectopic thyroid tissue in the head and neck. j otolaryngol. 1986;15(1):52-5. 12. rahbar r, yoon mj, connolly lp, robson cd, vargas so, mcgill tj, healy gb. lingual thyroid in children: a rare clinical entity. laryngoscope. 2008; 118(7):1174-9. 13. cordes s, nelson jj. papillary carcinoma arising in median ectopic thyroid tissue: management of the thyroid gland. ear nose throat j. 2010 ;89(5):e4-7. 14. kennedy tl, riefkohl wl. lingual thyroid carcinoma with nodal metastasis. laryngoscope. 2007; 117(11):1969-73. 15. danner c, bodenner d, breau r. lingual thyroid: iodine 131: a viable treatment modality revisited. am j otolaryngol. 2001; 22(4): 276-81. 16. kamijo k . lingual thyroid associated with graves’ disease and graves’ ophthalmopathy. thyroid. 2005;15(12):1407-8. 17. jaromír astl, betka j, vlcek p. heterotopy of thyroid tissue – a modified therapeutical approach. neuroendocrinology letters. 2001; 22:263–269. 18. long rt, evans am, beggs jh. surgical management of ectopic thyroid: report of a case with simultaneous lingual & subhyoid median ectopic thyroid. ann surg. 1964;160:824-7. 19. toso a, colombani f, averono g, aluffi p, pia f. lingual thyroid causing dysphagia and dyspnoea. case reports and review of the literature acta otorhinolaryngol ital. 2009 august; 29(4): 213– 217. patients are hypothyroid at presentation. fnac should be avoided in lingual thyroid for risk of brisk haemorrhage but maybe performed in suspected ectopic thyroid in neck. surgical excision may be avoided where this is the only functioning thyroid, provided vigilant follow up is observed except in cases where there is severe dysphagia, bleeding from the mass or respiratory obstruction. in the presence of normal thyroid gland surgical excision may be attempted. hypothyroidism must be corrected first before undertaking any surgical intervention as auto-transplantation of ectopic thyroid does not provide any added advantage. the chance of malignancy in ectopic thyroid is extremely rare and if present it is usually papillary carcinoma or its follicular variant. any suspicion of malignant change in the ectopic thyroid should be dealt with by complete excision of the mass based on oncological principles supported by radio-iodine therapy if required and lifelong follow up. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports 54 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2015; 30 (1): 54-58 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to present a rare case of primary parathyroid carcinoma and discuss its clinical findings and management. methods: design: case report setting: tertiary government hospital patient: one results: a 54-year-old woman presented with a 3-year history of recurrent nephrolithiasis despite several courses of shock wave lithotripsy. she had persistent hypercalcemia and parathyroid hormone levels were noted to be elevated. neck ultrasound showed a hypoechoic solid nodule measuring approximately 1.7 x 1.6 cm in the lateral inferoposterior aspect of the left thyroid lobe. parathyroid scintigraphy revealed a focal uptake on the left lower thyroidal bed. the patient underwent left inferior parathyroidectomy with subtotal thyroidectomy and isthmusectomy frozen section reported a parathyroid tumor and the final histopathologic results revealed a parathyroid carcinoma. conclusion: a rare case of parathyroid carcinoma was presented manifesting with recurrent nephrolithiasis. elevated serum calcium and intact parathyroid hormone (ipth) can confirm a primary hyperparathyroid problem. neck ultrasound and parathyroid scintigraphy help in the localization of a parathyroid tumor. only final histopathologic results can confirm the diagnosis of parathyroid carcinoma. complete surgical excision is the treatment of choice and offers a good prognosis. keywords: parathyroid carcinoma, primary hyperparathyroidism kidney stone formation or nephrolithiasis is a condition brought about by many factors such as low daily urine volume; saturation of urine with calcium, oxalate, calcium phosphate, uric acid or cystine, acidic urine and bacterial infection.1 the risk of nephrolithiasis is increased by certain medical conditions including primary hyperparathyroidism, obesity, diabetes, gout, intestinal malabsorption and anatomical abnormalities.2 the majority of patients with nephrolithiasis have calcium-containing stones. therefore, certain conditions that cause increased delivery of calcium to the kidney increase the risk for stone formation. the parathyroid gland is an endocrine organ that secretes parathyroid hormone (pth) parathyroid carcinoma manifesting as recurrent nephrolithiasis ma. melizza s. villalon, md celso v. ureta, md department of otorhinolaryngology head and neck surgery veterans memorial medical center correspondence: dr. celso v. ureta department of otorhinolaryngology head and neck surgery veterans memorial medical center north avenue, diliman, quezon city 1104 philippines phone: (632) 426 9775 email: enthns_vmmc@yahoo.com reprints will not be available with the author the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at philippine society of otolaryngology head and neck surgery, interesting case report contest (1st place), may 22, 2014, 4/f, w. office bldg., 11th avenue, cor. 28th st., bonifacio high street, bgc, taguig city. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 philippine journal of otolaryngology-head and neck surgery 55 case reports that regulates calcium balance in the body. in hyperparathyroidism, the serum pth level is inappropriately elevated and the net effect is a rise in the serum calcium concentration leading to kidney stone formation .3 primary hyperparathyroidism is the unregulated overproduction of parathyroid hormone (pth) resulting in abnormal calcium homeostasis secondary to an autonomous hyperfunctioning parathyroid tumor.4 less than 1% of urinary stone formers have primary hyperparathyroidism.3 hypercalcemia associated with elevated intact parathyroid hormone (ipth) indicates a primary hyperparathyroidism. primary hyperparathyroidism, while uncommon, can be benign or malignant. benign adenoma is the most common benign tumor of the parathyroid gland. parathyroid carcinoma is a rare endocrine malignancy and it is also considered an uncommon cause of pth-dependent hypercalcemia. a systematic literature review of 22,225 cases of primary hyperparathyroidism reported between 1995 and 2003 revealed that parathyroid carcinoma accounted for only 0.74 percent of the cases.5 among all cancers, it has a prevalence of 0.005% and is considered the least common endocrine malignancy. parathyroid carcinoma typically occurs among patients in their 40’s to mid-50’s. it may occur as a primary event or as part of a syndrome e.g. hyperparathyroidism-jaw tumor (hpt-jt) syndrome, multiple endocrine neoplasia types 1 and 2a, and familial hypocalciuric hypercalcemia.6 to the best of our knowledge there are no published local data on the incidence and prevalence of primary parathyroid carcinoma. it is the objective of this paper to present a very rare case of a primary parathyroid carcinoma and discuss the clinical findings and appropriate management thereof. case report a 54-year-old woman consulted due to hypogastric pain radiating to the flank. three years prior, she experienced frequent hypogastric pain radiating to the flank area and burning sensation during urination. she occasionally experienced joint stiffness in both hands with no evident joint swelling and occasional easy fatigability. there was no dyspnea, dysphagia, change in voice quality, fever, weight change or bowel habit changes. a consult with her private physician revealed that she had nephrolithiasis and she was advised to undergo shock wave lithotripsy. despite doing so, she experienced the same symptoms and had to undergo the same procedure three more times because of recurrent nephrolithiasis. she had no other comorbid conditions and was not taking any calcium supplements. her family history, personal and social history was unremarkable. one year prior to consult, because of recurrence of the aforementioned symptoms, she was advised urinary stent placement. while undergoing medical clearance for the procedure, routine serum electrolytes revealed hypercalcemia that was persistent on repeated examinations (2.89-3.40mmol/l). further laboratory tests showed normal baseline creatinine, blood urea nitrogen and thyroid function tests. however, parathyroid hormone (ipth) was markedly elevated at 33.54 pmol/l. neck ultrasound showed an enlarged isthmus measuring 1 cm in ap diameter and a hypoechoic solid nodule measuring approximately 1.7 x 1.6 cm in the lateral inferoposterior aspect of the left thyroid lobe with a parathyroid etiology considered. parathyroid scintigraphy revealed focal uptake in the left lower thyroidal bed. on physical examination, multiple hypopigmented patches were distributed all over her body because of vitiligo. there was no palpable neck mass or lymphadenopathies. the rest of the ent examination was unremarkable. with an admitting diagnosis of recurrent nephrolithiasis secondary to chronic hypercalcemia secondary to primary hyperparathyroidism, our patient underwent neck exploration and excision of parathyroid tumor. intraoperative findings revealed an enlarged left thyroid gland with an approximately 2 x 2 cm firm, dark, irregular nodular mass located at the inferior pole. (figure 1a) there was an approximately 1x1cm smooth, firm nodule at the inferior part of the thyroid isthmus. the right thyroid was grossly normal. the left thyroid mass including figure 1. a. intraoperative findings (left thyroid lobe freed and retracted from its bed) showing the left thyroid gland enlarged, with an approximately 2x2cm firm, dark, irregular nodular mass located at the inferior pole. there was an approximately 1x1cm smooth, firm nodule at the inferior part of the thyroid isthmus. the right thyroid was grossly normal. b. surgical specimen showing the parathyroid tumor. a b philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports 56 philippine journal of otolaryngology-head and neck surgery the lower and middle third of the left thyroid lobe and isthmus was excised. (figure 1b) frozen section revealed parathyroid tumor, left and benign thyroid nodule, isthmus. post-operative serum calcium decreased from 3.7 to 2.10mmol/l. (figure 2) although she only experienced mild symptoms of numbness of fingers that disappeared after 24 hours, oral calcium supplementation was started on the first postoperative day and she was discharged improved on the fourth postoperative day. regular follow-up was unremarkable. histopathologic results showed cells that were mostly in solid sheets with trabecular pattern and band forming fibrosis in some areas. some follicles were lined by oncocytic cells and there was note of vascular invasion by the tumor. (figure 3a-d) final histopathologic diagnosis was parathyroid carcinoma. figure 3. microscopic appearance of parathyroid carcinoma as seen in the patient. a. high-power view, hematoxylin and eosin stain (h&e) magnification 200x showing cells mostly in solid sheets with trabecular pattern (arrow) b. scanning view, h&e, 20x showing band forming fibrosis (arrow) c. highpower view, h&e, 200x showing follicles lined by oncocytic cells (arrow) and d. high-power view, h&e, 200x showing vascular invasion of the tumor (arrow) (hematoxylin and eosin, 200x) a b (hematoxylin and eosin, 20x) c (hematoxylin and eosin, 200x) d (hematoxylin and eosin, 200x) discussion primary hyperparathyroidism is the unregulated overproduction of parathyroid hormone (pth) resulting in abnormal calcium homeostasis. this is usually secondary to an autonomous hyperfunctioning parathyroid tumor. secondary hyperparathyroidism on the other hand figure 2. six-hourly serum calcium (mmol/l) of the patient; note post-operative drop from 3.7 to 2.1 mmol/l. serum calcium (mmol/l) philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 philippine journal of otolaryngology-head and neck surgery 57 case reports is the overproduction of parathyroid hormone secondary to a chronic abnormal stimulus for its production. typically, this is due to chronic renal failure.4 in primary hyperparathyroidism, the most commonly affected systems are the renal and skeletal. the classic, specific symptoms (bone disease, renal stones and hypercalcemic crisis) represent obvious manifestations of the disease. greater than 50% of patients with hyperparathyroidism develop renal symptoms manifested by nephrolithiasis and nephrocalcinosis. nephrolithiasis is a condition wherein there is formation of stones within the urinary tract while nephrocalcinosis is characterized by the deposition of calcium in the kidney parenchyma and tubules.7 the patient presented with hypogastric pain radiating to the flank area and burning sensation upon urination and was diagnosed with recurrent nephrolithiasis for which she underwent repeated lithotripsy procedures. in primary hyperparathyroidism, nonspecific symptoms include malaise, fatigue, depression and other psychiatric symptoms, sleep disturbance, weight loss, abdominal pains, constipation, vague musculoskeletal pains in the extremities and muscular weakness.7 our patient only complained of occasional joint stiffness and easy fatigability. on physical examination, she did not present any palpable neck mass or lymphadenopathies suggestive of parathyroid carcinoma rather than benign parathyroid pathology rather than parathyroid carcinoma. this is consistent with the observation that it is extremely unusual for patients with benign parathyroid lesions to have palpable abnormalities in the neck while a malignant pathology may present with palpable neck mass in 22-50% of cases.8 on routine electrolyte examination, our patient’s serum calcium was incidentally noted to be elevated and repeated tests showed persistent hypercalcemia. hypercalcemia may be attributed to medications or familial hypocalciuric hypercalcemia but most commonly primary hyperparathyroidism and malignancy.9 because of the persistent hypercalcemia, further tests such as parathyroid hormone level determination are needed to confirm the diagnosis of primary hyperparathyroidism. indeed, in this patient, intact parathyroid hormone was noted to be elevated which confirmed the diagnosis. was the recurrent nephrolithiasis brought about by primary hyperparathyroidism? physiologic calcium metabolism is primarily regulated by the parathyroid gland. the main effect of parathyroid hormone is to increase the concentration of plasma calcium by increasing the release of calcium and phosphate from bone matrix, increasing calcium reabsorption by the kidney and increasing renal production of 1,25-dihydroxyvitamin d-3 (calcitriol) which increases intestinal absorption of calcium.4 the overproduction of parathyroid hormone results in the elevation of serum calcium and in turn promotes calcium deposition in various organs. specifically, calcium deposits in the kidneys lead to nephrocalcinosis and nephrolithiasis. the calcium level of this patient was noted to be persistently higher than normal on several occasions. the elevated serum calcium in this patient leads us to suspect a parathyroid pathology that was eventually confirmed by elevated parathyroid hormone level. the presence of elevated calcium and parathyoid hormone is diagnostic of primary hyperparathyoidism. therefore, in this patient, the recurrent nephrolithiasis was brought about by primary hyperparathyroidism. the increase in secretion of parathyroid hormone in primary hyperparathyroidism is the result of the autonomous hyperfunctioning of one or more of the parathyroid glands. this may be a benign parathyroid adenoma or parathyroid carcinoma.10 there are diagnostic tests like neck ultrasound and parathyroid scintigraphy that may help detect parathyroid gland abnormalities. neck ultrasound and nuclear medicine studies such as technetium-99m sestamibi and parathyroid scintigraphy have been useful in localizing hyperfunctional parathyroid masses as well as parathyroid carcinoma. normal parathyroid glands are rarely visualized by ultrasonography because of their small size and insufficient acoustic difference compared to adjacent thyroid tissue. however, parathyroid tumors exhibit a relatively hypoechogenic pattern. they are usually well-circumscribed, tend to be solid and homogenously hypoechoic relative to echogenic thyroid tissue.11 the ultrasound appearance of parathyroid malignancy on the other hand is a hypoechoic soft tissue mass with irregular, poorly defined border with sign of invasion of adjacent structures.5 the neck ultrasound findings in this patient revealed a hypoechoic solid nodule in the lateral inferoposterior aspect of the left thyroid lobe suggesting a parathyroid origin. a parathyroid scintigraphy of this patient showed focal uptake in the same area that strongly supported the impression of a parathyroid pathology. in this patient, ultrasound and scintigraphy findings only suggested a parathyroid tumor but could not assess whether it was benign or malignant. some biochemical parameters may differentiate benign from malignant parathyroid tumors. the degree of hypercalcemia and hyperparathyroidism are often more pronounced in parathyroid carcinoma. calcium levels above 14 mg/dl (n.v. 8.5 9.9mg/dl) are more common in parathyroid carcinoma as compared to elevations of 1-2 mg/dl among other etiologies of primary hyperparathyroidism.8 in this patient, serum calcium levels ranged from 2.89 to 3.40 mmol/l (11.56 to 13.6 mg/dl) consistent with a benign parathyroid tumor rather than a carcinoma. up to 14% of patients with parathyroid carcinoma will present with hypercalcemic crisis manifested with depressed level of consciousness, dehydration and extreme hypercalcemia.4 our patient did not manifest philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports 58 philippine journal of otolaryngology-head and neck surgery references 1. hall pm. nephrolithiasis: treatment, causes, and prevention. cleve clin j med. 2009 oct; 76(10): 583-91. 2. fink ha, wilt tj, eidman ke, garimella ps, macdonald r, rutks ir, et al. medical management to prevent recurrent nephrolithiasis in adults: a systematic review for an american college of physicians clinical guideline. ann intern med. 2013 apr 2; 158(7):535-543. 3. craven bl, passman c, assimos dg. hypercalcemic states associated with nephrolithiaisis. rev urol. 2008 summer; 10(3): 218–226 4. kim m, harris eh, krause mw. hyperparathyroidism. medscape. [updated 2014 apr 28; cited 2014 mar]. available from: http://emedicine.medscape.com/article/127351-overview#a1 5. daly bd, coffey sl, behan m. ultrasonographic appearances of parathyroid carcinoma. br j radiol. 1989 nov; 62(743):1017-9 6. shane e. clinical review 122: parathyroid carcinoma. j clin endocrinol metab. 2001 feb; 86 (2): 485–493. 7. pellitteri pk, sofferman ra, randolph gw. chapter 125 management of parathyroid disorders. in: flint pw, haughey bh, lund vj, niparko jk, richardson ma, robbins kt, et al. cummings otolaryngology head and neck surgery. 5th edition. mosby elsevier. 2010. 1773-1805 8. goetz mp, erlichman c, kohli m, loprinzi cl. chapter 44 cancer of the endocrine system. in: de vita vt, lawrence ts, rosenberg sa. cancer: principles & practice of oncology, volume 2. 8th edition. lippincott williams & wilkins. philadelphia, usa. 2008. 1684-1687. 9. carroll mf, schade ds. a practical approach to hypercalcemia. am fam physician. 2003 may 1; 67(9):1959-1966. 10. essig gf, jameson mj, carter b, carron jd. parathyroid physiology. [updated 2014 nov 7; cited 2014 mar]. available from: http://emedicine.medscape.com/article/874690overview#aw2aab6b3 11. mohebati a, shaha ar. imaging techniques in parathyroid surgery for primary hyperparathyroidism. am j otolaryngol. 2012 jul-aug; 33(4): 457–468. 12. shane e. clinical review 122: parathyroid carcinoma. j clin endocrinol metab. 2001 feb;86(2):485– 93. 13. fang sh, lal g. parathyroid cancer. endocr pract. 2011 mar-apr; 17 suppl 1:36-43. 14. kleinpeter kp, lovato jf, clark pb, wooldridge t, norman es, bergman s, et al. is parathyroid carcinoma indeed a lethal disease? ann surg oncol. 2005 mar; 12(3):260–266. 15. delellis ra, lloyd rv, heitz pu, eng c. world health organization classification of tumours pathology and genetics of tumours of endocrine organs. lyon, france: iarc press. 2004 16. obara t, fujimoto y, hirayama a, kanaji y, ito y, kodama t, ogata t. flow cytometric dna analysis of parathyroid tumors with special reference to its diagnostic and prognostic value in parathyroid carcinoma. cancer. 1990 apr 15; 65(8): 1789-93. any of these problems. on intraoperative evaluation, a parathyroid carcinoma typically appears to be tan to grayish, hard, lobulated and fibrous in texture as compared to a parathyroid adenoma which is red or brown, soft and free of attachment to its surrounding structures.8 a larger gland size of > 3 cm has more tendency to be malignant and has a predilection to occur in the inferior parathyroid gland.8 in this patient, the gross finding which led to suspect malignancy was the firm, dark, irregular nodular mass that was closely adherent at the inferior thyroid pole. while it initially appeared to be a thyroid mass, the pathologist reported it as a parathyroid tumor on frozen section. unexpectedly, the final histopathologic diagnosis was parathyroid carcinoma. according to shane, if one or all of the malignant intraoperative findings may be absent, examination of frozen sections is of little value in distinguishing benign from malignant disease.12 the management of primary hyperparathyroidism is excision of the autonomous hyperfunctioning parathyroid gland. if found to be malignant, wide tumor excision should be performed, as parathyroid carcinomas are associated with an indolent, slowly progressive course13 and the most important factor affecting prognosis is the completeness of tumor resection. in this patient, the parathyroid tumor was completely excised en bloc with adequate margins. according to kleinpeter et al., patients who undergo complete en-bloc tumor resection can have survival rates as high as 90% at 5 years and 67% at 10 years.14 other treatment options like radiation therapy for parathyroid carcinoma have not been demonstrated to have a significant effect on the neck or sites of distant metastases.14 histologic diagnosis of parathyroid carcinoma is suggested by the presence of intra-operative features of local invasion and confirmed by the world health organization histopathological criteria for parathyroid carcinoma. these include the presence of vascular invasion, perineural space invasion, capsular penetration with growth into adjacent tissues and/or metastasis.15 a meta-analysis by obara et al. stated that the finding of fibrous bands was the most sensitive histopathological feature whereas trabecular growth pattern, capsular invasion and vascular invasion offers the highest specificity.16 this patient’s microscopic findings of trabecular pattern, fibrous bands and vascular invasion all confirmed the diagnosis of parathyroid carcinoma. post-operatively, serum calcium level should be monitored regularly with standby intravenous calcium infusion when clinical signs of hypocalcemia set in. this phenomenon of hypocalcemia after surgical removal of the hyperfunctioning parathyroid tumor can be explained by the sudden drop in the serum level of parathyroid hormone and subsequent drop of serum calcium. this phenomenon is called hungry bone syndrome wherein calcium is reabsorbed back toward the bone matrix resulting in decreased levels of calcium in the blood. this is a temporary event and usually stabilizes after 24 hours.12 in our patient, the calcium levels only dropped temporarily to 2.10 mmol/l then recovered quickly since oral calcium supplementation was started post-operatively. in conclusion, we presented a rare case of parathyroid carcinoma manifesting with recurrent nephrolithiasis. elevated serum calcium and intact parathyroid hormone (ipth) can confirm a primary hyperparathyroid problem. neck ultrasound and parathyroid scintigraphy help in the localization of the parathyroid tumor. only formal histopathology can definitely confirm the diagnosis of parathyroid carcinoma. surgery is still the treatment of choice for parathyroid malignancy and offers a good prognosis. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 case reports philippine journal of otolaryngology-head and neck surgery 17 abstract objective: to present a case of middle ear carcinoma masquerading as an aural polyp and describe our experience with the clinical presentation, management and outcome of an elderly patient with this pathology. methods: design: case report setting: tertiary public hospital patient: one results: a 63-year-old female presented with an aural polyp and preceding symptoms of inner ear disturbances followed by otorrhea and otalgia. ct scans revealed an erosive lesion occupying the entire middle ear cleft, external ear canal and mastoid cavity with involvement of inner structures. a repeat biopsy subsequently revealed malignancy leading to a diagnosis of middle ear carcinoma. the patient was offered surgical treatment but opted for radiotherapy and subsequently defaulted follow-up. conclusion: middle ear carcinoma is rare and can masquerade as a benign aural polyp. symptoms of severe otalgia and inner ear disturbances are indicators of possible malignancy, as are recentonset symptoms of otitis media developing over a relatively short course later in life. a high index of suspicion is needed to avoid late diagnosis. repeat deeper aural tissue biopsy is needed to exclude malignancy. computed tomography imaging is indispensable in delineating tumor extent and aids in tumor staging as well as prognostication. surgical resection with clear tumor margins, followed by postoperative radiotherapy, is the preferred choice of treatment. sole radiotherapy is reserved for tumors of small volume as well as in cases where surgery is not feasible. keywords: middle ear carcinoma; aural polyp; temporal bone carcinoma carcinomas of the middle ear are rare, with occurrences of less than 0.2% of head and neck tumors. 1 the presenting symptoms and signs share similarities to those of chronic ear infection as well as cholesteatoma. therefore, early diagnosis is rarely possible resulting in late-stage disease on presentation. no gender predilection is noted and they are usually reported to occur in patients with histories of irradiation as well as long-standing ear infection.2 we report the case of a patient diagnosed with middle ear carcinoma masquerading as aural polyp. middle ear carcinoma masquerading as an aural polyp doh jeing yong, mbbs, mrcs, dohns1 abd majid md nasir, mbbs, ms (orl-hns)1 bee see goh, mbbs, ms (orl-hns)2 1department of otorhinolaryngology hospital kuala lumpur, malaysia 2department of otorhinolaryngology universiti kebangsaan malaysia medical centre correspondence: dr. doh jeing yong department of otorhinolaryngology, hospital kuala lumpur, jalan pahang, 50586 kuala lumpur, malaysia phone: (+601) 2271 9921 fax: (+603) 2691 6725 email drdjyong@gmail.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2012; 27 (2): 17-19 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 case reports 18 philippine journal of otolaryngology-head and neck surgery references moody sa, hirsch be, myers en. squamous cell carcinoma of the external auditory canal: an 1. evaluation of a staging system. am j otol. 2000 jul;21(4):582–8. chee g, mok p, sim r. squamous cell carcinoma of the temporal bone: diagnosis, treatment and 2. prognosis. singapore med j. 2000 sep;41(9):441-446,451. austin jr, stewart k, fawzi n. squamous cell carcinoma of the external auditory canal. 3. therapeutic prognosis based on a proposed staging system. arch otolaryngol head neck surg 1994 nov;120(11):1228–32. paaske pb, witten j, schwer s, hansen hs. results in treatment of carcinoma of the external 4. auditory canal and middle ear. cancer 1987 jan;59(1):156–60. noorizan y, asma a. temporal bone carcinoma: a case report. 5. med j. malaysia. 2010 jun;65(2):162-164. maran agd, stell pm. tumours of the skin and ear. in: watkinson jc, wilson ja, gaze m, stell pm, 6. maran agd (eds). stell and maran’s head and neck surgery. 4th edition. oxford: butterworthheinemann; 2000. 431-440. hahn ss, kim ja, goodchild n, constable wc. carcinoma of the middle ear and external 7. auditory canal. int j radiat oncol biol phys.1983 jul;9(7):1003-1007. tay hl, hussain ss. the management of aural polyps. 8. j laryngol otol. 1997 mar;111(3):212-214 arriaga m, curtin h, takahashi h, hirsch be, kamerer db. staging proposal for external auditory 9. meatus carcinoma based on preoperative clinical examination and computed tomography findings. ann otol rhinol laryngol. 1990 sep; 99(9 pt1);714-21. pfreundner l, schwager k, wiillner j, baier k, bratengeier k, brunner fx, flentje m. carcinoma 10. of the external auditory canal and middle ear. int. j. radiat oncol biol phys. 1999 jul; 44(4); 777–788. graham md, sataloff rt, kemink jl, wolf gt, mcgillicudy je.11. total en bloc resection of the temporal bone and carotid artery for malignant tumors of the ear and temporal bone. laryngoscope 1984 apr;94(4):528 –533. yin m, ishikawa k, honda k, arakawa t, harabuchi y, nagabashi t, 12. et. al. analysis of 95 cases of squamous cell carcinoma of the external and middle ear. auris nasus larynx. 2006 sep:33(3);251–257. history of otorrhea denotes possible external ear origin.6 furthermore, there are frequent associations with chronic otitis media and aural polypectomy procedure.7 other risk factors include previous history of irradiation as well as human papilloma virus infection. this case report highlights the atypical presentation of middle ear carcinoma masquerading as an infarcted polyp. chronologically, our patient initially presented with inner ear symptoms for eight months followed by recent otorrhea and aural polyp. because the onset of otorrhea in an elderly lady was only for one month duration prior to the notice of an aural mass, this should have raised a red flag for earlier intervention as the long-standing symptoms of tubotympanic otitis media usually begin in childhood. the rather atypical sequence of symptoms in this case explains the tumor origin and extensive involvement of the inner ear at time of diagnosis. therefore, we feel that presence of an aural mass with inner ear symptoms denote a sinister alarm and warrant extensive workouts. a high index of suspicion is indeed needed for early diagnosis. the decision to repeat aural tissue biopsy is crucial in the diagnosis of temporal bone carcinoma as illustrated in this case. the initial biopsy report of infarcted polyp necessitated deeper re-biopsy and resulted in the glaring diagnosis of carcinomatous changes. aural polyp is commonly associated with inflammatory processes, cholesteatoma, tumor as well as foreign body. the association of aural polyp with cholesteatoma is well known with incidence in children as high as 45%.8 meanwhile, the association between aural polyp with malignancy is rare but is more prevalent among the elderly group. moreover, aural polyps may represent only the tip of the iceberg and mask extensive underlying pathological processes. high resolution computed-tomography imaging is indispensable in mapping the extent of the disease and helps in prognostication. where intracranial involvement is seen, further magnetic resonance imaging is suggested to further delineate the depth of soft tissue invasion. more importantly, this greatly aids in staging disease as major parts of the temporal bone are not amenable to clinical assessment. this forms the basis of the t-n-m staging system proposed by arriaga et al.9 which has been shown to provide reliable and reproducible staging segregation from a surgical point of view. t stages signify the tumor extent and pattern of infiltration as well delineate the extension of surgical resection. with the extensive involvement of inner ear structures, the patient was classified as stage 4 temporal bone carcinoma of middle ear origin with external ear extension. there was neither presence of regional lymphadenopathy nor distant metastasis. efforts to review the literature on optimal treatment for this tumor stage were futile due to the varied systems of tumor classification. nonetheless, the preferred choice for temporal bone carcinoma has been radical surgery with tumor-free surgical margins.7,10 the extent of surgical resection correlates with tumor stage. using arriaga’s classification, en-bloc excision of external ear canal for t1 tumors, partial temporal bone resection for t2 tumors and subtotal or total temporal bone resection for more advanced tumors have been recommended.9 chee et al.2 negate routine neck dissection in patients with absence of clinical neck disease and emphasize that resection of the parotid gland deep lobe is not necessary due to the rarity of advanced tumor spread to these sites. in cases of positive surgical margins or advanced stages, adjuvant postoperative radiotherapy and chemotherapy could improve survival.12 as in this case, sole radiotherapy is only employed whenever surgery is not feasible either in cases of intracranial extension, patient refusal or in surgically unfit patients. in conclusion, middle ear carcinoma is rare and may masquerade as a benign aural polyp. a high index of suspicion is needed to avoid late diagnosis. symptoms of severe otalgia and inner ear disturbances are indicators of possible malignancy, as are recent-onset symptoms of otitis media developing over a relatively short course later in life. in cases of refractory polyp where initial biopsy fails to yield positive findings, repeat deeper aural tissue biopsy is mandatory. high resolution temporal bone computed tomography is indispensable in delineating tumor extent and preoperative surgical planning as well as prognostication. primary surgical resection of tumor with clear surgical margins, followed by postoperative radiotherapy, is the preferred treatment modality in the management of middle ear carcinoma. discussion malignancies of the temporal bone are rare, accounting for less than 0.2% of head and neck tumors.1 these occurrences include cancer arising from the skin of the pinna that extend into the temporal bone, metastatic temporal bone lesions as well as primary tumors of the external ear canal, middle ear, mastoid cavity, petrous apex. nonetheless, the literature reviews on primary temporal bone carcinoma of middle ear origin are few. primary temporal bone carcinoma is often diagnosed late as the presenting symptoms share similarities with chronic ear infections. otorrhea, otalgia and bloody otorrhea were among the commonest presentations.2 deafness, tinnitus, vertigo, facial nerve palsy as well as referred pain of upper teeth have been reported.3,4,5 therefore, middle ear carcinoma should be considered when refractory aural polyp, severe otalgia and long-standing history of otorrhea are observed. absence of case report a 63-year-old female with no known medical illness presented with gradual onset, right non-pulsatile tinnitus, hearing loss and episodic vertigo for eight months. subsequently, she experienced persistent right otalgia associated with intermittent mucoid otorrhea and recently felt a mass at the meatus of the right ear canal. (figure 1) there was no headache or facial weakness. on examination, the right pinna was normal and non-tender. no mastoid swelling was noted. the external meatus was occupied with a greyish mass extending through the entire right ear canal. the mass was firm on probing and not pulsatile. the tympanic membrane was not visualized. regional lymph nodes were not palpable. tuning fork tests revealed right conductive hearing loss. facial nerve examination was normal. nystagmus and cerebellar signs were absent. the intraoral, indirect laryngeal and post nasal mirror examinations were normal. no neurological deficits were noted. with an initial impression of aural polyp, an aural biopsy was taken and the histopathological assessment reported as infarcted polyps with no evidence of malignancy. nonetheless, the patient was referred to our centre for further management. pure tone audiometry showed significant right conductive hearing loss with an average air-bone gap of 35dbhl. (figure 2) computed tomography of the temporal bone showed evidence of an extensive soft tissue mass occupying the right external ear canal, middle ear and mastoid cavity with erosion of the bony external ear canal, ossicles and lateral semicircular canal. (figure 3) the patient underwent re-biopsy of the right ear canal mass under general anesthesia and the histopathological assessment reported findings of squamous cell carcinoma. a final diagnosis of temporal bone squamous cell carcinoma t4n0m0 was made. however, the patient was not keen for surgery and radiotherapy was planned. unfortunately, the patient defaulted subsequent follow up. figure 1. right aural mass occupying the entire ear canal and external meatus (white arrow). figure 2. the pure tone audiogram threshold showing mixed hearing loss in the right ear. figure 3. computed tomography of the temporal bone axial view showing a soft tissue mass occupying the entire middle ear and mastoid cavity (black ring). inner ear bony erosions are prominent with loss of middle ear and inner ear structures. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 case reports philippine journal of otolaryngology-head and neck surgery 19 references moody sa, hirsch be, myers en. squamous cell carcinoma of the external auditory canal: an 1. evaluation of a staging system. am j otol. 2000 jul;21(4):582–8. chee g, mok p, sim r. squamous cell carcinoma of the temporal bone: diagnosis, treatment and 2. prognosis. singapore med j. 2000 sep;41(9):441-446,451. austin jr, stewart k, fawzi n. squamous cell carcinoma of the external auditory canal. 3. therapeutic prognosis based on a proposed staging system. arch otolaryngol head neck surg 1994 nov;120(11):1228–32. paaske pb, witten j, schwer s, hansen hs. results in treatment of carcinoma of the external 4. auditory canal and middle ear. cancer 1987 jan;59(1):156–60. noorizan y, asma a. temporal bone carcinoma: a case report. 5. med j. malaysia. 2010 jun;65(2):162-164. maran agd, stell pm. tumours of the skin and ear. in: watkinson jc, wilson ja, gaze m, stell pm, 6. maran agd (eds). stell and maran’s head and neck surgery. 4th edition. oxford: butterworthheinemann; 2000. 431-440. hahn ss, kim ja, goodchild n, constable wc. carcinoma of the middle ear and external 7. auditory canal. int j radiat oncol biol phys.1983 jul;9(7):1003-1007. tay hl, hussain ss. the management of aural polyps. 8. j laryngol otol. 1997 mar;111(3):212-214 arriaga m, curtin h, takahashi h, hirsch be, kamerer db. staging proposal for external auditory 9. meatus carcinoma based on preoperative clinical examination and computed tomography findings. ann otol rhinol laryngol. 1990 sep; 99(9 pt1);714-21. pfreundner l, schwager k, wiillner j, baier k, bratengeier k, brunner fx, flentje m. carcinoma 10. of the external auditory canal and middle ear. int. j. radiat oncol biol phys. 1999 jul; 44(4); 777–788. graham md, sataloff rt, kemink jl, wolf gt, mcgillicudy je.11. total en bloc resection of the temporal bone and carotid artery for malignant tumors of the ear and temporal bone. laryngoscope 1984 apr;94(4):528 –533. yin m, ishikawa k, honda k, arakawa t, harabuchi y, nagabashi t, 12. et. al. analysis of 95 cases of squamous cell carcinoma of the external and middle ear. auris nasus larynx. 2006 sep:33(3);251–257. history of otorrhea denotes possible external ear origin.6 furthermore, there are frequent associations with chronic otitis media and aural polypectomy procedure.7 other risk factors include previous history of irradiation as well as human papilloma virus infection. this case report highlights the atypical presentation of middle ear carcinoma masquerading as an infarcted polyp. chronologically, our patient initially presented with inner ear symptoms for eight months followed by recent otorrhea and aural polyp. because the onset of otorrhea in an elderly lady was only for one month duration prior to the notice of an aural mass, this should have raised a red flag for earlier intervention as the long-standing symptoms of tubotympanic otitis media usually begin in childhood. the rather atypical sequence of symptoms in this case explains the tumor origin and extensive involvement of the inner ear at time of diagnosis. therefore, we feel that presence of an aural mass with inner ear symptoms denote a sinister alarm and warrant extensive workouts. a high index of suspicion is indeed needed for early diagnosis. the decision to repeat aural tissue biopsy is crucial in the diagnosis of temporal bone carcinoma as illustrated in this case. the initial biopsy report of infarcted polyp necessitated deeper re-biopsy and resulted in the glaring diagnosis of carcinomatous changes. aural polyp is commonly associated with inflammatory processes, cholesteatoma, tumor as well as foreign body. the association of aural polyp with cholesteatoma is well known with incidence in children as high as 45%.8 meanwhile, the association between aural polyp with malignancy is rare but is more prevalent among the elderly group. moreover, aural polyps may represent only the tip of the iceberg and mask extensive underlying pathological processes. high resolution computed-tomography imaging is indispensable in mapping the extent of the disease and helps in prognostication. where intracranial involvement is seen, further magnetic resonance imaging is suggested to further delineate the depth of soft tissue invasion. more importantly, this greatly aids in staging disease as major parts of the temporal bone are not amenable to clinical assessment. this forms the basis of the t-n-m staging system proposed by arriaga et al.9 which has been shown to provide reliable and reproducible staging segregation from a surgical point of view. t stages signify the tumor extent and pattern of infiltration as well delineate the extension of surgical resection. with the extensive involvement of inner ear structures, the patient was classified as stage 4 temporal bone carcinoma of middle ear origin with external ear extension. there was neither presence of regional lymphadenopathy nor distant metastasis. efforts to review the literature on optimal treatment for this tumor stage were futile due to the varied systems of tumor classification. nonetheless, the preferred choice for temporal bone carcinoma has been radical surgery with tumor-free surgical margins.7,10 the extent of surgical resection correlates with tumor stage. using arriaga’s classification, en-bloc excision of external ear canal for t1 tumors, partial temporal bone resection for t2 tumors and subtotal or total temporal bone resection for more advanced tumors have been recommended.9 chee et al.2 negate routine neck dissection in patients with absence of clinical neck disease and emphasize that resection of the parotid gland deep lobe is not necessary due to the rarity of advanced tumor spread to these sites. in cases of positive surgical margins or advanced stages, adjuvant postoperative radiotherapy and chemotherapy could improve survival.12 as in this case, sole radiotherapy is only employed whenever surgery is not feasible either in cases of intracranial extension, patient refusal or in surgically unfit patients. in conclusion, middle ear carcinoma is rare and may masquerade as a benign aural polyp. a high index of suspicion is needed to avoid late diagnosis. symptoms of severe otalgia and inner ear disturbances are indicators of possible malignancy, as are recent-onset symptoms of otitis media developing over a relatively short course later in life. in cases of refractory polyp where initial biopsy fails to yield positive findings, repeat deeper aural tissue biopsy is mandatory. high resolution temporal bone computed tomography is indispensable in delineating tumor extent and preoperative surgical planning as well as prognostication. primary surgical resection of tumor with clear surgical margins, followed by postoperative radiotherapy, is the preferred treatment modality in the management of middle ear carcinoma. discussion malignancies of the temporal bone are rare, accounting for less than 0.2% of head and neck tumors.1 these occurrences include cancer arising from the skin of the pinna that extend into the temporal bone, metastatic temporal bone lesions as well as primary tumors of the external ear canal, middle ear, mastoid cavity, petrous apex. nonetheless, the literature reviews on primary temporal bone carcinoma of middle ear origin are few. primary temporal bone carcinoma is often diagnosed late as the presenting symptoms share similarities with chronic ear infections. otorrhea, otalgia and bloody otorrhea were among the commonest presentations.2 deafness, tinnitus, vertigo, facial nerve palsy as well as referred pain of upper teeth have been reported.3,4,5 therefore, middle ear carcinoma should be considered when refractory aural polyp, severe otalgia and long-standing history of otorrhea are observed. absence of case report a 63-year-old female with no known medical illness presented with gradual onset, right non-pulsatile tinnitus, hearing loss and episodic vertigo for eight months. subsequently, she experienced persistent right otalgia associated with intermittent mucoid otorrhea and recently felt a mass at the meatus of the right ear canal. (figure 1) there was no headache or facial weakness. on examination, the right pinna was normal and non-tender. no mastoid swelling was noted. the external meatus was occupied with a greyish mass extending through the entire right ear canal. the mass was firm on probing and not pulsatile. the tympanic membrane was not visualized. regional lymph nodes were not palpable. tuning fork tests revealed right conductive hearing loss. facial nerve examination was normal. nystagmus and cerebellar signs were absent. the intraoral, indirect laryngeal and post nasal mirror examinations were normal. no neurological deficits were noted. with an initial impression of aural polyp, an aural biopsy was taken and the histopathological assessment reported as infarcted polyps with no evidence of malignancy. nonetheless, the patient was referred to our centre for further management. pure tone audiometry showed significant right conductive hearing loss with an average air-bone gap of 35dbhl. (figure 2) computed tomography of the temporal bone showed evidence of an extensive soft tissue mass occupying the right external ear canal, middle ear and mastoid cavity with erosion of the bony external ear canal, ossicles and lateral semicircular canal. (figure 3) the patient underwent re-biopsy of the right ear canal mass under general anesthesia and the histopathological assessment reported findings of squamous cell carcinoma. a final diagnosis of temporal bone squamous cell carcinoma t4n0m0 was made. however, the patient was not keen for surgery and radiotherapy was planned. unfortunately, the patient defaulted subsequent follow up. figure 1. right aural mass occupying the entire ear canal and external meatus (white arrow). figure 2. the pure tone audiogram threshold showing mixed hearing loss in the right ear. figure 3. computed tomography of the temporal bone axial view showing a soft tissue mass occupying the entire middle ear and mastoid cavity (black ring). inner ear bony erosions are prominent with loss of middle ear and inner ear structures. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 24 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: as a guide to the clinical practice of infiltration of local anesthesia into the pterygopalatine fossa via the greater palatine canal, this study sought to determine and record the mean ct scan measurements of the following: 1) palatal mucosal thickness, 2) length and width of greater palatine canal, and 3) length and width of pterygopalatine fossa among adult patients in a private tertiary hospital in quezon city. methods: design: retrospective, descriptive study setting: tertiary private hospital subjects: paranasal sinus (pns) ct scans of 113 adult patients from january 2014 to may 2014 were reviewed and evaluated. excluded were images with pathology that distorted the anatomy of the sinuses and surrounding structures. results: our study showed average ct scan measurements of 5.98 mm palatal mucosal thickness, 16.99 mm greater palatine canal length, 18.75 mm pterygopalatine fossa length, 2.37 mm greater palatine canal width and 2.58 mm pterygopalatine fossa width. comparison of average measurements by sex was not statistically significant. there was statistical significance when comparing the right palatal mucosal thickness of 5.86 mm with the left which was 6.11 mm with p-value of 0.001. comparison between the length of the right pterygopalatine fossa of 18.48 mm with the left side at 19.01 mm showed statistical significance with p-value of 0.01. conclusion: as the average measurement of the mucosal palatal thickness combined with the length of the greater palatine canal was 22.97 mm, we recommend bending the needle 23 mm from the tip in a 45 degree angle for adult patients who will undergo sinus surgery, control of posterior epistaxis, trigeminal nerve block and minor oral cavity surgeries. keywords: pterygopalatine fossa infiltration, greater palatine canal, greater palatine foramen, regional anesthesia blocks the pterygopalatine fossa is a paired cone-shaped depression located posterior to the maxillary sinus. it contains the terminal third of the maxillary artery which gives off the sphenopalatine artery and maxillary nerve. the greater palatine canal is a passage in the skull which connects the pterygopalatine fossa and the oral cavity. it starts from the inferior end of the pterygopalatine fossa and goes through the sphenoid to reach the palate. it contains the descending palatine artery, vein and palatine nerves. pterygopalatine fossa infiltration: a radio-anatomic study among adult patients in a tertiary private hospital neil louis l. apale, md1 joel a. romualdez, md1 rodolfo e. rivera, md1 joseph benjamin m. lu, md2 1department of otolaryngology head and neck surgery st. luke’s medical center 2department of radiology st. luke’s medical center correspondence: dr. rodolfo e. rivera department of otolaryngology-head and neck surgery saint luke’s medical center 279 e. rodriguez ave., quezon city 1102 philippines phone: (632) 723 0101 local 6246 email: docodie2003@yahoo.com reprints will not be available from the author. the authors declare that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at philippine society of otolaryngology head and neck surgery, descriptive research contest, september 18, 2014, natrapharm, the patriot bldg., km 18 slex, paranaque city philipp j otolaryngol head neck surg 2015; 30 (1): 24-28 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 25 these anatomic structures are clinically important when preparing the nasal cavity preoperatively for endoscopic sinus surgery. hemostasis can be achieved by infiltrating the pterygopalatine fossa with lidocaineepinephrine solution through the greater palatine canal. this procedure is applicable in septorhinoplasty, management of refractory epistaxis, regional blocks for dental procedures and the treatment of trigeminal neuralgia.1,2,3,4 radio-anatomic measurements of the palatal mucosal thickness, greater palatine canal length and pterygopalatine fossa length are important to determine to accurately identify where to bend the needle used for injection. to the best of our knowledge, there have been no published local reports on ct scan measurements of palatal mucosal thickness, the greater palatine canal and pterygopalatine fossa. this study aims to provide data of the ct scan measurements of the following: 1) palatal mucosal thickness, 2) length and width of the greater palatine canal, and 3) length and width of the pterygopalatine fossa among adult patients in a private tertiary hospital in the philippines. based on the data gathered, we aim to recommend where to bend the needle for instillation of local anesthesia of the pterygopalatine fossa through the greater palatine canal. methods a descriptive retrospective study design was utilized in this study. the study was conducted in a private tertiary hospital in quezon city. a total of 113 computed tomography (ct) scans of the paranasal sinuses were reviewed and evaluated by the author and a radiologist. each scan was divided and recorded into left and right side totaling 226 cases. we included ct scans of the paranasal sinuses of patients 18-years-old and older done in our institution from january 2014 to may 2014. we excluded scans with pathologies that distorted the anatomy of the sinuses and the surrounding structures such as fractures and masses. archived ct images of patients who underwent functional endoscopic sinus surgery (fess) protocol ct scans of the paranasal sinuses were retrieved and reconstructed as specified in the multi detector computed tomography (mdct) protocol. identification, measurement and recording of data were done together with a radiologist. all pns fess protocol ct scans were performed using a 64-slice mdct scanner (philips brilliance ict, philips medical systems, ohio, usa). axial images, 3 mm slices in 1.5 mm intervals were acquired and reconstructed as sagittal and coronal images for each study. using the philips extended brilliance workspace software version 4.5.5.51035 (philips international b.v., amsterdam, the netherlands) slice thickness was adjusted with rotation of the angle views reaching 30 degrees in the axial and sagittal planes so that the entire pterygopalatine fossa and greater palatine canal could be viewed in a single slice. reconstructed images were reviewed and evaluated to measure the following: 1) thickness of the soft tissue in the palate labelled as ab; 2) greater palatine canal length labelled as bc and width; and 3) the pterygopalatine fossa height labelled as cd and width. the greater palatine canal was measured as the segment inferior to the maxillary sinus just prior to where it expanded widthwise becoming the pterygopalatine fossa. the pterygoplatine fossa was defined from the flared up superior extension of the greater palatine canal until it reached the inferior orbital fissure. the overlying oral soft tissue mucosa was measured starting from the free edge of the maxillary prior to becoming the greater palatine canal. the anatomic boundaries of the pterygopalatine fossa were the posterior wall of the maxillary sinus anteriorly, pterygoid plate posteriorly, inferior orbital wall superiorly and communication with the greater palatine foramen inferiorly. using the philips extended brilliance workspace software version 4.5.5.51035 (philips international b.v., amsterdam, the netherlands), measurements were taken by the radiologist with the otolaryngologist as the observer during the process. figure 1 shows a sample image parasagittal cut with the measurements of palatal mucosa thickness, greater palatine canal and pterygopalatine fossa. microsoft excel professional 2010 (microsoft, redmond, wa, usa) was used for data recording and analysis. the confidence intervals of the average measurements were computed. independent sample t-test was used to analyze the statistical significance of the measurements when compared according to sex and laterality. figure 1. parasagittal view showing the 1) ab = palatal mucosa, 2) bc = greater palatine canal, and 3) cd = pterygopalatine fossa. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 26 philippine journal of otolaryngology-head and neck surgery original articles results a total of 113 pns ct scans taken between january 2014 to may 2014 met the inclusion criteria and were reviewed and evaluated. the patients’ ages ranged from 24 to 77 years old with the mean age of 42.5 years old. fifty-nine (52.2%) were females and 54 (47.8%) were males. each ct scan study was divided and recorded into left and right side, totalling 226 sides. table 1 shows the ct scan measurements of palatal mucosal thickness, length of greater palatine canal and pterygopalatine fossa. the average palatal mucosal thickness was 5.98 mm with 95% confidence interval = 5.90–6.06 mm. the average length of the greater palatine canal was 16.99 mm with 95% confidence interval = 16.86-17.12 mm. the mean height of pterygopalatine fossa was 18.75 mm with 95% confidence interval = 18.54-18.94 mm. table 3 shows the ct scan measurements of palatal mucosal thickness, length of greater palatine canal and pterygopalatine fossa among males. the average palatal mucosal thickness was 6.05 mm with 95% confidence interval = 5.94–6.16 mm. the average length of the greater palatine canal was 17.02 mm with 95% confidence interval = 16.83-17.21 mm. the mean height of pterygopalatine fossa is 18.89 mm with 95% confidence interval = 18.57-19.21 mm. table 4 shows the ct scan measurements of the width of the greater palatine canal and pterygopalatine fossa among males. the average width of the greater palatine canal was 2.43 mm with 95% confidence interval = 2.31-2.55 mm. the mean width of pterygopalatine fossa was 2.66 mm with 95% confidence interval = 2.55-2.77 mm. table 1. ct scan measurements of palatal mucosa thickness, greater palatine canal length, and pterygopalatine fossa length among adult patients (in millimetres with 95% confidence interval) palatal mucosal thickness (mm) pterygopalatine fossa length (mm) greater palatine canal length (mm) right left combined 5.86 (5.76-5.96) 6.11 (6.00-6.22) 5.98 (5.90-6.06) 16.88 (16.70-17.06) 17.11 (16.90-17.30) 16.99 (16.86-17.12) 18.48 (18.22-18.74) 19.01 (18.69-19.31) 18.75 (18.54-18.94) table 2. ct scan measurement of the widths of the greater palatine canal and pterygopalatine fossa among adult patients (in millimetres with 95% confidence interval) greater palatine canal width (mm) pterygopalatine fossa width (mm) right left combined 2.42 (2.32-2.52) 2.32 (2.21-2.43) 2.37 (2.30-2.44) 2.62 (2.51-2.73) 2.53 (2.42-2.64) 2.58 (2.50-2.66) table 3. ct scan measurement of palatal mucosa thickness, greater palatine canal length, and pterygopalatine fossa length among adult male patients (in millimetres with 95% confidence interval) palatal mucosal thickness (mm) pterygopalatine fossa length (mm) greater palatine canal length (mm) right left combined 5.97 (5.82-6.12) 6.14 (5.99-6.29) 6.05 (5.94-6.16) 16.92 (16.67-17.17) 17.11 (16.82-17.40) 17.02 (16.83-17.21) 18.63 (18.21-19.05) 19.14 (18.66-19.62) 18.89 (18.57-19.21) table 2 shows the ct scan measurements of the width of the greater palatine canal and pterygopalatine fossa. the average width of the greater palatine canal was 2.37 mm with 95% confidence interval = 2.30-2.44 mm. the mean width of pterygopalatine fossa is 2.58 mm with 95% confidence interval = 2.50-2.66 mm. table 4. ct scan measurements of greater palatine canal width and pterygopalatine fossa width among adult male patients (in millimetres with 95% confidence interval) greater palatine canal width (mm) pterygopalatine fossa width (mm) right left combined 2.53 (2.39-2.67) 2.33 (2.14-2.52) 2.43 (2.31-2.55) 2.78 (2.64-2.92) 2.54 (2.37-2.69) 2.66 (2.55-2.77) table 5. ct scan measurements of palatal mucosa thickness, greater palatine canal length, and pterygopalatine fossa length among adult female patients (in millimetres with 95% confidence interval) palatal mucosal thickness (mm) pterygopalatine fossa length (mm) greater palatine canal length (mm) right left combined 5.77 (5.63-5.91) 6.10 (5.94-6.24) 5.93 (5.83-6.03) 16.84 (16.59-17.09) 17.10 (16.82-17.38) 16.97 (16.78-17.16) 18.34 (18.02-18.66) 18.88 (18.49-19.27) 18.61 (18.36-18.88) table 5 shows the ct scan measurements of the palatal mucosal thickness, length of the greater palatine canal and pterygopalatine fossa among females. the average palatal mucosal thickness was 5.93 mm with 95% confidence interval = 5.83–6.03 mm. the average length of the greater palatine canal was 16.97 mm with 95% confidence interval = 16.78-17.16 mm. the mean height of the pterygopalatine fossa was 18.61 mm with 95% confidence interval = 18.63-18.88 mm. table 6 shows the ct scan measurements of width of the greater palatine canal and pterygopalatine fossa among females. the average width of the greater palatine canal was 2.31 mm with 95% confidence interval = 2.22-2.4 mm. the mean width of the pterygopalatine fossa was 2.5 mm with 95% confidence interval = 2.38-2.62 mm. the average width of the greater palatine canal was 2.37 mm (95% ci = 2.3-2.44) and the average width of the pterygopalatine fossa was 2.58 mm (95% ci = 2.5-2.66). the average palatal mucosal thickness among philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 27 males was 6.05 mm (95% ci = 5.94-6.16) which was thicker compared to females at 5.93 mm (95% ci = 5.83-6.03) with p-value of 0.11. there was no statistically significant difference. the average length of the greater palatine canal among males was 17.02 mm (95% ci = 16.83-17.21) which was longer compared to females with 16.97 mm (95% ci = 16.78-17.16) with p-value 0.73. there was no statistically significant difference. the average length of the pterygopalatine fossa among males was 18.89 mm (95% ci = 18.57-19.21) which was longer compared to females at 18.61 mm (95% ci = 18.36-18.88) with p-value 0.19. there was no statistically significant difference. there was a statistically significant difference in the average measurements based on laterality. the average palatal mucosal thickness of the right side was 5.86 mm (95% ci = 5.76-5.96) which was thinner than the left with average thickness of 6.11 mm (95% ci = 6-6.22) with p-value of 0.001. the average length of the greater palatine canal of the right side was 16.88 mm (95% ci = 16.7-17.06) which was shorter compared to the left at 17.11 mm (95% ci = 16.9-17.3) with p-value of 0.09. there was no statistically significant difference. the average length of the pterygopalatine fossa of the right side was 18.48 mm (95% ci = 18.22-18.74) which was shorter than the left at 19.01 mm (95% ci = 18.69-19.31) with p-value of 0.01 which was not statistically significant. the average width of the greater palatine canal of both sides was compared with a p-value of 0.1 which was not statistically significant. when compared according to sex, the p-value was 0.13 which was not statistically significant either. the average width of the pterygopalatine fossa was compared based on its laterality with a p-value of 0.29, which was not statistically significant. comparison according to sex had a p-value of 0.05 which was statistically significant. discussion accurate and correct identification of the nasal and paranasal anatomy is of utmost importance in endoscopic sinus surgery to avoid complications. it is very difficult achieve this when there is bleeding in the surgical field. bleeding is an important problem during endoscopic sinus surgery. different methods are practiced to attain hemostasis including local application of decongestant-soaked cotton or cottonoid inside the nasal cavity, infiltration of lidocaine:epinephrine solution into the axilla of the middle turbinate and transpalatal infiltration of lidocaine:epinephrine solution into the pterygopalatine fossa through the greater palatine canal. wormald4 concluded that the infiltration of vasoconstricting solution to this fossa through the greater palatine canal demonstrated significant reduction of intraoperative bleeding during fess. a study on the effect of greater palatine canal injection on estimated blood loss in sinus surgery showed a decrease in estimated blood loss in patients who had a greater palatine canal injection.5 another study suggested that 2 ml of local anesthetic combined with adrenaline should be injected barely to the pterygopalatine fossa to achieve effective hemostasis.6 the ct scan measurements of the palatal mucosal thickness, greater palatine canal length and width and pterygopalatine fossa length and width of adult patients may help surgeons prepare local anesthetic solution with the appropriate needle gauge and correct measurement of where to bend the needle from its tip. bending the needle in the correct area may help prevent the tip of the needle being inserted further and possibly injuring the nerve and artery in the pterygopalatine fossa (which can result in complications such as intravascular injection with associated cardiovascular side effects, blindness due to vasoconstriction of the ophthalmic artery, infraorbital nerve injury, infratemporal fossa abscess and meningitis). in our study, the average palatal mucosa thickness was 5.98 mm (95%ci = 5.9-6.06). in the study by douglas and wormald6 the palatal mucosa thickness average measurement was 6.9 mm (95% ci = 6.27.6). this suggests a difference in average measurements between caucasians and our sample. in a study by methathrathip et al.,7 the mean palatal mucosal thickness among 55 thai cadaver heads was 6.7 mm (95% ci = 4.4 9), which is comparable with the results of our study. in our study, the average length of the greater palatine canal measured was 16.99 mm (95% ci = 16.86-17.12). douglas and wormald6 reported an average of 18.5 mm (95% ci = 17.9-19.1) among caucasian skulls. methathrathip et al.7 reported an average length of greater palatine canal combined with pterygopalatine fossa of 29.7 mm (95% ci = 25.5 – 33.9) among thai skulls. howard-swirzinski et al.8 studied caucasian patients and measured the greater palatine canal length using cone beam computed tomography with an average of 29 mm (95% ci = 26 – 32). two other studies reported lengths of 14.6 mm (9-20 mm) and 31.8 mm (30.45-33.19), respectively.9,10 the mean length of pterygopalatine fossa in our study was 18.75 table 6. ct scan measurements of greater palatine canal width and pterygopalatine fossa width among adult female patients (in millimetres with 95% confidence interval) greater palatine canal width (mm) pterygopalatine fossa width (mm) right left combined 2.32 (2.19-2.45) 2.31 (2.17-2.45) 2.31 (2.22-2.40) 2.47 (2.30-2.64) 2.53 (2.37-2.69) 2.50 (2.38-2.62) philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 28 philippine journal of otolaryngology-head and neck surgery original articles references 1. nader a, kendall mc, de oliveria gs, chen jq, vanderby b, rosenow jm, et al. ultrasound-guided trigeminal nerve block via the pterygopalatine fossa: an effective treatment for trigeminal neuralgia and atypical facial pain. pain physician. 2013 sep-oct; 16(5): 37-45. 2. broering r, reader a, drum m, nusstein j, beck m. a prospective, randomized comparison of the anesthetic efficacy of the greater palatine and high tuberosity second division nerve blocks. j endod. 2009 oct; 35(10):1337–1342. 3. bharadwaj vk, novotny gm. greater palatine canal injection: an alternative to the posterior nasal packing and arterial ligation in epistaxis. j otolaryngol. 1986 apr; 15(2): 94-100. 4. wormald pj, athanasiadis t, rees g, robinson s. an evaluation of effect of pterygopalatine fossa injection with local anaesthetic and adrenalin in the control of nasal bleeding during endoscopic sinus surgery. am j rhinol. 2005 may-jun; 19(3): 288–292. 5. eloy ja, kovalerchik o, bublik m, ruiz jw, casiano rr. effect of greater palatine canal injection on estimated blood loss during endoscopic sinus surgery. am j otolaryngol. 2014 jan-feb; 35(1): 1-4. 6. douglas r, wormald pj. pterygopalatine fossa infiltration through the greater palatine foramen: where to bend the needle. laryngoscope. 2006 jul; 116(7): 1255-1257. 7. methathrathip d, apinhasmit w, chompoopong s, lertsirithong a, ariyawatkul t, sangvichien s. anatomy of greater palatine foramen and canal and pterygopalatine fossa in thais: considerations for maxillary nerve block. surg radiol anat. 2005 dec; 27(6): 511-516. 8. howard-swirzinski k, edwards pc, saini ts, norton ns. length and geometric patterns of the greater palatine canal observed in cone beam computed tomography. int j dent. 2010; 2010:292753: 1-6. 9. hassmann h. form, mabe und verlaufe der schadelkana le. in: lang j, ed. clinical anatomy of the nose, nasal cavity and paranasal sinuses. new york: thieme medical publishers; 1989:114 10. sheikhi m, zamaninaser a, jalalian f. length and anatomic routes of the greater palatine canal as observed by cone beam computed tomography. dent res j. 2013 mar; 10(2): 155-161. 11. nimigean v, nimigean vr, butincu l, salavastru di, podoleanu l. anatomical and clinical considerations regarding the greater palatine foramen. rom j morphol embryol. 2013; 54(3 suppl): 779-783. mm (95% ci = 18.54-18.94). douglas and wormald6 reported 21.6 mm (95% ci = 20.7-22.5). table 7 shows the results of our studies compared to other published reports. there was a statistically significant difference with a p-value of <0.0001. the differences of the means could be due to: 1) difference of the anatomy of asians compared to caucasians; and 2) most of the studies published used cadavers as their population while our study used strictly ct scan images and did not use cadavers. table 7. result comparisons with other published studies palatal mucosal thickness (mm) pterygopalatine fossa length (mm) greater palatine canal length (mm) our study (2014) douglas and wormald 2006 methathrathip et al. 2005 howardswirzinski et al. 2010 hassman 1989 sheikhi et al. 2013 5.98 (5.90-6.06) 6.9 (6.2-7.6) 16.99 (16.86-17.12) 18.5 (17.9-19.1) 29 (26 – 32) 14.6 (9-20) 31.8 (30.45-33.19) 18.75 (18.54-18.94) 21.6 (20.7-22.5) 29.7 (25.5 – 33.9) (gpc + ppf) fossa via the greater palatine canal-a technique used to achieve hemostasis during endoscopic sinus surgery and other procedures as well (e.g. control of epistaxis, treatment of trigeminal neuralgia, local anesthesia for oral procedures). measuring the palatal mucosal thickness, the length and width of greater palatine canal and the length and width of pterygopalatine fossa in preoperative pns ct scans is recommended for the otolaryngologist to be able to properly prepare the needle for local injection of lidocaine and epinephrine solution for hemostasis prior to sinus surgery. with the average measurement of the mucosal palatal thickness combined with the length of the greater palatine canal at 22.97 mm, we recommend bending the needle for local anesthesia 23mm from its tip in a 45 degree angle for local patients who will undergo sinus surgery, trigeminal nerve block, control of posterior epistaxis and minor oral cavity and dental procedures under local anesthesia. the differences of the results of our study compared to other published reports could be attributed to differences in subjects studied (e.g. cadavers or skulls vs ct scan images) and anatomic differences between asians and caucasians. measuring the angle between the palatal mucosa and greater palatine canal was not done in this study and is recommended for future research. there have been several published reports recommending where to bend the needle. the recommendation of douglas and wormald6 is to bend the needle 25 mm from the tip at a 45 degree angle because the greater palatine canal and hard palate form an angle of approximately 60 degrees. this would facilitate the passage of the needle through the canal and to prevent the needle from penetrating too far the pterygopalatine fossa. this was supported by a study in thailand which reported that the mean angle of greater palatine canal in relationship with the hard palate is 57.9+5.8 degrees in thai skulls.7 in our study, we did a radio-anatomic measurement of the width of the greater palatine canal and pterygopalatine fossa. the average width of the greater palatine canal was 2.37 mm (95%ci=2.3-2.44) and pterygopalatine fossa was 2.58 mm (95%ci=2.5-2.66). there are several published reports regarding the diameter of the greater palatine canal. most studies were done with cadavers. nimigean et al.11 studied european skulls and measured the antero-posterior diameter of the greater palatine canal as 4.90 mm (95% ci = 4 – 5.8). methathrathip et al.7 studied thai skulls and measured the greater palatine canal at a diameter of 2.70 mm (95%ci = 2.65 – 3.2). the data from this study may be useful for the preoperative infiltration of lidocaine:epinephrine solution into the pterygopalatine philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 original articles 8 philippine journal of otolaryngology-head and neck surgery abstract objective: to determine whether psidium guajava leaves mouthwash is effective in the management of patients with aphthous ulcers. methods: design: randomized prospective open label clinical study setting: tertiary government training hospital subjects: thirty two patients diagnosed with aphthous ulcers were randomly divided into two groups, a treatment group using prepared guava leaves mouthwash, and a control group using isotonic sodium chloride solution mouthwash given thrice a day for seven days. patients were evaluated using a 10-point visual analog scale. the sizes of the aphthous ulcers were measured using a caliper, and compared on day 1 and day 7 for both treatment and control groups. results were subjected to statistical analysis using t-test, mann-whitney u test and fisher exact test. results: comparison of vas scores of guava treatment and nss control groups showed that there were no differences in pain experienced on days 1 and 2. however, the vas scores from day 3 to 7 had p values ranging from 0.02 0.0001 which showed significant differences in resolution of pain. there was statistically significant marked improvement of pain symptoms as early as three days post-treatment among patients who were administered guava leaves mouthwash. complete resolution of aphthous ulcers in 75% of the study group was observed on day 7. mean ulcer size post-treatment with guava gargle was 0.25mm compared to 0.75mm for nss gargle. the mean size difference at day 7 was 1.44mm for the guava treatment group and 0.88mm for the nss control group. there was a statistically significant faster resolution of ulcer size on day 7 in 16/16 or 100 % of patients in the treatment group compared with only 10/16 or 62.5% of patients in the control group. patients who were administered guava leaves mouthwash generally fared better than those administered isotonic sodium chloride solution. conclusion: guava leaves mouthwash was effective for aphthous ulcers in terms of reduction of symptoms of pain and faster reduction of ulcer size. further clinical trials comparing this mouthwash against other treatment options are recommended. keywords: guava leaves (psidium guajava), aphthous ulcers, mouthwash effectivity of guava leaves (psidium guajava) as mouthwash for patients with aphthous ulcers ferdinand z. guintu, md antonio h. chua, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. ferdinand z. guintu department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 743 6921; (632) 711 9491 local 320 ; (632) 922 8978070 email: ferdinandguintu@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not yet been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to conflict of interest. presented at the philippine society of otolaryngology – head and neck surgery analytical research contest (1st place), october 11, 2012, nathan hall, gsk bldg, chino roces avenue, makati city, philippines department of health 1st research forum (2nd place), national hospital week celebration 2012 on august 9, 2012 at dr. enrique t. ona auditorium, diagnostic center, national kidney and transplant institute, east avenue, quezon city, philippines annual residents research paper 2012 (3rd place), jose r. reyes memorial medical center, rizal avenue, sta cruz, manila, philippines philipp j otolaryngol head neck surg 2013; 28 (2): 8-13 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 original articles philippine journal of otolaryngology-head and neck surgery 9 herbal medicine is one of the main modalities in traditional as well as complementary and alternative medicine; and is increasingly acknowledged due to the extensive use of herbal remedies among the general population in developed and developing countries worldwide.1 “bayabas” or guava (psidium guajava) is a plant of the family myrtaceae.1 in the backyards of most filipino homes in the rural countryside, this plant is commonly seen and grown because of its many uses as fruit and as traditional remedy to treat various ailments. research studies have shown that almost all of the parts of this plant have medicinal qualities, making it one of the most popular therapeutic plants in the philippines and one of the approved medicinal plants of department of health.2 guava (psidium guajava) is a small tree that can grow up to 3 meters tall. the fruit, bark and leaves are used as herbal medicine. a decoction of its leaves is recognized for its effectiveness in curing several ailments, including the treatment of chronic diarrhea and gastroenteritis. the most common use of the leaves is for cleaning and disinfecting wounds by rinsing the afflicted area with a decoction of the leaves. it can also be used as a wash for uterine and vaginal problems, and is good for ulcers. leaf decoction may also be used as mouthwash.2 psidium guajava has also been used for the management of various diseases like toothache, sore throat, and inflamed gums.3 aphthous ulcers are the most common oral mucosal disorder.4 these are acute and extremely painful mouth ulcers usually involving nonkeratinized oral mucosal sites. aphthous ulcers are usually round with a slightly raised margin and erythematous halo4 and may be classified into minor, major and herpetiform.5 approximately 80 percent of patients have minor aphthous ulcers.5 these are 2 to 8 mm in diameter affecting nonkeratinized mucosa such as the labial and buccal mucosa and the floor of mouth or the ventral surface of the tongue. much less common are major aphthous ulcers, larger than minor ulcers, often 1 cm or more in diameter. 5 a third and even less common variety is termed “herpetiform ulceration” and comprises ulcers that are initially multiple and pinpoint.5 these may interfere with eating, drinking and swallowing. several causes have been implicated: local trauma, viral infection, systemic causes, poor oral hygiene, stress and others. although patients have spontaneous healing within 10-14 days, no specific treatment for aphthous ulcers is yet available.4,6 the goals of aphthous ulcer treatment have been to control pain and promote healing.7 mouthwashes may also help.8 this study was designed to determine whether psidium guajava leaves mouthwash is effective in the management of patients with aphthous ulcers. specifically, we sought to determine whether psidium guajava mouthwash as compared to isotonic saline mouthwash, decreases the symptoms of pain in patients with aphthous ulcers; and to assess whether psidium guajava mouthwash, as compared to isotonic saline mouthwash, will hasten aphthous ulcer resolution. methods study design: randomized prospective open label clinical study setting: tertiary government training hospital study population: patients aged 10 years old and above, diagnosed with minor aphthous ulcers in our hospital outpatient department from july to december 2011, who were able to understand and give written informed consent (or assent) and report adverse events were considered. excluded were those with major and herpetiform aphthous ulcers; those with an oral cavity mass with superimposed ulcer where malignancy could not be totally ruled out; those with co-morbid conditions, uncontrolled metabolic conditions or psychiatric conditions; and pregnant patients. thirty-two patients meeting the inclusion and exclusion criteria and who gave informed consent (or assent, where consent was obtained from the parent or legal guardian in those < 18 years of age) were included in the study, fulfilling the pre-determined sample size. patient procedure: subjects were divided into a treatment group and control group using a randomization table. treatment group patients used the psidium guajava leaves mouthwash. they were each given prepared guava mouthwash solution to gargle and instructed to gargle 250 ml of the solution for 3 minutes using any watch or clock thrice a day for one week. control group patients used isotonic sodium chloride solution (nss) mouthwash. they were each given prepared nss mouthwash and instructed to gargle 250 ml for 3 minutes using any watch or clock thrice a day for one week. patients were asked on day 7 if there was any adverse reaction to the gargle. treatment and control groups self-accomplished aphthous ulcer pain scoring daily using a 10-point visual analog scale (vas) where 0 indicated no symptoms and 10 indicated worst symptoms for the entire treatment phase, beginning with a baseline in clinic on day 1. blank vas scales (figure 1) were given to each participant and collected after 7 days. aphthous ulcer sizes for both treatment and control groups were also measured and recorded using one caliper (aesculap, tuttlingen, germany) pretreatment (day 1) and post-treatment (day 7) by a blinded outpatient resident on duty. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 original articles 10 philippine journal of otolaryngology-head and neck surgery preparation of materials fresh guava leaves were gathered from pampanga province and verified by a local biologist. the guava leaves were washed with water, and batches of 200 gm of guava leaves were boiled in 750 ml of water for 8 to 10 minutes. the boiled leaves were removed and the solution was cooled and transferred into sealed 1 liter clean clear plastic containers and placed in the refrigerator. commercially-available isotonic saline solution (euro-med, cavite) were transferred into sealed clean clear plastic containers for the control group. data management and analysis outcome measures were based on comparison of the two groups after 7 days. primary outcome measures were reduction in the median vas pain score and reduction in the median ulcer size. summary measures (mean and percentage) were also determined for the demographic distribution of study participants and other outcomes. the null hypotheses tested were as follows: 1. there is no significant difference in vas scores for pain between patients using guava mouthwash and patients using isotonic sodium chloride solution mouthwash. 2. there is no significant difference in size of the aphthous ulcer between patients using guava mouthwash and patients using isotonic sodium chloride solution mouthwash. all data were encoded and tallied in spss version 10 for windows (ibm, new york, usa). descriptive statistics were generated for all variables. for nominal data, frequencies and percentages were computed. for numerical data, mean ± sd were generated. analysis of the different variables was done using the t-test, mann whitney u test and fisher exact test. results of a total of 37 patients considered, three patients with uncontrolled diabetes mellitus and two patients with pulmonary tuberculosis were excluded. a total of 32 patients were included in this study. there were 26 females and six males, with ages ranging from 17 to 69 years. these patients were randomly allocated into two groups of 16 each: the guava leaves mouthwash treatment group (n=16) and isotonic sodium chloride solution control group (n=16). all participants completed the study. no adverse effects were recorded although one participant in the treatment group complained of nausea attributed to laryngopharyngeal reflux. there was no significant difference between the two groups in terms of demographic characteristics of age and sex with all p values >0.05 (table 1). day 1: aphthous ulcer pain scoring (visual analog pain scale) day 2: aphthous ulcer pain scoring (visual analog pain scale) day 3: aphthous ulcer pain scoring (visual analog pain scale) date: date: date: patient no.: patient no.: patient no.: 1. circle the number that shows how painful is your aphthous ulcer right now (bilugan ang numero na nagpapakita ng gaano kasakit ang iyong singaw ngayon) no symptom 0 1 2 3 4 5 6 7 8 9 10 very 1. circle the number that shows how painful is your aphthous ulcer right now (bilugan ang numero na nagpapakita ng gaano kasakit ang iyong singaw ngayon) no symptom 0 1 2 3 4 5 6 7 8 9 10 very 1. circle the number that shows how painful is your aphthous ulcer right now (bilugan ang numero na nagpapakita ng gaano kasakit ang iyong singaw ngayon) no symptom 0 1 2 3 4 5 6 7 8 9 10 very figure 1. sample blank visual analog scale table 1. comparison of demographic characteristics between the two groups nss (n=16) guava (n=16) p value age in years mean ± sd sex female male 44.06 ± 15.24 15 (93.8%) 1 ( 6.2%) 39.40 ± 12.30 11 (68.8%) 5 (31.2%) 0.34 (ns) 0.17 (ns) there was no significant difference in vas scores of both groups on days 1 and 2 (p = 0.78 and 0.32 respectively). however, there was a significant difference in vas scores of both groups from day 3 until day 7 (all p values <0.05). the vas scores of those given guava mouthwash philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 original articles philippine journal of otolaryngology-head and neck surgery 11 were significantly lower than those given nss (table 2). comparison of the differences in vas scores at different intervals between the two groups showed that there was a significant difference from days 3 to 7 (all p values <0.05). the decrease in vas scores of those given guava was significantly greater than those given nss (table 3). the mean vas scores table 4. comparison of ulcer size at days 1 and 7 between the two groups nss (n=16) guava (n=16) p value day 1 1mm 2mm 3mm mean ± sd day 7 0mm 1mm mean ± sd 9 (56.2%) 4 (25.0%) 3 (18.8%) 1.62 ± 0.80 4 (25.0%) 12 (75.0%) 0.75 ± 0.45 6 (37.5%) 9 (56.2%) 1 ( 6.3%) 1.69 ± 0.60 12 (75.0%) 4 (25.0%) 0.25 ± 0.45 0.80 (ns) 0.004 (s) table 2. comparison of vas scores at different intervals between the two groups nss (n=16) guava (n=16) p value day 1 mean ± sd day 2 mean ± sd day 3 mean ± sd day 4 mean ± sd day 5 mean ± sd day 6 mean ± sd day 7 mean ± sd 5.62 ± 1.36 5.44 ± 1.41 4.75 ± 1.00 3.94 ± 1.34 3.18 ± 1.38 3.12 ± 1.36 (3) 2.68 ± 1.14 (3) 5.50 ± 1.26 4.88 ± 1.74 3.62 ± 1.58 2.31 ± 1.74 1.31 ± 1.30 0.38 ± 0.72 (0) 0.31 ± 0.60 (0) 0.78 (ns) 0.32 (ns) 0.02 (s) 0.005 (s) 0.0004 (s) <0.0001 (s) <0.0001 (s) table 3. comparison of the differences (decrease) in vas scores at different intervals between the two groups nss (n=16) difference guava (n=16) p value day 1 vs day 2 mean ± sd day 1 vs day 3 mean ± sd day 1 vs day 4 mean ± sd day 1 vs day 5 mean ± sd day 1 vs day 4 mean ± sd day 1 vs day 6 mean ± sd day 1 vs day 7 mean ± sd 0.18 ± 0.54 (0) 0.88 ± 0.96 1.68 ± 1.44 2.44 ± 1.26 1.68 ± 1.44 2.50 ± 1.03 2.94 ± 1.18 0.62 ± 1.02 (0) 1.88 ± 1.36 3.18 ± 1.94 4.18 ± 1.68 3.18 ± 1.94 5.12 ± 1.31 5.18 ± 1.16 0.17 (ns) 0.02 (s) 0.01 (s) 0.002 (s) 0.01 (s) <0.00001 (s) <0.00001 (s) figure 2. mean vas scores at different intervals between the two groups at different intervals between the two groups are presented graphically in (figure 2). there was a statistically significant, marked improvement of pain symptoms as early as three days post-treatment in the guava leaves mouthwash group as compared to the isotonic sodium chloride solution mouthwash group. the comparison of ulcer sizes between the two groups showed no significant difference on day 1 (p = 0.80). on the other hand, there was a significant difference noted in size on day 7 (p = 0.004). the mean size of ulcers in those given guava mouthwash was significantly smaller than those given nss with a mean of 0.25mm and 0.75mm respectively (table 4). there was a significant size difference between the two groups (p = 0.03). the decrease in size of those given guava mouthwash was significantly greater than those given nss with a mean decrease in size of 1.44mm and 0.88mm respectively (table 5). the distribution of subjects according to ulcer size at days 1 and 7 is presented graphically in (figure 3). there was a statistically significant, philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 original articles 12 philippine journal of otolaryngology-head and neck surgery and morphine were used as standard reference for comparison.10 the numerous tannins, polyphenolic compounds, flavonoids, ellagic acid, triterpenoids, guiajaverin, quercetin and other chemical compounds present in the plant account for the observed anti-inflammatory and analgesic effects of the plant’s leaf extract.10 much of the traditional uses of p. guajava have been validated by scientific research. toxicity studies in mice and other animal models as well as controlled human studies show both leaf and fruit are safe without any side effects.17 the effectivity of guava leaves in pain alleviation may largely be due to the numerous flavonoids, tannins, polyphenolic compounds, ellagic acid, triterpenoids, guiajaverin, quercetin and other chemical compounds present in the plant.10 flavonoids inhibit biosynthesis of prostaglandins, which are involved in various immunologic responses and are the end products of the cyclooxygenase and lipoxygenase pathways.18 protein kinases are another class of regulatory enzymes affected by flavonoids. inhibition of these enzymes provides the mechanism by which flavonoids inhibit inflammatory processes.19 significant decrease in the size of aphthous ulcers may be attributed to the presence of flavonoids extracted from guava leaves including morin-3-o-lyxoside, morin-3-o-arabinoside, quercetin and quercetin3-o-arabinoside which were reported to have strong antibacterial and antiviral action.9 since it is hypothesized that one of the causes of aphthous ulcer is hypersensitivity and inflammation, the resolution of size may be due to the effects of flavonoids. a significant amount of work has been done on the pharmacological and biological activity and possible application of chemical compounds. the taste and scent of guava are a limiting factor in proper standardization of clinical trials as patients could easily recognize its taste and scent. hence, vas was combined with measurement of aphthous ulcer size to more objectively document its therapeutic potential. our study showed that guava leaves mouthwash, compared to isotonic saline solution, was effective for aphthous ulcers in terms of reduction of symptoms of pain and faster reduction of ulcer size. further clinical trials comparing this mouthwash against other treatment options are recommended. markedly faster resolution of aphthous ulcer size in the guava leaves mouthwash group as compared to the isotonic sodium chloride solution mouthwash group. the results obtained suggest that guava leaves mouthwash is effective as an alternative treatment for aphthous ulcers. discussion p. guajava has been known to have antimicrobial,9 antiinflammatory,10 antitumor,11 antiallergic,12 antihyperglycemic,10,13 and antimutagenic14 activities. it has been used to treat wounds,15 cough3 and dental diseases.16 flavonoids extracted from guava leaves including morin-3-o-lyxoside, morin-3-o-arabinoside, quercetin and quercetin-3o-arabinoside were reported to have strong antibacterial action.9 an in vitro study of aqueous extract of psidium guajava reduced the cellsurface hydrophobicity of strep. sanguinis, strep. mitis and actinomyces sp. responsible in development of dental plaques.16 psidium guajava also has been used for the management of various diseases like toothache, sore throat, inflamed gums, and a number of other conditions.3 growth of staphylococcus aureus and beta-streptococcus group a, as determined by the disc diffusion method, was inhibited by extract of dry guava leaves.3 the anti-inflammatory and analgesic properties of the plant’s leaf extract were determined by using experimental animals. diclofenac table 5. comparison of ulcer size difference between the two groups nss (n=16) guava (n=16) p value size difference 0mm 1mm 2mm mean ± sd 6 (37.5%) 6 (37.5%) 4 (25.0%) 0.88 ± 0.80 0 9 (56.2%) 7 (43.8%) 1.44 ± 0.51 0.03 (s) figure 3. distribution of subjects according to size at day 1 and day 7 between the 2 groups mm philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 original articles philippine journal of otolaryngology-head and neck surgery 13 references 1. rattanachaikunsopon p, phumkhachorn p. contents and antibacterial activity of flavonoids extracted from leaves of psidium guajava. journal of medicinal plants research. 2010; 4(5): 393396. 2. quisumbing e. medicinal plants of the philippines. katha publishing company. jmc press, quezon city, philippines. 1978 3. jaiarj p, khoohaswan p, wongkrajang y, peungvicha p, suriyawong p, saraya ml et al. anticough and antimicrobial activities of psidium guajava linn. leaf extract. j ethnopharmacol. 1999 nov 1; 67(2): 203-212. 4. scully c. clinical practice. aphthous ulceration. n engl j med. 2006 jul 13; 355(2):165-172. 5. thornhill mh, baccaglini l, theaker e, pemberton mn. a randomized, double-blind, placebocontrolled trial of pentoxifylline for the treatment of recurrent aphthous stomatitis. arch dermatol. 2007 apr; 143(4):463-470. 6. chattopadhyay a, shetty kv. recurrent aphthous stomatitis. otolaryngol clin north am. 2011 feb; 44(1): 79–88. 7. barrons rw. treatment strategies for recurrent oral aphthous ulcers. am j health syst pharm. 2001 jan 1; 58(1):41–53. 8. thomas m, del mar c, glasziou p. how effective are treatments other than antibiotics for acute sore throat? br j gen pract. 2000 oct; 50(459):817–820. 9. arima h, danno g. isolation of antimicrobial compounds from guava (psidium guajava l.). biosci. biotechnol. biochem. 2002 aug; 66(8): 1727-1730. 10. ojewole ja. antiinflammatory and analgesic effects of psidium guajava linn. (myrtaceae) leaf aqueous extract in rats and mice. methods find exp clin pharmacol. 2006 sep; 28(7):441-6. 11. manosroi j, dhumtanom p, manosroi a. anti-proliferative activity of essential oil extracted from thai medicinal plants on kb and p388 cell lines. cancer lett. 2006 apr 8. 235(1): 114-120. 12. tona l, kambu k, ngimbi n, cimanga k, vlietinck aj.. antiamoebic and phytochemical screening of some congolese medicinal plants. j ethnopharmacol.1998 may; 61(1): 57-65. 13. mukhtar hm, ansari sh, bhat za, naved t, singh p. antidiabetic activity of an ethanol extract obtained from the stem bark of psidium guajava (myrtaceae). pharmazie. 2006 aug; 61(8): 725727. 14. grover is, bala s. studies on antimutagenic effect of guava (psidium guajava) in salmonella typhimurium. mutat res. 1993 jun; 300(1): 1-3. 15. chah kf, eze ca, emuelosi ce, esimone co. antibacterial and wound healing properties of methanolic extracts of some nigerian medicinal plants. j ethnopharmacol. 2006 mar 8; 104(1-2): 164-167. 16. razak fa, othman ry, rahim zh. the effect of piper betle and psidium guajava extracts on the cell-surface hydrophobicity of selected early settlers of dental plaque. j oral sci. 2006 jun; 48(2): 71-75. 17. kamath jv, rahul n, ashok kumar ck, lakshmi sm. psidium guajava: a review. int j green pharm. 2008; 2:9-12. 18. moroney ma, alcaraz mj, forder ra, carey f, hoult jr. selectivity of neutrophil 5-lipoxygenase and cyclooxygenase inhibition by antiinflammatory flavonoid glycoside and related aglycone flavonoids. j pharm phamocol. 1988 nov; 40(11): 787-92. 19. manthey ja, grohmann k, guthrie n. biological properties of citrus flavonoids pertaining to cancer and inflammation. curr med chem. 2001 feb; 8(2): 135-153. philipp j otolaryngol head neck surg 2011; 26 (1): 10-15 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles 10 philippine journal of otolaryngology-head and neck surgery abstract objectives: to calculate the accuracy, sensitivity, specificity and positive predictive values of the siemens hearcheck™ navigator in detecting hearing loss and to compare values of these parameters when the examination is done in a soundproof booth and in a quiet room. methods: design: analytical, cross-sectional study setting: tertiary public university hospital patients: patients seen at the ear unit of a tertiary public university hospital from june 2009 to august 2010 were tested using the siemens hearcheck™ navigator and pure tone audiometry, inside a soundproof audiometry booth and in a quiet room with an ambient noise of 50db, with a different investigator for each examination. each ear was treated as a separate subject. results obtained from the hearcheck™ navigator were designated as observed values and were classified as “no hearing loss” for green light, and “with hearing loss” for yellow or red lights. results were compared with pure tone air conduction averages designated as gold standard values. normal hearing acuity (0-25 db) was classified as no hearing loss. pure tone air conduction averages of 26db and above were classified as “with hearing loss” and were further stratified as mild hearing loss (26-40db) and moderate or worse hearing loss (>41 db). observed and gold standard values were compared and tabulated in a 2x2 table for all levels of hearing loss, mild hearing loss, and moderate or worse hearing loss. accuracy, sensitivity, specificity, positive and negative predictive values of the siemens hearcheck™ navigator inside a soundproof audiometry booth and in a quiet room were determined using pure tone audiometry as the gold standard. results: 100 patients (200 ears) were tested, with a median age of 43 years old (range 15-75), and an almost equal number of male and female participants (52 males, 48 females). accuracy rate of the siemens hearcheck™ navigator inside the soundproof audiometry booth and in a quiet room were 82.5% and 84% respectively for all levels of hearing loss. sensitivity, specificity, positive and negative predictive values were similar whether the examination was done inside the soundproof audiometry booth or in a quiet room. these values were notably higher in accuracy of siemens hearcheck™ navigator as a screening tool for hearing loss kathleen r. fellizar-lopez, md, mph1 generoso t. abes, md, mph1,2 ma. rina t. reyes-quintos, md, mclinaud1,2 ma. leah s. tantoco, md, mclinaud2 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2philippine national ear institute national institutes of health university of the philippines manila correspondence: dr. kathleen r. fellizar-lopez department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 554 8400 loc 2152 fax: (632) 525 5444 email: orlpgh@yahoo.com reprints will not be available from the author the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the hearcheck™ navigator was complementarily provided by siemens for research purposes. the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the analytical research contest (1st place), philippine society of otolaryngology head and neck surgery, natrapharm patriot building, paranaque city, philippines,october 13, 2010 patients with moderate or worse hearing loss compared to patients with mild hearing loss. conclusion: the siemens hearcheck™ navigator shows potential as an accurate, portable, easy-to-use tool to screen for hearing loss, especially for cases of moderate or worse hearing loss, without the need for soundproof audiometry booths or special training. it is recommended that further studies be done to differentiate degrees of hearing loss, and to evaluate its usefulness in other target populations, including school children and the elderly. keywords: hearing screening, hearing screening tool, accuracy, hearing loss, hearcheck™ navigator hearing loss is a prevalent problem in adults and children. it can have long-term negative consequences, resulting in loss of productivity, social stigma and low self-esteem.1,2 half of all cases of hearing impairment are avoidable through prevention, early diagnoses and management.3 hearing screening is of utmost importance for early detection and intervention and in decreasing this functional disability.4 like most developing countries, the philippines is in need of a hearing screening instrument that is available, affordable, easy to use and cost-effective, that can be brought to remote communities to be used in the primary care setting by community health workers. this screening tool must be accurate and reliable. bedside tests (ie. finger rub, ballpen click, watch tick, whispered speech, rinne and weber) and disability questionnaires, although easy to perform, are subjective, difficult to standardize and have suboptimal sensitivity (60%), relatively good specificity (74%), and variable positive predictive value (24-100%) for detecting hearing loss.5 in a local study, the 512hz tuning fork was shown to be an accurate and precise hearing screening tool, with a high accuracy rate of 97%, specificity of 97%, sensitivity of 91% and a positive predictive value of 81%.6 however, tuning fork tests, while inexpensive, require proper training, particularly the proper movement for the production of sound and placement of the tool in relation to the external auditory meatus, and interpretation of results. a collaborative program between the philippine national ear institute and the department of education included training of school nurses in hearing screening with the use of a penlight and a 512hz tuning fork.7 among the observed difficulties with the use of the tuning fork was difficulty in eliciting sound and/or vibration because of the inability to perform the proper wrist movement, particularly in the presence of arthritic joints, as well as wrist pain from contact with the tuning fork. a study by burkey et al. in 1998 showed that the rinne tuning fork test could be very effective at detecting hearing loss when performed by an experienced examiner and when masking was employed. sensitivity was lower when masking was not used and lowest when the rinne test was performed by a less-experienced investigator. in the primary care setting, the rinne test would be an effective part of a screening program for conductive hearing loss, but should not be the sole indicator for referral to a hearing center for other examinations.8 objective examinations, such as otoacoustic emissions (oaes), auditory brainstem response (abr) and auditory steady state response (assr) are currently gaining popularity and have allowed early physiologic detection of hearing impairment. prospects for this trend in developing countries remain doubtful because of adverse socioeconomic conditions9 either leading to lack of equipment or poor access to facilities. otoacoustic emissions and pure tone audiometry are the recommended equipment in hearing centers today. these instruments, along with abr and assr, require expensive and delicate equipment which are difficult to transport, technical know-how and proper training on handling and operation, rely on electricity and are not readily available and accessible. because of the paucity of these machines, there is still a lack of knowledge on the prevalence of hearing loss in the country. an integrated national hearing screening program has yet to be developed. while searching for an alternative tool for hearing screening, the investigators considered portable handheld screening audiometers which are available in the country today. one such audiometer is the siemens hearcheck™ navigator (siemens, germany). it is a simple and portable instrument. however, there has been no study which measures its accuracy and reliability based on a pubmed medline literature search (search words: siemens hearcheck navigator, hearing screening, accuracy, reliability). this paper aims to determine the accuracy of the siemens hearcheck™ navigator in screening for hearing loss using pure tone audiometry diagnosis as gold standard. specifically, it aims: 1. to calculate the accuracy, sensitivity, specificity and positive predictive values of the siemens hearcheck™ navigator in detecting hearing loss; 2. to compare values of the above parameters when the examination is done in a soundproof booth and in a quiet room; 3. to determine accuracy, sensitivity, specificity and positive predictive value among patients with mild hearing loss only (on pure tone audiometry); and 4. to determine accuracy, sensitivity, specificity and positive predictive value among patients with at least moderate hearing loss (on pure tone audiometry). philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles philippine journal of otolaryngology-head and neck surgery 11 methods patients referred to the ear unit of a tertiary government hospital for pure tone audiometry from june 2009 to august 2010 were included in this analytical cross-sectional study. informed consent was obtained and demographic data for each patient was taken. no harm was done to any of the study participants. the study was conducted in accordance to the principles of the declaration of helsinski. the siemens hearcheck™ navigator is a portable handheld screening audiometer, with three light indicators (green, yellow, red), a start button, battery compartment housing two aaa batteries, ear cover, label and a disposable ear cup. (figure 1) it has been factory calibrated and should be recalibrated three years from the manufacturing date. it presents sound at 35db, 55db and 75db at test frequencies of 375hz, 1000hz and 3000hz. all patients were tested using the device in a quiet room, followed philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles 12 philippine journal of otolaryngology-head and neck surgery by a test done inside a soundproof audiometry booth, and pure tone audiometry. (figure 2) five-minute rest periods were allotted between each test. each ear was treated as a separate subject. 1. hearcheck™ navigator testing physician a performed the test with the device in a quiet room. the ambient noise inside the room (average of 50db) was determined using a tes1350a sound level meter (tes electrical electronic corp., taiwan, 2000) prior to each test. the device was held gently to the head of the patient, with the ear cover completely surrounding the ear ensuring skin contact all around. the test sequence started when the start button was pressed. a short automatic functional test was performed, afterwhich all three light indicators would flash, indicating that the device was ready to start. the patient was instructed to raise his/her hand when a tone was heard. (figure 2) when the patient raised his/her hand, the examiner pressed the start button. the test for the particular frequency was terminated automatically when the start button was not pressed within 20 seconds. the result of the test was indicated with a red, yellow or green light for another 20 seconds. physician b performed the test with the device in a soundproof audiometry booth, with the same preparations and steps as described above. each examiner was blinded to the results of the other examinations. 2. pure tone testing with a diagnostic audiometer a technician blinded to the results of the two previous tests performed all the pure tone audiometry tests using an ad229b diagnostic audiometer (interacoustics a, s, assess, denmark, 2005) that was calibrated weekly. figure 1. siemens hearcheck™ navigator portable handheld screening audiometer with disposable ear cups. table 1. world health organization grades of hearing impairment (geneva, 1991)10 grade of impairment corresponding audiometric iso value (average of 500, 1000 and 2000hz) none mild impairment moderate impairment severe impairment profound impairment including deafness 25db or better 26-40 db 41-60 db 61-80 db 81db and above table 2. two-by-two table hearcheck™ navigator pure tone audiometer with hearing loss (+) no hearing loss (-) no hearing loss (-) false positive true negative with hearing loss (+) true positive false negative figure 2. photographs illustrating test sequence using the portable handheld hearing screening instrument by physician a in a quiet room (a) and physician b inside a soundproof booth (b). philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles philippine journal of otolaryngology-head and neck surgery 13 results obtained from the hearcheck™ navigator were designated as observed values and were classified as positive for hearing loss with yellow or red results, and negative for hearing loss with green results. the results were compared with pure tone air conduction average (500hz, 1000khz, 2000khz), which were designated as gold standard values. normal hearing acuity (0-25 db) was classified as no hearing loss. pure tone air conduction averages of 26db and above were classified as positive for hearing loss, based on the world health organization grades of hearing impairment, and were further stratified into mild hearing loss (26-40db hearing loss) and moderate or worse hearing loss (>41db hearing loss)10 (table 1). observed and gold standard values were compared according to presence or absence of hearing loss. the results were tabulated in a two by two table (table 2). accuracy, sensitivity, specificity, positive and negative predictive values of the siemens hearcheck™ navigator inside the soundproof audiometry booth and in a quiet room were determined, using pure tone audiometry as the gold standard. computations were done for all patients, patients with mild hearing loss only and those with at least moderate hearing loss computed values of results obtained inside the soundproof audiometry booth and in a quiet room were compared using the z test for two proportions, with a level of significance of 0.05. results a total of 200 ears (100 patients) were tested, with a median age of 43 years old (range 15-75 years old), with almost an equal number of male and female participants (52 males, 48 females, ratio of 1.08:1). the values obtained from 200 ears are shown in table 3 for all levels of hearing loss, table 4 for mild hearing loss and table 5 for moderate or worse hearing loss. the corresponding computations obtained from the results of each of the above tables are shown in table 6. no statistically significant difference was noted (α=0.05) whether the examination was done inside a soundproof audiometry booth or in a quiet room for all computed values. patients with hearing loss were grouped into those with mild hearing loss only and those with at least moderate hearing loss. no statistically significant difference was noted in the computed values for both groups inside the soundproof booth and in a quiet room. note, however, that accuracy and sensitivity were significantly lower for patients with mild hearing loss compared to patients with at least moderate hearing loss. sensitivity of the hearcheck™ navigator was high in patients from the latter group but was suboptimal in patients from the former. table 3. hearcheck navigator vs puretone audiometry for all levels of hearing loss hearcheck™ navigator pure tone audiometer with hearing loss without hearing loss total inside booth quiet roomtotal total with hearing loss 104 30 134 with hearing loss 105 29 134 without hearing loss 5 61 66 without hearing loss 3 63 66 109 91 200 108 92 200 table 4. hearcheck™ navigator vs puretone audiometry for mild hearing loss hearcheck™ navigator pure tone audiometer with hearing loss without hearing loss total inside booth quiet roomtotal total with hearing loss 19 17 36 with hearing loss 16 20 36 without hearing loss 5 61 66 without hearing loss 3 63 66 24 78 102 19 83 102 table 5. hearcheck™ navigator vs puretone audiometry for moderate and worse hearing loss hearcheck™ navigator pure tone audiometer with hearing loss without hearing loss total inside booth quiet roomtotal total with hearing loss 85 13 98 with hearing loss 89 9 98 without hearing loss 5 61 66 without hearing loss 3 63 66 90 74 164 92 72 164 table 6. results obtained for the different values inside the booth and in a quiet room for all levels of hearing loss, mild hearing loss and moderate or worse hearing loss all levels of hearing loss mild hearing loss (26-40db) moderate or worse hearing loss (>41db) parameter accuracy sensitivity specificity positive predictive value negative predictive value inside booth (%) 82.5 77.61 92.42 95.41 67.03 inside booth (%) 78.43 52.77 92.42 79.17 78.21 inside booth (%) 89.02 86.73 92.42 94.44 82.44 quiet room (%) 84 78.36 95.45 97.22 68.48 quiet room (%) 77.45 44.44 95.45 84.21 75.90 quiet room (%) 92.68 90.92 95.45 96.74 87.50 z-test* ns ns ns ns ns z-test ns ns ns ns ns z-test ns ns ns ns ns philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles 14 philippine journal of otolaryngology-head and neck surgery table 7. summary of portable handheld screening audiometer studies study no. of patients accuracy yeartype of handheld screening audiometer used penaflor, et al6 lichtenstein, et al12 ciurlia-guy, et al13 125 178 104 94% 78.6% 88.17% 2001 1998 1993 siemens sd 10 handheld tester audioscope audioscope discussion with puretone audiometry as the gold standard, the high specificity rate of the hearcheck™ navigator, indicates that we can rule in the presence of hearing loss when the device shows a yellow or red light, whether the examination is done inside the soundproof booth (92.42%) or in a quiet room (95.45%). the high positive predictive value means that among those with hearing loss based on the hearcheck™ navigator results, the probability of having actual hearing loss is 9 out of 10, especially in cases of moderate or worse hearing loss. false positive results are practically nil. however, sensitivity of the hearcheck™ navigator is not as high as its specificity. for all types of hearing loss combined, sensitivity is only 77.61% in a soundproof booth and 78.36% in a quiet room, indicating that only 7 out of 10 of those with hearing loss according to the device have actual hearing loss, and that hearing loss can be missed. the negative predictive value of the device is likewise not very high for all levels of hearing loss. 4 out of 10 may be mislabeled as normal when in fact they may indeed have hearing loss. results obtained when computations are done separately for those with mild hearing loss and moderate or worse hearing are higher for the latter. accuracy and sensitivity of the hearcheck™ navigator were noted to be significantly higher in patients with at least moderate degrees of hearing loss compared to patients with mild hearing loss. while several cases of mild hearing loss were correctly labeled by the device as having hearing loss (yellow light), most of the false negatives had mild hearing loss on pure tone audiometry. this indicates that the hearcheck™ navigator is better at detecting moderate or worse hearing loss (41db and above air conduction average) than mild levels of hearing loss (26 to 40db air conduction average), and that mild hearing loss may be missed. thus, with these current values, we cannot confidently rule out hearing loss in the presence of a negative test as indicated by a green light but it can be confidently ruled in by the presence of a red or yellow light. caution must be employed in observing patients that we suspect of having hearing loss but register a negative result on the hearcheck™ navigator, so as not to miss a hearing problem. in such a case, the test may be repeated in order to validate a previous negative result. referral for further testing (ie. pure tone audiometry, abr/assr) may be indicated if screening results are negative but hearing loss is highly suspected. according to cadman et al., a high sensitivity rate, high specificity rate and high positive predictive values are attributes of a good test for a screening program.11 the hearcheck™ navigator was able to fulfill two of these characteristics – a high specificity rate and a high positive predictive value. it can confidently rule in hearing loss, but we cannot say that the device could confidently rule it out. in cases of moderate or worse hearing loss, all these criteria were fulfilled by the hearcheck™ navigator. the accuracy rate of the hearcheck™ navigator inside a soundproof booth or in a quiet room is 82.5% and 84% respectively. the accuracy rate of the hearcheck™ navigator is comparable to other portable handheld screening audiometers used in other studies. 6,12-13 (table 7) these studies had bigger sample sizes compared to this. hence, this study is being continued to obtain a more adequate sample size for a more significant analysis. it is important to note also that the devices used in these studies are expensive, require technical know-how and special training in their operation and interpretation of results, and cannot be readily brought to remote communities to be used by local community health workers. in contrast to the 512hz tuning fork, whose usefulness as a screening tool may be limited to disorders presenting with low-frequency hearing loss (ie. external or middle ear disorders),6 the frequencies presented by the hearcheck™ navigator include higher frequencies. thus, this device is capable of detecting disorders presenting as high frequency hearing loss, such as early presbycusis. this study was conducted in an ideal test environment. subjects included were referrals from physicians, hence, the positive predictive value could be overestimated as disease prevalence is known to be higher in referral centers than in the community or in the primary care setting.11 it is recommended that this test be validated by studies done among different populations at the community level, including the elderly and the pediatric population. the hearcheck™ navigator is a portable, light-weight, non-invasive device that is very simple and easy to use. no statistically significant difference was noted in the values obtained whether the test was done inside a soundproof audiometry booth or in a quiet room indicating that a soundproof booth is not necessary for the device to perform its function. it does not rely on an external electric supply and runs on two aaa batteries. results are available in seconds. no intensive philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles philippine journal of otolaryngology-head and neck surgery 15 acknowledgements we acknowledge romeo l. villarta, md, mph, drph (cand) and erasmo gonzalo dv llanes, md for their scientific advice, marieflor cristy m. garcia, md, kathryn llanos dee, md and ma. luz m. san agustin bsba for the data collection, hypte raymund v. aujero, md for the photographs and ms. michelle mañanes for general assistance with this research. references 1. mulrow cd, aguilar c, endicott je, tuley mr, velez r, charlip ws, et al. quality-of-life changes and hearing impairment. a randomized trial. ann intern med. 1990 aug 1; 113(3):188-194. 2. yueh b, shapiro n, maclean ch, sheckelle pg. screening and management of adult hearing loss in primary care. jama. 2003 apr 16; 289:1976-85. 3. who deafness and hearing impairment fact sheet n°300. place: world health organization. april 2010. [cited 2010 may 26] available from:http://www.who.int/mediacentre/factsheets/ fs300/en/index.html. 4. wang yf, wang ss, tai cc, lin lc, shiao as. hearing screening with portable screening puretone audiometer and distortion-product otoacoustic emissions. zhonghua yi xue za zhi (taipei). 2002; 65(6); 285-92. 5. boatman df, miglioretti dl, eberwein c, alidoost ms, reich sg. how accurate are bedside hearing tests? neurology. 2007 apr 17; 68(16):1311-4. 6. penaflor na, hilario o, abes gt. accuracy of 512 hertz air conduction test for hearing screening. philipp j otolaryngol head neck surg. 2001; 16(1):25-33. 7. gloria-cruz ti, chiong cm, chan al, llanes ed, reyes-quintos rt, abes gt. training of nurses in ear examination and hearing screening in the school setting. southeast asian j trop med pub health. 2007 jan;38(1):188-94. 8. burjey jm, lippy wh, schuring ag, rizer fm. clinical utility of the 512-hz rinne tuning form test. am j otol. 1998 jan; 19(1):59-62. 9. olusanva b. early detection of hearing impairment in a developing country: what options? audiology. 2001 may-jun;40(3):141-7. 10. who grades of hearing impairment. [monograph? on the internet] geneva; world health organization; 1991. [cited 2010 may 26]. available from http://www.who.int/pbd/deafness/ hearing_impairment_grades/en/index.html. 11. cadman d, chambers l, feldmann w, sackett d. assessing the effectiveness of community screening program. jama. 1984 mar 23-30; 251(12): 1580-1585. 12. lichtenstein mj, bess fh, logan sa. validation of screening tools for identifying hearingimpaired elderly in primary care. jama. 1988 may 20; 259(19): 2875-2878. 13. ciurlia-guy e, cashman m, lewsen b. identifying hearing loss and hearing handicap among chronic care elderly people. gerontologist. 1993;33:644-649. training is required for its operation. as such, it can be easily used by local community workers, non-physicians and non-audiologists. it can be brought to communities who have no access to hearing screening centers. since the ultimate utility of this study entails its use by local community examiners, the results should also be validated by studies performed among different populations carried out by actual local community health workers. corollary to this, inter-investigator variability must also be evaluated in order to validate if it can be easily used by different investigators in the community but still arrive at the same results in a patient. the use of the siemens hearcheck™ navigator as a tool for a screening program appears to be promising. while the device appears to be ideal for community use based on its physical characteristics, its accuracy and reliability as a screening tool must further be validated. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 philippine journal of otolaryngology-head and neck surgery 37 under the microscope a 65-year-old male with a two-month history of cough and hoarseness underwent direct laryngoscopy which showed a 1.5 cm diameter polypoid glottic mass. a polypectomy was performed revealing spindle cell carcinoma. the world health organization (2005) defines a spindle cell carcinoma as “a biphasic tumor composed of a squamous cell carcinoma, either in-situ and/or invasive, and a malignant spindle cell component with a mesenchymal appearance, but of epithelial origin.”1 spindle cell carcinomas go by a variety of synonyms such as sarcomatoid carcinoma, spindle cell squamous carcinoma and carcinosarcoma. the larynx is a preferred site of involvement where they often present as polypoid masses.1,3 microscopic examination often shows predominance of the sarcomatoid, spindle-cell component, which can range from fairly bland, reactive-looking fibroblastic-proliferation-like processes, to cytologically malignant and mitotically active proliferations that mimic other spindle-cell sarcomas such as leiomyosarcoma, fibrosarcoma or malignant fibrous histiocytoma.1,2,3 (figure 1, double arrows) the squamous cell carcinoma component may be in the form of an overlying carcinoma-in-situ, or of a focal keratinizing invasive squamous cell carcinoma that requires multiple sections to disclose.1,2 (figure 1, single arrow) cytokeratin-reactivity in the spindle cells, which may be quite focal as in this case, points to their epithelial derivation.1,2,4 (figure 2) favorable prognostic findings include polypoid morphology and, like conventional laryngeal squamous cell carcinomas, a low-stage and a glottic site of origin. reported 5-year survival rates range from 65 – 95%.1 spindle cell carcinomas of the upper aerodigestive tract correspondence: dr. jose m. carnate, jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st., ermita, manila 1000 philippines phone (632) 526 4450 fax (632) 400 3638 email: jmcjpath@yahoo.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2012; 27 (2): 37-38 c philippine society of otolaryngology – head and neck surgery, inc. jose m. carnate, jr., md department of pathology college of medicine university of the philippines manila philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 under the microscope 38 philippine journal of otolaryngology-head and neck surgery references barnes l, eveson jw, reichart p, sidransky d. pathology and genetics of head and neck tumors. 1. in who classification of tumors. international agency for research on cancer (iarc) press, lyon 2005. gnepp dr, ed. diagnostic surgical pathology of the head and neck. wb saunders company, 2. 2009. thompson ld, wieneke ja, miettinen m, heffner dk. spindle cell (sarcomatoid) carcinomas of 3. the larynx: a clinicopathologic study of 187 cases. am j surg pathol. 2002 feb; 26(2):153–170. lewis je, olsen kd, sebo tj. spindle cell carcinoma of the larynx: review of 26 cases including 4. dna content and immunohistochemistry. hum pathol. 1997 jun; 28(6):664 – 673. (hematoxylin and eosin, 400x) figure 1. predominant malignant spindle cell component (double arrows) with focal keratinizing squamous cell carcinoma component (single arrow) (hematoxylin and eosin, 400x) (pancytokeratin immunohistochemistry, 400x) figure 2. focal cytokeratin reactivity among spindle cells, (pancytokeratin immunohistochemistry, 400x) philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery passages mariano b. caparas, md (1932 2017) alfredo q.y. pontejos jr., md it is very difficult to write about a man who is bigger than life. and such was dr. mariano b. caparas, professor and former chairman, department of otorhinolaryngology, college of medicine philippine general hospital, university of the philippines manila. a native of balagtas, bulacan, his first love was to be an artist (a painter) but his parents dissuaded him from doing so and asked him to take up medicine instead. he entered the university of the philippines college of medicine (upcm) and graduated in 1958. he went on to train in the then department of eye, ear, nose and throat (eent) in upphilippine general hospital (pgh). two years in training, ophthalmology separated from otolaryngology. he chose otolaryngology, graduating in 1961. he went on to do further training in the princess margaret hospital in canada specializing in maxillofacial prosthesis. my first encounter with dr. caparas was when, as a first year student in the upcm, we had an immersion program in bay, laguna. he was one of our facilitators who stayed with us in the barrio for one week. he taught us how to be true and caring physicians and at the same time, instilled in us the true spirit of nationalism. dr. cap as he is fondly called was the fiery consultant with a lot of vision, patriotism, and a very strong desire to improve otorhinolaryngologyhead and neck surgery in the country. the early part of his term as chair from 1978-1987 was a time of unrest and national strife. we had limited resources then, so he taught us to be selfreliant. he started the development of instruments, from scraps or rundown machines that were practical and easy to use, like suction dissectors, headlights, myringotomy sets and otoscopes. this started the era of innovation in the department. as a teacher, he would not just give you facts but rather teach you the hows and whys of things. he challenged you to think out of the box. as a surgeon, he was highly skilled and did a lot of innovative techniques. we had flaps which were fondly called cap flaps. he was bold enough to attempt unconventional techniques. he was also co-founder of the asean otorhinolaryngological head and neck federation in 1980. it was organized to present and discuss common orl problems in our region. he always believed in asean first. he was a true nationalist. during the marcos era, he led us to fight for freedom. he was at the forefront in the fight against corruption, imperialism and militarism. as one of the prime movers of the then doctors for cory, he risked his life for democracy. apart from his being a nationalist and a great doctor, he was also an artist and a great painter. we marvel at how he would go up to the board and draw the anatomy of the ear or the neck. he had a gallery of paintings which he gave out to his friends and residents. on the lighter side, he was an avid golfer. he taught us to learn the sport. when he was getting old and weak, golf kept him going. when he got sick two years ago of prostate cancer, he did not want any further treatment but we, his orl family convinced him to fight the big c. he agreed and allowed us to support him in his battle (and thank all who helped him). we will miss you dr. caparas. but i know that you live in each one of us you trained. you have touch the lives of so many filipinos. your legacy will live on. goodbye sir and may you rest in peace. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 philippine journal of otolaryngology-head and neck surgery 35 under the microscope we present a case of a 16-year-old lad with a one year history of gingival mass of the left maxillary alveolar ridge. excision revealed a cystic mass with brown fluid and irregular calcified material within the cavity. histopathologic examination of the cyst lining shows a stratified cuboidal epithelium with palisading of the basal layer. the cells of the latter show reverse nuclear polarization reminiscent of ameloblastic epithelium. the superficial layers have a stellate reticulum-like appearance and contain large eosinophilic polygonal ghost cells. (figure 1, 2) some of the ghost cells show calcifications. (figure 3) sections from the hard, bony fragments show haphazard deposition of dentin and enamel-like material. (figure 4) with these features, this case was called a calcifying cystic odontogenic tumour in association with a complex odontoma. calcifying cystic odontogenic tumor (ccot) is a benign neoplasm characterized by an ameloblastoma-like epithelium with ghost cells that often show calcification.1 it comprises only 2% of all benign odontogenic neoplasms.2 there is equal distribution of involvement for the maxilla and mandible, no sex predilection with most cases diagnosed at the second to third decade of life.1,2 the classic histologic findings are the presence of a stratified epithelium consisting of cuboidal to columnar cells with reverse polarization of the basal layer and the presence of ghost cells. a stellate reticulum-like appearance of epithelial cells is also seen. ghost cells are the most characteristic feature of ccot and this may represent an abnormal type of keratinization or the coagulative necrosis of the odontogenic epithelium.3 calcifying cystic odontogenic tumor associated with a complex odontoma correspondence: dr. jose m. carnate, jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st., ermita, manila 1000 philippines phone (632) 526 4450 fax (632) 400 3638 email: jmcjpath@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2013; 28 (2):35-36 c philippine society of otolaryngology – head and neck surgery, inc. jenny maureen l. atun, md1 jose m. carnate, jr., md2 1department of laboratories, university of the philippines philippine general hospital 2department of pathology, university of the philippines college of medicine philippine general hospital figure 1. hematoxylin and eosin (400x) cyst lining with basal palisading, stellate reticulum and ghost cells (hematoxylin and eosin, 400x) philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 under the microscope 36 philippine journal of otolaryngology-head and neck surgery references 1. praetorius f, ledesma-montes c. calcifying cystic odontogenic tumour. in: barnes l, eveson jw, reichart p, sidransky d. eds. world health organization classification of tumours. pathology and genetics of head and neck tumours. 2005; lyon: iarc press. p. 313. 2. chindasombatjaroen j, poomsawat s, klongnoi b. calcifying cystic odontogenic tumor associated with other lesions: case report with cone-beam computed tomography findings. oral surg oral med oral pathol oral radiol. 2012 mar; 113(3);414-420. 3. sharma b, singh s, bhardwaj p. calcifying cystic odontogenic tumour: a case report and review on nomenclature. international journal of oral and maxillofacial pathology. 2012; 3(1):79-85. 4. cury se, cury sn, cury m, calderoni a, fajardo vd, carvalho mr, et al. calcifying cystic odontogenic tumor: case report. webmedcentral oral medicine 2011;2(12):wmc002583. [cited 24 october 2013] available fromhttp://www.webmedcentral.com/wmcpdf/article_wmc002583. pdf. 5. sidana s, poonja k, galinde j, poonja ls. calcifying cystic odontogenic tumor with compound odontoma. journal of contemporary dentistry. 2013 jan-apr; 3(1): 36-39. doi: 10.5005/jp-journals-10031-1032. 6. zhu zy, chu zg, chen y, zhang wp, ly d, genb n, yang mz. ghost cell odontogenic carcinoma arising from calcifying cystic odontogenic tumour: a case report. korean j pathol. 2012 oct; 46(5): 478-482. 7. habibi a, saghravanian n, salehinejad j, jafarzadeh h. thirty years clinicopathological study of 60 calcifying cystic odontogenic tumours in iranian population. the journal of contemporary dental practice 2011 may-jun; 12(3): 171-173. doi: 10.5005/jp-journals-10024-1029. (hematoxylin and eosin, 400x) figure 2. hematoxylin and eosin (400x) ghost cells, stellate reticulum and basal palisaded cell figure 3. hematoxylin and eosin (400x) calcifications within the ghost cells. (hematoxylin and eosin, 400x) ccot may present alone or in association with other odontogenic tumours.2,4 association with an odontoma has been reported in 20% to 24% of cases of ccot.5 complex odontoma is a hamartomatous lesion characterized by haphazard arrangement of matrix-producing epithelium, enamel, dentin and cementum-like tissue, in contrast to the more regular structure of a compound odontoma.1 ccot associated with odontoma (ccotao), in contrast to ccot alone, has a slight female predominance (2:1), a younger age of presentation (mean 16 years) and a predilection to the maxilla (61.5 %).5 sidana et al. postulated several possible pathogenesis of ccotao including the possibility that ccot develops secondarily from the epithelium figure 4. hematoxylin and eosin (100x) haphazard deposits of dentine and enamel-like matrix of the complex odontoma. (hematoxylin and eosin, 100x) involved in the formation of odontoma or that the odontoma develops secondarily from the epithelium in ccot.5 enucleation is the treatment of choice and is curative. a close histologic differential diagnosis is an acanthomatous ameloblastoma. acanthomatous ameloblastoma contains distinct squamous epithelium within nests of ameloblastic epithelium, and ghost cells are absent. very rarely, transformation into its malignant counterpart, ghost cell odontogenic carcinoma (gcoc), has been reported in recurrent cases.6,7 infiltrative borders, nuclear atypia and increased mitotic activity indicate this change.6,7 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 editorial 4 philippine journal of otolaryngology-head and neck surgery peer review is widely accepted as the hallmark of scholarly, scientific publication. it helps journal editors determine whether research conclusions are justified and “new,” gives them an idea of the potential or actual significance of a work1 and adds a “human judgment” element to the academic process while lightening their workload.2 ideally, this results in a “decision that is constructive, transparent, timely and fair,”1 and that will enhance the final writing product.3 journals use peer review because it serves as a quality control filter for scholarly information.4 more papers are churned out than can be printed, and the peer review process can weed out fraud and eliminate “bad” science, pseudoscience and harmful science, thereby upholding ethical standards.2,4 peer review also serves as a mechanism for improving manuscripts; it promotes originality, academic rigor and improves the critical thinking and writing skills of authors, reviewers and editors.3 it reduces bias and improves the quality of published articles.3 the peer review process bestows a collegial stamp of approval on a manuscript and bestows an aura of “quality.”4 however, as dominy and bhatt4 point out, there are famous papers that were published and did not get peer reviewed (including watson & crick’s 1951 letter on the structure of dna in nature, abdus salam’s 1968 paper on weak and electromagnetic interactions that led to the nobel prize, and alan sokal’s 1996 hoax now known as the sokal affair). there are also famous papers that were published and passed peer review, but later proved to be fraudulent (including jan hendrik schon’s 15 papers from 1998-2001 in science and nature and igor and grichka bogdanov’s 1999 and 2002 theoretical physics papers “believed by many to be jargon-rich nonsense”).4 perhaps most telling are the famous papers that got rejected and later turned out to be seminal works (including krebs and johnson’s “1937 paper on the role of citric acid on metabolism” … “rejected by nature as being of ‘insufficient importance’ – “now known as the krebs cycle” and “recognized with a nobel prize in 1953).4 peer review is clearly not infallible; but its benefits still far outweigh its flaws. this greatly depends on the quality of reviewers and on the system of peer review. our journal utilizes a double-blinded multi-stage review system that allows reviewers to judge, and authors to respond and revise, manuscripts. this system presumes that reviewers are experts in their chosen field, and are able to provide an “unbiased opinion on the quality, timeliness and relevance of the submitted manuscript.”5 reviewers have four responsibilities – to the editor and journal, to his/ her specialty or subspeciality, to patients and study subjects, and to the author.5 correspondence: prof. dr. josé florencio f. lapeña, jr. office of the vice chancellor for administration 8f, rcb building, philippine general hospital university of the philippines manila taft ave., ermita, manila 1000 philippines phone: (632) 526 6110 telefax: (632) 524 4455 email: lapenajf@upm.edu.ph reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines reviewing peer review philipp j otolaryngol head neck surg 2014; 29 (1): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 5 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 editorial the responsibility to the editor and journal means reviewers are responsible for protecting the reputation of the journal, as well as the integrity of their specialty/subspecialty, their area of expertise and profession. reviewers, therefore, should “make sure rubbish does not get published.”5 reviewers are also responsible for protecting the welfare of subjects, both human and animal. finally, reviewers should ensure a fair treatment of the authors’ manuscript, remembering that all manuscripts are the private property of authors and highly privileged communications.5 they should never publicly discuss the authors’ work, or steal their ideas before publication. public discussion includes soliciting opinions on the manuscript from others, including postings on internet discussion groups. stealing ideas can range from plagiarism to intellectual property and patent theft. such misconduct is of a higher order, because of the authority of the reviewer. inadvertent breach of confidentiality, while unintended, has the same consequences for the author. to further ensure confidentiality, reviewers should destroy copies of the reviewed manuscript after completing the review, to prevent such copies from falling into the wrong hands. reviewers should try to make the manuscript better, providing helpful suggestions for improvement, even if the manuscript is rejected.5 needless to say, they should be familiar with the journal and its requirements, including its instructions to authors, types of papers published, journal style, and standards of the journal. they should also understand the basics of the peer-review process. such understanding can be facilitated through formal training, complemented by actual review experience. in general, a manuscript review consists of comments to the editor, and comments to authors. the confidential comments to the editor should include a conflict of interest disclosure of any real or potential matters that may result in a biased review.3 if in doubt, it is better to inform the editor.5 confidential comments to the editor are “not forwarded to the authors, and may include a ‘bottom line’ summary, hunches, ethical concerns.”3 a suggested disposition (accept, minor revisions, major revisions, reject) is part of these comments. the comments to authors start with a “summary of key findings, validity and value to readers.”3 these are followed by general comments on “relevance to mission, internal validity, external validity, level of evidence and ethical conduct”3 as well as major strengths and weaknesses5 the review may then give specific comments by section (title, abstract and keywords, introduction, methods, results, discussion and conclusion, references)5 or by specific page, paragraph and line number.3 a concluding paragraph summarizes “key positive and negative comments without any statement of recommended disposition.”3 the actual structure and contents of the review will also vary depending on type of scientific article reviewed. various organizations, including the philippine council for health research and development and the philippine society of otolaryngology head and neck surgery organize workshops on medical writing for authors, as well as workshops on peer review for reviewers. reviewing for local and international journals further enhances the knowledge, skills and attitudes of the reviewer. as with our other roles as clinicians, scientists, leaders, and researchers, that of educator, mentor and peer-reviewer needs adequate training and experience. we invite our reviewers to make good use of such opportunities to acquire knowledge, hone their skills and develop appropriate attitudes that will enable them to take on the great privilege and responsibility of reviewing the unpublished work of others. references 1. siegel v. “reviewing peer review” departments of medicine and cell and developmental biology, vanderbilt university. cited may 30, 2014. available from: medicine.mc.vanderbilt.edu/ sites/.../reviewing%20peer%20review%204.ppt 2. eklof t. “is peer review peerless?” james joyce library. university of dublin. lir seminar 2009. lir heanet user group for libraries. cited may 30, 2014. available from: lirgroup.heanet.ie/sites/ default/files/seminars/2009/tony%20eklof.ppt 3. rosenfeld rm. how to review journal manuscripts. otolaryngol head neck surg 2010 142, 472486. 4. dominy p, bhatt j. “peer review in the google age: is technology changing the way science is done and evaluated?” cited may 30, 2014. available from: eprints.rclis.org/7411/1/peer_review_ in_the_google_age%5b1%5d.pptg 5. peh wcg, ng kh. effective medical writing (pointers to getting your article published): role of the manuscript reviewer. singapore med j 2009; 50(10):931-933. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 30 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the factors related to spontaneous passage of ingested coins in children. methods: design: retrospective study setting: tertiary government hospital subjects: the records of 136 pediatric patients with a history of coin ingestion seen at the emergency room department of our institution between december 2012 and may 2014 were retrospectively reviewed. demographic data such as age and gender of the patient were recorded, including the type of coin, location of coin in the esophagus, time of ingestion and time of spontaneous passage into the stomach (for those that passed spontaneously). results: spontaneous passage in 27 out of 136 pediatric patients with radiographic evidence of a round radio-opaque foreign body initially located in the esophagus eventually passed into the stomach or intestines, accounting for 20% of the total number of cases. coin ingestion was more common in patients aged 5 to 6 years (33% of cases), with slight male predominance (58%). one peso coins were the most common type of coin ingested, however only 24% of these spontaneously passed. the rate of spontaneous passage was highest in smaller sized coins (5 and 25 centavo coin) compared to larger sized coins (5 peso). proximally located coins, albeit more common than middle and distally located coins, were the least likely to spontaneously pass (12%). average time interval from ingestion to passage of the coin was 12 hours. conclusion: many factors are related to spontaneous passage of foreign bodies in the esophagus. the age of the patient, type of coin ingested, and initial location of the coin in the esophagus should be considered. older patients, smaller sized coins, and distally located coins have the highest probability of spontaneous passage beyond the esophagus. a 12-hour observation period may be considered in patients with single esophageal coin ingestion. keywords: foreign body, esophagus, esophagoscopy in children, the most common foreign body ingested are coins, comprising 75% of all cases.1 the decision whether to first observe or operate on pediatric patients has been discussed in several articles.2-6 spontaneous passage of ingested coin in children patrick joseph l. estolano, md antonio h. chua, md correspondence: dr. antonio h. chua department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue, sta. cruz, manila 1003 philippines phone: (632) 743 6921; (632) 711 9491 local 320 email: entjrrmmc@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at philippine society of otolaryngology head and neck surgery descriptive research contest, september 18, 2014. natrapharm, the patriot bldg., km 18 slex, paranaque city. philipp j otolaryngol head neck surg 2015; 30 (2): 30-33 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 31 several surgical procedures for the removal of esophageal foreign bodies have been proposed and are currently in use, ranging from the use of a foley catheter, bougienage, and esophageal dilators to flexible esophagoscopy for retrieval of blunt foreign bodies. careful endoscopic removal of foreign bodies under direct visualization by rigid esophagoscopy is the safest management for patients with foreign body ingestion.1 however, complications from this “safe” intervention may also arise, the most common of which is respiratory distress occurring during the procedure.1 this may result from accidental dislodging of the endotracheal tube.1 other possible complications such as esophageal perforation, retroesophageal abscess, mediastinitis and death can occur, but these are rare.1 several studies show that there is a high rate of spontaneous passage of esophageal coins into the stomach.1-6 soprano et al. reported an incidence of spontaneous passage of esophageal coins as high as 28%.2 they suggested that a 12to 24-hour observation period should be given among children with single esophageal coin ingestion, with no history of esophageal disease and no respiratory compromise on presentation.2 waltzman et al. reported factors that may predict spontaneous passage of esophageal coins, including the initial location in the distal esophagus, male gender, and age older than 5-years-old.3 they suggested that an observation period of 8 to 16 hours is appropriate in otherwise healthy children with asymptomatic esophageal coins.3 however, prolonged observation for spontaneous passage can also lead to several complications. complications arise when there is prolonged obstruction leading to inflammation and edema of the surrounding tissue, resulting in ischemia and eventual erosion and esophageal perforation which may lead to several life-threatening complications.1 these may present as hemoptysis, pneumonia, atelectasis, abscess formation, or fever.1 in order to avoid such complications, early detection and decision on whether to observe for spontaneous passage or initiate surgical intervention is required. in our institution, there are no guidelines on when to watchfully wait for spontaneous passage and when to proceed with surgery. this study aims to identify the factors affecting spontaneous passage of ingested coins in children. methods study design: retrospective study setting: tertiary public hospital subjects: with institutional ethical review board approval, the medical records of 136 pediatric patients less than 18-years of age with a history of coin ingestion seen at the emergency room department of our institution between december 2012 and may 2014, were retrospectively reviewed. demographic factors of the patients such as age and gender were recorded. similarly, the type of coin ingested, time of ingestion, time of spontaneous passage beyond the esophagus (for those that passed spontaneously), and initial location of the coin in the esophagus (proximal, middle, distal third) were tabulated. initial diagnosis of the coin in the esophagus and spontaneous passage were confirmed through radiography. data and statistical analysis: the mean age, gender ratio, age distribution, mean time interval between coin ingestion and passage beyond the esophagus were computed from the data gathered. the percentage of cases that spontaneous passed into the esophagus per age group, gender, type of coin, and location in the esophagus, were likewise determined. results during the 18 month period, a total of 136 pediatric patients (79 or 58% male, 57 of 42% female) consulting at the emergency department with pertinent complaints were diagnosed with coin ingestion located in the esophagus at the time of consult. spontaneous passage beyond the esophagus was observed in 27 children (20%). of these, 16 were male (59%) and 11 were female (41%). coin ingestion was more common in the 5to 6-year-old age group, comprising 45 out of the 136 patients (33.1%). the highest percentage of coin passage was seen in the older age group, in one patient 14 to 16 years of age-a 100% spontaneous passage rate (1 out 1 patient). on the other hand, patients aged 0 to 2 years had the lowest percentage of spontaneous coin passage into the gi tract (2 of the 18 cases, 11%). (table 1) for the cases in which spontaneous passage was observed, the youngest patient was 11 months old, and the oldest was 16 years old. table 2 shows the percentage of coins that spontaneously passed per type of coin ingested. one-peso coins were the most commonly ingested coins encountered (97 out of 136 cases), with a spontaneous passage rate of 24%. the highest percentage of spontaneous passage was seen in the case of 5 centavo and 25 centavo coins, having a 100% spontaneous passage rate. on the other hand, only 1 out of the 11 ingested 5 peso coins spontaneously passed beyond the esophagus (9%). no data regarding the type of coin swallowed was retrieved for 24 cases. proximally located coins comprised the majority of cases of coin ingested during the 18 month study period, accounting for 110 out of the total 136 cases (81%). however, the passage rate in this group was only 12%. on the other hand, despite having the lowest number of cases (8 of the 136 cases 5.9%), coins located in the distal third of the esophagus had a 75% spontaneous passage rate (6 out of 8 patients with distally-located coins). coins located in the middle third of the philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 32 philippine journal of otolaryngology-head and neck surgery original articles esophagus had a passage rate of 44% (8 out of the 18 cases). (table 3) the mean average time from ingestion to passage of the coin lodged in any segment of the esophagus was 12.4 hours (range 2 – 72 hours). discussion most cases of foreign body ingestion involve the pediatric age group, a majority occurring between the ages of 1 to 3 years.1 pediatric patients are susceptible to accidental foreign body ingestion at this age because they curiously tend to explore the environment by placing objects in their mouth, and they often run or play with objects in their mouth, causing accidental swallowing.1 of the 136 patients seen and diagnosed with coin ingestion in our study, the majority of cases belonged to the 5to 6-year-old age group, comprising 33% of total cases, with male patients being more commonly involved than females (58% and 42% respectively). these results are similar to the other studies where most of the patients were toddlers and preschoolers.2,3,5 in terms of age, older patients had a higher chance of spontaneous coin passage into the stomach, with the highest percentage seen in the older age group of 14 – 16 years (100% passage rate), followed by those aged 11 to 12 years old (75% passage). on the other hand, the lowest percentage of coin passing was seen in patients younger than 3 years of age, having a passage rate of only 11%. these reflect the findings of waltzmann et al., who concluded that spontaneous passage of ingested coin tends to increase as the patient gets older, noting that incidence of spontaneous passage was higher in patients older than 5 years of age.3 in our study, larger sized 5 peso coins (diameter 27 mm) were less likely to spontaneously pass compared to smaller diameter, 5 centavo (15.5 mm) and 25 centavo (20 mm) coins. the size of the foreign body is inversely related to the probability of the coin passing through the esophageal constrictions and lumen. we observed that the mean time interval from time of ingestion to time of passage beyond the esophagus was 12.4 hours, regardless of the segment where the coin was initially located. similar studies such as that of stringer and capps showed spontaneous passage of the coin 12 hours post-ingestion in 33% of cases.4 this was also observed by soprano et al. who suggested an observation period of 12 – 24 hours from the time of coin ingestion in asymptomatic patients with a simple case of coin ingestion (i.e. no history of esophageal disease or surgery) prior to performing an invasive procedure.2 their study concluded that there is a 28% chance of spontaneous passage of the coin into the stomach.2 the most common area where foreign bodies lodge is the cervical esophagus, particularly the area just below the cricopharyngeus muscle.1 this was likewise observed in our study wherein 110 out of the 136 coins lodged in the proximal third of the esophagus (81% of cases). on the other hand, coins that lodged in the middle and distal third was less commonly encountered in our study, occurring in 44% and 6% of the cases respectively. obstruction in this part of the esophagus is often table 1. spontaneous passage of coins per age group table 2. spontaneous passage per type of coin age (years) number of cases of esophageal coin ingestion (n = 136) number of cases with spontaneous passage of coin (n = 27) percentage of cases that spontaneously passed (%) birth to 2 3 to 4 5 to 6 7 to 8 9 to 10 11 to 12 13 to 14 14 to 16 17 to 18 18 36 45 20 12 4 1 2 5 10 4 2 3 1 11 14 22 20 17 75 100 type of coin ingested number of cases of esophageal coin ingestion (n = 136) number of cases with spontaneous passage of coin (n = 27) percentage of cases that spontaneously passed (%) 5 centavo 10 centavo 25 centavo 50 centavo 1 peso 5 peso undetermined type 1 2 1 0 97 11 24 1 1 1 0 23 1 0 100 50 100 24 9 0 table 3. spontaneous passage of coin per initial location in esophagus location: number of cases of esophageal coin ingestion n = 136 number of cases with spontaneous passage of coin n =27 percentage of cases that spontaneously passed (%) proximal third middle third distal third 110 18 8 13 8 6 12 44 75 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 33 references 1. holinger ld, poznanovic sa. foreign bodies of the airway and esophagus. in. flint pw, haughey bh, lund vl, niparko jk, richardson ma, robbins kt, et al., editors. cummings otolaryngology head and neck surgery 5th edition. philadelphia: mosby elsevier.2010. p. 2935 –2947. 2. soprano jv, fleisher gr, mandl kd: the spontaneous passage of esophageal coins in children. arch pediatradolesc med. 1999 oct; 153(10):1073 – 1076. 3. waltzman ml, baskin m, wypij d, mooney d, jones d, fleisher, g. a randomized clinical trial of the management of esophageal coins in children. pediatrics 2005 sep; 116(3):614-9. 4. stinger md, capps sn. rationalising the management of swallowed coins in children. bmj. 1991 jun; 302(6788): 1321-322. 5. conners gp, chamberlain jm, ochsenschlager dw. symptoms and spontaneous passage of esophageal coins. arch pediatr adolesc med. 1995 jan; 149(1): 36 – 39. 6. caravati em, bennett dl, mcelwee ne. pediatric coin ingestions: a prospective study on the utility of routine roentogenograms. am j dis child. 1989 may; 143(5): 549 – 551. 7. snell rs, taylor c, horvath k, sanders v, montalbano j, smock d, et al. the thorax: part 1: the thoracic wall.clinical anatomy by regions, 8th edition. philadephia: lipincott williams & wilkins. 2008. 8. nahman bj, mueller cf. asymptomatic esophageal perforation by a coin in a child. ann emerg med. 1984 aug; 13(8):627 – 629. 9. doolin ej. esophageal stricture – an uncommon complication of foreign body. ann otol rhinol laryngol. 1993 nov; 102(11): 863 – 866. 10. dahiya m, denton js. esophagoarotic perforation by foreign body (coin) causing sudden death in a 3 year old child. am j forensic med pathol. 1999 jun; 20(2):184-188. 11. conners gp, cobaugh dj, feinberg r, lucanie r, caraccio t, stork cm. home observation for asymptomatic coin ingestion: acceptance and outcomes. the new york state prison control center coin ingestion study group. acad emerg med. 1999 mar; 6(3): 213-217. caused by extra-luminal compression by the aortic arch or the left main stem bronchus.1 in terms of location, the area from where spontaneous passage of the coin most occurred was the distal third of the esophagus–with a passage rate of 75%. in contrast, the proximal third of the esophagus (which was the most common area where ingested foreign bodies lodged) had the lowest rate of spontaneous passage of coins (12%), while the middle third had a 44% spontaneous passage rate. the low passage rate of coins from the proximal third of the esophagus may be attributed to the area of the cricopharyngeal muscle, which corresponds to the first anatomic constriction of the esophagus.7 in general, our study found a 20% spontaneous passage rate of coins beyond the esophagus regardless of initial location. treatment options in patients with foreign body ingestion are controversial. performing outright surgery versus observation for spontaneous passage has been debated, giving rise to numerous studies on rates of spontaneous passage of ingested foreign bodies.2-6 conners et al., suggest that the decision whether to operate or observe first depends on the initial location of the coin in the esophagus.5 they suggested that immediate surgical intervention is warranted in patients with esophageal coins lodged in the proximal and middle third.5 according to their study, none of the coins lodged in these segments passed. on the other hand, coins situated in the distal part of the esophagus can be observed for a period of 24 hours for the possibility of the coin to pass on its own.5 as much as 60% of cases of distal esophageal coin obstruction passed spontaneously after observation.5 contrary to conners et al., soprano et al. suggested that a 12 to 24 hour observation period should still be implemented even for coins lodged in the proximal and middle third of the esophagus as spontaneous passage may still occur (22% and 33% of cases, respectively).2 similarly, caravati et al. reported a high spontaneous passage rate of 77% of coins lodged in the esophagus.6 complications from prolonged esophageal foreign body obstruction include formation of true / false esophageal fistulas, aorticoesophageal fistula, esophageal perforation leading to foreign body migration to surrounding structures, esophageal stricture formation, and respiratory distress.8-10 however, recent studies reported that observation for < 24 hour periods have not led to any adverse complications.2,3 soprano et al. reported no adverse events during the observation periods, but noted adverse events during or after endoscopic procedures, including pharyngeal bleeding, bronchospasm, accidental extubation, stridor and hypoxia.2 in our study, no adverse reactions or complications were encountered from time of ingestion to time of passage of the coin. withholding immediate surgical intervention and opting for more conservative management such as observation in an otherwise asymptomatic patient has been advocated in several studies.2-4 however, initial observation for patients with asymptomatic coin ingestion has not been generally accepted, as most parents would opt for immediate removal of the foreign body.11 this issue should be wellexplained to the caregivers prior to deciding whether to observe first or perform surgery. in summary, many factors affect spontaneous passage of an esophageal coin, and no single factor can predict whether a coin will pass beyond the esophagus or remain lodged in it. factors associated with a greater possibility of spontaneous passage of esophageal coin include age older than 5 years (the older the patient, the higher the possibility for spontaneous passage), smaller sized coins (5 centavo and 25 centavo coins) and location in the distal third of the esophagus. in an otherwise asymptomatic and stable pediatric patient with a history of coin ingestion, an observation period of 12 hours from the time of ingestion may be recommended due to the possibility of spontaneous passage beyond the esophagus. repeat radiography after the allotted observation period is generally recommended to identify the location and/or document passage of the coin. the parent/guardian’s informed consent is important prior to recommending any plan of management for a patient with foreign body ingestion. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles philippine journal of otolaryngology-head and neck surgery 5 philipp j otolaryngol head neck surg 2011; 26 (2): 5-9 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: this study aimed to determine the prevertebral soft tissue thickness among normal patients aged 0-14 years old in a tertiary government training hospital, to compare these values with divergent criteria in the standard otorhinolaryngology and radiology texts used in our institution, and to recommend adoption of a set of criteria based on the results. methods: design: descriptive study setting: tertiary government hospital subjects and methods: lateral cervical radiographs taken from may 2007 to august 2009 which were initially read as normal were collected. fifty (50) patients, 39 males and 11 females, aged 0-14 years old meeting inclusion criteria were reviewed and prevertebral soft tissue thicknesses (pvst) and cervical vertebral body diameter at levels c2, c5, c6 were measured and compared to criteria set by standard otorhinolaryngology and radiology textbooks. results: the average pvst at c2 ranged from 4.02 mm for 2–3 year-olds (n= 2) to 8.16 mm for 1 –2 year-olds (n=2). the average pvst at c5 ranged from 8.11mm for 1–2 year-olds to 10.75 mm for for 0-1 year-olds. the average pvst at c6 ranged from 7.13 mm for 1 – 2 year-olds to 10.36 mm for 0-1 year-olds. only 12% of the patients satisfied the criteria set by keats and lusted, while 100% satisfied duncan’s criteria, 94% and 98% satisfied wippold’s first and second criteria respectively. conclusion: all of the pvst criteria mentioned in cummings’ textbook of otorhinolaryngology head and neck surgery had a more than 90% accuracy compared to only 12% for those mentioned in keats and lusted’s atlas of roentgenographic measurement. therefore, we recommend the use of any criteria for pvst contained in the former over the latter. keywords: prevertebral soft tissue thickness, cervical vertebra prevertebral soft tissue thickness (pvst) evaluation using soft tissue lateral neck x-rays is an important tool for otorhinolaryngologists in the diagnosis and management of pathologies involving the deep neck spaces particularly deep neck infections (dni). despite recent advancements in antibiotics, dni’s remain associated with severe illness and death, especially among children. prevertebral soft tissue thickness among pediatric patients manuelito m. reyes, md1 rosario r. ricalde, md1 jennifer b. tanalgo, md2 concepcion j. baldoz md2 1department of otorhinolaryngology head and neck surgery quirino memorial medical center 2department of medical imaging quirino memorial medical center correspondence: dr. manuelito m. reyes department of otorhinolaryngology head and neck surgery quirino memorial medical center katipunan road ext., project 4, quezon city 1108 philippines phone: (632) 421 2250 local 117 email: docnoelreyes@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles 6 philippine journal of otolaryngology-head and neck surgery the assessment of the pvst is critical especially when any pathologic condition involving the pvst poses danger of obstructing the airway warranting tracheostomy tube insertion or any other life saving intervention. at our institution’s department of medical imaging, the pvsts of requested soft tissue lateral neck x-rays are measured and compared to the standards published in the atlas of roentgenographic measurement by keats and lusted which adopted a 1939 study by hay et al.1 the department of otorhinolaryngology head and neck surgery however uses criteria contained in the textbook of otorhinolaryngology head and neck surgery by cummings et al.2,3 in fact, within this textbook are three (3) standards: the first by duncan on the chapter on infections of the airway2 and the second and third by wippold in the chapter on diagnostic imaging of the larynx.3 this difference in standards often poses problems for practitioners making their resolution significant in the management of patients. this study aims to determine the prevertebral soft tissue thickness among normal patients aged 0-14 years old in our institution, to compare these values with divergent criteria in the standard otorhinolaryngology and radiology texts used in our institution, and to recommend adoption of a set of criteria based on the results. methods lateral cervical radiographs initially read as normal from patients aged 0-14 years old from may 2007 to august 2009 were retrospectively reviewed. only radiographs of patients taken in neutral neck position with no history of head and neck infection, intubation, nasogastric tube insertion and congenital or acquired abnormality of the cervical spine were included. all patients were confirmed trauma or child abuse cases and their radiographs had been taken within 24 hours of the injury for medicolegal clearance. the x-ray machines used were 1000ma hitachi trophy n800 and hitachi trophy n500 (hitachi corporation, japan) with the following settings: tube current (mas) 2-2.5, tube voltage (kvp) dependent on patient’s thickness. magnification was disregarded. individual measurements of all radiographs were independently performed in separate venues over different time periods by the four authors: two from the department of otorhinolaryngology and two from the department of medical imaging using two vernier calipers. the prevertebral soft tissue widths and vertebral body diameter at levels c2, c5, c7 were measured to the nearest hundredths of a millimeter using a vernier caliper (figure 1). it was measured from the most anterior and inferior aspect of the adjacent cervical vertebral body up to the posterior pharyngeal wall. figure 2 illustrates the schematic diagram of the prevertebral soft tissue thickness at each vertebral level. data obtained were tabulated and averaged using a microsoft excel figure 2. actual lines of measurement for pvst. vb (vertebral body), st (prevertebral soft tissue) figure 1. prevertebral soft tissue thickness measurement using a vernier caliper 2010 file (microsoft corporation, redmond, wa, usa) rounded to the nearest hundredths place. the ranges, mean and standard deviations were determined. age stratification was adapted from keats and lusted1 for validation purposes and to account for the physical changes during growth and development. the data was then compared to the four traditionally used criteriathe first from keats and lusted (table 1) and the second, third and fourth from cummings. results there were 50 radiographs of patients included in the study. thirtynine (39) or 78% were male and 11 or 22% were female. table 2 shows the age distribution of the patients. tables 3 to 5 show the range of prevertebral soft tissue and vertebral philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles philippine journal of otolaryngology-head and neck surgery 7 body diameters at levels c2, c5 and c6. the means and standard deviations of the prevertebral soft tissue thickness and vertebral body diameters of c2, c5, c6 are summarized according to age groups in tables 6 to 8. the data collected was validated using the formula suggested by keats and lusted1 wherein the c5 vertebral body diameter was used as reference. of the 50 radiographs reviewed, 44 (88%) patients were above normal limits and only 6 (12%) patients satisfied the criteria. using duncan’s criteria all patients were within normal limits. on the other hand, using wippold’s 1st criteria at c2 level, 47(94%) patients were within normal limits while 3 patients were above normal limits. at c6 level, 49 (98%) satisfied the criteria while only 1 (2%) did not. table 9 shows the summary of patients who passed and failed using keats’ and cummings’ standards. discussion since 1939, prevertebral soft tissue measurement has been commonly used for assessing prevertebral pathology such as abscesses or hematomas after injury.2 radiographs, particularly soft tissue lateral cervical roentgenograms are often requested for evaluation. compared with computed tomography, lateral cervical neck films are about 83% sensitive in children. extremes of neck extension or flexion can produce misleading findings as can films taken during forced inhalation.1 the first step in the algorithm followed in our institution in diagnosing deep neck infections in pediatric patients includes a neck soft tissue lateral x-ray in neutral position. although computed tomography is readily available and can provide more information on the extent of infection, it is still costly and harder to perform in children especially if serial imaging is needed to monitor disease progression. children often have to be sedated since they must remain still for a few minutes compared to a few seconds when taking an x-ray. in the evaluation of pvst, otorhinolaryngologists in our institution use criteria contained in cummings’ textbook of otolaryngology head and neck surgery.2,3 the three sets of criteria contained therein have sparked debate as to which should be used. the first (by duncan) stating that the pvst at c2 should not exceed twice the diameter of the c2 vertebral body cited a 1991 study by coulthard.4 however, this was a review of the management of retropharyngeal abscesses and not a study to actually derive such a formula. in another chapter, wippold mentioned two standards and cited a 1995 study by pontell 5 which suggested that the prevertebral soft tissue should not exceed 7 mm measured from the most anterior aspect of c2 to the posterior pharyngeal wall and at c6, the thickness of the retropharyngeal tissues should not be >14 mm in children and 22 mm in adults. again, pontell’s study was a case series of 20 patients with retropharyngeal abscess. table 2. age distribution of patients age range frequency percentage (%) 0 -1 1 – 2 2 – 3 3 – 6 6 14 total 6 % 4% 4% 24% 62% 100% 3 2 2 12 31 50 table 1. upper normal limits of the soft tissue spaces of the neck (keats) age range post pharyngeal soft tissue postventricular soft tissue 0 – 1 1 – 2 2 – 3 3 – 6 6 – 14 1.5c5 0.5c5 0.5c5 0.4c5 0.3c5 2.0c5 1.5c5 1.2c5 1.2c5 1.2c5 postcricoid adult male malefemale female 0.3c5 0.7c50.3c5 0.6c5 table 3. range of prevertebral soft tissue and vertebral body diameters at level c2 age range prevertebral soft tissue range (mm) vertebral body range (mm) 0-1 1-2 2-3 3-6 6-14 4.53 – 10.45 4.13 – 12.20 3.73 – 4.31 3.71 – 6.64 3.73 – 7.68 5.54 – 8.38 9.29 – 9.60 9.23 – 9.35 8.90 – 13.23 11.63 – 20.63 table 4. range of prevertebral soft tissue and vertebral body diameters at level c5 age range prevertebral soft tissue range (mm) vertebral body range (mm) 0-1 1-2 2-3 3-6 6-14 9.18 – 12.60 6.55 – 9.68 7.86 – 13.18 4.45 – 13.38 7.86 – 16.03 6.16 – 9.73 10.14 – 11.00 9.50 – 10.60 8.43 – 12.69 11.38 – 21.78 table 5. range of prevertebral soft tissue and vertebral body diameters at level c6 age range prevertebral soft tissue range (mm) vertebral body range (mm) 0-1 1-2 2-3 3-6 6-14 7.74 – 13.03 4.70 – 9.55 9.18 – 10.63 3.84 – 10.23 6.10 14.18 6.70 – 10.95 10.80 – 11.10 9.86 – 11.26 9.35 13.94 11.13 – 23.31 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles 8 philippine journal of otolaryngology-head and neck surgery these formulas were used and validated but were not actually set or determined in that study. from the time our hospital was established, the department of medical imaging has been using keats and lusted as a reference for the evaluation of pvst, citing a formula derived by hay in 1939 to compute normal prevertebral soft tissue at certain age levels. the formula was derived from a sample of 25 pediatric and 50 adult normal patients.1 age stratification was used for pediatric patients but only up to 14 years of age. for purposes of validation, we adopted this age stratification for this study. several studies have focused on the radiographic evaluation of prevertebral soft tissues in adults. chen et al. in 1999 stated that the maximum retrocricoid soft tissue thickness was 0.7 x c5 diameter and that the maximum retrotracheal thickness was 1.0 x c5 diameter.6 sistrom and colleagues in 1993 identified factors affecting cervical soft tissue thickness by measuring the soft tissues anterior to c2 through c4 in lateral cervical spine films of 227 patients examined over two years.7 these measurements were correlated with patient age, sex, weight, shoulder width, neck width and calculated radiographic magnification. they found that only patient weight and age had a statistically significant correlation with soft tissue thickness. using a stepwise regression model they produced a simple equation for predicting the mean value of the soft tissue thickness at c3 based on the patient’s age and weight, and determined that weight and age account for 28% of the observed variability in the soft tissue measurements at c3. these relationships were similar at c2 and c4. the study by haug, et al.,8 of 86 normal lateral soft-tissue radiographs reported that the mean thickness in the retropharyngeal region ranged from 6.2 mm in the infant to 3.7 mm in the adult while the mean thickness in the retrotracheal region ranged from 9.2 mm in the preschool group to 12.1 mm in the adult. this study was cited by craig and colleages as their reference for normal values in their study on retropharyngeal acesses in children.9 another study by chi measured the pvst from c1 to c7 in 150 chinese patients and compared values with western populations from previous studies. they found significant differences in pvst between young (n=106) and older (n=25) subjects and between males (n=52) and females (n=79) at c6, concluding that pvst was thicker in males and the elderly compared to females and younger subjects. there was no difference between their data and values from the western studies.10 studies on normal prevertebral soft tissue measurements often involve adults.6,7,8,10 an obvious reason for the very limited number of studies in pediatric patients is the ethical issue of subjecting normal children to radiation. *population ** cervical vertebra *** prevertebral soft tissue thickness (mm) ****vertebral body diameter (mm) age pop* (n=50) c2** st*** mean sd mean sd vb**** 0-1 1-2 2-3 3-6 6-14 3 2 2 12 31 7.25 8.16 4.02 5.18 5.49 ±2.99 ±5.71 ±0.42 ±1.14 ±1.36 6.60 9.44 9.29 11.44 19.81 ±1.55 ±0.22 ±0.08 ±1.47 ±2.53 table 6. mean and standard deviation (mm) of the prevertebral soft tissue and vertebral body diameter at level c2 age pop (n=50) c2 st mean sd mean sd vb 0-1 1-2 2-3 3-6 6-14 3 2 2 12 31 10.75 8.11 10.52 8.12 10.67 ±1.73 ±2.21 ±3.76 ±2.47 ±1.57 7.54 10.57 10.05 11.20 16.40 ±1.92 ±0.61 ±0.78 ±1.35 ±2.51 table 7. mean and standard deviation (mm) of the prevertebral soft tissue and vertebral body diameter at level c5 age pop (n=50) c6 st mean sd mean sd vb 0-1 1-2 2-3 3-6 6-14 3 2 2 12 31 10.36 7.13 9.90 7.59 9.99 ±2.64 ±3.43 ±1.02 ±1.89 ±1.91 8.25 10.95 10.56 11.90 17.63 ±2.35 ±0.21 ±0.99 ±1.26 ±2.80 table 8. mean and standard deviation (mm) of the prevertebral soft tissue and vertebral body diameter at level c6 age pvst ≤ 7mm at c2 level pvst ≤ 14 mm at c6 level keats etal cummings et.al. wippold duncan pvst ≤ 2c2 pass* fail** pass fail pass passfail fail 0-1 1-2 2-3 3-6 6-14 total % 3 2 0 1 0 6 12% 0 0 2 11 31 44 88% 2 1 2 12 30 47 94% 1 1 0 0 1 3 6% 3 2 2 12 30 49 98% 3 2 2 12 31 50 100% 0 0 0 0 1 1 2% 0 0 0 0 0 0 0% table 9. number of patients (n=50) who passed and failed using keats’ standard, and cummings’ standards *pass= within normal limits **fail= above normal limits philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles philippine journal of otolaryngology-head and neck surgery 9 references 1. keats te, lusted lb. atlas of roentgeongraphic measurement 4th ed, year book medical publishers inc. 1981. 2. duncan no. infections of the airway. in: cummings c, flint pw, harker la, haughey bh, richardson, ma, robbins kt, et.al., editors. cummings c. otorhinolaryngology head and neck surgery 4th ed. philadelphia: elsevier mosby; 2005. chapter 195. 3. wippold fj. diagnostic imaging of the larynx. in: cummings c, flint pw, harker la, haughey bh, richardson, ma, robbins kt, et.al., editors. cummings c. otorhinolaryngology head and neck surgery 4th ed. philadelphia: elsevier mosby; 2005. chapter 88. 4. coulthard m, isaacs d. retropharyngeal abscess. archives of disease in childhood 1991; 66: 12271230. 5. pontell j, har-el g, lucente f. retropharyngeal abscess: clinical review. ear nose throat j. 1995 oct; 74(10):701-4. 6. chen my, bohrer sp. radiographic measurement of prevertebral soft tissue thickness on lateral radiographs of the neck. skeletal radiol.1999 aug; 28(8): 444-6. 7. sistrom cl, southall ep, peddada sd, shaffer ha jr. factors affecting the thickness of the cervical prevertebral soft tissues. skeletal radiol. 1993; 22(3):167-71. 8. haug rh, wible rt, lieberman j. measurement standards for the prevertebral region in the lateral soft-tissue radiograph of the neck. j oral maxillofac surg. 1991 nov; 49(11):1149-51. 9. craig fw, schunk je. retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. pediatrics 2003;111:1394-1398. 10. chi lj, wang adj, chen lk. prevertebral soft tissue measurements on lateral roentgenogram of cervical spine in chinese. chin j radiology. 2002; 27: 151-155. recent studies recommend the use of computed tomography instead of traditional radiographs since ct scan can differentiate more accurately between retropharyngeal absess and cellulitis, both of which cause prevertebral soft tissue thickening but have different management.9 however, our institution still utilizes less expensive radiographs. our study utilized radiographs of medicolegal trauma cases taken within 24 hours of injury and initially read as normal, minimizing the chances of soft tissue swelling. frank cervical vertebra injuries and soft tissue hematomas would have been clinically and radiographically evident within 24 hours and were excluded. further, all 50 patients whose radiographs were included in our study had been apparently well and discharged from the emergency room. only 12% of the patients satisfied the criteria set by keats and lusted while 100% satisfied duncan’s criteria, 94% and 98% satisfied wippold’s first and second criteria, respectively. all of the criteria mentioned in cummings’ textbook of otorhinolaryngology head and neck surgery had a more than 90% accuracy compared to only 12% for those mentioned in keats and lusted’s atlas of roentgenographic measurement. persisting in using the latter criteria would result in more of the pvst being read as abnormal and subsequent over-treatment. therefore, we recommend the use of any criteria for pvst contained in the former over the latter. in light of the results of this study, we recommend that future studies reevaluate the previously “abnormal” readings excluded from this study, to find out how many of them would actually be false positives (with no actual prevertebral soft tissue thickening based on cummings’ criteria), possibly resulting in over-treatment with prolonged antibiotics and/or tracheotomy. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 philippine journal of otolaryngology-head and neck surgery 69 under the microscope a 34-year-old woman with a 4-year history of a slowly enlarging thyroid gland underwent a total thyroidectomy. histologic sections showed multinodular colloid goiter. in addition, a 1.2 centimeter diameter discrete mass with a solid white cut surface was noted within the left lobe. sections from the left lobe mass show a well-demarcated tumor whose cells are arranged in trabecular and nested growth patterns. (figure 1) the cells are polygonal to spindly and have ample eosinophilic, slightly granular cytoplasm and oval to angular nuclei that are often grooved. (figure 2) hyaline material and a delicate fibrovascular stroma surround the nests and trabeculae, and occasional psammoma bodies are seen. (figure 3) these features led us to a diagnosis of hyalinizing trabecular tumor. hyalinizing trabecular tumor (htt) is a rare thyroid neoplasm of follicular cell derivation.1, 2 the tumor occurs in adults with a wide age range (4th – 7th decades) and a mean age of 47 years. it is more common in females.1 the classic histologic findings are of a solid circumscribed epithelial neoplasm with or without a thin capsule composed of medium to large-sized polygonal to fusiform cells that are arranged in alveolar, trabecular and nested groups. the cells have finely hyalinizing trabecular tumor of the thyroid gland correspondence: dr. jose m. carnate, jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st. ermita, manila 1000 philippines phone (632) 526 4450 telefax (632) 400 3638 email: jmcjpath@gmail.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2015; 30 (1):69-70 c philippine society of otolaryngology – head and neck surgery, inc. vincent g. te, md1 jose m. carnate, jr., md2 1department of laboratories philippine general hospital university of the philippines manila 2department of pathology college of medicine university of the philippines manila figure 1. hematoxylin and eosin (40x) well-circumscribed tumor with a nested and trabecular growth pattern and adjacent residual normal thyroid tissue (star) (hematoxylin and eosin, 40x) philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 under the microscope 70 philippine journal of otolaryngology-head and neck surgery references carney ja, volante m, papotti m, asa s. hyalinizing trabecular tumor. in: delellis, ra, lloyd rv, 1. heitz pu, eng. c, editors. world health organization classification of tumours: pathology and genetics of tumours of endocrine organs. lyon, france: international agency for research on cancer press, 2004. gnepp dr, editor. diagnostic surgical of the head and neck. 22. nd ed. philadelphia: saunders elsevier, 2009, p. 587-88. carney ja, hirokawa m, lloyd rv, papotti m, sebo tj. hyalinizing trabeculart tumors of the 3. thyroid gland are almost all benign. am j surg pathol. dec 2008; 32(12): 1877-1889. doi: 10.1097/pas.0b013e31817a8f1b. galgano mt, millis se, stelow eb. hyalinizing trabecular adenoma of the thyroid revisited: a 4. histologic and immunohistochemical study of thyroid lesions with prominent trabecular architecture and sclerosis. am j surg pathol. 2006 oct; 30(10):1269-73. lee s, hong s, koo js. immunohistochemical subclassification of thyroid tumors with a 5. prominent hyalinizing trabecular pattern. apmis. 2011 aug; 119(8):529-36. doi: 10.1111/j.16000463.2011.02762.x. epub 2011 may 24. hirokawa m, carney, ja, ohtsuki, y. june 2000. hyalinizing trabecular adenoma and papillary 6. carcinoma of the thyroid gland express different cytokeratin patterns. am j surg pathol.2000 jun; 24(6):877-881. granular, acidophilic, amphophilic or clear cytoplasm. nuclei often have prominent grooves and small nucleoli. calcospherites (psammoma bodies) may be present. colloid is scant or absent. 1, 2, 3 because of overlapping nuclear features, a follicular variant of papillary thyroid carcinoma is a differential diagnosis. histologic features are usually sufficient to distinguish the entities as a nestedalveolar architecture is rarely a prominent feature of a papillary carcinoma.2 immunohistochemistry may be of aid in this distinction especially in difficult cases with limited material. cytokeratin 19 and hbme1 are negative in htt and are usually positive in papillary thyroid carcinomas.4, 5, 6 neuroendocrine markers are also negative in htt and are positive in medullary thyroid carcinomas and paragangliomas.2 htt is of uncertain malignant potential and a 2008 review of 119 htts has shown only one case progressing to malignancy.3 the majority of cases have behaved in a benign fashion and thus may be treated conservatively.1figure 2. hematoxylin and eosin (100x) nested growth pattern with hyaline material surrounding the nests; (400x inset) polygonal to spindly cells with eosinophilic cytoplasm and oval nuclei arranged in nests with hyaline material around the nests (hematoxylin and eosin, 100x) figure 3. hematoxylin and eosin (400x) polygonal to spindly cells with eosinophilic cytoplasm and oval nuclei that are often grooved. a psammoma body (long arrow) and a pseudoinclusion (short arrow) are also seen. (hematoxylin and eosin, 400x) philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 practice pearls 42 philippine journal of otolaryngology-head and neck surgery superior semicircular canal dehiscence (sscd) syndrome is an unusual cause of vertigo that was first identified by minor in 1998. the patients initially described by minor presented with vertigo, oscillopsia and/or dysequilibrium related to sound, changes in middle ear pressure and/or changes in intracranial pressure due to an absence of the bony layer that normally covers the superior semicircular canal.1 subsequent clinical studies have shown that the condition may lead to a variety of vestibular and/or auditory symptoms that mimic other otologic disorders. these symptoms include autophony, ear blockage or fullness, conductive hearing loss, pulsatile tinnitus, dizziness or vertigo with head movements and general disequilibrium.2 in a patient with the appropriate symptoms, the diagnosis of superior semicircular canal dehiscence syndrome rests on the identification of a dehiscence in the bone overlying the semicircular canal on coronal high-resolution temporal bone computed tomographic scans (white arrowhead, figure 1). technique of multi-planar ct image reconstruction for the evaluation of superior semicircular canal dehiscence syndrome correspondence: dr. nathaniel w. yang department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax : (632) 525 5444 email: nwyang@gmx.net reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (2): 42-44 c philippine society of otolaryngology – head and neck surgery, inc. nathaniel w. yang, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila philippine national ear institute national institutes of health university of the philippines manila department of otolaryngology head and neck surgery far eastern university-nicanor reyes memorial foundation institute of medicine figure 1. high-resolution ct scan of temporal bone, coronal view. note dehiscence in the bone overlying the semicircular canal (white arrowhead). philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 philippine journal of otolaryngology-head and neck surgery 43 practice pearls it must be emphasized that due to the low specificity of images taken at 1.0and 1.5-mm collimation, current radiologic literature advocates the use of coronal reformatted images based on submillimeter (0.4 – 0.6-mm) collimated axial scans. it must also be stressed that although reformatted coronal images are sufficient for the radiologic evaluation of sscd in most cases, oblique reformatted images in the stenver and pöschl planes are necessary in equivocal cases.3 when operative management is indicated, these views are indispensable for proper surgical planning. the images in oblique planes of reconstruction can be created on radiologic imaging software that allows multiplanar reconstruction (mpr) of the raw axial ct data set. this software allows the original data set to be simultaneously viewed in the standard sagittal, coronal and axial orthogonal planes of orientation (figure 2) and manipulated into non-orthogonal or arbitary planes of orientation (oblique and doubleoblique). the images in this article were made using syngo ct (version 2010b) software (siemens ag, berlin and münchen). this software has a set of toggle buttons in the 3d task window that allow manipulation of the primary image data set (figure 3). button a (free view mode) – allows the reference lines in the three reconstructed views to be moved and rotated to achieve the desired image orientation. moving the reference line in one view changes the position and orientation of the viewed image in the other two reconstructed views. button b (hide reference lines) – removes the reference lines to have an unobstructed display of the reconstruction views button c (orientation control) – allows a 3d image to be rotated to the desired anatomic orientation. this function is not relevant to the task of identifying dehiscences in the semicircular canals button d (rotate images) – allows rotation of the image in three dimensions, independent of the reference lines button e (zoom / pan) – changes the magnification of the selected reconstruction view and allows the image to be moved in order to view the desired portion button f (home zoom / pan) – returns all of the reconstructed views to their original orientation and magnification the orthogonal axial image at the level of the superior semicircular canal is used as the primary reference image (figure 4). the image has been zoomed in and panned using the zoom/pan function to center the image on the superior semicircular canal. with the free view mode activated, aligning the first reference line in the primary reference image to the long axis of the petrous bone and centered between the arms of the superior semicircular canal (white bar, figure 4) creates a secondary reference image in the stenver plane (figure 5). aligning the second reference line in the primary reference image to the short axis of the petrous bone and running through both arms of the superior semicircular canal (black arrow, figure 4) creates the tertiary image in the pöschl plane that allows visualization of the superior semicircular canal as a complete ring (figure 6). as the superior semicircular canal may not be perfectly vertically oriented in the orthogonal axial reference image, adjustments in the vertical reference line of the secondary reference image in the stenver plane to run along the long vertical axis of the superior semicircular canal are made (white bar, figure 5). this will allow perfect visualization of the ring of the superior semicircular canal and any dehiscences of the overlying bone in the pöschl plane (white arrowhead, figure 6). figure 2. multiplanar reconstruction in standard orthogonal planes of orientation (sagittal, coronal, axial) using syngo ct (version 2010b) software. figure 3. toggle buttons in the 3d task window of syngo ct (version 2010b) software that allow manipulation of the primary image data set. the toggle buttons have been alphabetically labeled (a-f) for the purpose of identification in this article. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 practice pearls 44 philippine journal of otolaryngology-head and neck surgery references 1. minor lb, solomon d, zinreich js, zee ds. soundand/or pressure-induced vertigo due to bone dehiscence of the superior semicircular canal. arch otolaryngol head neck surg. 1998 mar; 124(3):249-258. 2. zhou g, gopen q, poe ds. clinical and diagnostic characterization of canal dehiscence syndrome: a great otologic mimicker. otol neurotol 2007 oct; 28(7):920-926. 3. branstetter bf 4th, harrigal c, escott ej, hirsch be. superior semicircular canal dehiscence: oblique reformatted ct images for diagnosis. radiology 2006 mar; 238(3):938-942. imaging of the inner ear structures in non-orthogonal planes of orientation are not usually provided to the clinician by radiology centers in the philippines. with a small investment in time and effort at the radiology workstation, it is possible for the clinician to view the inner ear structures especially the semicircular canals in their actual anatomic planes. this will allow the accurate diagnosis and management of less common but treatable causes of otologic symptoms. figure 4. primary reference image, orthogonal axial image, level of superior semicircular canal. figure 5. secondary reference image, stenver plane, created by aligning the first reference line in the primary reference image to the long axis of the petrous bone and centered between the arms of the semicircular canal. figure 6. tertiary image, pöschl plane, allows visualization of the superior semicircular canal as a complete ring. note dehiscence in the overlying bone (white arrowhead). philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 original articles philippine journal of otolaryngology-head and neck surgery 7 philipp j otolaryngol head neck surg 2012; 27 (2): 7-11 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to describe the vocal acoustic measures of non-smoking filipino young adults without voice complaints at a private tertiary hospital in quezon city; to determine if our baseline values are distributed normally and comparable to data in similar studies done abroad; and to recommend normative voice parameters which may be used as baseline data in our institution and for comparison in future studies. methods: design: cross-sectional study setting: private tertiary hospital participants: a total of 70 subjects were recruited at random results: values extracted for f0, jitter %, jitter db, shimmer %, shimmer db and nhr showed normal distribution of results. the average vocal acoustic values found in the present study for male voices producing the vowel /a/ were fo = 130.6 ± 13.65hz, jitter = 0.0.46 % ± 0.184, jitter db: 37.62db ± 16.664, shimmer %= 0.23%, shimmer db=0.23 ± 0.67 and nhr = 0.13 ± 0.010. the average values found for female voices, producing the vowel /a/ were fo = 218.38 ± 26.192hz, jitter = 0.87% ± 0.61, jitter db: 34.82 ± 22.5, shimmer %= 2.72 ± 1.07 shimmer db=0.23db ± 0.67 and nhr = 0.12db ± 0.016. values retrieved from this study show similar trends with other papers abroad. conclusion: voice acoustic systems are composed of different recording criteria, recording instrumentations and algorithms which primarily cause the differences in the results obtained in various studies, thus, precluding a single normalization. following international recommendations for individual normalization per institution, we have obtained our own values. our data was comparable to the results of other international studies. however, further investigation is recommended in areas where possibilities of interdialectic variation may produce an effect on the outcome of the study. keywords: vocal acoustic measures, computerized speech lab, normative voice parameters in the philippine setting, voice and speech problems are often initially assessed by ear, nose and throat (ent) specialists. these evaluations are generally gauged subjectively by means of hearing perception. perceptual evaluation of voice is an important scientific process in clinical investigation and in assessing voice quality, relevant deficiencies and their effect on the subject’s ability to communicate. however, perceptual evaluation has some restrictions because of its poor correlation between evaluators.1 moreover, there exists a number of scales and their reliability varies from study to study. these limitations lead to numerous differences and nonstandardization. vocal acoustic measures of asymptomatic filipino young adults at a private tertiary hospital in quezon city – a pilot study kirt areis e. delovino, md ray u. casile, md frederick y. hawson, md department of otorhinolaryngology head and neck surgery st. luke’s medical center correspondence: dr. kirt areis e. delovino department of otorhinolaryngology head and neck surgery st. luke’s medical center 279 e. rodriguez ave, quezon city 1102 philippines fax: (632) 723 0101 local 5543 e-mail: edot_ii@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the descriptive research contest, philippine society of otolaryngology head and neck surgery, glaxo smith kline (gsk) bldg., chino roces ave., makati city, philippines, october 11, 2010. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 original articles 8 philippine journal of otolaryngology-head and neck surgery over the past decade, an increasing number of studies have aimed at different objective analyses of vocal acoustics. among these tools, computer-based acoustic analysis has become a more popular system in studies intended for the objective assessment of vocal parameters. a lot of these researches were intended to establish parameters necessary to create normal and standard values. many acoustic parameters of the human voice are evaluated by these computer systems. the most common parameters used in voice assessment in the literature are: fundamental frequency (f0), cyclecycle perturbations such as jitter (jitt) and shimmer (shim) and the noise-harmony ratio (nhr).2, 3, 4, 5 the fundamental frequency is an important parameter in both functional and anatomical larynx assessment.4,6 it is determined by the number of cycles produced by the vocal folds per second and is reflective of the interaction of vocal fold length, mass and tension during speech.3 among acoustic parameters, fundamental frequency has been proven to have higher uniformity among different acoustic analysis systems and is less sensitive to voice recording characteristics.3,4 during phonation wherein there is sustained vibration of the vocal folds, there are occasional slight variations of the vocal folds’ regular oscillation from cycle to cycle, otherwise termed as perturbations. these phenomena are called frequency perturbation (jitter) and amplitude perturbation (shimmer). these two correlate with the subjects’ degree of roughness.2, 6 the noise-harmony ratio characterizes the relationship between the two components of the acoustic wave of a sustained vowel: 1) the periodic component, which are the vocal fold regular sign and the additional noise coming from the vocal folds; and 2) the vocal tract.3, 7 at present, there are several different automated vocal acoustic analysis systems and each system provides consistent, reliable and repeatable results in extraction of fundamental voice parameters. however, uniformity between these systems varies considerably. felippe et al.3 recommended establishing and normalizing vocal parameter values individually as their values differ considerably. thus it is necessary to normalize the data from the software we are utilizing.2,3,4 instrumental measures of the vocal function form an integral component of the clinical process in institutions abroad, rather than a supplement to assessment and treatment.9 objective acoustic analysis will certainly add more accuracy and impartiality in the evaluation of dysphonic patients resulting in more scientific management. aside from providing an objective measure, this noninvasive procedure would also present adjuvant approaches to dysphonia and allow reliable comparison of voice samples (e.g., before and after treatment), therapeutic methods (e.g., microsurgery versus laser), or surgical groups. these measurements may also serve to provide baseline data in monitoring the degree of improvement in patients undergoing voice training as well as those in speech rehabilitation. the local paradigm of treatment in patients with voice and speech problems usually involves initial otolaryngologic evaluation. management is usually based on laryngoscopic examinations. acoustic examination is seldom considered unless long term therapy is required. in most common subtle symptoms of dysphonia (observed in singers with difficulty reaching habitual pitches), this measure may offer assistance in the diagnosis and treatment. the goal of the present study is to describe the vocal parameters fundamental frequency, jitter, shimmer and noise-harmony ratio (nhr) measures for the csl 4400 software, from kay elemetrics, used in the voice analysis laboratory of a private tertiary hospital in quezon city and to determine if our data is comparable to international studies. methods study design this was a quantitative cross-sectional descriptive study. this study was approved by the ethics committee for research of the department of otorhinolaryngology, st. luke’s medical center, and informed consent was obtained from all participants. setting data collection was carried out in a sound treated room at the voice analysis laboratory of the st. luke’s medical center. participants a total of 70 subjects were recruited at random by one of the authors from among department consultants, resident physicians, nurses and other hospital employees, medical interns and clinical clerks. as a pilot study, the number of proponents was set arbitrarily in consonance with international literature. inclusion criteria were age between 20 and 45 years, absence of any signs and symptoms of voice change and no smoking history.7 exclusion criteria were: recent history of altered voice performance, voice complaints such as hoarseness, voice fatigue, voice failure or irritated throat since these symptoms suggest organic alterations of voice that might affect study results;14 common cold, sore throat or upper respiratory tract infections since these conditions may cause phonation apparatus edema and dysfunction or other diseases that could limit voice production during the evaluation; or any prior voice therapy or professional voice training and/or otorhinolaryngologic treatment as these subjects may consciously alter self-monitoring of voice and compromise voice quality. singing in choirs or professional singers was also excluded to avoid subjects with trained voices. data gathering and sampling procedure after giving informed consent, the subjects were given a data checklist to be answered completely to assess the selection criteria and afterwards interviewed for history-taking. aside from not presenting voice alterations signs and symptoms (from data checklist and historyphilippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 original articles philippine journal of otolaryngology-head and neck surgery 9 taking), the participants’ voices were also screened using the grbas system by a speech therapist who worked with the speech rehabilitation clinic in the same hospital and an otolaryngologist/vocologist who was also an author of the study. only data from the individuals considered with normal voice were included in the study. data collection was obtained using the multi-dimensional voice program software with computerized speech lab cslmodel 4400 from kay elemetrics (kaypentax, montvale new jersey, usa). coupled with the csl kay elemetrics model 4400 digital recorder, a hi-fidelity microphone was used, senheisser model e 815 s (sennheisser electronic corporation, lyme, connecticut, usa) and it was kept at a fixed distance of 5 cm in front of the subject’s mouth.3, 7, 8, 10 the subjects were seated facing away from the monitor to prevent self-monitoring and conscious alteration of their voices during sampling. we used the sustained vowel /a/ at a habitual frequency and intensity following a deep breath, issuing the sound to achieve maximum phonation time without using expiratory reserve air. in order to stimulate habitual pitch and loudness, the subjects were also asked to utter a phrase immediately prior to the sustained vowel. the sustained vowel is preferred over regular speech in vocal acoustic assessment as it provides more reliable results.10 a total of five samplings were done for at least 3 seconds each. the first two samples were excluded to avoid voice onset effects on data analysis. vocal intensity was controlled by monitoring the software’s vu meter. when the sample exceeded the software’s acceptable vu range, a new sample was collected. figure 1. kolmogorov-smirnov test histogram showing normal distribution curves per parameter among male and female subjects. the voice samples were studied based on following acoustic parameters: fundamental frequency (hz), jitter (%), absolute jitter (db), shimmer (%), absolute shimmer (db) and noise-harmony ratio (nhr). each of these parameters was also analyzed as to gender. the descriptive statistical data analysis was carried out through spss for microsoft windows version 16.0 (ibm corporation, armonk, new york, usa). data were assessed statistically by applying descriptive statistics. the kolmogorov-smirnov method was applied for assessing the normality of results; the significance level was set at 5% (p> 0.05); this yielded a results distribution curve (figure 1) and was applied for normality testing. (figure 2) results a total of 56 young adults (28 men and 28 women) met inclusion criteria and participated in this study. their ages ranged between 22-43 years old (mean 29) and included hospital employees, nurses, medical clerks and interns, consultants, resident physicians and staff figure 2. kolmogorov-smirnov test for normality – computed adjusted scores with application of lilliefors correction. all parameters for male and female subjects revealed normal distribution. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 original articles 10 philippine journal of otolaryngology-head and neck surgery discussion there is a growing international trend for significant technological developments in the field of voice and speech evaluation, especially in the advancement of vocal acoustic analysis software. for this reason, standardization of normal acoustic measures is necessary due to the variation of systems protocols and software algorithms. given the paucity of data regarding acoustic voice analysis in the philippine literature, we decided to conceptually discuss findings obtained from the equipment used at our voice analysis laboratory. as a pilot local study, we set the number of proponents in accordance to other international papers, and this may by far be the largest for this type of research compared to other studies done abroad. several acoustic analysis softwares have demonstrated normal and pathological voice conditions. despite the accuracy and reliability of each machine, authors have agreed to standardize normative data individually due to a number of factors that may cause variations among each system. these possibilities include the type of programming of the acoustic analysis software, the use of recording criteria, type of microphone and other devices used in voice recording. not only do measures vary when measured by different software; there is also a wide range of normal voices. this fact is possibly due to individual differences, since voice is a personal feature, and no voice is perfectly equal to any other.9 the uniqueness of each voice also varies with race and language. these considerations led us to establish our own set of normal values for comparison data for voice analysis. the fundamental frequency (f0) is one of the most frequently used measures by clinicians to characterize human voice and the parameter which shows uniform results among different acoustic analysis systems. the f0 is related with vocal fold length, mass and strain. thus, lengthening the vocal folds will cause the glottic cycles to occur faster, yielding more acute resulting frequencies. variations of this measure also result from other factors, such as different speech tasks (sustained vowels, reading, conversation, and singing) different languages and dialects, smoking, stress, dysphonia and analysis forms.5,13 measures of the f0 using the sustained vowel /a/ in this study (figure 3) showed a mean value of 130.62hz ± 13.65 in the males. this value was relatively higher compared to the results obtained by felippe et al.3 (120hz), horii11 (125hz), araujo et al.3 (127.61hz), behlau and tosi3,9(113.01hz), and lower than those of morente et al.3 (139.72hz). measures of the f0 in the female group had a mean of 218.38hz ± 26.19; this variation range and mean values were similar to those proposed by araujo et al.3 (215.42hz) where 40 female voices issuing the vowel /a/ were evaluated using the analise da voz voice analysis software. our values were higher than the values found by felippe3 (206hz; csl model 4300), ferrand8 (209.68hz; csl model 4300) and finger et al.9 (210.92hz, praat software) and lower than those found by morente3 (267.33hz). this shows that our results are within the acceptable range in reference to international values and that there is a similar trend between studies figure 3. test results: stock chart graph showing individual parameter results overall, and in male and female groups. who worked at the voice analysis laboratory of the hospital. of the 70 initially recruited for the study, four were excluded due to recent-onset upper respiratory tract infection with noticeable voice changes, six had just quit smoking for less than a month and another four refused to enroll in the study. values extracted for f0, jitter %, jitter db, shimmer %, shimmer db and nhr showed normal distribution of results. (figures 1-2) the average vocal acoustic values found in the present study for male voices producing the vowel /a/ were fo = 130.6 ± 13.65hz, jitter = 0.0.46 % ± 0.184, jitter db: 37.62 db ± 16.66, shimmer %= 0.23%, shimmer db = 0.23 ± 0.67 and nhr = 0.13 ± 0.010.(figure 3) the average values found for female voices, producing the vowel /a/ were fo = 218.38 ± 26.192hz, jitter = 0.87% ± 0.61, jitter db: 34.82 ± 22.5, shimmer %= 2.72 ± 1.07 shimmer db = 0.23db ± 0.67 and nhr = 0.12db ± 0.016. (figure 3) fundamental frequency in females was significantly higher than their male counterparts as well as their shimmer however their nhr were slightly lower. jitter values also showed independent variation between the two groups, jitter % was higher in females but with a relatively lower jitter db. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 original articles philippine journal of otolaryngology-head and neck surgery 11 references núñez batalla f, corte santos p, sequeiros santiago g, señaris gonzáles b, suárez nieto c. 1. perceptual evaluation of dysphonia: correlation with acoustic parameters and reliability acta otorrinolaringol esp. 2004 jun-jul; 55(6): 282-287. toran kc, lal bk. objective analysis of voice in normal young adults. 2. kathmandu univ med j. 2009 oct-dec; 7(28): 374-377. naufel de felippe ac, grillo mh, grechi th. standardization of acoustic measures for normal 3. voice patterns. braz j otorhinolaryngol. 2006 sep-oct; 72 (5): 659-64. morris rj, brown ws jr. comparison of various automatic means for measuring mean 4. fundamental frequency. j voice. 1996 jun; 10(2):159-65. murry t, brown ws jr, morris rj. patterns of fundamental frequency for three types of voice 5. samples. j voice. 1995;9: 282–289 wang cc, huang ht, voice acoustic analysis of normal taiwanese adults. 6. j chin med assoc. 2004 apr; 67(4): 179-84. tajada jd, liesa rf, arenas el, gálvez mjn, garrido cm gormedino pr, garcía ao. the effect of 7. tobacco consumption on acoustic voice analysis. acta otorrinolaringol esp 1999; 50(6): 44852. ferrand ct. harmonics-to-noise ratio: an index of vocal aging. 8. j voice 2002; dec; 16 (4):480-7. finger ls, cielo ca, schwarz k. acoustic vocal measures in women without voice complaints 9. and with normal larynxes. braz j otorhinolaryngol. 2009 may-jun; 75 (3): 432-440. parsa v, jamieson dg. acoustic discrimination of pathological voice: sustained vowels versus 10. continuous speech. j speech lang hear res. 2001 apr; 44(2):327-39 when using the f0 measure in both genders even when using other voice analysis software. cycle-to-cycle perturbation measures assess acoustic signal variations; they relate to how much a specific glottic vibration period is different from the ensuing period with relation to frequency (jitter) and intensity (shimmer).13 jitter, which is voice frequency cycle-to-cycle perturbation,9 is an objective and reproducible measure that evaluates minor glottic pulse irregularities and may reflect hoarseness or voice noise. jitter and shimmer have proved to be useful in the description of normal and dysphonic speakers when using sustained vowels, being respectively related to hoarseness and roughness.3,11 conversely, hnr is more sensitive to subtle differences in vocal function than is jitter according to ferrand8 after studying 42 adult women with normal voices and testing for the correlation of hoarseness and the degree of hnr. it is important to note that the results of jitter and shimmer depend on the method applied in each software and this may differ with age, sex and the vowel that is used. there are distinctive methods for extracting jitter, such as absolute jitter, relative jitter, relative average perturbation (rap), pitch perturbation quotient (ppq) which varies across different voice analysis softwares.9 as to the average jitter in sustained vowel /a/ among male subjects, results showed a mean value of 0.0.46% ± 0.184 and 37.62db ± 16.66 which was higher than the values collected by felippe3 (0.498%) and araujo3 (0.37%) but lower than the values of horii11 (0.66%). as for the females, results showed a mean jitter 0.87% ± 0.6, higher than the ones collected by felippe3 (0.62%), araujo3 (0.85%) and ferrand8 (0.69%). shimmer measures reflect the cycle to cycle amplitude variation during vibration of the vocal folds; their increase is related with a decreased or inconsistent vocal fold contact coefficient.9 different software encodes these signals in relative and absolute values however this feature may not always be present in all voice analysis programs. furthermore, these measures may also be related with voice soprosity or noise in general. the shimmer average for males, producing the vowel /a/ showed a relative shimmer of 2.65% ± 0.76 with an absolute shimmer at 0.23db ± 0.067. this value was similar to the values of felippe et al.3 (0.23db), higher than those found by horii11 (0.47 db), but significantly lower than those of araújo et al.3 (2.37db). average shimmer for females producing the vowel /a/ was 0.28db and also showed similar trends with the studies done by felippe et al.3 (0.22db) and finger9 (0.268db) at 2.96%. however, this was lower than the values of araújo et al3. (2.52db) using the analise da voz software. a lot of controversies regarding jitter and shimmer parameters remain unsettled among studies and measures are not yet standardized. the harmony-noise ratio characterizes the relationship between the two components of the acoustic wave of a sustained vowel: the periodic component, vocal fold regular sign and the additional noise coming from the vocal folds and the vocal tract.3,8 a lower nhr and a higher hnr indicate superior voice quality. they reflect a general assessment of noise in a given signal. it is also influenced by age, being lower for the elderly (from 70 to 90 years), when compared to a group of young (from 21 to 34 years) and middle age women (from 40 to 63 years).8 nhr values in our study for males and females were 0.132 and 0.117 respectively. the values for women were similar to those of brum9 (ranging from 0.03 to 0.14; mean 0.11), schwarz9 (ranging from 0.09 to 0.17; mean 0.14) and oguz et al.9 (0.157). despite similarities in the trends of vocal parameters in various studies, we felt the need to further explore the reference values for males as most of these papers involved female subjects. the average vocal acoustic values found in the present study for male voices producing the vowel /a/ were fo = 130.62hz ± 13.65, jitter% = 0.46% ± 0.18, jitter db = 37.62db ± 16.66, shimmer% = 2.65% ± 0.76, shimmer db = 0.23db ± 0.067 and nhr = 0.132 ± 0.009. the average values found for female voices, producing the vowel /a/ were fo = 218.38hz ± 26.19, jitter% = 0.0.87% ± 0.61, jitter db = 34.82db ± 22.55, shimmer% = 2.72% ± 1.07, shimmer db = 0.25db ± 0.105 and nhr = 0.117 ±0.016. the differences in the programming of the various acoustic analysis systems, as well as the use of recording criteria, recording instrumentation such as computers, microphones and other devices individualize each of these voice acoustics systems, precluding a single normalization. following international recommendations for individual normalization per institution, we have obtained our own values, with comparable results to other studies. this endeavor will help in our local setting establish a set of reference values for future researches in the evaluation of voice and voice related problems. in our study, the result pattern showed normal distribution of values, meeting normality of results based on kolmogorov-smirnov test. it is recommended that in obtaining voice samples, a strict standard procedure is followed with at least five samplings to elicit normal habitual voice and avoid false vocalization due to consciousness during the sampling. further investigation is also suggested in areas where possibilities of interdialectic variation which may produce an effect on the outcome of the study. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 original article 6 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2012; 27 (1): 6-11 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to determine the prevalence of hearing loss among infants six months old and below sent for newborn hearing screening in our institution, and to measure the accuracy, sensitivity, specificity and positive predictive values of reflexive behavioral (“baah”) test in detecting hearing loss in infants. methods: design: cross-sectional study setting: ear unit of a tertiary government hospital participants: infants less than six months old sent for newborn hearing screening at the ear unit of a tertiary government hospital from april to september, 2011 were recruited. all participants were tested with oae for hearing screening. oae was also used as the standard for evaluating hearing impairment. the reflexive behavioral (“baah”) test was then done using the human voice as a loud sound stimulus, and the response recorded were auropalpebral, startle and blinking response to the sound. the sensitivity, specificity, accuracy, positive and negative predictive value of the test was then measured. results: from april to september 2011, a total of 101 patients were tested, with a male to female ratio of 1.1:1 (53 males, 48 females). the prevalence of hearing impairment in this study population was 6.9% (7 out of 101). the reflexive behavioral (“baah”) test was found to have sensitivity of 71.4%, specificity of 95.7%, accuracy rate of 94%, positive predictive value of 55.6% and negative predictive value of 97.8%. conclusion: the reflexive behavioral (“baah”) test shows potential as an accurate, acceptable and cost-effective screening tool to identify infants that may be at higher risk for hearing impairment. this test may aid the health care providers, in areas without oaes, in identifying infants who are in need further hearing diagnostic evaluation, with oaes or other hearing tests. it is recommended that the “baah” test be implemented in the community to test its reproducibility in a larger population and outside the hospital setting. keywords: reflexive behavioral test, “baah” test, otoacoustic emission, hearing screening accuracy of reflexive behavioral (“baah”) test in the screening for hearing impairment in infants six months old and below marieflor cristy m. garcia, md1 charlotte m. chiong, md1,2 generoso t. abes, md, mph1,2 ryner jose c. carrillo, md, msc1 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2philippine national ear institute university of the philippines, manila national institutes of health correspondence: dr. marieflor cristy m. garcia department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 phone: (632) 526 4360 email: marieflorcristy@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the analytical research contest (1st place) philippine society of otolaryngology-head and neck surgery, glaxosmithkline (gsk) bldg. chino roces ave., makati city, philippines, october 12, 2011. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 original article philippine journal of otolaryngology-head and neck surgery 7 language impairment due to hearing loss is a preventable condition, provided that it is diagnosed and managed early in life. hearing loss, if not detected and addressed at an early age, not only leads to speech and language difficulties, but may also lead to poor cognitive, social, and emotional development.1 this reality has led several countries and organizations to advocate a universal system of newborn hearing screening in order to ensure early detection and provide opportunities for early intervention. in the united states, several groups such as the joint committee on infant hearing, the american academy of pediatrics, centers for disease control and prevention, and healthy people 2010 have formulated and implemented recommendations. by 2007, 37 states in america had enacted legislation requiring that hearing screening be performed on all newborns in hospitals and birthing centers.2 at present, the accepted standard of care for newborn hearing screening is otoacoustic emissions (oae) and/or auditory brainstem response (abr). these are reliable tests that are based on physiologic responses, making the results objective, in contrast to other tests that rely on an observer’s assessment of specific responses. different countries and hospitals have their own protocols for newborn hearing screening, such as: (1) oaes before a newborn is discharged, followed by an outpatient oae re-screen for those who did not pass the first oaes, (2) oae inpatient screening and abr re-screen for those who did not pass, (3) oae and abr inpatient screens, and (4) abr inpatient and abr re-screens.1,3,4 these protocols depend on the standards set by the institution, balanced by the availability of resources, so that the protocol can be applied to the most number of individuals. in the philippines, the newborn hearing screening act or republic act 9709 has already been signed into law. its purpose is to “institutionalize measures for the prevention and early diagnosis of congenital hearing loss among newborns and the provision of referral, early intervention, counseling and other support services of newborns with hearing loss.”5 however, a primary barrier to the implementation of a universal health system in developing countries such as ours is the lack of affordable, reliable, and easy-to-use methodology that can be employed in farflung communities. in the philippines, oae machines are usually found only in tertiary institutions or in the city, and are almost unheard of in rural areas. in a developing country, only very few local government units and hospitals are willing to invest in these instruments, as they give priority to more life-threatening and emergent health problems.6 the number of those who can operate these instruments is even more limited. provision of these hearing screening instruments to all the local government units in the country may take a long while given the country’s present economic situation. as time passes, more and more deaf babies will grow up past the critical age with their condition undetected. the incidence of bilateral congenital profound hearing impairment is about 1.3 per 1000 filipino newborns.7 for the year 2010, the number of live births in the philippines was estimated to be over 2 million.8,9 with these figures, about 2,600 profoundly deaf babies are born every year, majority of which are born at home or in centers without newborn hearing screening equipment. this number still excludes those with milder forms of hearing loss that are also at risk for some degree of speech and/or language impairment. with the desire to improve early detection of hearing loss and reach the greatest number of population, we were in search of a reliable and simple hearing screening technique. in 1930, a study by bryan noted that blinking, startling, and stirring reactions in response to a loud sound is typical for newborn infants.10 several behavioral tests have then been developed relying on observation of the behavior of the infants and children being tested. although the older literature may find some responses to be less reliable to diagnose hearing loss, the auropalpebral reflex in the newborn has been established. similar to the moro test as an indicator for neuromuscular development of infants, the auropalpebral reflex might be useful as a screening tool for possible hearing impairment.10, 11 in the philippines, a pilot study was done by abes et al., to test the validity of human voice as the loud sound stimulus that may be used to provoke reflexive reactions from infants. results of the study showed that the sound “baah” covers both high and low frequencies (1505000hz) which is similar to the frequencies tested by the oaes. this is in contrast with the other sound investigated (i.e., “psst”) that carries only high frequency tones, which, if used for hearing screening, may falsely label as profoundly hearing-impaired those with residual hearing at low frequencies. it has also been found that at a distance of 1 meter, 85% of males and females recited the word “baah” at an intensity of 80db spl or louder, in contrast with “psst” that was produced in lower and more variable intensities. hence, if the goal is to prioritize early detection and referral of the profoundly hearing impaired children, the sound “baah” appears to be the more appropriate sound stimulus.12 based on these data, this study was developed to test whether the sound “baah” and the reflexive response of newborns may be used as a screening tool for identifying possible hearing impairment in a newborn. the objective of the study was to determine the prevalence of hearing philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 original article 8 philippine journal of otolaryngology-head and neck surgery loss among infants 6 months old and below sent for newborn hearing screening in our institution, and to calculate the accuracy, sensitivity, specificity and positive predictive values of reflexive behavioral (“baah”) test in detecting hearing loss in infants. methods study design this was a cross sectional study. the research protocol was presented to and approved by the research committee of the department of otorhinolaryngology of the philippine general hospital, and abided by the helsinki declaration. setting the study was performed in a quiet, enclosed, air-conditioned room designated for oae testing at the ear unit of the philippine general hospital, a tertiary national university hospital. the baby was laid on a flat bed while the parent or guardian was seated on a designated area at bedside. participants from april to september 2011, parents of infants six months old or younger sent for oae testing during the duty schedules of the tester and observer were asked to enroll their child in the study, hence, convenience sampling was used. for each of the parent or guardian, detailed information regarding the study was provided in a written form, which was supplemented by verbal explanation for all the recruits. a consent form was signed by the parent or guardian upon agreement to participate in the study. inclusion criteria were: (1) male and female infants from 0-6 months old, (2) with parent or guardian’s informed consent, (3) with developed ear canal for oae testing. excluded were those (1) without consent from the parent or guardian, (2) those with ear canal deformity in which the oae probe could not be inserted. all infants sent to the ear unit were stable and comfortable in room air since oae testing is an elective procedure. calibration of stimulus intensity ten infants were recruited for a pilot study which were also obtained from the oae referrals at the ear unit. a single designated tester was trained to provide the voice stimulus (“baah”). these initial 10 infants were not counted in the total number of subjects in the study. the trained tester and observer were both technicians working at the ear unit. an a-and-c-weighted sound level meter (tes-1350a digital sound level meter, tes electrical electronic corp., taiwan) was placed beside the infant’s head during the “baah” test for all the infants. the stimulus was produced by the trained tester, whose mouth was at a set distance of one foot away from the head of the infant. the tester took two deep breaths and then produced the sound “baah” in a sudden manner, as described by abes, et al.12 based on the sound level meter, the stimulus produced was consistently recorded between 80 to 95db spl intensity during the pilot study. a single observer was trained to observe and record the response of the infants. the most common reflex demonstrated was either blinking or a more forceful and sudden shutting of the infants’ already closed eyelids. additional responses were startling and stirring reflexes demonstrated by sudden head and body movement right after the sound was produced. the observer records the response as “present” if the infant demonstrated one or more of the responses above, and “absent” if none of the above responses was observed. intervention or observation procedures the baby was placed at the designated quiet room and laid on a bed. once the baby had settled and was in a quiet state, oae (dp-oae) was administered in each ear using otoreadtm oae test instrument (interacoustics®, denmark). the oae was tested by one of the five trained audiologists designated for the day. the oae test instrument automatically started the test once the ambient noise was acceptably low and a seal was produced with a probe in the infant’s ear canal. when a “refer” result appeared, the ear probe was removed, the baby’s ear was massaged to release ear canal retraction, and the test was again repeated when the infant was settled. if “refer” was again obtained, the result was recorded as “refer” in that ear. if “pass” result was obtained on the first or second test, then the result was recorded as “pass.” the audiologist recorded the result on the official form and left the room. the trained tester and observer then entered the room, blinded to the oae result. the tester positioned herself at the vertex part of the head of the infant, with her mouth one foot away from the infant’s head. the trained observer positioned herself at the side of the infant to focus on its facial reactions. the tester then provided the stimulus “baah” and the observer recorded the presence of absence of response. the stimulus was provided two to three times, depending on the infant’s response. the investigator then collected and tabulated the data provided in the oae result form, as well as the data gathered by the “baah” investigator. main and secondary outcome measures the main outcome measures were presence or absence of a response reported in the oae and presence or absence of a response in the “baah” test. if the oaes were absent in either ear (a “refer” result), it was recorded as “disease positive.” the “baah” test was recorded “test positive” if the philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 original article philippine journal of otolaryngology-head and neck surgery 9 infant failed to demonstrate any reflexive response to at least two out of three stimuli. the “baah” test was recorded “test negative” if the infant was able to demonstrate reflexive response to at least two stimuli. data analysis data was tabulated in a 2 x 2 table comparing the test stimulus (“baah”) and the standard (oae). (table 1) accuracy, sensitivity, specificity, positive and negative predictive values, likelihood ratios, figure 1. age distribution of the sample population table 1. 2x2 table for reflexive behavioral (“baah”) test vs. oae test baah (+) (n) baah (-) (n) 5 (a=true positive) 2 (c=false negative) sensitivity = a/(a+c) = 71.4% 4 (b=false positive) 90 (d=true negative) specificity = d/(d+b) = 95.7% positive predictive value =true positive/test outcome positive = a /(a+b) = 55.6% negative predictive value =true negative/test outcome negative = d/(c+d) = 97.83% accuracy = a+d/(a+b+c+d) = 94.1% oae (+) (n) oae (-) (n) p<0.0001 table 2. likelihood ratios and post-test probabilitiesfor “baah” test likelihood ratio for a positive test (lr+) likelihood ratio for a negative test (lr-) posttest probability for a positive test (posttestprob+) posttest probability for a negative test (posttestprob -) = (sensitivity)/(1-specificity) =0.71429/(1 0.95745) = 16.786 = (1-sensitivity)/specificity =(1-0.71429)/0.95745 = 0.298407 =pretestodds×lr+)/(1+[pretestodds×lr+]) = ([7/94]x16.786) / (1+[{7/94}x16.786]) = 0.55556 =55.6% =(pretestodds×lr-)/(1+(pretestodds×lr-)) = ([7/94]x0.298)/(1+[{7/94}x0.298]) = 0.02171 = 2.17% and post-test probabilities were calculated using the centre for evidence-based medicine (cebm) stats calculator.13 the 2x2 table was analyzed using the fisher exact test, with a p value of <0.05 considered as significant. the p value was calculated using the graphpad software (graphpad software, inc., usa).14 the age in days and the gender of the infants were recorded, as well as the incidence of hearing impairment based on oae. results from april to september 2011, a total of 101 patients, with a male to female ratio of 1.1:1 (53 males, 48 females), were tested. the mean age was 10.33 days (range 0 to 182 days). the age distribution is shown in figure 1. test results for the 101 patients are shown in table 1.the sensitivity of the “baah” test was calculated at 71.4% with a specificity of 95.7%. the positive predictive value was 55.6% and the negative predictive value was 97.8%. the p value was <0.0001, indicating that the association between the “baah” test and oae is statistically significant. the likelihood ratios for positive and negative test results were 16.786 and 0.298, respectively. (table 2) seven out of 101 infants tested positive (i.e. with hearing impairment) with oaes with a prevalence of 6.9% in this study population. the posttest probability for a positive “baah” test was 55.6% and the post-test probability for a negative “baah” test was 2.1%. in summary, correct (true positive and true negative) diagnosis was achieved in 95 out of 101 infants giving the test an accuracy of 94%. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 original article 10 philippine journal of otolaryngology-head and neck surgery discussion the “baah” test has a high specificity of 95.7%, which indicates a low false positive rate. hence, infants that tested positive for “baah” have a high probability of indeed having a hearing impairment. the rather low sensitivity of 71.4% (hence a considerable number of false negatives) and positive predictive value of 55.6% indicate that those that tested negative for “baah” may still have hearing loss, therefore these infants need to be continually monitored for hearing milestones and parents need to be advised to watch out for any indication of poor speech and/ or language development. the negative predictive value means that using the “baah” test, 97.8% of those without hearing loss were correctly labeled as such. the likelihood ratio for a positive test means that a positive “baah” test would be about 17x as likely to be seen in someone with as opposed to someone without hearing loss. in this study, all infants had a 6.9% probability of having hearing loss prior to the test (i.e. prevalence). after conducting the “baah” test, a specific infant that turned out positive for the test now had a 55.6% probability of having hearing loss (i.e. post-test probability for a positive test). this value may be clinically significant to compel the health care provider to send the infant with a positive “baah” test for further hearing evaluation. applying this to the rural setting where oaes are not readily available, a child that turns out positive for “baah” test will have a more justifiable reason to be referred to the city for further hearing tests (oaes, abr, etc) in order to confirm whether he or she has hearing loss. for a certain population with a higher prevalence of hearing loss (for example, infants with risk factors such as maternal rubella and use of antibiotics during the neonatal period, etc.), the probability of having hearing loss may be higher after a positive “baah” test. figure 2 shows the curve on how the post-test probability would increase depending on the pre-test probability of hearing loss in a specific population.13 one limitation of this study is the selection of a gold standard to confirm the diagnosis of hearing loss. at present, there is no single, true gold standard for the diagnosis of newborn hearing loss. even if an infant passes the oaes or abr test, it is still not assured that the child indeed has normal hearing, as oae and abr are merely physiologic observations that are indirect measures of hearing. therefore when a child passes the screening test, regardless of the specific tool used, it is advised that the infant be continually monitored for hearing milestones.1 the most valid confirmatory tool for evaluation of hearing is a behavioral test, which is usually through pure tone audiometry to check whether the individual actually responds to auditory input. 4, 15,16,17 although these behavioral techniques may be possible for children as young as 6 months old, these techniques are not always easy to perform for this age group, as proper timing and motivation to gain the child’s cooperation is necessary to obtain a reliable result.1 despite its limitations, oaes are still the more popular neonatal hearing screening tool. while oaes and abrs are both objective tests, oae testing is less expensive and easier to administer, while abr takes a longer time and requires the infant to be asleep. this may necessitate sedation to keep the baby in a quiet state for the duration of the test, although it is often not recommended until after five months of age. oae results are found to be highly specific (91.8 to 99.7% specificity) with sensitivity close to 100%.3 a local study by llanes and chiong also showed that the otoacoustic emission test had good concordance with abr in neonates.18 in this study, we selected oaes as our standard for the presence of newborn hearing loss due to the reasons mentioned above. this study shows that the reflexive behavioral (“baah”) test has potential as an accurate and cost-effective screening tool to identify infants that may be at greater risk for hearing impairment, and who will need further diagnostic test in a higher level of health care institution. the ability of the test can be assessed in larger population or by field testing in a community-based study. a stronger gold standard for figure 2. graph of post-test probabilities for a positive or negative “baah” test (y-axis) given a pre-test probability for a specific group (x-axis). in this study population, for example, the prevalence of hearing loss is 6.9%. prior to the “baah” test, a child has a 6.9% (0.069) probability of having hearing loss (tail end of dashed arrow). after conducting the “baah” test, a specific infant that turns out positive for the test now has 55.6% (0.556) probability of having hearing loss (head of dashed arrow).* *graph created through kt clearinghouse center for evidence based medicine toronto13 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 original article philippine journal of otolaryngology-head and neck surgery 11 acknowledgements we thank dr. rina reyes-quintos, for her review of the initial proposal; ms. aneezah joy mutuc and ms. floriza araneta, our participating investigators, and dr. patrick labra for his assistance with the newborns. we also thank those who helped with the pso-hns analytical research contest: dr. romeo villarta for his ideas and inputs on the presentation, dr. warren holgado and dr. rikka ramos for the paper submission, and dr. marion acuin and dr. micaela pacis-vinarao for covering for the other hospital duties. references 1. cummings cw, flint pw, haughey bh, robbins kt, thomas jr, harker la, et al, editors. cummings otolaryngology—head &neck surgery.4th ed. philadelphia: mosby, inc; 2005. p. 4387-4390. 2. wrightson as. universal newborn hearing screening. am fam physician. 2007 may; 75(9): 13491352. 3. freitas vs, alvarenga kf, bevilacqua mc, martinez man, costa oa. critical analysis of three newborn hearing screening protocols (original title: análise crítica de três protocolos de triagem auditiva neonatal). pró-fono revista de atualização científica. 2009 jul-sep; 21(3):201-6. 4. porter hl, neely st, gorga mp. using benefit-cost ratio to select universal newborn hearing screening test criteria. ear hear. 2009 aug; 30(4): 447–457. 5. republic act 9709. an act establishing a universal newborn hearing screening program for the prevention, early diagnosis and intervention of hearing loss. republic of the philippines, fourteenth congress, second regular session, metro manila. senate and house of representatives of the philippines. 28 jul 2008. 6. olusanya bo. addressing the global neglect of childhood hearing impairment in developing countries. plos med. 2007 apr; 4(4):e74. erratum in: plos med. 2007 jun; 4(6):e203. [cited january 2010]. available from: www.plosmedicine.org. 7. santos-cortez r, chiong cm. cost-effectiveness of universal hearing screening in the philippines. acta medica philippina. submitted 2011. 8. unicef. at a glance: philippines. [cited september 2011]. available from: http://www.unicef.org/ infobycountry/philippines_statistics.html 9. united nations, department of economic and social affairs, population division: world population prospects. new york. [updated 2010, cited september 2011]. available from: http:// esa.un.org/unpd/wpp/country-profiles/pdf/608.pdf 10. mencher gt, davis ac, devoe sj, beresford d, bamford jm. universal neonatal hearing screening: past, present, and future. am j audiol. 2001 jun; 10(1):3-12. 11. mccormick, b. neonatal hearing screening and assessment: the distraction test as a procedure for hearing screening—a recommended test protocol. [updated august 13, 2002, cited january 2010]. available from: www.nhsp.info/prots.shtml. 12. abes fll, gloria-cruz tl, abes gt. the voice test as an alternative hearing test for the universal newborn hearing screening program in the philippines. acta medica philippina. submitted 2011. 13. kt clearinghouse center for evidence based medicine toronto – statistical calculator. toronto, canada. © 2000-2012. [cited september 2011]. available from: http://ktclearinghouse.ca/ cebm/practise/ca/calculators/statscalc 14. graphpad software. quickcalcs, online calculators for scientists. graphpad software, inc. ca, usa. © 2002-2005, [cited april 2012]. available from: http://www.graphpad.com/quickcalcs/ contingency1.cfm 15. kennedy c, mccann d. universal neonatal hearing screening moving from evidence to practice. arch dis child fetal neonatal ed. 2004 sep; 89(5):f378–f383. 16. declau f, boudewyns a, van den ende j, peeters a, van den heyning p. etiologic and audiologic evaluations after universal neonatal hearing screening: analysis of 170 referred neonates. pediatrics. 2008 jun; 121(6): 1119-26. 17. american speech-language-hearing association. (2004). guidelines for the audiologic assessment of children from birth to 5 years of age [guidelines]. available from www.asha. org/policy. 18. llanes egd, chiong cm: evoked otoacoustic emissions and auditory brainstem responses: concordance in hearing screening among high risk children. acta otolaryngol 2004; 124:387390. measuring the accuracy of the “baah” test may be used, such as retesting with oaes or confirmation through abr, as well as possible long-term follow-up to eventually conduct pure tone audiometry when the child is cooperative enough for a behavioral test. the use of this test may lead to earlier detection of hearing impairment for infants in the rural communities who cannot be readily tested with oaes or abr. this may provide greater awareness to the community and lead to more referrals with more sophisticated screening and diagnostic tools. should this test be considered in community practice, the production of the sound stimulus “baah” may be taught to community health workers during their training seminars, to be able to produce a standardized stimulus, as well as be trained to assess an infant’s normal reactions to sound. it may also be worthwhile to investigate the utility of “baah” test in combination with the evaluation of risk factors and hearing milestones of infants, which might result in a more sensitive community-based newborn hearing screening program. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 philippine journal of otolaryngology-head and neck surgery 37 from the viewbox this middle-aged gentleman with no previous medical history presented to the local ent outpatient clinic complaining of right-sided hearing loss. no history of trauma or previous head and neck surgery was elicited. following clinical and auditory assessment a right sensorineural hearing loss was confirmed. a right-sided facial palsy was additionally identified on examination. a mri of the internal auditory meati was performed (figure 1a & 1b). following radiologist review, mri and mra of the brain was undertaken. sensorineural hearing loss: what lies beneath? neurovascular conflict secondary to a dural arteriovenous malformation correspondence: dr. ian c. bickle consultant radiologist department of radiology ripas hospital bandar seri begawan ba1710 brunei darussalam phone: + 00 673 8 612182 fax: + 00 673 224 2690 email: firbeckkona@gmail.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2014; 29 (2): 37-38 c philippine society of otolaryngology – head and neck surgery, inc. ian c. bickle, mb, bch, bao, frcr department of radiology ripas hospital, bandar seri begawan brunei darussalam figures 1a & b. axial and coronal t2 sequences of the iams a b discussion auditory impairment is a condition with a legion of potential causes. one of the routine aspects of the assessment process for those with sensorineural hearing loss is mr imaging (mri) of the internal auditory meati (iams). the vast majority of mri studies are normal, however one of the more commonly identified pathologies are cerebrovascular abnormalities. the most-well recognised is neurovascular conflict of the vestibulocochlear nerve by a vascular loop at the root entry zone (rez), however a broader range of potential responsible structural abnormalities philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 from the viewbox 38 philippine journal of otolaryngology-head and neck surgery are known. a wide range of processes for auditory dysfunction have been outlined.1 these include: cerebral ischemia events, subarachnoid hemorrhage, cerebrovascular malformations and rarely dural arteriovenous fistulas (davfs). dural avf’s are abnormal vascular communications between the dural venous sinuses and an arter(ies) most frequently branches of the external carotid artery. sensorineural hearing impairment is one of the rarer presenting symptoms. the mechanism for hearing impairment is believed to result from either direct vascular compression on the vestibulocochlear nerve from an enlarged aberrant draining vein or from a vascular steal phenomenon (figures 2a & 2b). an engorged draining vein from the davf causing mechanical compression on the nerve is the most well recognized.2 a single prior case has been reported of compression from an intraossesous davf of the skull base.3 references 1. tabuchi,s. auditory dysfunction in patients with cerebrovascular disease. the world scientific journal. 2014, id 261824. doi/10.1155/2014/261824. 2. lasjaunias, p, chiu, m, ter brugge, k et al. neurological manifestations of intracranial dural arteriovenous malformations. j neurosurg 1986; 64: 724-30. 3. kim ms, oh cw, han dh, kwon ok, jung hw, han mh. intraosseous dural arteriovenous fistula of the skull base associated with hearing loss. j neurosurg. 2002; 96(5):952-5. the arteriovenous fistula may be directly identified (figure 3) along with the associated signs of enlarged cerebral cortical veins and white matter change of venous hypertension (figure 4). figures 2a & b. axial and coronal t2 sequences of the iams. a: engorged aberrant veins crowding the right iam (white arrows). b: engorged veins compressing the intracanalicular right vestibulocochlear nerve (thin white arrow). normal left side for comparison (thick white arrow) figure 3. axial mra brain raw data set: a direct communication (arrow) between a distal external carotid artery branch (triangle) and the sigmoid-tranverse sinus junction (star) in keeping with a dural av fistula figure 4. axial mri flair brain: extensive periventricular high signal (black arrows) due to cerebral venous hypertension. distended cerebral cortical veins are also present (white arrow) a b philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 philippine journal of otolaryngology-head and neck surgery 41 letter to the editor philipp j otolaryngol head neck surg 2012; 27 (1): 41-43 c philippine society of otolaryngology – head and neck surgery, inc. dear editor: time has proven that endoscopy is generally a safe and effective tool in the diagnosis and treatment of various conditions. it offers superior visualization with markedly decreased morbidity and mortality. in otolaryngology, otoendoscopy has been gaining acceptance in providing improved otoscopic visualization and video recording of the tympanic membrane. we describe a technique of myringotomy and ventilation tube insertion under endoscopic visualization using a rigid hopkins rod scope previously described by other authors based on their accepted clinical guidelines for myringotomy. 1,2 the use of rigid endoscopes provides visualization of the entire tympanic membrane with excellent resolution, better fidelity of color with a well-angled or side-to-side vision. the procedure is generally safe, convenient and can be performed in an out-patient setting. correspondingly, the video recordings could improve disease documentation for baseline and post-myringotomy evaluation. they can also be a tool to enable better understanding for patients. 3 methods: a total of seven patients with symptomatic and non-resolving otitis media with effusion (ome) previously managed conservatively for 3-6 months from october 2009 to march 2010 were included in the study. the patients also had disabling otalgia with four of the subjects having more than 30 db hearing loss. subjects who had poor pain threshold, were deemed non-cooperative and those in the pediatric age group were excluded from the study. informed consent with strict compliance to institutional ethical standards was signed by all patients. the procedures were all performed by the junior author at the e.n.t diagnostic unit of a private tertiary university hospital. materials used for the procedure were the same as with conventional myringotomy (eg. aural speculum, kley or sickle knife, hartmann ear forceps and ventilation tube/s). the anesthetic used was an eutectic mixture of local anesthesia (emla®) cream 5 % (astra-zeneca, sodertalje, sweden) in a 1 cc tuberculin syringe, and 20-25% aqueous form of phenol solution. a 0 degree 4 mm x 107.5 mm rigid endoscope (karl storz gmbh & co. kg mittelstr., tuttlingen, germany) was used. (figure 1) first an otoendoscopy was performed and the clinical indications and risks for myringotomy were thoroughly discussed with each patient. emla® cream was applied to the ear canal and to the external surface of the tympanic membrane using a 1 cc tuberculin syringe. after 60 minutes, the external ear canal was cleared for complete visualization of the tympanic membrane. (figure 2) the patient was then positioned seated on the examining chair with head tilted to the opposite side. using a 0 degree 4 mm x 107.5 mm rigid endoscope, the posterior third of the external auditory canal and the tympanic membrane was visualized. the scope was held with the left hand only up to the anterior portion of the cartilaginous canal to avoid involuntary activation of the xth cranial nerve and to allow further advancement of other instruments to the posterior canal. a shorter rigid otoendoscope (4 mm x 45 mm) or a smaller diameter pediatric rigid endoscope (2.7 mm x 107.5 mm) may be used if available. a kley knife or myringotomy knife was dipped lightly in phenol solution and carefully advanced to the tympanic membrane for the preferred myringotomy stab incision. (figure 3) endoscopic myringotomy and ventilation tube placement: a valuable otolaryngologic procedure under topical anesthesia adrian f. fernando, md1,2 kenneth z. calavera, md1 1department of otorhinolaryngology head and neck surgery university of the east – ramon magsaysay memorial medical center, inc. quezon city, philippines 2the head and neck reconstructive surgery fellowship consortium department of otorhinolaryngology head & neck surgery east avenue medical center, east ave. quezon city, philippines jose r. reyes memorial medical center sta. cruz, manila, philippines rizal medical center, pasig blvd., pasig city, philippines the medical city, ortigas ave., pasig city, philippines university of sto. tomas hospital, sampaloc manila, philippines correspondence: dr. adrian f. fernando department of otorhinolaryngology head & neck surgery rm. 463, hospital service bldg., uermmmc, inc., 64 aurora blvd., quezon city 1113 philippines phone: (632) 7150861 local 257 fax: (632) 7161789 e-mail: ianfernando_md@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the surgical innovation and instrumentation contest, philippine society of otolaryngology – head and neck surgery, crowne plaza hotel, ortigas, pasig city. october 19, 2010. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 letter to the editor 42 philippine journal of otolaryngology-head and neck surgery care was taken to avoid contact of the phenol and knife tip with the canal wall to avoid stimulating unnecessary movement, canal abrasion or dermal irritation from the phenol solution during the entire procedure. (figure 3) the myringotomy incisions were made at the posterior-inferior tympanic membrane quadrant for ease of access and drainage. (figure 4) evacuation of middle ear fluid was performed using a 2 and 3 mm frazer middle ear suction tip. the myringotomy incision was made large enough to admit the ventilation tube in four subjects with copious effusions. in these four, the tube was introduced and adjusted using a 1 mm x 8 cm (working length) hartmann ear forceps. a 1.14 mm i.d. armstrong beveled fluoroplastic grommet ventilation tube (xomed, jocksonville, fl) was used in three subjects while a sheehy collar button tube without wire (micromedics inc, st. paul, minnesota, usa) was used in one. the choice of tube depended mainly on the authors’ preference, taking tube designs available for specific ear conditions into consideration. (figure 4) all subjects were instructed to avoid vigorous activities for the first 48 hours post-myringotomy with strict water precautions. ofloxacin otic drops were then prescribed. results there were a total of seven patients, three males and four females, with age ranging from 25 to 65 years (mean=50). all of them tolerated the procedure well. ventilation tubes were inserted in four subjects with copious middle ear effusions. all had minimal intra-operative (pas 2-5) and post-operative pain (pas 0-2). the procedures were done on an out-patient basis. co-morbid conditions were likewise treated. (table 1) six of the seven subjects experienced immediate subjective relief of otalgia and hearing loss after myringotomy while one subject had persistent complaint of ear fullness. the main indication for the procedure was otitis media with effusion with significant hearing loss, otalgia and ear fullness non-responsive to three months conservative figure 1. instruments and materials for endoscopic myringotomy. a. aural speculum for aural toilet and examination; tb syringe with emla®; kley (or sickle) knife; 0-degree rigid endoscope; others: phenol solution and endoscopy unit; b. ventilation tube; c. hartmann 1.2 mm ear forceps with 8 cm working length. (note: materials and instruments may vary based on surgeon’s preference, anatomical considerations and availability) figure 2. topical anesthetization. a. aspiration of emla® cream with a tb syringe; b. application of emla to the outer surface of the tympanic membrane and the external auditory canal wall. figure 3. instrumentation. one hand instrumentation with direct endoscopic visualization of the posterior external auditory canal and the tympanic membrane. figure 4. endoscopic myringotomy and ventilation tube insertion. a. endoscopic view of the bulging and non-mobile right tympanic membrane with middle ear effusion; b. myringotomy incision with a kley aural knife (with phenol) at the postero-inferior tympanic membrane quadrant; c. drainage and suctioning of middle ear fluid; d. bi-flanged ventilating tube in-place. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 philippine journal of otolaryngology-head and neck surgery 43 letter to the editor references 1. lee fp. an alternative use of video-telescopic guidance for insertion of myringotomy tube. j laryngol otol. 2006 feb;120(2):e10. 2. abou-elhamd ke. telescopic myringotomy and tube application. j laryngol otol. 2000 aug;114(8):581-3. 3. patricoski c, kokesh j, ferguson as, koller k, zwack g, provost e et al. a comparison of in-person examination and video otoscope imaging for tympanostomy tube follow-up. telemed j e health. 2003 winter;9(4):331-44. 4. rosenfeld rm., culpepper l, doyle kj, grundfast km, hoberman, a, kenna ma, et al. clinical practice guideline: otitis media with effusion. otolaryngol head neck surg. 2004 may; 130(5 suppl):s95-118. 5. summerfield mj, white ps. ventilation tube insertion using topical anesthesia in children. j laryngol otol. 1992 may; 106(5):427-8. 6. bigham b, hawke m, halik j. the safety and efficacy of emla cream topical anesthesia for myringotomy and ventilation tube insertion. j otolaryngol. 1991 jun; 20(3):193-5. 7. badr-el-dine m. value of ear endoscopy in cholesteatoma surgery. otol neurotol. 2002 sep; 23(5):631-5. management. all patients had significant contributing factors for ome such as frequent infectious rhinitis or chronic persistent allergic rhinitis. six of the seven subjects had markedly improved hearing. four subjects with a preoperative pure-tone evaluation of >30-40 db hearing loss had pure-tone average improvement to 10-15 db after subsequent hearing examinations. all subjects were evaluated post-operatively with otoendoscopy. one case was unresponsive and subsequently diagnosed with adhesive otitis media and advised to undergo myringoplasty. discussion endoscopic myringotomy under topical anesthesia is a generally safe and practical procedure. its indications are the same with conventional myringotomy with or without ventilation tube insertion such as otitis media with effusion persisting beyond three months with associated significant hearing loss, impending mastoiditis or intracranial complications, recurrent episodes of acute otitis media (> 3 episodes in 6 months or > 4 episodes in 12 months), chronic tympanic membrane or pars flaccida, barotrauma, autophony (hearing body sounds; eg. breathing) due to patulous or widely open eustachean tube, craniofacial anomalies predisposing to middle ear dysfunction (e.g. cleft palate), and middle ear dysfunction due to head and neck radiation and skull base surgery.4 endoscopic visualization of the tympanic membrane enables better patient understanding of their ear conditions. such has been the basis for the procedure along with the use of 5% emla® to decrease the pain and discomfort of patients undergoing out-patient myringotomy procedures.5 phenol, on the other hand, aids in faster creation of tympanic membrane incision and decreases post-operative bleeding through its tissue vaporizing chemical cauterization effect with negligible toxicity if given in minute amount.6 furthermore, for postoperative cases of middle ear surgeries, it can be used for surveillance and middle ear cleaning. this can improve post-operative follow-up and possibly decrease the need for second look surgery.7 generally, endoscopic myringotomy provides a complete and enhanced visualization of the tympanic membrane and some middle ear structures that only appear as silhouettes with conventional otoscopy. rigid endoscopes may have less illumination and magnification compared to an operating microscope traditionally used in myringotomy procedures but it can provide an angled or “off line-of-site” visualization of the tympanic membrane and canal wall advantageous in trans-canal visualization of the tympanic membrane. just like the conventional out-patient myringotomy, endoscopic myringotomy under topical anesthesia is less costly than performing the procedure under general anesthesia or through sedation requiring a more controlled clinical setting. smaller diameter and shorter endoscopes may be more feasible for diagnostic otoendoscopy but a rigid 4 mm endoscope is more widely available in most local clinics. the major disadvantage of this procedure is the instrumentation in very young or uncooperative patients with a narrow external auditory canal. one-handed instrumentation and lens fogging may also be encountered but can be reduced with familiarity with the procedure. the indications for endoscopic myringotomy as with those for traditional myringotomy remain suggestions and do not represent the standard of care. clinicians can modify them when medically necessary as treatment options should always be individualized to meet each patient’s need. failure to improve hearing may suggest another middle ear condition that necessitates further evaluation. some cases may need myringotomy tube replacement while surgery is reserved for failed tympanic membrane healing. lastly, like any other surgical technique and instrumentation, the major key to a successful endoscopic myringotomy is still good patient selection. table 1. description of patients who underwent myringotomy and/or ventilation tube insertion. subjects’ age & sex indications other related conditions myringotomy +/ventilation tube (vt) pre-operative pta 50/f 25/f 60/m 27/m 29/f 65/m 45/m chronic ome, au; recurrent ome, au recurrent ome, au chronic ome, au; unresponsive to medical management x 2 yrs chronic ome, as ome, au; severe hearing loss and otalgia ome, au infectious rhinitis infectious rhinitis, allergic rhinitis infectious rhinitis allergic rhinitis; subsequently diagnosed w/ adhesive otitis media, as allergic rhinitis infectious rhinitis infectious rhinitis + vt, au -vt +vt, au -vt, as -vt, as +vt, ad +vt, ad 40 db hearing loss 30 db hearing loss 30 db hearing loss 40 db hearing loss philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 philippine journal of otolaryngology-head and neck surgery 33 from the viewbox this 17-year-old young man attended the oromaxillofacial (omf) department of a tertiary surgical center. he had attended both local and overseas ent departments since the age of 5 years. previously, an unspecified surgery had been performed as a child with ongoing problems since with a discharging sinus on the anterior aspect of the lower left side of the neck. on clinical examination, several scars were present on the anterior aspect of the neck and a skin opening was evident in the left para-midline of the lower neck. following clinico-radiological discussion a barium swallow was undertaken (figures 1 and 2). pyriform sinus fistula correspondence: dr. ian c bickle department of radiology ripas hospital bandar seri begawan ba1710 brunei darussalam phone: (673) 8 612182 telefax: (673) 224 2690 email: firbeckkona@gmail.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2014; 29 (1): 33-34 c philippine society of otolaryngology – head and neck surgery, inc. ian c bickle, mb, bch, bao, frcr department of radiology ripas hospital, bandar seri begawan brunei figure 1. a,b,c: barium swallow: a serpiginous tract of barium is delineated in the left side of the neck arising from the left pyriform sinus extending to the skin opening. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 from the viewbox 34 philippine journal of otolaryngology-head and neck surgery references park sw, han mh, sung mh, kim io, kim kh, chang kh, han mc. neck infection associated with 1. pyriform sinus fistula: imaging findings. ajnr am j neuroradiol. 2000 may; 21(5):817-22. taylor we, myer cm, hays ll et al. acute suppurative thyroiditis in children. 2. laryngoscope. 1982; 92: 1264-1273. wang hk, tiu cm, chou yh, chang cy. imaging studies of pyriform sinus fistula. 3. pediatr radiol. 2003 may; 33(5):328-33. yolmo d, madana j, kalaiarasi r, gopalakrishnan s, kiruba shankar m, krishnapriya sj. 4. retrospective case review of pyriform sinus fistulae of third branchial arch origin commonly presenting as acute suppurative thyroiditis in children. laryngol otol. 2012 jul; 126(7):737-42. cigliano b, cipolletta l, baltogiannis n, esposito c, settimi a. endoscopic fibrin sealing of 5. congenital pyriform sinus fistula. surg endosc. 2004 mar; 18(3):554-6. figure 2. clinical image: during the swallow examination barium exuded from the skin opening, confirming the fistulous tract discussion a pyriform sinus fistula is an uncommon but, well documented condition. it is most commonly observed in the pediatric community usually presenting with an acute neck infection. the vast majority occur on the left side of the neck with reports documenting fistula on this side accounting for between 83 and 100%.1,2 it is highly associated with an underlying congenital third, or fourth branchial cyst. various imaging modalities have been employed in the identification and characterization of a pyriform sinus fistula. barium swallow has been traditionally used and may elegantly illustrate the fistula in a dynamic fashion. however, the tract is not always well demonstrated. use of a cross sectional modality (ideally mri) is essential in identifying; the fistula and its course, any underlying branchial cyst, an associated acute neck infection and whether the thyroid gland is involved.3 thyroid gland involvement is frequently encountered given the typical course of the fistula.4 fiberoptic endoscopy is also employed to identify the origin of the fistula in the pyriform sinus and is an important part of the diagnostic process. definitive treatment is complete excision of the fistula and any underlying cystic focus. alternative methods have been employed with success, including chemo-cauterization and the use of fibrin to close the fistulous tract.5 philippine journal of otolaryngology-head and neck surgery 47 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports philipp j otolaryngol head neck surg 2015; 30 (2): 47-49 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to present a rare case of primary laryngeal aspergillosis manifesting with hoarseness in a seemingly healthy, immunocompetent, postpartum patient and discuss the probable contributing factors leading to this unusual disease process. methods: design: case report setting: tertiary private university hospital subject: one results: a 28-year-old previously healthy postpartum woman presented with hoarseness of a few weeks duration and recent intake of antibiotics and steroids. videolaryngoscopy revealed a creamy, exophytic mass overlying both vocal folds. microscopic examination revealed septated, dichotomously branching hyphae with acute angles characteristic of aspergillus sp. the patient recovered with anti fungal medications. conclusion: the clinical presentation of laryngeal aspergillosis can be very non-specific and should not be disregarded merely on the basis of immune competence. it should be considered, together with other host and environmental factors when a patient responds poorly to conventional treatment. there is a need for quick and accurate diagnosis as the disease responds quite rapidly with appropriate anti fungal medications. keywords: aspergillosis, hoarseness, larynx, postpartum, immunosupression laryngeal aspergillosis is rare and usually involves immunocompromised individuals.1 primary laryngeal aspergillosis is even rarer, with just 21 cases involving immunocompetent individuals in the english literature.1,2 we present a case of primary laryngeal aspergillosis manifesting with hoarseness in a seemingly healthy, immunocompetent, postpartum patient and discuss the probable contributing factors leading to this unusual disease process. case report a 28-year-old previously well bank teller with no known co-morbidities, presented with fever, cough and colds one day after a cesarean delivery under spinal anesthesia. she was given iv antibiotics which did not relieve her symptoms. two days postpartum, after several bouts of forceful coughing, she started having hoarseness. antibiotics was continued for five more days primary laryngeal aspergillosis in a postpartum patientjose carlo r. villanueva, mdalejandro p. opulencia, md kenneth z. calavera, md william l. lim, md department of otorhinolaryngology head and neck surgery university of the east – ramon magsaysay memorial medical center, inc. correspondence: dr. jose carlo r. villanueva department of otorhinolaryngology – head & neck surgery rm. 463, hospital service building., uermmmci 64 aurora blvd., quezon city 1113 philippines phone: (632) 715 0861 local 257 telefax: (632) 716 1789 e-mail: carlovillanueva.md@gmail.com reprints will not be available from the author. the authors declare that this represents original material. that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest poster presentation, 2013 american academy of otolaryngology – head and neck surgery foundation annual meeting and oto expo, vancouver, b.c., canada, september 29-october 2, 2013. 48 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports and the cough, colds and fever resolved, but her hoarseness persisted. she consulted an otorhinolaryngologist after discharge and was started on cefuroxime 500 mg and loratadine 5mg + betamethasone 500mcg twelve-hourly, esomeprazole 40 mg and prednisone 50 mg once daily for two weeks with no improvement of her hoarseness. she consulted in our institution, where videolaryngoscopy revealed a creamy exophytic mass overlying both vocal folds. (figure 1) there was good movement of both true vocal folds but incomplete closure due to the lesion. chest x-ray, complete blood count, serum chemistries and electrolytes were all normal. she underwent direct laryngoscopy with excision of tvf mass under general anesthesia. tissue sections stained with hematoxylin and eosin revealed acutely angled, dichotomously branching, septated hyphae characteristic of aspergillus. (figure 2) an hiv screen was negative, and neck and chest ct scans were normal. with a diagnosis of laryngeal aspergillosis, she was treated with oral voriconazole 400 mg once daily for a month. the patient’s voice gradually improved with the anti fungal medications, and follow up videolaryngoscopy eventually revealed normal findings. (figures 3, 4) discussion aspergillus is an inherently non pathogenic or weakly pathogenic fungus that produces a group of opportunistic infections.3 it afflicts mostly immunocompromised patients and manifests mainly as a primary pulmonary disease with secondary systemic involvement.4 it is due to this nature of the organism that there have been only a few cases of primary laryngeal aspergillosis in immuno-compromised patients5 and even less in immuno-competent patients.1 according to shohami and levitz, “aspergillus is a highly aerobic mold with several hundred mold species with worldwide distribution. it is a saprophyte that draws nutrients from soil and vegetation. spores are easily aerosolized and humans inhale and ingest hundreds of conidia on a daily basis.”6 international and local data has shown that the most frequently isolated airborne mold is aspergillus.7,8 in an immune competent host, ingested or inhaled spores are rapidly cleared by the innate immune response.6 resident and monocytederived macrophages ingest and kill conidia, preventing transition into the invasive hyphal form.6 figure 1. videolaryngoscopy showing creamy curd like exophytic lesion over both vocal folds. figure 3. videolaryngoscopy two weeks post treatment with voriconazole showing clearing of the lesions. figure 4. normal videolaryngoscopy after ten months.figure 2. histopathological section showing acutely angled dichotomously branching septated hyphae characteristic of aspergillus. 49 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports the disease form of aspergillosis most commonly involves the lungs and the tracheo-bronchial tree with subsequent systemic dissemination when host immunity deteriorates.2,4 because of this usual clinical presentation, the fungus has been greatly regarded as an opportunistic infection. it has been reported to have had secondary spread to almost all parts of the human body, including the larynx,9 but the most frequent otolaryngologic sites colonized by aspergillus are the external auditory canal and the paranasal sinuses.6 primary localization in the larynx is rare specially in patients with intact immune systems. a 20-year literature review of 9,743 patients by jombo et al. showed the larynx primarily involved only 7 times. altogether, liu et al. have listed a total of 20 cases since 1969. because aspergillus is weakly pathogenic and is by nature an opportunist, it is worthwhile to look closely into cases such as this, involving healthy individuals and localizing only in the larynx.8 previous case reports have dwelled upon the possible etiologic and contributing factors to the development of the disease in immunocompetent patients.2,4,5,6,9 one factor that has been cited is the use of corticosteroids, particularly inhaled corticosteroids owing to the substantial proportion of particles deposited in the larynx.10 corticosteroids significantly affect the patient’s response to the aspergillus conidia by inhibiting production of reactive oxidant intermediates (a component of intracellular killing) and by depressing neutrophil and macrophage function.2 another potentially contributory factor is the use of broad spectrum antibiotics that could alter local bacterial flora and disturb the ecological balance between bacteria and fungi, allowing the overgrowth of aspergillus. several cases of invasive aspergillosis have been observed in patients receiving multiple antibiotics.11 factors that disrupt the normal mucosal integrity of the larynx have also been implicated. an intact epithelial barrier is an esential protective component. vocal abuse resulting in disruption of true vocal fold mucosa and vocal fold cysts have been cited as potential aggravating factors.12,13 several of these factors were present in our patient, and may explain how she developed laryngeal aspergillosis. although she had no history of vocal abuse, the episodes of forceful coughing could have created areas of disruption or injury in the laryngeal mucosa. she was then given broad spectrum antibiotics and oral steroids, which have all been implicated as possible factors in the development of laryngeal aspergillosis.2-11 whether her post partum status (marked by decreased natural killer cell function)14 was contributory may be a matter for conjecture, as natural killer cells are integral to the innate immune response and play an important role in the body’s defense against fungi. all these factors coincidentally occuring simultaneously may have lead to the development of this rare form of primary laryngeal aspergillosis. to the best of our knowledge, this is the twenty-second reported case of primary laryngeal aspergillosis occurring in an immunocompetent patient in the english literature, the first occurring during the postpartum period, and the first in the philippines. the clinical presentation of laryngeal aspergillosis can be very nonspecific and should not be disregarded merely on the basis of immune competence. it should be considered, together with other host and environmental factors (fungal exposure, corticosteroid and antibiotic use, vocal fold injury, recuperative / postpartum states) when a patient responds poorly to conventional treatment. there is a need for quick and accurate diagnosis as the disease responds quite rapidly with appropriate anti fungal medications. references 1. liu yc, zhou sh, ling l. aetiological factors contributing to the development of primary laryngeal aspergillosis in immunocompetentpatients. j med microbiol. 2010 oct; 59(pt 10):1250–1253. doi 10.1099/jmm.0.021634-0. 2. doloi pk, baruah dk, goswami sc, pathak gk. primary aspergillosis of the larynx: acase report. indian j otolaryngol head neck surg. 2014 jan; 66(suppl 1): 326-8. doi 10.1007/s12070-0110299-2. 3. agarwal p, yadav rp, upadhyay sn. a new method of detection and differentiation of pathogenic from non-pathogenic aspergillus species. j med microbiol. 2001 jul; 50(7); 653–654. 4. shakoor mt, ayub s, ayub z, mahmood f. fulminant invasive aspergillosis of the mediastinum in an immunocompetent host: a case report. j med case rep. 2012 sep 18; 6:311. 5. jombo gta, banwat ab, gyoh sk. pulmonary and extra pulmonary manifestations of aspergillosis in clinical practice and potential challenges in management: an analysis of literature review. j clin med res. 2010; 2(11): 185-193. 6. shohami s, levitz sm. the immune response to fungal infections. br j haematol. 2005 jun; 129(5): 569–582 doi:10.1111/j.1365-2141.2005.05397. 7. agbayani bt, reyes ac, lingao al, fontanilla e. a study of airborne fungi in manila. acta medica philippina. 1968; 5(2) 73-76. 8. sharma r, deval r, priyadarshi v, gaur sn, singh vp, singh ab. indoor fungal concentration in the homes of allergic/asthmatic children in delhi, india. allergy rhinol. 2011 jan; 2(1): 21-32. doi: 10.2500/ar.2011.2.0005. 9. jombo gta, banwat ab, gyoh sk. pulmonary and extra pulmonary manifestations of aspergillosis in clinical practice and potential challenges in management: an analysis of literature review. j clin med res. 2010; 2(11): 185-193. 10. fairfax aj, david v, douce g. laryngeal aspergillosis following high dose inhaled fluticasone therapy for asthma. thorax. 1999 sep; 54(9):860–861. 11. nong d, nong h, li j, huang g, chen z. aspergillosis of the larynx: a report of 8 cases. chin med j. 1997 sep; 110(9): 734-736. 12. mehanna hm, kuo t, chaplin j, taylor g, morton rp. fungal laryngitis in immunocompetent patients. j laryngol otol. 2004 may; 118(5): 379–381. 13. wittkopf jc, connelly s, hoffman h, smith r, robinson r. infection of true vocal fold cyst with aspergillus. otolaryngol head neck surg. 2006 oct; 135(4): 660-1. 14. groer m, el-badri n, djeu j, harrington m, van eopoel j. suppression of natural killer cell cytotoxicity in postpartum women. am j reprod immunol. 2010 mar 1; 63(3): 209-213. doi:10.1111/j.1600-0897.2009.00788.x. philippine journal of otolaryngology-head and neck surgery 25 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 case reports philipp j otolaryngol head neck surg 2014; 29 (2): 25-27 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to present a case of vocal cord polyp in a pediatric patient and discuss its differential diagnosis, assessment and management. methods: design: case report setting: tertiary public hospital patient: one results: a seven-year-old girl presented with hoarseness and a benign, unilateral mass seen at the junction of the anterior and middle third of the vocal cord. the hoarseness resolved after excision and histopathology confirmed an inflammatory vocal cord pseudo polyp. conclusion: vocal cord polyps occur infrequently in children and adolescents. these cases are seldomly seen and reported and may arise from chronic abuse of the larynx, vocal cord trauma or phonotrauma. hoarseness is the most common presenting symptom. differential diagnoses include recurrent respiratory papillomatosis, laryngeal cyst and laryngeal nodule. the management of vocal cord polyps involves surgical removal followed by speech therapy. keywords: hoarseness, phonotrauma, vocal cord polyp, recurrent respiratory papillomatosis, vocal cord nodule, vocal cord cyst, flexible laryngoscopy, speech therapy case report a 7-year-old girl from bulacan, philippines was referred to us for hoarseness and stridor. the history of present illness started three months prior to admission when she swallowed a fish spine resulting in minimal bleeding from the throat. no foreign body sensation, dysphagia, odynophagia, frequent coughing, difficulty in breathing or associated symptoms were noted and no medical consult was made. a week after the incident, the child experienced hoarseness and occasional dysphagia. no cough, colds or fever were noted. a pediatrician prescribed unrecalled medications which afforded no relief. two months prior to admission, the patient developed stridor and difficulty in breathing on supine position. follow up consult with the same pediatrician resulted in treatment for bronchial asthma which only relieved the difficulty of breathing. one month prior to admission, due to persistent hoarseness and stridor, the girl was brought to another pediatrician who again managed her as a case of bronchial asthma. due to persistence of symptoms, she was finally referred to us. on examination, flexible laryngoscopy revealed a white pedunculated mass on the right vocal cord. it sucked-in on inspiration but popped out of the glottic area during phonation or expiration. (figure 1) she was admitted on intravenous hydrocortisone and oral cetirizine, and she underwent direct laryngoscopy with excision under general anesthesia. (figure 2) she tolerated the procedure well and stridor resolved. initially, there was no noticeable improvement in voice quality despite the absence of residual vocal cord mass on pre-discharge flexible laryngoscopy. (figure 3) however improvement in voice quality and smooth breathing were noted on follow-up consultation after a week. the histopathology report was consistent with inflammatory pseudopolyp. (figure 4) a vocal cord polyp in a pediatric patient ma. joan nemis nalangan, md department of otorhinolaryngology head and neck surgery armed forces of the philippines medical center correspondence: dr. ma. joan nemis nalangan department of otorhinolaryngology head and neck surgery armed forces of the philippines medical center 7th floor, armed forces of the philippines medical center, v. luna avenue, quezon city 0840 philippines phone: (632) 426 2701 locals 6172 / 8972 email: ent_afpmc@yahoo.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at nemec annual residents’ interesting case contest, 24 march 2011, valdes hall, veterans memorial medical center and pso-hns annual convention free paper presentation, 04 december 2012, sofitel plaza hotel. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 case reports 26 philippine journal of otolaryngology-head and neck surgery discussion most surveys of children show a 6% to 9% incidence of voice disorders.1 the underlying cause can be organic or functional. functional disorders are caused by emotional or psychological problems such as personality disorder, anxiety or adjustment but can lead to anatomic alterations of the vocal cords.2 organic voice disorders result from congenital or acquired anatomic abnormalities which include laryngeal papilloma, web, stenosis, malignant tumor, polyps, nodules and cysts. hoarseness is a voice disorder characterized by altered vocal quality, pitch, loudness or vocal effort that impairs communication or reduces voice-related quality of life. it is a common complaint in children of all ages. among children, prevalence rates vary from 3.9% to 23.4%, the most affected age range is between 8 to 14 years old.3 most cases related to viral upper respiratory tract infections are self-limited and require no special treatment. other common causes include figure 1. preoperative flexible laryngoscopy showing a whitish, pedunculated mass occupying the middle third of right true vocal cord that sucked in on inspiration and protruded during expiration or phonation figure 3b. one week follow-up laryngoscopy with improved voice quality and smooth breathing figure 4. histopathologic section, hematoxylin and eosin (25x) showing overlying benign stratified squamous epithelium with underlying edematous stroma infiltrated by inflammatory cells (lymphocytes, plasma cells, histiocytes and occasional neutrophils) with several congested small blood vessels figure 2. gross specimen showing a 0.5 x 0.5 cm, white, round, firm mass attached to and excised from the right true vocal cord figure 3a. pre-discharge flexible laryngoscopy with no residual vocal cord mass philippine journal of otolaryngology-head and neck surgery 27 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 case reports vocal nodules, allergic or infectious laryngitis and laryngitis from gastroesophageal reflux. occasionally, hoarseness heralds the onset of upper airway obstruction or may be the presenting symptom of serious systemic illness and thus warrants a more thorough evaluation and timely, appropriate therapy.4 based on presenting symptoms and endoscopy, differential diagnoses of this case include respiratory papillomatosis, vocal cord cyst and nodule. recurrent respiratory papillomatosis is the most common benign neoplasm of the larynx in children and is the second most frequent cause of childhood hoarsenes.5,6 it is of viral etiology. for this patient, it was ruled out based on the clinical assessment. the patient had hoarseness and stridor but there was no respiratory distress, tachypnea, decreased air entry, cyanosis or other symptoms that may indicate impending respiratory collapse which are usually present in recurrent respiratory papillomatosis. the documented lesion in this patient also differed from the characteristic multiple warty excrescences on the mucosal surface of the respiratory tract typical of papillomatosis. vocal cord cysts are subepidermal epithelial-lined sacs located within the lamina propria, and may be mucus retention or epidermoid in origin. mucus retention cysts form when a mucous gland duct becomes obstructed (usually during an upper respiratory infection or with overuse) retaining glandular secretions.7 histopathology ruled out this entity. vocal cord nodules are typically bilateral swellings of the midportion of the membranous vocal folds or may occur at the free edge of anterior and middle third of vocal cord. they are of variable size and are characterised histologically by thickening of the epithelium with a variable degree of inflammation in the underlying superficial lamina propria.8 the prevalence of nodules in the general population is not known but it has been reported as being the cause of hoarseness in up to 23.4% of children.9 the etiology of vocal nodules is not known but traditionally they are thought to be due to ‘voice abuse’ and psychological factors especially in children. other medical conditions such as infection, allergy and reflux may also play a role in the etiology.10 among the differential diagnoses mentioned, vocal cord nodules were most likely but histopathology ruled it out. vocal cord polyps as mentioned, occur infrequently in children and adolescents.11,8 they are usually seen at the junction of the anterior and middle third of the vocal cord and may be fusiform, pedunculated or generalized.12 the pathophysiology is believed to be attributable to breakage of a capillary in reinke space (superficial lamina propia) with subsequent extravasation of blood, resultant local edema and ultimate organization with hyalinized stroma.7 polyps are believed to result from phonotrauma; however, they are also recognized to potentially arise from a single episode of hemorrhage. it was found that the combination of signs of recent bleeding and depositions of fibrin and iron pigment in macrophages resided almost exclusively in polyps when compared with other benign lesions.13 morphological analyses of vocal cord polyps show lamina propria with edema, vessel proliferation and inflammation; basement membrane with adhesion loss in some areas; and a dense network of references 1. wilson dk. management of voice disorders in children and adolescents, semin speech lang hear. 1983; 4:245-258. 2. toohill r. the psychosomatic aspects of children with vocal nodules. arch otolaryngol.1975 oct; 101 (10):591-5. 3. schwartz sr, cohen sm, dailey sh, rosenfeld rm, deutsch es, gillespie mb. et al. clinical practice guideline: hoarseness (dysphonia). otolaryngol head neck surg. 2009 sep; 141 (3 suppl 2): s1-s31. 4. chang k, inglis a. . evaluation and management of hoarseness in children: curr opin oto head neck surg. 1996 dec; 4:396-400 5. gallagher tq, derkay cs. recurrent respiratory papillomatosis: update 2008, curr opin otolaryngol head neck surg. 2008 dec; 16(6):536-542. 6. morgan ah, zitsch rp. recurrent respiratory papillomatosis in children: a retrospective study of management and complications. ear nose throat j. 1986 sep; 65 (9):19-28. 7. altman kw. vocal fold masses. otolaryngol clin north am. 2007 oct; 40 (5):1091–108. 8. nagata k, kurita s, yasumoto s, maeda t, kawasaki h, hirano m. vocal fold polyps and nodules. a 10-year review of 1,156 patients. auris nasus larynx 1983; 10 suppl:s27-35. 9. silverman em. incidence of chronic hoarseness among school-age children. j speech hear disord. 1975 may; 40 (2):211-5. 10. mchugh-munier c, scherer kr, lehmann w, scherer u. coping strategies, personality, and voice quality in patients with vocal fold nodules and polyps. j voice. 1997 dec; 11 (4):452-61. 11. kambic v, radsel z, zargi m, acko m. vocal cord polyps: incidence, histology and pathogenesis. j laryngol otol. 1981 jun; 95 (6):609-18. 12. kleinsasser o. pathogenesis of vocal cord polyps. ann otol rhinol laryngol. 1982 jul-aug; 91 (4 pt1):378-81. 13. dikkers fg, nikkels pg. benign lesions of the vocal folds: histopathology and phonotrauma. ann otol rhinol laryngol. 1995 sep;104(9 pt 1):698-703. 14. martins rh, defaveri j, domingues ma, de albuguergue e silva r. vocal polyps: clinical, morphological, and immunohistochemical aspects. j voice. 2011 jan; 25 (1): 98-106. 15. bouchayer m, cornut g. microsurgical treatment of benign vocal folds lesions: indications, technique, results. folia phoniatr (basel). 1992; 44 (3-4):155-84. subepithelial collagen.14 in our patient, the histopathologic report noted pieces of tissue with overlying benign stratified squamous epithelium. the underlying stroma was edematous, infiltrated by inflammatory cells, consisting of lymphocytes, plasma cells, histiocytes and occasional neutrophils. several congested small blood vessels are also seen with no cellular atypia. histopathology confirmed the diagnosis of laryngeal polyp. although the single episode of trauma specifically ingestion of fish spine was not properly documented, the patient was well prior to this event. the possibility that this was the etiology should be considered and reported, hence this case report. vocal cord polyps occur infrequently in children and adolescents. these cases are seldomly seen and reported and may arise from chronic abuse of the larynx, vocal cord trauma or phonotrauma. hoarseness is the most common presenting symptom. differential diagnoses include recurrent respiratory papillomatosis, laryngeal cyst and laryngeal nodule. although most voice disorders in children result from vocal cord nodules, we should also consider vocal cord polyps in a hoarse patient. hoarseness in children should not be ignored since vocal cord polyps may cause partial airway obstruction and may need immediate management. hoarse patients should be evaluated by an otolaryngologist and direct visualization must be done even in children. the management of vocal cord polyps involves surgical removal followed by speech therapy.1,12,15 philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 philippine journal of otolaryngology-head and neck surgery 43 passages when giants pass, they leave giant footprints and giant shoes to fill. dr. leh siu chuan passed away last august 2013, after suffering multi-organ failure following a stroke secondary to sick sinus syndrome. in life, he was a fighter, refusing to give up the ghost for three years and three months, living in an intensive care unit at the hospital he spent his life serving and loving. siu chuan y. leh was born in manila august 22, 1935, the third generation of chinese immigrants from the fukien province in china. he was the second child in a brood of 12, easily the brightest child and the apple of his father’s eye. he completed his medical studies at the pontifical university of santo tomas. during the ignominous vietnam war of the 60’s, he was able to get a position for a residency position in otolaryngology at the university of pennsylvania, and trained under the venerable dr. atkins, a protégé of both dr. jackson, sr. and dr. tucker of endoscopic fame. he had to leave his family behind – his wife benita leh, and three children – shirley, frederick and sandra. on his second year of training, he sent for his wife and son, frederick who would later follow in his footsteps as an otolaryngologist. life was difficult during that time for a married resident. he received a stipend of only $200 a month and had to moonlight in emergency rooms on weekends to make ends meet. when he finally completed his residency and passed the american board of otolaryngology exams, he gave up a possible lucrative partnership with his mentor to go back to the philippines to serve his countrymen. dr. leh was invited to the chinese general hospital and medical center, and served prominently as its brightest ear nose and throat practitioner. he became well-known in the chinese community, taking time to hold clinic in ong’s association building along benavidez in chinatown. he later served as chinese general hospital’s executive assistant medical director until his health started to fail. he was also active in the philippine otolaryngology scene, serving continuously as a board examiner, much feared by examinees for his strict and no-nonsense grilling of would-be diplomats. dr. leh rose rapidly through the ranks to become president of the philippine society of otolaryngology head and neck surgery. under his watch, the psohns expanded exponentially, gaining many new member hospitals and programs. he organized and professionalized the criteria for the accreditation program, ensuring high quality from all applicant programs. with all the kudos, fame and fortune, dr. leh was still not done. he was asked to take over a fledgling tzu chi philippine chapter, part of a taiwanese buddhist foundation seeking to bring relief to the poor of the world. dr. leh organized and founded tima (the tzu chi international medical missions and assistance), which later became the model for other medical missions in the world. for this dr. leh was awarded many times by tzu chi foundation. his dream continues as the tima continues to treat thousands of people daily, and will soon open a clinic and perhaps a hospital to serve the less fortunate. dr. leh siu chuan is survived by his wife of 54 years, benita leh and two doctor sons: patrick, an orthopaedic surgeon and frederick, an otolaryngologist; and two daughters: shirley, an auditor in new york and sandra, district manager for e. excel pharmaceuticals of taiwan. he will live on in the memory of his colleagues and loved ones and all who had the good fortune of knowing him. siu chuan y. leh, md (1935-2013) “when giants pass” frederick o. leh, md philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine if ehretia microphylla (tsaang gubat) decoction tea and placebo can improve the symptoms of mild intermittent allergic rhinitis in comparison to loratadine and control tea. methods: design: double-blind, randomized controlled trial setting: tertiary-government training hospital participants: twenty-four patients diagnosed with mild intermittent allergic rhinitis from october 2015 to july 2016 were randomly divided into a treatment group given ehretia microphylla (tsaang gubat) decoction tea and placebo, and a control group given control tea and loratadine, both taken for 7 days. patients underwent pre– and post–intervention evaluation by anterior rhinoscopy, sino-nasal outcome test 22 (snot 22) questionnaire and 10-point visual analog scale (vas). data were encoded and subjected to statistical analysis using mann whitney u test and wilcoxon signed rank test. results: age and gender of the treatment and control group participants were comparable. prior to intervention, no differences in symptoms were noted between both groups on snot 22 and vas scores. after intervention, no differences in symptoms were noted between the 2 groups on snot 22 and vas scores either. comparison of pre(30.4 ± 17.3) and post(7.2 ± 6.5) intervention mean snot 22 scores of the loratadine control group with pre(32.5 ± 23.7) and post(7.8 ± 10.4) intervention mean snot 22 scores of the ehretia microphylla treatment group showed significant improvement of symptoms in both groups. likewise, comparison of preand post-intervention mean vas scores of the loratadine control group and preand post-intervention mean vas scores of the ehretia microphylla treatment group based on symptoms of sneezing, rhinorrhea, nasal congestion and pruritus showed significant improvement of symptoms in both groups (p-values of < .001). conclusion: ehretia microphylla (tsaang gubat) decoction tea may improve symptoms of allergic rhinitis (sneezing, rhinorrhea, pruritus and nasal congestion) and be taken as an alternative to loratadine in patients with mild intermittent allergic rhinitis. further clinical trials with more participants may provide stronger evidence for this conclusion. keywords: allergic rhinitis, tsaang gubat, ehretia microphylla, loratadine ehretia microphylla (tsaang gubat) versus loratadine as treatment for allergic rhinitis: a randomized controlled trial fatima angela c. umali, md antonio h. chua, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. antonio h. chua department of otorhinolaryngology – head and neck surgery 4th floor, jose r. reyes memorial medical center rizal avenue, sta. cruz, manila 1003 philippines phone: (+632) 711 9491 local 320 email: entjrrmmc@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery analytical research contest (3rd place), november 17, 2016, bella ibarra, quezon avenue, quezon city. philipp j otolaryngol head neck surg 2017; 32 (2): 6-10 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery original articles allergic rhinitis is a common health problem affecting all ages with prevalence of 20% among filipino adults.1 patients present with symptoms of sneezing, rhinorrhea, nasal congestion and pruritus. these symptoms result from the inflammatory reaction caused by the interplay of inflammatory cells and mediators due to exposure to allergens. current treatment guidelines include recommendations for environmental modifications, antihistamines, decongestants, intranasal cromolyn, intranasal anti-cholinergics, intranasal corticosteroids and immunotherapy.2 allergic rhinitis carries the burden of impaired quality of life and enormous cost implications.3 thus, treatment goals focus on alleviating troublesome symptoms of allergic rhinitis at a viable economical cost. ehretia microphylla (tsaang gubat) is 1 of the 10 medicinal plants approved by the republic of the philippines department of health to treat different ailments.4 the leaves are traditionally used for medicinal purposes as an anti-spasmodic, mouthwash and body cleanser, attributed to the effects of different components (phenolic acids, flavonoids, benzoquinones, cyanogenetic glycosides, and fatty acids).5 it also contains rosmarinic acid and nitrile glucosides which are antiallergic substances that counter histamine release from mast cells that cause type-1 reactions.5,6 unfortunately, to the best of our knowledge, there is still no study detailing the use of this herbal medicine for allergic rhinitis. a pubmed, embase and herdin search of the english literature using the keywords “allergic rhinitis,” “tsaang gubat,” “ehretia microphylla,” and “loratadine” did not yield any study on the use of ehretia microphylla for allergic rhinitis. this study aims to determine if ehretia microphylla (tsaang gubat) decoction tea and placebo can improve the symptoms of allergic rhinitis in comparison to loratadine and control tea. methods with institutional review board approval, this double blind, randomized controlled trial was conducted at the ear, nose, throat – head and neck surgery (ent-hns) out-patient department of the jose r. reyes memorial medical center, a tertiary government training hospital from october 2015 to july 2016. participants the target population were patients aged 18 years old and above who complained of sneezing, rhinorrhea, nasal congestion and pruritus; with pale, edematous, boggy mucosa on anterior rhinoscopy; clinically diagnosed with mild intermittent allergic rhinitis (symptoms <4 times per week or for <4 weeks, with normal sleep, and no impairment in daily activities, sport, leisure, work or school). excluded were patients with nasal mass, polyp and nasal trauma, those with history, symptoms or signs of ehretia microphylla allergy, and those who could not tolerate ingestion of the tea decoction. preparation of ehretia microphylla (tsaang gubat) decoction tea7 fresh leaves were gathered from baliuag, bulacan and authenticated at the university of santo tomas – research center for natural and applied sciences herbarium. after washing the leaves thoroughly in running water, one cup (200 ml) of leaves was chopped and boiled per 2 cups (400 ml) of water for 15 to 20 minutes under low heat. the boiled leaves were drained, cooled, transferred to clean plastic containers and refrigerated. the ehretia microphylla tea was given to participants in 1l bottles that were refilled every 2 days during the study. preparation of control tea one (1) teabag of lipton® yellow label tea (uniliver, manila) was soaked per 2 cups (400 ml) of water just off the boil for 3 to 5 minutes. the teabag was removed and the tea preparation cooled, transferred to clean plastic containers and refrigerated. the control tea was given to participants in 1l bottles that were refilled every 2 days during the study. procedure clinical histories were obtained and physical examinations, including anterior rhinoscopy were performed by ent-hns resident physicians on duty. each patient was asked to answer the allergic rhinitis questionnaire2 as guide for fulfilling inclusion criteria. after obtaining informed consent 24 participants fulfilling these criteria were considered for inclusion in the study. subjects were assigned to either of the 2 groups via electronic randomizer using microsoft excel for mac 2011, version 14.5.6 (150930) (microsoft corp., redwood ca, usa). the treatment group was given ehretia microphylla tea taken by cupful (200 ml) every 4 hours when awake and placebo (flour dummy pill) taken once nightly, for 7 days. the control group was given loratadine 10 mg / tablet taken once nightly and control tea taken by cupful (200 ml) every 4 hours when awake, also for 7 days. the sino-nasal outcome test 22 (snot22) questionnaire (washington university, st. louis, missouri) and 10-point visual analog scale (vas) scores per symptom of sneezing, rhinorrhea, nasal congestion and pruritus were obtained before and after intervention by the blinded outpatient resident physician on duty. data were encoded and tallied in spss version 24 (ibm, 64 bit edition). statistical analysis of different variables, mean and standard deviation were computed and analyzed using mann whitney u test, and wilcoxon signed rank test, and p-values were set with 95% confidence interval. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery results twenty four participants, 11 males (45.8%) and 13 females (54.2%) with mean age of 44 years (range 18-77) were randomly assigned to two groups of 12 persons each and completed the study with no adverse events reported. there were no significant differences in age and gender between treatment and control groups. comparison of scores of individual snot 22 items between groups showed that there were no significant differences in symptoms before and after intervention. (table 1, 2) comparison of mean snot 22 scores pre(30.4 ± 17.3) and postintervention (7.2 ± 6.5) in the loratadine control group with mean snot table 1. comparison of the pre-intervention snot 22 between the two groups snot 22 control group (n=12) p-valuetreatment group (n=12) pre-intervention 1. need to blow nose 2. sneezing 3. runny nose 4. cough 5. post-nasal discharge 6. thick nasal discharge 7. ear fullness 8. dizziness 9. ear pain/pressure 10. facial pain/pressure 11. difficulty falling asleep 12. wake up at night 13. lack of a good night’s sleep 14. wake up tired 15. fatigue during the day 16. reduced productivity 17. reduced concentration 18. frustrated/restless/ irritable 19. sad 20. embarrassed 21. sense of smell/taste 22. congestion/ obstruction of nose 2 4 3.5 1 1 0.5 1 1 0.5 0.5 1 0 0 0 0 0 0 1 1 0.5 0 3 2 4 4 1.5 1 1 1 1 0.5 0.5 1 1 1 0 0.5 0.5 0 0.5 0.5 0 0 4 .68 (ns) 1.00 (ns) .44 (ns) .56 (ns) .88 (ns) .69 (ns) .86 (ns) .74 (ns) .78 (ns) .98 (ns) .90 (ns) .44 (ns) .65 (ns) .78 (ns) .66 (ns) .73 (ns) .71 (ns) .44 (ns) .44 (ns) .55 (ns) .97 (ns) .54 (ns) table 2. comparison of the post-intervention snot 22 between the two groups snot 22 control group (n=12) p-valuetreatment group (n=12) post-intervention 1. need to blow nose 2. sneezing 3. runny nose 4. cough 5. post-nasal discharge 6. thick nasal discharge 7. ear fullness 8. dizziness 9. ear pain/pressure 10. facial pain/pressure 11. difficulty falling asleep 12. wake up at night 13. lack of a good night’s sleep 14. wake up tired 15. fatigue during the day 16. reduced productivity 17. reduced concentration 18. frustrated/restless/ irritable 19. sad 20. embarrassed 21. sense of smell/taste 22. congestion/ obstruction of nose 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 .95 (ns) .57 (ns) .18 (ns) 1.00 (ns) .89 (ns) .69 (ns) .91 (ns) 1.00 (ns) .62 (ns) .91 (ns) .32 (ns) .57 (ns) .93 (ns) .93 (ns) 1.00 (ns) .58 (ns) 1.00 (ns) .44 (ns) .91 (ns) .51 (ns) .95 (ns) .65 (ns) 22 scores pre(32.5 ± 23.7) and post(7.8 ± 10.4) intervention in the ehretia microphylla treatment group showed significant improvement of symptoms in both groups (p = .002 and p = .017, respectively) as shown in table 3. there were no significant differences in the pre–intervention vas scores of both groups specifically for symptoms of sneezing, rhinorrhea, nasal congestion and pruritus as shown in table 4. likewise, there were no significant differences in the post-intervention vas scores of both groups. there was significant improvement noted in the preand post-intervention vas scores (p = .002 and p = .003) for both groups as shown in table 5. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery discussion in this randomized controlled trial, both ehretia microphylla (tsaang gubat) decoction tea (plus placebo) and loratadine (plus control tea) improved the symptoms of allergic rhinitis. comparison of the snot22 and vas scores before and after the intervention both for the loratadine control group and ehretia microphylla treatment group showed improvement in sneezing, rhinorrhea, nasal congestion and pruritus. the leaves of ehretia microphylla (tsaang gubat) have been investigated for their anti-inflammatory property. the active components, rosmarinic acid and nitrile glucosides5,6 are claimed to be anti-allergic substances that counter histamine release from mast cells, rosmarinic acid being one of the particularly active principles. ehretia microphylla has been found useful in the treatment of different inflammatory ailments.7 rosmarinic acid is a strong anti-inflammatory agent according to several studies.5,8 a study by osakabe et al., found a significant increase in responder rates for itchy nose, watery eyes and total symptoms in patients with seasonal allergic rhinoconjunctivities supplemented with rosmarinic acid.9 a decrease in the number of neutrophils and eosinophils in the lavage fluid from the same patients was noted with no adverse events recorded.9 improvement of symptoms of sneezing, rhinorrhea, nasal congestion and pruritus in allergic rhinitis may be attributed to the anti-inflammatory effect of rosmarinic acid, by inhibition of histamine release and inhibition of adhesion molecule, chemokine and eicosnoid synthesis.6,9 in a study by oh, rosmarinic acid inhibited ige production, histamine release, inflammatory cytokine production and cox-2 expression.10 this study has several limitations. since tsaang gubat was not compared with loratadine alone (loratadine was combined with a tea), possible interactions of tea with loratadine and effects of tea on allergic rhinitis itself were not accounted for in this study. moreover, tsaang gubat can be prepared in various concentrations and administered in various forms, none of which were accounted for in this trial. tsaang table 3. comparison of the preand post-intervention snot 22 mean scores mean snot 22 control group (n=12) treatment group (n=12) pre post p-value mean 30.4 7.2 mean 32.5 7.8 sd 17.3 6.5 sd 23.7 10.4 p-value .843 (ns) .671 (ns) .002 (s) .017 (s) table 4. comparison of preand post-intervention vas scores per symptom of allergic rhinitis a. sneezing control group (n=12) treatment group (n=12) vas pre post wilcoxon p-value mean 7.8 1.1 mean 7.9 1.0 sd 1.8 0.9 sd 1.6 1.0 mann-whitney 68.0 65.0 p-value 0.843 (ns) 0.713 (ns) 3.075 .002 (s) 3.078 .002 (s) b. rhinorrhea control group (n=12) treatment group (n=12) vas pre post wilcoxon p-value mean 6.8 1.0 mean 7.2 0.4 sd 1.4 1.0 sd 1.2 0.5 mann-whitney 58.5 46.5 p-value .443 (ns) .143 (ns) 3.089 .002 (s) 3.140 .002 (s) c. nasal congestion control group (n=12) treatment group (n=12) vas pre post wilcoxon p-value mean 6.1 1.2 mean 6.7 1.1 sd 2.5 1.0 sd 2.3 1.2 mann-whitney 61.5 68.5 p-value .551 (ns) .843 (ns) 3.108 .002 (s) 3.077 .002 (s) d. pruritus control group (n=12) treatment group (n=12) vas pre post wilcoxon p-value mean 6.4 1.0 mean 7.4 1.3 sd 1.2 0.7 sd 1.0 0.8 mann-whitney 38.0 54.0 p-value .052 (ns) .319 (ns) 3.084 .002 (s) 3.072 .002 (s) table 5. comparison of the preand post-intervention vas mean scores mean vas control group (n=12) treatment group (n=12) pre post p-value mean 2.6 0.5 mean 2.8 0.5 sd 1.6 0.5 sd 2.1 0.7 p-value .713 (ns) .514 (ns) .002 (s) .003 (s) philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles 10 philippine journal of otolaryngology-head and neck surgery acknowledgements the authors would like to thank dr. samantha s. castañeda, the research coordinator who prereviewed this paper, mr. fercy b. cavan for the statistical analysis of data, and the jrrmmc ent-hns residents who helped in data gathering. references 1. abong jm, kwong sl, alava hd, castor ma, de leon jc. prevalence of allergic rhinitis in filipino adults based on the national nutrition and health survey 2008. asia pac allergy. 2012 apr;2(2):129-135. doi: 10.5415/apallergy.2012.2.2.129. pmid: 22701863 pmcid: pmc3345326. 2. bousquet j, reid j, van weel c, baena cagnani c, canonica gw, demoly p, et al. allergic rhinitis management pocket reference 2008. allergy. 2008 aug;63(8):990-996. doi: 10.1111/j.13989995.2008.01642.x. pmid: 18691301. 3. green rj, davis g. the burden of allergic rhinitis. j allergy clin immunol current allergy & clinical immunology. 2005 nov;18(4):176-178. 4. ammakiw c, odiem m. availability, preparation, and uses of herbal plants in kalinga, philippines. eur sci j. 2013; 4:1857. 5. simpol lr, otsuka h, ohtani k, kasai r, yamasaki k. nitrile glucosides and rosmarinic acid, the histamine inhibitor from ehretia philippinensis. phytochemistry. 1994;36(1):91-95. 6. yamamura s, simpol lr, ozawa k, ohtani k, otsuka h, kasai r, et al. antiallergic dimeric prenylbenzoquinones from ehretia microphylla. phytochemistry. 1995 may;39(1):105-110. pmid: 7786482. 7. alvarez, aa. tsaang gubat or wild tea (ehretia microphylla lam.). [retrieved 2015 mar 6] available from: http://www.philippineherbalmedicine.org/tsaang_gubat.htm. 8. sanbongi c, takano h, osakabe n, sasa n, natsume m, yanagisawa r, et al. rosmarinic acid inhibits lung injury induced by diesel exhaust particles. free radic biol med. 2003 apr 15; 34(8):1060–1069. pmid: 12684091. 9. osakabe n, takano h, sanbongi c, yasuda a, yanagisawa r, inoue k, et al. anti-inflammatory and anti-allergic effect of rosmarinic acid (ra); inhibition of seasonal allergic rhinoconjunctivitis (sars) and its mechanism. biofactors. 2004;21(1-4):127-131. pmid: 15630183. 10. oh ha, park cs, ahn hj, park ys, kim hm. effect of perilla frutescens var. acuta kudo and rosmarinic acid on allergic inflammatory reactions. exp biol med. 2011 jan; 236(1): 99-106. doi: 10.1258/ebm.2010.010252. pmid: 21239739. 11. farnsworth nr, akerele o, bingel as, soejarto dd, guo z. medicinal plants in therapy. bull world health organ. 1985;63(6): 965–981. gubat itself may vary in effect depending on where it is sourced (studies have shown such variation for other herbals). it is important to note that the possible active ingredient(s) in tsaang gubat that have anti allergic and anti inflammatory properties were not isolated and may be present in varying concentrations as well. in conclusion, ehretia microphylla (tsaang gubat) decoction tea may improve symptoms of allergic rhinitis (sneezing, rhinorrhea, nasal congestion and pruritus) and be taken as an alternative to loratadine in patients with mild intermittent allergic rhinitis. further clinical trials with more participants may provide stronger evidence for this recommendation. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 philippine journal of otolaryngology-head and neck surgery 45 letters to the editor philipp j otolaryngol head neck surg 2014; 29 (2): 45 c philippine society of otolaryngology – head and neck surgery, inc. dear sir: i greatly enjoyed reading the paper by david and lim on “congenital bilateral vocal fold paralysis”1 and complement the authors on their excellent surgical outcome. they also very appropriately underscored the primacy of careful clinical assessment over costly investigations, particularly in an environment of scarce resources. we have previously reported on the mri findings in 23 children with bilateral vocal fold dysfunction (bvfd) as an isolated abnormality that was present at birth. we found mri abnormalities in 35%, but these were all non-specific.2 this study indicated that mri was of research and clinical value but did not identify any major cns structural abnormalities in this patient group. however, the case reported by david and lim involved the delayed onset of symptoms at two years of age that may have increased over the next three years. this acquired and possibly progressive disease process differs from that of congenital bvfd. the likelihood of arnoldchiari malformation or another significant structural cns abnormality being present would appear to be higher when symptoms of bvfd are acquired later in life compared to when they are present at birth. anecdotally, i have been involved with a case of acquired bvfd presenting at a similar age where the underlying cause was found to be a posterior fossa tumour. the 3-year history of symptoms in the child in the case report would very likely preclude this diagnosis but certainly another cns cause needs to be considered to explain the development of delayed-onset brainstem dysfunction and this would require mri. best wishes, robert g. berkowitz, md department of otolaryngology royal children’s hospital 50 flemington road parkville victoria 3052 australia cns imaging is essential in acquired bilateral vocal fold dysfunction in children references 1. david rb, lim wl. congenital bilateral vocal fold paralysis in a two-year-old girl. philipp j otolaryngol head neck surg 2014, 29(1):30-32. 2. steiner ji, fink am, berkowitz rg. magnetic resonance imaging findings in pediatric bilateral vocal fold dysfunction. ann of otol rhinol laryngol 2013, 122:417-420. dear sir: we would like to express appreciation for the comments given as well as for sharing your research findings in relation to the case. we agree that a neurological problem must be properly ruled out most especially when there is a delayed onset of neurological symptoms with progression over time. indeed, the presence of vocal fold dysfunction in children should make one consider cns pathologies most common of which is the arnoldchiari malformation. however, the following are our reasons for concurring with the pediatric neurology service in not requesting imaging: aside from vocal fold paralysis, no other neurological 1. symptom or finding was noted such as presence of swallowing and feeding difficulties, dizziness or uncoordination usually present in brainstem pathologies manifesting with vocal fold paralysis such as chiari type i.1,2 previous and subsequent neurological examinations showed 2. a bilaterally intact gag reflex which somewhat made the possibility of a cns lesion affecting the vagus unlikely. furthermore, no findings indicative of cerebellar dysfunction (such as dysdiadokinesia) were noted. thank you very much. reylan b. david, md william l. lim, md department of otorhinolaryngology head and neck surgery saint luke’s medical center 279 e. rodriguez ave., quezon city 1102 philippines response from the authors references 1. greenlee jd, donovan ka, hasan dm, menezes ah. chiari i malformation in the very young child: the spectrum of presentations and experience in 31 children under age 6 years. pediatrics. 2002 dec;110(6):1212-9. 2. aitken la, lindan ce, sidney s, gupta n, barkovich aj, sorel m, wu yw.chiari type i malformation in a pediatric population. pediatr neurol. 2009 jun;40(6):449-54. doi: 10.1016/j. pediatrneurol.2009.01.003. 28 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports abstract objective: hamartomas are relatively uncommon, non-neoplastic malformations indigenous to the involved anatomic site. respiratory epithelial adenomatoid hamartoma (reah) is a subset of hamartoma characterized by prominent glandular proliferation lined by ciliated epithelium originating from the surface epithelium. their location in the nasal cavity is rare and when present, mostly associated with the posterior nasal septum. we present such a case arising from the anterior nasal septum. methods: design: case report setting: tertiary university referral center patient: one results: a 32-year-old lady who presented with a long-standing nasal block was found to have a broad-based nasal mass arising from the left anterior nasal septum. the lesion was histologically diagnosed as respiratory epithelial adenomatoid hamartoma following surgical excision. conclusion: respiratory epithelial adenomatoid hamartoma although rare must be taken into consideration in the differential diagnosis of nasal lesions. keywords: respiratory epithelial adenomatoid hamartoma; anterior nasal septum; nasal block hamartomas are benign, non-neoplastic malformations or inborn errors of tissue development that result from excessive proliferation of otherwise normal local tissue components. hamartomas can occur anywhere in the body, including lung, liver, spleen and kidney but involvement of the head and neck and in particular, the nasal cavity and paranasal sinus is relatively uncommon.1 respiratory epithelial adenomatoid hamartoma of the nasal septum siti zulaili zulkepli, md salina husain, mbbs, ms(orl-hns) balwant singh gendeh, mbbs, ms(orl-hns) department of otorhinolaryngology head and neck surgery universiti kebangsaan malaysia medical center correspondence: dr salina husain department of otorhinolaryngology head and neck surgery universiti kebangsaan malaysia medical center jalan yaacob latif, 56000 kuala lumpur, malaysia phone: (+603) 9145 5555 fax: (+603e) 9145 6675 email: drsalina_h@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2012; 27 (1): 28-30 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 29 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports hamartomas can be further classified into mesenchymal and epithelial subtypes according to predominant element on histopathologic examination. a particular subset of epithelial subtype known as respiratory epithelial adenomatoid hamartoma (reah) was first described in 1995 by wenig and heffner in a series of 31 cases from the files of the otolaryngic tumor registry at the armed forces institute of pathology.2 until now, there is limited literature regarding reah and most of the articles have been published as case reports. the challenge of this lesion is not to over-diagnose it as malignant as it can be treated with a simple excision. we present a case report of a 32-year-old lady with reah localized in the left anterior nasal septum. case report a 32-year-old chinese lady presented with a long-standing unilateral nasal blockage associated with nasal discharge and hyposmia. there was no history of facial pain, epistaxis or eye symptoms. she was otherwise healthy with no known co-morbidities. on physical examination, there was a broad-based 2 x 1.5 cm swelling originating from the left anterior nasal septum. it was firm and non-tender on palpation. the overlying mucosa appeared normal and smooth. the patient underwent an excisional biopsy under general anesthesia. histological evaluation revealed a polypoidal mass lined by respiratory epithelium and contained glandular and florid proliferation of tubular glands lined by ciliated, respiratory-type epithelium and goblet cells. the stroma was mostly oedematous with areas of hyalinization and a focus of chronic inflammatory infiltrate. no atypia or increased mitotic figures were observed. these findings were consistent with the diagnosis of respiratory epithelial adenomatoid hamartoma (reah). (figure 1 and 2) post-operatively, the excisional biopsy site re-epithelialised and healed well. there was no recurrence observed after four months of follow up. discussion reah is a benign lesion predominantly affecting adult men with male to female ratio of about 7:1 and associates with tobacco use.2 prior to 1995, only 13 cases involving the head and neck region other than wenig and heffner have been reported. to date, about 60 cases have been published as case reports, confirming the rare nature of this proliferation. in the head and neck region, it commonly occurs in the nasal cavity, paranasal sinuses and nasopharynx. their localization in the nasal cavity is mostly described in the posterior nasal septum although lesions arising from the lateral nasal wall have also been reported.1, 3 the lesion in our patient was found to arise from the anterior part of nasal septum, a few millimeters behind the mucocutaneous junction. involvement of the anterior part of the nasal septum is an unusual location and to our knowledge only one such case has been reported in english literature.4 other areas in the sinonasal tract where the lesion has been documented are maxillary sinus, ethmoid sinus and nasopharynx.5-7 the etiology of the lesion is unclear. reah of the nasal cavity has been described in association with nasal polyposis that supports the hypothesis that inflammation could be one of the inducing factors.8 commonly described presenting complaints were nasal obstruction, nasal stuffiness, epistaxis, rhinorrhea, chronic recurrent sinusitis, facial pain, proptosis and hyposmia.2, 4 this lady had similar presenting complaints of nasal block, discharge and hyposmia. the histologic picture is usually characterized by the presence of a glandular proliferation lined by ciliated respiratory epithelium, originating from the surface respiratory epithelium. the glands are typically round to oval in shape and small to medium in size with prominent dilation. stromal tissue separates the gland and no destructive growth was noted.1figure 1. low-power photomicrograph of a reah shows glandular and tubular proliferation lined by respiratory type epithelium (h&e, 40x). figure 2. high power photomicrograph of polypoidal mass lined by respiratory type epithelium (h&e 400x). (hematoxylin-eosin, 40x) (hematoxylin-eosin, 400x) 30 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports references nair s, bahal a, gupta ml, lkhtakia r. reah: unusual case of unilateral nasal blockage. 1. mjafi. 2008 jul; 64(3): 280-281. wenig bm, heffner dk. respiratory epithelial adenomatoid hamartomas of the sinonasal tract 2. and nasopharynx: a clinicopathologic study of 31 cases. ann otol rhinol laryngol. 1995 aug; 104(8): 639-645. cao zw, gu zw, yang j, jin mz. respiratory epithelial adenomatoid hamartoma of bilateral 3. olfactory clefts associated with nasal polyposis: 3 case report and literature review. auris nasus larynx. 2010 jun; 37(3): 352-356. gajda m, zagolski o, jasztal a, lis gj, pyka-fosciak g, litwin ja. respiratory epithelial 4. adenomatoid hamartoma of the anterior nasal septum is a rare localization of an unusual tumour in a child: a case report. cases j. 2009 sep; 16(2): 8151-8152. mortuaire g, pasquesoone x, leroy x, chevalier d. respiratory epithelial adenomatoid 5. hamartomas of the sinonasal tract. eur arch otorhinolaryngol 2007 nov; 264(4): 451-453 starska k, lukomski m, ratynska m. rare case of respiratory epithelial adenomatoid hamartoma 6. of the nasal cavity, maxillary sinus and ethmoid sinus: a clinicopathologic study. otolaryngol pol 2005; 59(3): 421-424 kessler hp, unterman b. respiratory epithelial adenomatoid hamartoma of the maxillary sinus 7. presenting as a periapical radiolucency: a case report and review of literature. oral surg oral med oral pathol oral radiol endod 2004 may; 97(5): 607-612 delbrouk c, aguilar sf, choufani g, hassid s. respiratory epithelial adenomatoid hamartoma 8. associated with nasal polyposis. am j otolaryngol. 2004 jul; 25(4): 282-284. there is no specific feature on imaging studies. reah can mimick any benign sinonasal tumor with the most common finding of reah being an opacification of the affected sinus and some connection to the nasal septum. calcification may be visualized within the lesion but bone erosion and intracranial involvement are uncommon.4 it is important to consider this diagnosis as the definitive treatment for reah is simple surgical excision. excision is an adequate treatment with excellent prognosis. reah does not progress and does not regress spontaneously. following surgical excision there was no reported recurrence in the literature so far.2, 8 respiratory epithelial adenomatoid hamartoma is a rare lesion in the head and neck region. one should be familiar with this entity and it should be considered in the differential diagnosis of nasal lesions. diagnosis misinterpretation only results in unnecessary surgical intervention. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 philippine journal of otolaryngology-head and neck surgery 39 letter to the editor dear editor, papillomas are primary benign epithelial neoplasms producing finger–like projections that typically cover fibrous stalks.1 the term inverted papilloma (ip) describes the endophytic projection of epithelium into the stroma. also known as schneiderian papillomas, ips predominantly affect males in the sixth decade.2 they usually arise from the lateral nasal wall and seldom involve the frontal or sphenoid sinuses.2 the frequency of ip on the nasal septum is even less.3 we report a case of ip of the nasal septum and the role of endoscopic resection of the ip without any sign of recurrence. case report a 52-year-old man who was a chronic smoker and worked as a cook presented with a 1 year history of progressively worsening unilateral nasal blockage and hyposmia. rigid nasoendoscopy revealed a reddish grape-like mass filling the right nasal cavity. the mass extended posteriorly to the posterior nasal space and crossed to the left side and had a broad-based attachment to the posterosuperior part of the nasal septum. computed tomography (ct) scan showed a heterogeneously-enhanced soft tissue density mass in the right nasal cavity and a soft tissue density in the right ethmoid and sphenoid sinus most likely representing retained secretions. the patient underwent endoscopic excision of the mass using integrated power console (ipc®) system coupled to straightshot® m4 microdebrider (medtronic, minneapolis mn, usa) under general anaesthesia. after induction, each nostril was packed with five rayon neuro-patties (raycot®, american surgical company, lynn ma, usa) soaked with 2ml cocaine 10%, 2ml adrenaline 1:1000 and 6ml of water, carefully placed along the septum, floor and turbinate region. this method reduces the bleeding significantly and prevents blood from impairing the endoscopic view. during the operation, a septal perforation was found at the origin of the mass. no further removal of nasal septum was performed. histopathological examination (hpe) confirmed the diagnosis of inverted papilloma. he has been under our follow-up for the past five years and remains well and symptom-free with no evidence of recurrence detected on endoscopic examination. discussion inverted papilloma (ip) poses many clinical, pathological and even management challenges. there are various surgical techniques advocated for treating ip. radical transfacial approaches like lateral rhinotomy, minimally invasive endoscopic techniques and even midfacial degloving procedures are among some of the surgical techniques advocated.4 most authors agree that complete surgical removal is the hallmark in treating ip.1, 2, 4, 5 traditionally, en bloc excision of the correspondence: associate prof. dr goh bee see department of otorhinolaryngology head and neck surgery universiti kebangsaan malaysia medical centre jalan yaacob latiff, 56000 cheras, kuala lumpur, malaysia phone: (603) 9145 6045/6053 fax: (603) 9173 7840 email address: irenegbs@yahoo.com reprints will be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. min han kong, md, ms (orl-hns) bee see goh, md, ms (orl-hns) department of otorhinolaryngology head and neck surgery universiti kebangsaan malaysia medical centre inverted papilloma of nasal septum philipp j otolaryngol head neck surg 2012; 27 (2): 39-40 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 letter to the editor 40 philippine journal of otolaryngology-head and neck surgery references 1. roh hj, procop gw, batra ps, citardi mj, lanza dc. inflammation and the pathogenesis of inverted papilloma. am j rhinol. 2004 mar-apr; 18(2): 65-74. 2. krouse jh. endoscopic treatment of inverted papilloma: safety and efficacy. am j otolaryngol. 2001 mar-apr; 22(2): 87-99. 3. buchwald c, franzmann mb, jacobsen gk, juhl br, lindeberg h. carcinomas occurring in papillomas of the nasal septum associated with human papilloma virus (hpv). rhinology. 1997 jun; 35(2): 74-8. 4. eggers g, mühling j, hassfeld s. inverted papilloma of paranasal sinuses. j craniomaxillofac surg. 2007 jan; 35(1): 21-9. doi: 10.1016/j.jcms.2006.10.003 5. waitz g, wigand me. results of endoscopic sinus surgery for the treatment of inverted papillomas. laryngoscope. 1992 aug; 102(8): 917-22. 6. lawson w, ho bt, shaari cm, biller hf. inverted papilloma: a report of 112 cases. laryngoscope. 1995 mar; 105(3 pt 1): 282-8. lateral nasal wall via lateral rhinotomy approach is the standard surgical option for ip arising from the lateral nasal wall. this approach provides good access to the tumor. despite achieving complete surgical removal, ip tends to recur.1 recurrence rates of ip when treated surgically are as high as 71%.2 persistent disease is unacceptable especially with the possibility of malignant transformation.1, 2 it is reported that malignancy in ip is particularly high at 10 to 15%.1 as for ip of the nasal septum, lawson et al. in 1995 reported five of 112 ip patients (4%) with isolated septal lesions that were treated by septectomy.6 our patient underwent transnasal endoscopic resection of the tumor without further need of posterior septectomy. the tumor was removed using a microdebrider. using the microdebrider for septal surgery usually involves a lateral (pns and nasal cavity) to medial (septum) process, and posterior inferior to anterior superior shaving technique, also minimizes blood from impairing the endoscopic view. any visible tumor at the margins was also removed. unlike conventional polypectomy, complete removal of the tumor and sterilization of the margins is the hallmark in treating ip. removal of ip without sterilization of the margins should be avoided. sterilization of the margin is not necessarily by microdebrider only; other authors have reported debulking tumor completely and sterilizing the margins and underlying bone using a diamond burr.5 transnasal endoscopic surgery avoided aggressive surgery and facial scarring in this patient. we observed no evidence of recurrence on follow up to date using this method. although this tumor has the ability to destroy bone, tends to recur, and is associated with malignancy, we demonstrated that transnasal endoscopic resection of ip limited to nasal septum may be safely performed without the need for further septectomy. however, we do not advocate this technique in cases of large tumor or when malignancy is suspected. endoscopic surgery would not adequately visualize the whole tumor and risk recurrence of tumor.2 larger series and better study design are required to support our observation and establish an acceptable and safe technique indicated for ip on the nasal septum. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 philippine journal of otolaryngology-head and neck surgery 71 passages jomar s. tinaza, md (1969-2015) emmanuel tadeus s. cruz, md karen adiel d. rances, md “every morning you have two choices: continue to sleep with your dreams or wake up and chase them.” – j.s. tinaza dr. tinaza may not have been shakespeare, poe or frost but he was known for his meaningful verses which he posted on viber, mundane and profound thoughts about life and recent photos he captured in his timeline. dr. jomar s. tinaza obtained his doctor of medicine degree from the de la salle university college of medicine in 1995. he joined the quezon city general hospital residency training program with dr. carmina g. galang in january 2000. in january 2003, the philippine board of otolaryngology – head and neck surgery accredited the training program. dr. galang graduated in 2004 while jomar opted to extend his training for two years to complete the four years needed to become board-eligible. hence, jomar was the first alumnus of the qcgh ent department. he passed the diplomate exam on sep 17, 2010. his extended stay was instrumental for our full accreditation and dr. pascual, his previous training officer and chair admired him for his extraordinary ideas and trusted him to accomplish certain tasks beyond his comfort zone. he saw the potential of a good clinical practice in cosmetic surgery and pursued subspecialty training in facial aesthetic surgery under the facial aesthetic core of ent surgeons (faces) in 2010. afterwards jomar and his wife amy established the asian aesthetic center in katipunan ave. he became a visiting and subspecialty consultant in maxillofacial, facial plastic and reconstructive surgery of the department in 2011. as a mentor, he unselfishly shared his skills and diligently assisted the residents during surgery working pro bono as a visiting consultant. he came early to attend grand rounds, was never satisfied with mediocre answers, persistently scrutinizing and demanding precision and accuracy. sometimes his queries may have been perceived as nitpicking but they certainly echoed the effervescence and eagerness of a budding junior consultant plunging into the dynamics of clinical discussion. he helped organize the series of international postgraduate courses in facial plastic surgery in qcgh from 2010 – 2012. as a consultant, jomar was a silent worker who actively participated and contributed voluntarily. he co-authored the paper on a case series of tessier patients which is published in the current issue of this journal; he assisted in a case of tuberous sclerosis which he proposed as a case report to represent the department this year; he was preparing a descriptive paper on a case series of rhinoplasty in cleft noses; and he helped amputate an abbe flap on a clinical patient with lip cancer, a week before he left. he was invited to lecture in a postgraduate course at st. luke’s medical center after the psohns annual convention and he subsequently gave an inspirational talk where he emphasized the value of hard work and patience to succeed during the residents’ graduation last december. one of his passions was photography. he had a keen eye for taking pictures of people in action, picturesque sceneries and documenting events. he even proposed a post-graduate course on photography especially in selecting the proper angle, exposure and lighting before and after cosmetic surgery and showcased a photo exhibit of his works. jomar treated his patients with compassion and pampered them with care with his motto and familiar verse: do all things with kindness. he was generous and gracious to hospital employees and treated the residents as members of an extended family. to break loose from the monotony and grime of daily routine, he would often invite residents to have dinner in their new house at lgv, share thoughts and perspectives about life over a bottle of beer or shots of tequila once in a while dishing out songs from his own repertoire. the staff will miss his silly grin while holding the microphone during videoke nights at the perennial watering hole in bauschmann cafe. he had a toast for all occasions with a pocketful of cheers and stories to tell. one of his favorite lines was, for good looks and good life… jomar had a penchant for gadgets -bought gifts especially for his wife, he savored food, dining and vacations with his family. as a husband, amy could not ask for more. during the necrological rites, she confided that there were times when she would wake up and catch jomar staring at her, giving her the impression that she was the most beautiful woman in this world. and to his two sons, earl and marcus, jomar was a loving father who woke up early and took them to school, securing a brighter future for both of them. true to his words, jomar never slept and chased his dreams. he undoubtedly touched many people’s lives along the way. the staff grieves and deeply mourns the passing of a fellow, colleague, comrade, mentor, brother and friend. his gestures and verses will continue to reverberate, long after he has gone. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 editorial 4 philippine journal of otolaryngology-head and neck surgery the philippine society of otolaryngology head and neck surgery has been promoting research among residents and fellows through various fora (including research contests), even creating a research fund (albeit, with no takers). it has also supported the philippine journal of otolaryngology head and neck surgery as its official scientific publication and primary forum for publishing research. this year, our board of trustees has finally taken concrete steps to merge our research and publication initiatives in order to streamline both processes. in effect, all papers submitted to the various research contests of the society will be reviewed and revised prior to oral presentation, through the editorial management system of our journal. in this manner, both the contests and the journal benefit, as pre-final papers chosen for oral presentation would have already been reviewed and revised for publication. indeed, “publishing” means to make something public.2 if the ratio of research presentations to publications is taken, it is fair to conclude that we may not lack in research, but we certainly lag in publication. why publish? “similar to others who write (historians and poets), scientists and those involved in research need to write … to leave behind a documented legacy of their accomplishments.”1 whatever we discover or unearth in the laboratory, clinic or in the field; whether from samples, specimens, subjects, patients or participants; utilizing theoretical or applied instruments, materials and methods; simply “did not happen” unless it is documented and disseminated. in filipino,“kung hindi nakasulat, hindi nangyari.” how often do we hear side-comments like “naisip ko na iyan,” or “na-presenta ko na iyan” or even “sinulat ko na iyan” at a scientific meeting where a speaker presents a study. the sad fact of the matter is many of these colleagues may indeed have had similar thoughts, or delivered previous oral presentations, or even written reports. but because not of these had been properly published, they remain inaccessible to subsequent scholars, and are therefore neither cited nor acknowledged. “while ‘doing’ the research is important, ‘writing’ about why and how it was done, what was found, and what it means is far more important as it serves as a permanent record of scientific work that has been completed and accepted by peers.”1 and writing and publishing are an entirely different ball game from researching alone. publication, or “making ideas public,” allows correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft ave., ermita, manila 1000 philippines phone: (632) 526 4360 telefax: (632) 524 4455 email: lapenajf@upm.edu.ph reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines on research and publication: the specialty society and its scholarly journal philipp j otolaryngol head neck surg 2013; 28 (1): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. “research, no matter how ‘good’, is incomplete, until it has been published.”1 philippine journal of otolaryngology-head and neck surgery 5 philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 editorial “scholars (to) provide each other with the opportunity to build on each other’s contributions, create dialogue (sometimes heated) with one another and join the documented and ongoing history of their field.”2 it is by participating in this “documented and ongoing history” of our field that we and our specialty society gain international recognition and become internationally competitive. taking your place in the history of scholarship starts where you are, as an author. publication involves communication between the author and his or her audience via the written article.3 unlike public speakers or performing artists, the author’s interaction with the audience is limited by the written and published work. hence, “a successful researcher is usually a good communicator who has the ability to maximize the transmission of research findings to his or her chosen audience.”1 our journal editors “go the extra mile” to maximize manuscripts for communication. unlike most journals, we do not reject poorly-written submissions outright and often help rewrite them extensively. aside from formand contentediting, we even assist in revisions following the review process. unfortunately, few authors seem to appreciate or understand this—and ironically, those who do are mostly overseas authors. perhaps our local colleagues do not fully realize the career, professional, institutional and practical advantages that can be gained from writing and publication.4 career benefits of publication “may have the most direct bearing on … appointment, promotion, tenure and advancement within your institution, organization and discipline.”2 this is especially true for those of us in academe, but it certainly should also be true as far as our specialty training and accreditation programs are concerned. for instance, publications of specialty board examiners and accreditors are integral to their appointment and retention in learned societies here and abroad. professional benefits include “applying for positions in foreign institutions, and when applying for competitive overseas fellowships”1 i have received numerous urgent requests from residents and young diplomates (unaware of the editing and peer review process) to publish research they undertook in training so they can fulfill publication requirements for overseas positions or fellowships. for more senior consultants, “gaining recognition as experts … at regional and international levels leads to invitations to lecture at scientific meetings … appointments as consultants to external agencies … and advisory boards.”1 closer to home, publication “increases depth of references peh wcg, ng kh. effective medical writing (pointers to getting your article published): why 1. write? singapore med j 2008; 49(6):443. publish, not perish: the art and craft of publishing in scholarly journals. university of colorado 2. 2006. available from http://www.publishnotperish.org [cited may 25, 2013]. clearihan lyn. writing for publication. monash uniiversity, melbourne. available from: http://3. www.phcris.org.au/conference/2005/workshops/clearihan.pdf [cited may 25, 2013]. peh wcg. scientific writing and publishing: its importance to radiologists. 4. biomed imaging interv j 2007;3(3):e55 doi: 10.2349/biij.3.3.e55 knowledge in a particular subject that complements and hones clinical skills, and enables better teaching of students, clinical trainees and postgraduates.”1 concerning institutional benefits, “publication in peer-reviewed journals is arguably the most important means to achieve international recognition for an individual, department, hospital, and university.”1 moreover, “the author’s country, and even the region, may also derive benefit from published work, particularly if it is on a topic of major importance.”1 at least in the medical field, filipino publications have made their mark, although sparsely. finally, the practical benefits gained from engaging in the research and publication process cannot be overlooked. the “inherent training gained during the process of manuscript preparation,” the “discipline of performing a thorough literature search, collating and analyzing data and drafting and repeatedly revising the manuscript”1 during the editing and review process, provide undeniable practical benefits to the author. researchers who have published are much better positioned to evaluate scholarly publications, having themselves experienced the writing, editing and review process. in this era of “information overload” the published researcher can more effectively evaluate and utilize available evidence. this translates to elevating the scientific and scholarly milieu in our specialty society and training institutions. indeed, we are entering a new era for both the psohns and pjohns. hopefully, the streamlined submission and review process will facilitate presentation and publication, in quantity and quality for many years to come. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 the nineteenth of june 2011 marks a century and fifty years since the birth of josé protasio rizal in 1861.1 the ninth of november 2011 also marks the golden jubilee of the foundation of the departments of ophthalmology and otorhinolaryngology of the philippine general hospital (pgh) in 1961, dividing the original department of eye, ear, nose and throat that was established a century ago in may 1911. the national hero of the philippines and pride of the malay race2 is immortalized in countless ways, reflecting his multiple accomplishments that mark a true renaissance individual. the two departments of the national university of the philippines (up) have likewise made their mark in pace with the many achievements of their alumni. rizal was a polyglot and polymath poet, painter, sculptor, sportsman, scientist and patriot, whose writings led to his execution and sparked the philippine revolution of 1898.1,3 he was also a physician and an ophthalmologist who insightfully dissected the ills of his patients and society.4 what have the departments and their hospital contributed to health and to humankind? if precedence were the measure of significance, the pioneering “firsts” would have to include the first laryngo-fissure operation by founding department head dr. reinhard rembe in 1913, the first intracapsular cataract lens extraction in the country using a suction erisophake after the technique of barraquer by the next chair (and nephew of the national hero) dr. aristeo rizal ubaldo in 1920, the first laryngectomy by drs. ubaldo and founding president of the philippine academy of ophthalmology antonio s. fernando in 1923 and the first labyrinthectomy by drs. ubaldo and vicencio c. alcantara in 1927.5 there was a time when the chairs and senior consultants of most departments of otorhinolaryngology head and neck surgery in the philippines were alumni of the up-pgh, as was the leadership of the philippine society of otolaryngology and bronchoesophagology (later philippine society of otolaryngology head and neck surgery) which separated from the philippine ophthalmological and otolaryngological society (subsequently philippine academy of ophthalmology and otolaryngology) in 1956. but those are bygone days, and the folly of resting on one’s laurels becomes all too apparent, as these are quickly eclipsed by the capabilities of newer, better-equipped health care facilities that are manned by experts trained in their respective institutions. thus the race to super-specialize and sub-specialize, perhaps to regain lost ground and primacy at the expense of tertiary general health care has become the battle cry for some, led by the present administration of the pgh. editorial 4 philippine journal of otolaryngology-head and neck surgery correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft ave., ermita, manila 1000 philippines phone (632) 526 4360 telefax (632) 524 4455 email lapenajf@upm.edu.ph reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author has no relevant financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. josé florencio f. lapeña, jr., m.a., m.d. department of otorhinolaryngology college of medicine, university of the philippines manila department of otorhinolaryngology head and neck surgery east avenue medical center, diliman, quezon city rizal, renaissance and reform: reflections on ophthalmology and otorhinolaryngology in the philippine general hospital philipp j otolaryngol head neck surg 2011; 26 (1): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 editorial philippine journal of otolaryngology-head and neck surgery 5 and yet, the majority of filipinos still do not have access to primary health care.6 they who do not even have the services of a basic physician much less can avail of special care of their sight, hearing and balance, smell and taste, breathing, swallowing or speaking, nor of the face with which they face the world. witness the number of adults with unrepaired cleft lips and untreated head and neck tumors roaming the streets of the city. the up college of medicine (upcm) founded in 1905 aims “towards leadership and excellence in community-oriented medical education, research and service directed particularly to the underserved.”5 as the teaching hospital of the upcm, with whom it shares such academic and clinical departments as ophthalmology and otorhinolaryngology, the hundred-year-old philippine general hospital and its leadership cannot and must not turn a blind eye or deaf ear to the underserved it is mandated to serve. its true strength lies in relevance, which is quickly lost if it succumbs to the delusionary glitter of super-specialization beyond the reach of most people. of what benefit is it to be the “first,” if it does not redound to the good of the “many?” of rizal, it has been said “to his patients he gave sight; and to his country he gave vision.”7 as the departments of ophthalmology and otorhinolaryngology pursue the arts and sciences of vision, hearing and balance, olfaction and gustation, respiration and deglutition, phonation and facial expression, may they sharpen the sensitivity of health providers in pgh and other loco-regional general hospitals to the real issues of health and humankind in the developing world and embolden us to overcome the apathy to “hear no evil, see no evil, speak no evil.” references craig a. lineage, life and labors of josé rizal: philippine patriot. in: the project gutenberg 1. ebook of lineage, life and labors of jose rizal: philippine patriot, a study of the growth of free ideas in the trans-pacific american territory by austin craig manila: philippine education publishing co., 1913. [online ebook # 6867 cited november 23, 2010.] available from: http:// www.gutenberg.org/ebooks/6867. palma r. the pride of the malay race: a biography of josé rizal. new york: prentice-hall, 1949.2. laubach fc. rizal: man and martyr. manila: community publishers, 1936. [copyright 1909 3. by frank c. laubach, online version] available at: http://joserizal.info/biography/man_and_ martyr/portal.htm accessed november 26, 2010. lapeña jf. josé protacio rizal (1861-1896): physician and philippine national hero. 4. singapore med j. 2011 june; 52(6): (forthcoming). jamir jc, lapeña jf. annual report of the department of otorhinolaryngology 1998. history 5. excerpted in: arcellana-nuqui ey, danguilan jl, agbayani bf, alfonso om, balgos aa, caballes ab, et al., (editors). siyento: the up college of medicine centennial commemorative book. manila: upcm centennial executive committee, 2005. blueprint for universal health care 2010-2015 and beyond. the up forum 2009 nov-dec 10(6) 6. [cited 2011 may 20] available from: http://akane.upd.edu.ph/upforum.php?issue=34&i=289 ravin tb. josé rizal: philippine national hero and ophthalmologist. 7. arch ophthalmol 2011 feb; 119(2):280-84. available at: http://archopht.ama-assn.org/cgi/content/full/119/2/280 accessed november 26, 2010.0 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 philippine journal of otolaryngology-head and neck surgery 59 surgical innovations and instrumentation philipp j otolaryngol head neck surg 2015; 30 (1): 59-62 c philippine society of otolaryngology – head and neck surgery, inc. the use of a soft gel capsule as a medium for modified barium esophagogram in detecting esophageal foreign body philip jan p. arenga, md joebert m. villanueva, md department of otorhinolaryngology head and neck surgery western visayas medical center correspondence: dr. joebert m. villanueva western visayas medical center ent office q. abeto st. mandurriao, iloilo city 5000 philippines phone: (6333) 509 0077 fax: (6333) 321 1797 email: joebert_md@yahoo.com.ph reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the poster session contest on surgical innovation & instrumentation (1st place), philippine society of otolaryngology head and neck surgery, sofitel philippine plaza hotel, ccp complex, manila, december 2, 2014. abstract objectives: to test a soft gel capsule with barium sulfate as a medium for modified barium esophagogram in detecting esophageal foreign body. methods: design: preliminary diagnostic test assessment; consecutive convenience sample setting: tertiary government hospital patient: soft gel capsule with barium sulfate was pilot tested on patients with a history and diagnosis of radiolucent foreign body ingestion between june 1 and november 30, 2014. results: seven patients (6 males, 1 female; aged 26 – 61 years) underwent the procedure. in all seven, the enhanced capsule immediately stopped above the level of the esophageal foreign body, easily identifying the exact location of the obstruction. foreign bodies included 1 embryonated duck-egg white “balut”, 5 chunks of pork meat and 1 claspless denture. all were successfully marked by the capsule on fluoroscopy and documented on x-ray. esophagoscopy under general anesthesia was successfully performed after fluoroscopy in all patients. conclusion: we were able to improvise a new medium for use in modified barium esophagograms that was easy to prepare and that rendered good radiographic imaging and localization of radiolucent foreign bodies. a randomized trial in comparison to the prevailing test may confirm our findings further. meanwhile, we recommend exploring the procedure in other hospitals as an alternative to barium-soaked cotton in the diagnosis of radiolucent esophageal foreign bodies keywords: soft gel capsule, barium suphate, esophagogram, esophageal foreign body esophageal foreign body obstruction is a common and potentially serious cause of morbidity among a wide spectrum of age groups.1,2 in our setting, the most common esophageal foreign bodies are radiolucent (impacted meat or other food).3 imaging including contrast studies are performed to identify the character and location of the foreign body and to rule out any complications. biplane radiographs are the initial imaging modality of choice. contrast examination is not recommended because of associated risk of aspiration and coating the foreign body or the mucosa precluding subsequent endoscopy.4 however, widespread local practice employs a cotton-ball coated in barium sulfate to diagnose radiolucent esophageal foreign bodies. as an alternative to cotton, we decided to test a soft gel capsule with barium sulfate as a medium for modified barium esophagogram in detecting esophageal foreign body. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 surgical innovations and instrumentation 60 philippine journal of otolaryngology-head and neck surgery methods study design preliminary diagnostic test assessment; consecutive convenience sample participants with technical review board approval, all patients with a history of foreign body ingestion consulting in the emergency room of the western visayas medical center (wvmc) between june 1 and november 30, 2014 were considered for this study. all those who were clinically diagnosed to have radiolucent foreign body ingestion and who gave informed consent was included. patients diagnosed to have radiopaque foreign body ingestion were excluded. preparation the materials used were: 1. ibuprofen (advil®) soft gel capsule (pfizer consumer inc.; zuellig, philippines) (figure1a &1b) 2. barium sulphate (ez-hd®) 98g/100g powder for suspension (oral) radiocontrast media 340g (e-z-em, inc., anjou, quebec, canada) (figure 1b) 3. terumo® 3cc syringe with gauge 23 needle (terumo philippines corporation) (figure 1c) figure 1a. ibuprofen (advil®) soft gel capsule before, and b. after replacing contents with barium sulphate solution. figure 1b. barium sulphate (ez-hd®) 98g/100g powder for suspension (oral) radiocontrast media 340g (e-z-em, inc., anjou, quebec, canada) figure 1c. terumo® 3cc syringe with gauge 23 needle (terumo philippines corporation) 4. absolute pure distilled drinking water (asia brewery, inc., philippines) each soft gel capsule content was aspirated using a 3cc syringe with gauge 23 syringe needle. a solution of 1:2 (barium sulphate: water) was injected back into the soft gel capsule using another syringe barrel with plunger into the same needle until the entire capsule was filled. procedure each patient donned a hospital gown was positioned standing for fluoroscopy using a flexavision collimator r-300 (shimadzu europa gmbh, dulsburg, germany) at the wvmc radiology section and swallowed a prepared capsule with sips of water. as the soft gel capsule was ingested, it was tracked through the esophagus until it reached the area of obstruction. (figure 2a) while the movement of the soft gel containing barium was being tracked on a fluoroscopic video monitor, a chest x-ray apl image was obtained using the same machine. (figure 2b). esophagoscopy under general anesthesia was done after fluoroscopy. a b philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 philippine journal of otolaryngology-head and neck surgery 61 surgical innovations and instrumentation figure 2a. fluoroscopic study of a 56-year-old woman showing soft gel barium capsule as it was tracked through the esophagus until it reached the area of obstruction. figure 2b. chest x ray in a 56-year-old woman showing location of ingested meat marked by soft-gel barium capsule. figure 3a. soft tissue lateral x ray in a 29-year-old man showing location of ingested meat with bone. figure 3b. antero-posterior x ray in a 29 year-old man showing location of ingested meat with bone figure 3c. soft tissue lateral x ray in a 29-year-old man showing location of ingested meat with bone marked by soft-gel barium capsule. figure 3d. comparative image of soft tissue lateral x ray in a 29-year-old man showing location of ingested meat with bone marked by barium impregnated cotton. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 surgical innovations and instrumentation 62 philippine journal of otolaryngology-head and neck surgery references 1. gonzales dc, gonzales rl. esophageal foreign body impaction from ingested duck egg (balut) allantois: a case report. research folio [serial on internet]. 2000-2006 [cited 2015 may 12]. available from: http://www.herdin.ph/index.php/component/herdin/?view=research&ci d=1368. 2. abrenica rb, chua ah. esophageal and tracheobronchial foreign bodies: a ten year restrospective study. philipp j otolaryngol head neck surg. 2004; 19(1-2): 33-40. 3. ikenberry so, jue tl, anderson ma, appalaneni v, banerjee s, menachem t, et al. management of ingested foreign bodies and food impactions. gastrointest endosc. 2011 jun; 73(6): 1085– 1091. 4. libuit j, banez v. repeated foreign body ingestion in psychiatric patient. j interv gastroenterol. [serial on the internet] 2014 oct-dec; [cited 2014 nov 20]; 4:4 [about 135-138 p.] available from: http://www.jigjournal.org/sites/default/files/135-138%20%20jig-2014.pdf. 5. jackson cl. foreign bodies in the esophagus. am j surg. [serial on the internet] 1957 feb [cited 2014 oct 2]; (2): [about 308–312p.]. available from: http://www.americanjournalofsurgery.com/ article/0002-9610%2857%2990783-3/pdf. 6. palme ce, lowinger d, petersen aj. fish bones at the cricopharyngeus: a comparison of plain‐film radiology and computed tomography. laryngoscope. [serial on the internet] 1999 dec [cited 2014 oct 2]; 109(12): [about 1955-8p]. available from: http://onlinelibrary.wiley.com/ doi/10.1097/00005537-199912000-00011/full. 7. levine ms, rubesin se, laufer i. barium esophagography: a study for all seasons. clin gastroenterol hepatol. [serial on the internet] 2008 jan [cited 2014 oct 2]; 6(1): [about 11–25p.] available from: : http://www.cghjournal.org/article/s1542-3565%2807%2901058-0/fulltext 8. hanes t. information about soft gel ibuprofen. livestrong.com. (serial on the internet) 2014 [updated 2013 aug 16; cited 2014 oct 1]. available from: http://www.livestrong.com/ article/147723-information-about-soft-gel-ibuprofen/ results seven (7) patients underwent the procedure, six (6) males and one (1) female with ages ranging from 26 – 61-years-old (mean age, 43-yearsold). in all seven, the enhanced capsule immediately stopped above the level of the esophageal foreign body easily identifying the exact location of the obstruction. the findings were one (1) embryonated duck-egg white “balut”, five (5) chunks of pork meat and one (1) claspless denture. all were successfully marked by the capsule on fluoroscopy and documented on x-ray. (figures 3 a-d) in all 7 patients, esophagoscopy under general anesthesia was performed after fluoroscopy. discussion accidental foreign body or large food bolus ingestion occurs primarily in edentulous, alcohol intoxicated or mentally impaired elderly subjects.5 at the western visayas medical center, food (typically meat and egg white of an embryonated duck egg or “balut”) bolus impactions are the most common cause of esophageal foreign body obstruction in adults. it is hard to identify the exact location, presence or absence of a foreign body in the absence of bone or denture wires.6 although endoscopy is of value in assessing gastrointestinal tract mucosal disease, barium studies are indispensable for clarifying uncertain findings at endoscopy or ct. however, barium studies are physically taxing, labor-intensive and difficult for radiologists to master.7 in our setting, a modified barium swallow involves the use of a cotton ball coated in barium sulfate solution which can be messy and uncomfortable for the patient as well. in our study, all subjects swallowed the soft gel capsule without difficulty and expressed their ease in swallowing. we were also able to obtain a good radiographic view of the exact location of the foreign body in all cases. no adverse reactions were noted in any of the participants. we were able to improvise a new medium for use in modified barium esophagograms that was easy to prepare and that rendered good radiographic imaging and localization of radiolucent foreign bodies. our study only assessed our proposed diagnostic test in a preliminary manner, using a consecutive convenience sample without comparison to the prevailing test, and our results may not be applicable in all indicated situations. a randomized trial involving more subjects over a longer period in comparison to the prevailing test may confirm our findings further. meanwhile, we recommend exploring the procedure in other hospitals as an alternative to barium-soaked cotton in the diagnosis of radiolucent esophageal foreign bodies. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 case reports 20 philippine journal of otolaryngology-head and neck surgery abstract objective: to report a case of vertebrobasilar dolichoectasia presenting with ipsilateral facial nerve paresis and concomitant severe sensorineural hearing loss. methods: design: case report setting: secondary government hospital patient: one results: we report a case of vertebrobasilar dolichoectasia with concomitant ipsilateral facial nerve paresis and severe sensorineural hearing loss in an elderly female. she presented to us with left facial nerve palsy house-brackmann grade iii and prior history of ipsilateral sensorineural hearing loss. mri of the brain showed normal inner ear structures but revealed a dilated and tortuous basilar artery with compression on the left medulla and possible branches of anterior inferior cerebellar artery as it coursed superiorly and possible partial thrombosis of proximal basilar artery. conclusion: concomitant facial nerve paresis and sensorineural hearing loss can be the clinical presentations of this rare but important condition. mri is vital in diagnosing vertebrobasilar dolichoectasia. keywords: vertebrobasilar dolichoectasia, facial nerve palsy, sensorineural hearing loss, basilar artery vertebrobasilar dolichoectasia is also known as megadocholichoectasia, fusiform aneurysm of the vertebral and basilar arteries and tortuous vertebrobasilar system. vertebrobasilar dolichoectasia is defined as an elongation and dilatation of the major arteries of the posterior fossa.1 it is a rare but well-known condition in clinical neurology with an incidence ranging from 0.06-5.8%.2 it is recognized as an important independent risk factor for stroke.3 besides that, these dilated vessels can give rise to manifestations of interest to an ent surgeon. we report a case of vertebrobasilar dolichoectasia in an elderly female with an ipsilateral facial nerve paresis and concomitant sensorineural hearing loss. a rare case of vertebrobasilar dolichoectasia presenting with ipsilateral facial paresis and concomitant severe sensorineural hearing loss mee ling tang, mbbs1 govindaraju revadi, ms1 raman rajagopalan, ms2 sushil brito-mutunayagam, ms1 1department of otorhinolaryngology, ampang hospital, selangor, malaysia. 2department of otorhinolaryngology, faculty of medicine, university of malaya, malaysia correspondence: dr. mee ling tang department of otorhinolaryngology, ampang hospital, jalan mewah utara, pandan mewah, 68000 ampang, selangor darul ehsan. malaysia phone: +(601) 9259 6621 telefax: +(603) 9102 3037 email: meelingt2001@yahoo.com reprints will be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2014; 29 (1): 20-22 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 case reports philippine journal of otolaryngology-head and neck surgery 21 case report a 73-year-old malay woman with a past history of diabetes mellitus and hypertension presented to us with a sudden onset of incomplete left facial weakness for three days and a gradual left ear hearing impairment with intermittent tinnitus (sounds of wind) for four months. there was no history of otorrhoea or dizziness reported nor prior history of upper respiratory tract infection (urti), head injury, vesicular rashes or stroke. she was on oral antihypertensives, subcutaneous insulin injection and aspirin for her medical illness. on examination, she had left facial asymmetry with loss of left forehead groove and left nasolabial fold and full eye closure but weak to resistance consistent with house-brackmann grading iii. the otoscopic findings were normal. tuning fork tests showed negative rinne test on the left ear with weber test lateralizing to the right, suggestive of left sensorineural hearing loss (snhl). the rest of the cranial nerve examination was normal with negative cerebellar signs. no other neurological deficits were noted in both upper and lower limbs. tympanometry was type a bilaterally and pure tone audiometry (pta) showed left moderate to severe sensorineural hearing loss with right ear normal hearing with an 8khz dip. she completed a course of oral steroids and neurobion and underwent facial physiotherapy. the facial weakness resolved completely after a few months with persistent asymmetry of the left-sided severe sensorineural hearing loss. a contrast-enhanced magnetic resonance imaging of the internal acoustic meatus revealed a tortuous, elongated and ectatic basilar artery, measuring 4.1mm in its widest axial diameter. there was compression on the left medulla and possibly branches of the anterior inferior cerebellar artery as it coursed superiorly. the left vestibulocochlear nerve did not appear directly compressed. there was mixed heterogeneity of intraluminal signal intensity suspicious of thrombosis. there was no abnormal increase in signal intensity within the pons to suggest infarcts. the cerebellopontine angle, internal acoustic meatus, and all the inner, middle and outer ear structures were reported as normal. she was diagnosed to have atherosclerotic vertebrobasilar dolichoectasia with partial thrombosis of the proximal basilar artery. discussion vertebrobasilar dolichoectasia is an anatomic variant consisting of enlargement and dilatation of the vertebrobasilar artery which is often tortuous and elongated.1 histologically, there are early fragmentation of the internal elastic lamina, intimal hyperplasia and intramural hemorrhage in these dilated arteries. this condition is most likely due to prolonged systemic arterial hypertension.4 as a result of the increased diameter of the dilated artery, there is presence of both orthograde and retrograde flow within the same arterial segment. this can create turbulence in the blood flow of the artery causing thrombus formation.2 there are various clinical presentations of vertebrobasilar dolichoectasia depending on the location and nature of the vessel. m titlic et al. performed a topical review on its various clinical manifestations.2 the vicinity of the ectatic basilar artery in the brainstem can cause compression symptoms of the surrounding structures of the brainstem leading to cranial nerve palsies. cranial nerves palsies involving ivth (trochlear) nerve, vith (abducens) nerve, viith (facial) nerve, viiith (vestibulocochlear) nerve and even vth (trigeminal) nerve and optic tract, albeit rare have all been described. the presentation includes diplopia, trigeminal neuralgia, hemifacial spasm and sensorineural hearing loss with vertigo. the cranial nerves compressed may be isolated or combined depending on the diameter of the basilar artery.1 to the best of our knowledge, no case has been described in the english literature to involve both viith (facial) and viiith (vestibulocochlear) nerves together. due to the dilated nature of the artery, the turbulence in blood flow can also cause vertigo and pulsating tinnitus in the affected patient.2 these symptoms can be very debilitating. facial nerve paresis as a sole presenting complaint in vertebrobasilar dolichoectasia is rare as there is only one case so far reported by mishra et al. regarding recurrent incomplete alternating facial hemiparesis secondary to a dolichoectatic vertebrobasilar artery in a middle-aged man. in that reported case, the man eventually required an operation and clipping was done. postoperatively, there was improvement in the facial weakness up to 95% over a 5-month duration.5 in our case study, the patient presented with ipsilateral facial nerve paresis which coincided with the compressed side of the brainstem. however, there was no demonstration of direct compression of the facial nerve. we speculate that the facial nerve paresis in this patient was the consequence of either compression of the arterial supply to the facial nerve or a thrombus formation which later recanalized. the facial nerve receives an arterial supply from branches of the anterior inferior cerebellar artery between its exit from the pons and internal auditory meatus.6 microembolism of the thrombi is a possibility in view of the suspicious thrombus seen on mri. however, an idiopathic cause or bell’s palsy also cannot be ruled out in her case. the usual etiologies of unilateral sensorineural hearing loss include noise-induced, ototoxic, basal meningitic, acoustic neuroma and vascular causes. vascular causes of sensorineural hearing loss are usually due to embolism or thrombosis of the labyrinthine or cochlear artery. in our case, the persistent unilateral sensorineural hearing loss prompted us to investigate for a possible retrocochlear cause and this rare condition was an incidental finding. the unilateral sensorineural hearing loss may be attributed to the affected arterial supply from the labyrinthine artery that supplies the inner ear. in the reported cases, patients with sensorineural hearing loss secondary to vertebrobasilar dolichoectasia may or may not have vestibular component involvement, philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 22 philippine journal of otolaryngology-head and neck surgery case reports and their outcomes vary from temporary to residual or permanent total hearing loss.5,7-9 tinnitus has been reported secondary to turbulent blood flow from the ectatic basilar artery but in her case, it may also possibly be part of the symptoms of sensorineural hearing loss. other than the clinical manifestations mentioned above, the initial presentation of vertebrobasilar dolichoectasia includes cerebellar dysfunction, central sleep apnea, arterial dissection or aneurysm, ischemic or hemorrhagic stroke and hydrocephalus.1,5 magnetic resonance imaging (mri) and magnetic resonance angiography (mra) of the brain has been the method of choice in the study of vertebrobasilar dolichoectasia.10 mri is non-invasive and can display vascular anatomy and its related posterior fossa structures, and delineate mural thrombi. mra has the additional advantage of demonstrating the direction of vascular blood flow. there is a role for surgery for the treatment of cranial nerve disorders such as trigeminal neuralgia and hemifacial spasm. microvascular decompression surgery was first introduced in the 1960s and popularized after 15 years. this surgery aims to alleviate the symptoms completely with minimal surgical complications. it is usually done by interposing teflon, felt or other synthetic implants between the dilated vessel and the compressed nerves.4 we speculate that both the snhl and facial nerve paresis could be a manifestation of vbd that occurred asynchronously. the benefit of surgery is not clear in this patient, however, it is important to educate her about the importance of antiplatelet treatment and emphasize the risk not only for stroke but recurrent facial hemiparesis/palsy as well as involvement of other cranial nerves reported in the literature. a cohort study by ubogu et al. suggested that vertebrobasilar dolichoectasia is an independent risk factor for stroke.3 it is also important to be aware of the progression of this condition which includes dissection, aneurysm, sah and hydrocephalus. references 1. smoker wr, corbett jj, gentry lr, keyes wd, price mj, mckusker s. high-resolution computed tomography of the basilar artery: 2. vertebrobasilar dolichoectasia: clinical-pathological correlation and review. ajnr am j neuroradiol 1986 jan-feb; 7(1):61–72. 2. titlic m, tonkic a, jukic i, kolic k, dolic k. clinical manifestations of vertebrobasilar dolichoectasia. bratisl lek listy. 2008; 109(11): 528–530. 3. ubogu ee, zaidat oo. vertebrobasilar dolichoectasia diagnosed by magnetic resonance angiography and risk of stroke and death: a cohort study. j neurol neurosurg psychiatry. 2004 jan; 75(1):22–26. 4. pereira-filho a, faria m, bleil c, kraemer jl. brainstem compression syndrome caused by vertebrobasilar dolichoectasia: microvascular repositioning technique. arq. neuropsiquiatr. 2008 jun;66(2b): 408-411. 5. melo aa, leão fs, campos ajc, antunes mrta, bunzen d, neto ssc. megadolicho basilar artery as a cause of asymmetrical sensorineural hearing loss case report. int. arch. otorhinolaryngol. 2011 jul-sep;15(3):385-387. doi: 10.1590/s1809-48722011000300019. 6. blunt mj. the blood supply of the facial nerve. j anat. 1954 oct; 88(4): 520–526. 7. nuti d, passero s, di girolamo s. bilateral vestibular loss in vertebrobasilar dolichoectasia. j vestib res. 1996 mar-apr; 6(2):85-91. 8. büttner u, ott m, helmchen c, yousry t. bilateral loss of eighth nerve function as the only clinical sign of vertebrobasilar dolichoectasia. j vestib res.1995 jan-feb; 5(1):47-51. 9. senkal ha, özkan s, oguz kk, turan e. dolichoectatic and tortuous vertebrobasillary arterial system causing progressive left-sided hearing loss in a patient with previous right-sided deafness. mediterr j otol 2008; 4: 143-147. 10. vieco pt, maurin ee 3rd, gross ce. vertebrobasilar dolichoectasia: evaluation with ct angiography. ajnr am j neuroradiol. 1997 aug; 18(7):1385-1388. figure 1. a. a cross-section t2 weighted mri of the cerebellum showed a tortuous, elongated and ectatic basilar artery (arrow) measuring 4.1mm in its widest axial diameter. mixed heterogeneity of intraluminal signal is suspicious of thrombosis. b. a cross-section t2 weighted mri of the cerebellum demonstrated compression of the contrasted basilar artery (arrow) on the left medulla. a b figure 1. the pure tone audiogram showed normal hearing with an 8khz dip in the right ear and moderate to severe sensorineural hearing loss in the left ear. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 featured grand rounds 62 philippine journal of otolaryngology-head and neck surgery laryngeal stenosis is a partial or complete narrowing of the endolarynx and has many etiologies. common causes of laryngeal stenosis are iatrogenic (prolonged intubation, laryngeal surgery), external neck trauma, congenital, burns, ingestions, infection, and inflammation (gastroesophageal reflux or wegener’s). laryngeal stenosis secondary to trauma usually affects the posterior endolaryngeal region in adults and the subglottic region in children.1 patients with mild to moderate laryngeal stenosis are usually asymptomatic and if otherwise, majority of the presenting signs and symptoms are mainly related to the airway, feeding and voice resulting to marked respiratory distress, dysphagia/odynophagia and altered voice, respectively. we present a case of hypopharyngeal, supraglottic and subglottic stenosis occurring 1 week after intubation. case report a 3-year-old boy from ormoc city was admitted in our institution for dysphagia of 2 months. three months prior to admission, he was treated for hypersensitivity reaction after eating shrimp and crab. the boy experienced sudden onset perioral swelling with bluish discoloration, dyspnea, severe drooling and vomiting of previously ingested food immediately after taking a vitamin supplement syrup that had been preceded by the dinner of crustaceans. he was immediately brought to a primary hospital in ormoc city but was not relieved by nebulization and unrecalled intravenous medications. the boy was eventually transferred to a tertiary hospital in ormoc city. during this time, perioral swelling, dyspnea and cyanosis with associated severe drooling persisted. he was also noted to have stridor, was intubated and subsequently admitted to the intensive care unit for 7 days with an impression of severe hypersensitivity reaction secondary to crustacean ingestion. he was fed via a nasogastric tube (ngt). his condition eventually improved and the endotracheal tube was removed after 7 days. according to the relatives, there was significant increase in expectoration of saliva hours after removal of the endotracheal tube, allegedly occurring almost every minute, accompanied by drooling. there was no fever, no difficulty of breathing, no aspiration, no vomiting episodes and no easy fatigability noted at this time. however, the boy was noted to have dysphagia associated with frequent coughing and expectoration of saliva on intake of both fluids and solid food following removal of the ngt. his relatives denied any episodes of dyspnea, vomiting, cyanosis, easy fatigability or fever, and he was subsequently discharged after 1 month of confinement. one month and three weeks prior to admission, he still presented with dysphagia, frequent spitting of saliva and now with associated wheezing and weight loss on follow-up at the hospital. he was referred to a pediatric pulmonologist in cebu city for further evaluation and management. one month before admission, a thickened epiglottis was seen on neck and chest ct-scan and “acquired subglottic stenosis, post intubation” was diagnosed, for which direct laryngoscopy was recommended. the relatives did not consent, and the boy was discharged on betamethasone + dexchlorpheniramine syrup for 5 days, montelukast na oral granules for 30 days, and amoxicillin suspension and salbutamol syrup for 7 days. nineteen days prior to admission, with persistence of the previously-mentioned symptoms, the boy was brought to our outpatient service and subsequently admitted. hypopharyngeal, supraglottic and subglottic stenosis after 1-week intubation correspondence: dr. niel khangel s. reyes department of otorhinolaryngology head and neck surgery armed forces of the philippines medical center 7th floor armed forces of the philippines medical center v. luna avenue, quezon city 0840 philippines phone: (632) 426 2701 local 6172 email: nielkhangel_reyes@yahoo.com reprints will not be available from the author. the author declares that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. niel khangel s. reyes, md department of otorhinolaryngology head and neck surgery armed forces of the philippines medical center philipp j otolaryngol head neck surg 2015; 30 (2): 62-64 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 philippine journal of otolaryngology-head and neck surgery 63 featured grand rounds on admission, he was ambulatory and not in cardiorespiratory distress. he still had symptoms of increased expectoration and drooling with associated dysphagia for both liquids and solid foods. because of difficulty inserting a nasogastric tube, he had to subsist on small, frequent sips of fluids consisting mostly of milk and water. fluid thickeners improved swallowing. initial flexible nasopharyngolaryngoscopy revealed a thickened epiglottic area obscuring the vocal cords. a modified barium swallow and airway fluoroscopy showed aryepiglottic fold thickening and non-persistent episodes of narrowing at the supraglottic and glottic areas. a trace of nasopharyngeal regurgitation was also noted without any gross tracheal aspiration. flexible nasopharyngolaryngoscopy by a laryngologist revealed a normal nasopharynx, absent epiglottis, absent pyriform sinuses, stenotic hypopharynx and supraglottis, normal vocal cord structure and mobility with grade 1 subglottic stenosis. (figures 1 a-d) possible laser surgical release of fibrosis and removal of strictures was recommended, with close observation until then. meanwhile, due to persistent dysphagia and significant weight loss, he underwent gastrostomy and was started on supplements for nutritional build up. figure 1a. normal nasopharynx a figure 1b. absent epiglottis b figure 1c. absent pyriform sinuses; stenotic hypopharynx and supraglottis c figure 1d. normal vocal fold structure and mobility with grade 1 subglottic stenosis d discussion laryngeal stenosis is a partial or complete cicatricial narrowing of the endolarynx and may be congenital or acquired.1 trauma is the most common cause of acquired laryngeal stenosis, both in children and in adults, and is classified as external laryngeal trauma or internal laryngeal trauma. the latter is more commonly due to iatrogenic causes, especially prolonged endotracheal intubation.2 approximately 90% of cases of acquired chronic subglottic stenosis in infants and children occur secondary to endotracheal intubation. the reported incidence of stenosis after intubation ranges from less than 1% to 8.3%.1 in our case, the patient initially presented with persistent dysphagia with associated excessive drooling and increased expectoration after intubation for 1 week. a study by gallo et al. of 70 patients with laryngeal stenosis revealed that the causes of stenosis may be numerous (including intubation, autoimmune disease, iatrogenic) and multiple areas of the airway can be involved.3 the reported incidence of tracheal stenosis following laryngotracheal intubation ranges from 6% to 21%.3 they further explained that erosion and mucosal necrosis occur within hours of philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 featured grand rounds 64 philippine journal of otolaryngology-head and neck surgery endotracheal intubation and full thickness injury exposes cartilage with development of perichondritis if the tube is not withdrawn within a week. re-epithelialization of the edges of the ulceration follows and healing is completed within 4 weeks. the previous site of the ulceration is usually marked with fibrosis and metaplastic squamous epithelium. the risk of tissue damage and development of laryngotracheal stenosis increases depending on the severity of the ulceration and if the healing process is delayed by secondary infection.3 duration of intubation and size of the endotracheal tube are the most important factors in the development of laryngeal stenosis, but no definite safe time limit for endotracheal intubation has been established. severe injury has been reported after 17 hours of intubation in adults and 1 week after intubation in neonates. the area most commonly injured in children is the subglottic region.1 initial evaluation when suspecting laryngeal stenosis includes radiographic evaluation to aid in assessing the degree and length of stenosis. computed tomography scanning (ct) and magnetic resonance imaging (mri) scanning are not standard techniques to assess the laryngotracheal airway but may be used as an adjunctive diagnostic technique to help determine the length of the stenosis or concurrent vascular compression.4 initial computed tomography (ct) scans prior to admission revealed only thickening of the epiglottis with narrowing of the subglottic region. the extent of involvement was not determined until flexible nasopharyngolaryngoscopy revealed absence of the epiglottis and pyriform sinuses, hypopharyngeal and supraglottic stenosis and grade 1 subglottic stenosis with normal vocal cord structure and mobility. flexible and rigid endoscopy should be a part of assessment as they allow direct inspection of the dynamic laryngeal and hypopharyngeal airway.4 as illustrated in this case, fluoroscopy is also helpful in studying tracheal dynamics.1 the basic techniques for management of laryngeal stenosis include endoscopic and external methods. wiatrak suggested that conservative management or a “wait-and-see” approach may be considered.4 the management of laryngeal stenosis in infants and young children should be conservative, since in the majority of cases, the stenosis will improve with laryngeal growth.5 while such management may be considered in our case, it is rarely successful for acquired laryngeal stenosis. endoscopic methods including balloon dilatation and laser assisted excision are options, although the former is only beneficial in cases of early, soft stenosis, before mature, firm stenosis has developed.4 open surgical methods include expansion and resection surgery. open surgical procedures should only be recommended when it has been established by careful endoscopic assessment that the laryngeal lumen has not increased in size.5 according to gallo et al., tracheal resection and anastomosis is considered the treatment of choice for tracheal stenosis.3 however, this approach may not be applicable when the glottis and/or the subglottis are also involved. moreover, it may not be feasible due to the extent of the stenosis, underlying disease and general health of the patient.3 while grade 1 stenosis may be managed by open surgery, it may also be amenable to endoscopic techniques. the challenge for this case includes correction of the laryngeal area, ensuring stability of airway and improving general status and health with the least invasive management possible. the use of stents offers another management option for laryngeal stenosis. alshammari and monnier used laryngotracheal stents on 65 patients during open surgery and endoscopy to keep the airway expanded after surgical reconstruction or trauma. however, they also reiterate that stents should be avoided unless absolutely necessary since there are potential risks for mucosal injuries, ulcerations, granulation tissue formation and subsequent restenosis.6 according to zanetta et al., there is no ideal stent for the treatment of subglottic stenosis in children and that it can act as a foreign body in the reconstructed airway causing difficulties for feeding and in voice production.7 our proposed method for addressing the laryngeal stenosis is to attempt laser excision to correct the affected areas and hopefully improve the feeding status while ensuring stability of the airway. at present, nutritional build up is the initial target in preparation for the contemplated procedure. laryngeal stenosis in the pediatric population is one of the most controversial topics in pediatric otolaryngology. there are various techniques available for management of laryngeal stenosis. therapeutic procedures range from repeated dilatation, prolonged laryngeal stenting with or without the use of steroids, the use of carbon dioxide laser to create an airway with or without tracheostomy (through a laryngeal mask airway), to early tracheostomy and open surgery.5,8 however, feasibility of the technique, invasiveness, as well as possible outcome are some of the problems a physician may encounter. we should always consider individualizing our management according to pathologic findings, patient’s age, degree and consistency of stenosis and importantly, the general condition of the patient. echoing evans, one could at least give the parents of pediatric patients a reasonably accurate prognosis, and the hope that their child can be restored to normality.5 references 1. zalzal gh, cotton rt. glottic and subglottic stenosis. in: flint pw, haughey bh, lund vj, niparko jk, richardson ma, robbins kt et al., editors. cummings otolaryngology head and neck surgery. 5th edition. philadelphia: mosby; 2010. p. 2912-2924. 2. khalid an, goldenberg d. surgical management of upper airway stenosis. in: flint pw, haughey bh, lund vj, niparko jk, richardson ma, robbins kt et al., editors. cummings otolaryngology head and neck surgery. 5th edition. philadelphia: mosby; 2010. p. 943-952. 3. gallo a, pagliuca g, greco a, martellucci s, mascelli a, fusconi m, de vincentiis m. laryngotracheal stenosis treated with multiple surgeries: experience, results and prognostic factors in 70 patients. acta otorhinolaryngol ital. 2012 jun; 32(3): 182-188. 4. wiatrak bj. glottic and subglottic stenosis in children. in: ossoff rh, shapshay sm, woodson ge, netterville j, editors. the larynx. philadelphia: lippincott williams and wilkins; 2003. p. 451469. 5. evans jng. stenosis of the larynx. in: kerr ag, groves j, evans jng, editors. scott-brown’s otolaryngology volume 6. 5th edition. london: butterworth; 1987. p. 34. 6. alshammari j, monnier p. airway stenting with the lt-mold for severe glotto-subglottic stenosis or intractable aspiration: experience in 65 cases. eur arch otorhinolaryngol. 2012 dec; 269(12): 2531–2538. 7. zanetta a, cuestas g, rodriguez h, tiscornia c. a novel laryngeal stent in the treatment of subglottic stenosis in children. acta otorrinolaringol esp. 2014; 65(2): 120-122. 8. vorasubin n, vira d, jamal n, chhetri dk. airway management and endoscopic treatment of subglottic and tracheal stenosis: the laryngeal mask airway technique. ann otol rhinol laryngol. 2014 april; 123(4): 293-298. philippine journal of otolaryngology-head and neck surgery 43 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports philipp j otolaryngol head neck surg 2015; 30 (1): 43-46 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to report a case of a large sinus haller cell that presented with chronic rhinosinusitis and proptosis and its surgical management. methods: design: case report setting: tertiary government hospital patient: one results: a 34-year-old lady with proptosis and secondary sinusitis due to a giant infected haller cell was successfully treated by lateral rhinotomy approach and clearance of all diseased mucosa therein into the nasal cavity. conclusion: approach to diseased sinonasal structures via lateral rhinotomy is an alternative to endoscopic sinus surgery in the presence of an unusually large haller cell. keywords: haller cell, proptosis, maxillary sinusitis, lateral rhinotomy ‘haller cells’ — named after swedish anatomist albrecht von haller are abnormally migrated anterior or posterior ethmoid air cells that may pneumatize the roof of the maxillary sinus. with an incidence reported to vary from 2-45%,1 haller cells are usually seen in the inferomedial wall or floor of the orbit (i.e. roof of the maxillary sinus) at the level between medial and inferior rectus, adjacent to and above the natural ostium of maxillary sinus. although a haller cell is considered a normal anatomical variant, when enlarged it can significantly constrict the posterior aspect of the ethmoidal infundibulum and maxillary ostium from above. if such a cell becomes diseased, the natural ostium of the maxillary sinus may rapidly become obstructed and secondary maxillary sinusitis may develop. a statistically significant increase in maxillary sinus mucosal disease was associated with medium to large haller cells (45.8%) compared with small cells (28.9%,p<0.05).2 an unusually large haller cell also hinders the approach to other sinonasal diseasesed structures during endoscopic sinus surgery. the prevalence of haller cells on panoramic radiographs is 38.2% but the incidence with which they are seen in a normal population may be less frequent than in individuals with chronic rhinosinusitis.3 diagnosis of haller cells is typically made by ct scans as they cannot be identified by diagnostic nasal endoscopy because of their typical location lateral to the infundibulum. sinoscopic examination of the maxillary antrum can also identify an enlarged or diseased haller cell. only diseased haller cells or large cells blocking the ethmoidal infundibulum need to be addressed surgically and endoscopic resection of such cells remains the lateral rhinotomy for a large, infected haller cell causing proptosisdebangshu ghosh, ms 1 dilip kumar baruah, ms (ent)2 subodh chandra goswami, ms (ent)3 sumit kumar basu, ms (ent)1 1department of ent r.g.kar medical college and hospital, kolkata,west bengal, india 2private practitioner guwahati, assam, india 3department of ent guwahati medical college guwahati, assam, india correspondence: dr. debangshu ghosh kalyan nagar (near k.g. school) p.o.-kalyan nagar, via-panshila, dist.-24 parganas (north), kolkata700112 west bengal india phone: +91 33 9038336301/ +91 33 25680293 e-mail: ghoshdr.d777@ymail.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each authorbelieves that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports 44 philippine journal of otolaryngology-head and neck surgery treatment of choice. surgical intervention is also indicated when a haller cell contributes to ostiomeatal complex obstruction and inflammation of the sinuses. we report the case of a large infected haller cell causing proptosis and maxillary sinusitis that achieved complete remission after the cell was excised through a lateral rhinotomy approach instead of endoscopically. case report a 34-year-old woman presented in the department of ent of gauhati medical college & hospital with progressive frontal headache and nasal congestion for one year, right-sided nasal obstruction with on-and-off foul, purulent nasal discharge and outward protrusion of the right eyeball for six months, and a painful, red swelling below the right medial canthus for 10 days with intermittent fever. she was initially diagnosed with preseptal orbital cellulitis resulting from acute on chronic maxillary sinusitis and was started on broad-spectrum systemic antibiotics, topical and systemic nasal decongestants. the headache started insidiously and initially localized to the right side only before it became generalized. there were no changes in vision, nasal bleeding, weight loss or swelling in the neck or anywhere else in the body. unrelieved after consulting several ophthalmologists, she attended the ent department and was admitted. the patient was normotensive, non-diabetic, on average diet and an occasional betel-nut chewer. she was not immunocompromised and there was no significant past or family history. on general survey, she was afebrile with pulse rate of 70/min and bp-110/70 mmhg. there was a tense, mildly tender fluctuant swelling situated just below the right inner canthus with reddening of superficial skin. the right eye was superolaterally displaced but visual acuity and intraocular pressure were normal. (figure 1) on anterior rhinoscopy there was a well-circumscribed fleshy mass arising from the right lateral nasal wall that did not bleed on probing. on nasal endoscopy with a 0˚ 4 mm telescope, the swelling was seen to arise from the lateral nasal wall in the region of the middle turbinate axilla beyond which the endoscope could not be passed and the exact origin of the mass could not be determined. initially, occipitomental radiographs did not reveal any abnormality except right-sided maxillary sinusitis. paranasal and orbit ct scans revealed a large, well-defined, fairly hypodense lesion along the roof of the right maxillary sinus showing fairly formed bony walls. it showed severe mass effect compressing the maxillary sinus and nasal cavity and distorting the ostiomeatal unit, middle turbinate, frontal recess and ethmoid sinus without sclerosis or erosion of surrounding bones. the mass encroached into the orbit causing displacement of the medial rectus and inferior rectus muscle and intraconal fat and causing figure 1. patient with right-sided proptosis and local skin inflammation. photo printed in full with permission. proptosis of the globe. (figure 2) the overall impression was of a large haller nasi cell with mass effect on right sinonasal structures. punch biopsy revealed congested and inflamed tissue lined by epithelium. broad-spectrum parenteral antibiotics were started according to our hospital protocol, consisting of cefotaxime-sulbactum and tinidazole along with an analgesic and oral decongestant. owing to the palpable swelling in the medial canthus of the right eye, we opted for a lateral rhinotomy (moore) incision for easy access and wide exposure. immediately beneath the subcutaneous tissue in the superomedial portion of the maxillary sinus roof, a 1.5 cm diameter mass lined by a thin bony capsule was punctured yielding frank pus. the sac was freely communicating with the ipsilateral nasal cavity. proptosis decreased immediately and the inferomedial orbital wall was intact. (figure 3) the wound was closed in layers and an antibiotic-impregnated anterior nasal pack was inserted. postoperative antibiotics were given for 7 days and the nasal pack and stitches were removed after 48 hours and 7 days, respectively. the patient was regularly followed up and was doing well at 2 weeks, 1 month and 6 months with no recurrence of symptoms. (figure 4) discussion since the development of endoscopic sinus surgery techniques, pneumatization of anatomic structures of the nose and paranasal sinuses has become a topic of increasing importance to rhinologists. anatomic variations in the nose and sinuses do not necessarily indicate a pathologic state but can predispose some patients to sinus diseases by causing obstruction that can lead to inflammatory disease. a haller (infraorbital) cell is such an anomaly that can narrow the ostiomeatal philippine journal of otolaryngology-head and neck surgery 45 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports figure 2 a & b. axial and coronal computed tomography images showing right haller cell encroaching into the orbit (causing proptosis), maxillary antrum and nasal fossa. a haller cell can be solitary or multiple and can be classified as small, medium or large.7 asymptomatic in a majority of patients,1 haller cells may present with various symptoms. progressive frontal headache was one of the presenting complaints of our patient. in a study by hammad et al. sinus ct revealed haller cell in 5 (18.75%) of 40 patients with rhinogenic headache.8 sinusitis can result from infundibular obstruction with or without another anatomical variation such as concha bullosa. figure 3. intraoperative photograph showing tip of the cannula in the haller cell figure 4. post-operative appearance of the patient. photo printed in full with permission. a b complex if large.4 as migrated anterior ethmoidal air cells that pneumatize the roof of the maxillary sinus or floor of the orbit, they are also termed ‘orbitoethmoidal’ or ‘maxilloethmoidal’ cells. easily seen on coronal computerized tomography (ct) of the sinuses,5 they have been described as well-defined, round, oval or teardrop-shaped, unilocular or multilocular radiolucencies with smooth borders that may or may not appear corticated, located medial to the infraorbital foramen.6 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports 46 philippine journal of otolaryngology-head and neck surgery acknowledgement the authors would like to thank the principal, gauhati medical college and hospital for allowing us to conduct the work. references 1. stallman js, lobo jn, som pm. the incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. ajnr am j neuroradiol. 2004 oct; 25(9):16131618. 2. stackpole sa, edelstein dr. anatomic relevance of haller cells in sinusitis. am j rhinol. 1997 may-jun; 11(3):219-223. 3. ahmad m, khurana n, jaberi j, sampair c, kuba rk. prevalence of infraorbital ethmoid (haller’s) cell on panoramic radiographs. the saudi dental journal. 2006 may; 101(5):658-661. 4. stammberger h, hawke m. endoscopic and radiologic diagnosis. in: essentials of endoscopic sinus surgery. st. louis, missouri: mosby;1993.p.92. 5. yanagisawa e, citardi mj. endoscopic view of the infraorbital ethmoid cell (haller cell). ear nose throat j. 1996 jul; 75(7):406-407. 6. raina a, guledged mv, patil k. infraorbital ethmoid (haller’s) cells: a panoramic radiographic study. dentomaxillofac radiol. 2012 may; 41(4):305-308. 7. balasubramanian t. infected haller cell. radiology image of the issue. otolaryngology journal online. 2012 jul; 2(1). [cited 2015 mar 9]. available from: http://works.bepress.com/drtbalu/48 8. hammad ms, gomaa ma. role of anatomical nasal abnormalities in rhinogenic headache. egypt j ear, nose, throat allied sci. 2012 mar; 13(1):31-35. 9. wanamaker hh. role of haller’s cell in headache and sinus disease: a case report. otolaryngol head neck surg.1996 feb; 114(2):324-327. 10. sebrechts h, vlaminck s, casselman j. orbital edema resulting from haller’s cell pathology: 3 case reports and review of literature. acta otorhinolaryngol belg. 2000; 54(1):39-43. 11. christmas da, mirante jp, yanagisawa e. endoscopic view of the removal of an obstructing haller’s cell. ear nose throat j. 2006 jun; 85(6): 360-1. in the absence of frank sinusitis, blockage of the sinus drainage pathway may result in sinus malventilation, vacuum headache and pressure headache. headache was mostly located at frontal area (64%) followed by face and periorbital area (36% each).8 our case also presented with sinusitis and proptosis. haller cell may cause recurrent or chronic sinusitis and persistent sinugenic headache without significant findings on physical examination including nasal endoscopy and the presence of a large ethmoidal cell on coronal ct in a patient with corresponding symptoms deserves consideration as the potential cause of the symptoms.9 orbital involvement from haller cell is very rare and infrequently reported in the literature. sebrechts et al. reported three cases of unilateral orbital edema resulting from inflammation of ipsilateral haller cell.10 we believe proptosis resulting from a large haller cell as we found in our case has not been reported in the english literature. the management of pathologic haller’s cell is usually approached endoscopically through the middle meatus using a microdebrider to remove the uncinate process including its inferior attachment.11 the cell is visualized and carefully uncapped with a curved microdebrider blade and then its inferior and medial portions are carefully removed. the procedure widens the infundibulum and the outflow tract of the maxillary sinus. the superior portion of the haller’s cell is not dissected so that integrity of the orbital floor is not disturbed.11 a previous study reported that overall improvement in headache intensity after endoscopic surgical intervention was statistically significant (p = 0.003).8 in our case as the swelling presented more subcutaneously just below the medial canthus than in the nasal cavity, we opted for lateral rhinotomy approach. this avoided difficulty in finding the antrum due to its distortion from a large cell situated above as well as inadvertent orbital entry. this approach also provided quick exposure to the operative area. however, this approach may be feasible only for haller cells large enough to cause cosmetic deformity of overlying nasal skin. further experience may be necessary to prove its effectiveness and formulate indications for its use. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 22 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2013; 28 (2): 22-25 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to present a rare case of a large ossifying fibroma of the frontoethmoid sinus and describe our experience with the clinical presentation, diagnosis, management dilemmas, surgical approach and outcome of our patient. methods: design: case report setting: tertiary government general hospital patient: one results: a 29-year-old housewife consulted with a large left frontoethmoidal mass of 20 years duration causing significant facial deformity, left eye proptosis, headache and psychosocial distress. initial ct scans and mri revealed a well-encapsulated mass occupying the frontoethmoid sinus, left orbit and anterior cranial fossa and subsequent surgical management involved three important aspects: 1) wide extirpation of the tumor; 2) preservation of the brain, left orbital contents and function; and 3) reconstruction of the facial defect using calvarial bone graft, abdominal fat and temporalis muscle flaps. conclusion: a large ossifying fibroma of the frontoethmoidal sinus threatens the integrity of the vital structures it compresses and poses compelling diagnostic and surgical challenges. adequate imaging, multidisciplinary planning and surgical expertise are needed to ensure a successful outcome. keywords: ossifying fibroma, frontoethmoid sinus, mucocele, orbital preservation, calvarial bone graft, abdominal fat graft ossifying fibroma is a rare, benign, slow-growing neoplasm commonly found in the maxillarymandibular area. it is infrequently found in the paranasal sinuses much less in the frontoethmoidal area. delayed surgical management may allow these lesions grow to massive proportions and cause a variety of complications demanding specialized multidisciplinary treatment. we present one such case. case report a 29-year-old single mother of three from camarines norte, philippines consulted for a large left orbital mass that began 20 years ago with progressive proptosis of her left eye associated with tearing and redness with no medical consult or medications. about 16 years ago, she started to have severe episodic left sided headache and consulted a private physician. a ct scan revealed a left frontoethmoid sinus tumor with intracranial and retro-orbital extension. she underwent partial transcranial excision of the left retro-orbital mass relieving left eye proptosis and headache. histopathology revealed cementifying fibroma. she was then advised complete excision of the frontal sinus tumor but was unable to comply because of personal and financial reasons. she was discharged improved after three weeks. giant ossifying fibroma of the frontoethmoid sinus: a silent periljoman q. laxamana, mdrene louie c. gutierrez, md roberto c. claridad, md department of otorhinolaryngology head and neck surgery east avenue medical center correspondence: dr. joman q. laxamana department of otorhinolaryngology head & neck surgery 6th floor, east avenue medical center east avenue, diliman, quezon city 1100 philippines phone: (632) 928 0611 local 324 fax: (632) 435 6988 email: jqlaxamana@gmail.com reprints will not be available from the author the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the interesting case contest (2nd place), philippine society of otolaryngology head and neck surgery, best western hotel, a venue, makati city, may 23, 2013. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 case reports philippine journal of otolaryngology-head and neck surgery 23 meanwhile, the left orbital mass progressively enlarged with anteroinferior displacement of the left eyeball causing gross physical deformity and significant social and emotional distress. remarkably, she claimed to have no blurring of vision or diplopia. four months before admission with a still enlarging left orbital mass and occasional mild headache she consulted at our institution and was subsequently admitted. ct scan and mri results revealed a 6.2 x 7.0 x 9.6cm predominantly cystic irregularly shaped mass with multiple enhancing internal septations and solid components. the mass compressed the skull base and left frontal lobe superiorly, the left maxillary sinus inferiorly, the left superior nasal turbinate medially, temporal bone laterally and the frontal and temporal lobe posteriorly. (figure 1) a b figure 1. a. ct scan showing the frontoethmoid mass and inferoanteriorly displaced left orbit b. mri showing the hyperintense ossifying fibroma with a surrounding expansile mucocele figure 2. preoperative photo showing a large left frontoethmoid mass causing inferoanterior displacement of the left orbit figure 3. preoperative planning using 3d rendering and virtual excision of the mass using surgicase® 5.0 (materialise, belgium) physical examination showed a 7.0 x 6.5 cm hard, fixed, non-tender left orbital mass with associated proptosis and inferior displacement of the left eye. (figure 2) both eyes were equally reactive to light with a visual acuity of 20/20 for the right eye and 20/125 for the left. there was moderate upward gaze deficit in the left eye. preoperative evaluation with 3-d rendering using surgicase® 5.0 (materialise, belgium) showed a substantial defect that could cause orbital compromise, brain herniation and difficult reconstruction. (figure 3) a virtual excision allowed accurate planning of the surgical approach minimizing intraoperative decision making. in the operating room, a coronal incision and midfacial degloving exposed the mass from which 10cc of straw-colored fluid was aspirated. (figure 4) the bony capsule of the mass was meticulously extirpated from all its attachments preserving the frontal lobe and left eyeball yielding a 6 x 7 x 10 cm round, well delineated cystic mass with a bony capsule. (figure 5) the orbital floor was intact but inferiorly displaced. the left optic nerve and extraocular muscles were elongated but preserved. posteriorly, the anterior and posterior frontal tables had been eroded exposing a 4 x 3 cm portion of the frontal lobe with intact dura, which was assessed to have no need for mesh support. (figure 6) an abdominal fat graft was laid into the orbital defect, followed by an ipsilateral temporalis muscle sling supporting the frontal lobe. (figure 7) a right parietal split-thickness calvarial bone graft was contoured and fixed into the left superior orbital rim. the donor site was also covered with a right temporalis muscle sling. (figure 8) the procedure lasted six hours with a total estimated blood loss of 500cc. postoperative neurosurgical monitoring showed no neurologic deficits. ophthalmologic evaluation revealed decreased proptosis (figure 9) with the same preoperative extraocular movement on the left eye and acceptable visual acuity. the patient recovered uneventfully without any dizziness, headache or diplopia and was subsequently discharged. final histopathological examination of the mass revealed ossifying fibroma. she was well at one-month follow-up. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 24 philippine journal of otolaryngology-head and neck surgery case reports figure 6. posterior frontal table defect. the intact dura is seen shining at the posterior wall of the mass. figure 7. a. overlaying of abdominal fat b. temporalis muscle sling supporting the orbit c. harvesting of calvarial bone graft d. contouring of the graft figure 4. a. coronal incision markings b. aspiration of cystic contents a b figure 5. extirpation of the bony capsule grasped using a babcock c l amp. a b c d figure 8. a. fixation of the calvarial bone graft using titanium plates and screws b. temporalis muscle sling over the donor site a b figure 9. post-operative photo showing decreased proptosis philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 case reports philippine journal of otolaryngology-head and neck surgery 25 obstructing paranasal sinus lesions have also been shown to cause dural defects and intradural expansion.8 this case showed that careful extirpation and thorough intraoperative neurosurgical evaluation can justify a conservative approach to the management of frontal bone defects. calvarial bone grafts have been used to reconstruct defects of the anterior cranial fossa and orbit to obtain satisfactory aesthetic and functional results with minimal complications.9 abdominal fat has been used as a safe and practical orbital implant following ocular evisceration despite its gradual volume reduction over time.10 temporalis muscle flaps have also been utilized in reconstruction of facial defects after excision of ethmoid tumors.11 this case provides evidence that these autologous grafts can safely be used to reconstruct large craniofacial defects. currently the patient is well and free of recurrence. the proptosis has been markedly reduced allowing her to wear sunglasses to protect and conceal her left eye. a second stage orbital reconstruction is planned after six months to allow the orbit to assume a definite position after adequate wound healing, fat resorption and contraction. in summary, a large ossifying fibroma of the frontoethmoid sinus is a rare condition appearing as an externally enlarging mass that can cause significantly more internal destruction while asymptomatic but gradual mucocele formation, bony erosions, brain involvement and orbital displacement put the patient in significant peril. ct scans and mri are vital in accurate diagnosis and surgical planning. a multidisciplinary approach to complete surgical resection is needed for successful excision and functional orbital preservation. the use of autologous reconstructive methods such as calvarial bone graft, abdominal fat and temporalis muscle flaps were effective, safe and practical options in this case. discussion ossifying fibroma is a benign maxillofacial fibro-osseous lesion commonly located in the mandibular molar area and rarely found in the frontoethmoid area.1 usually, it is neither aggressive nor excessively destructive but has a propensity for osseous cortical expansion approximately equal in all directions. it is more frequent in women than in men (4:1) in the third and fourth decade of life. clinically, these tumors manifest as painless, well delineated, slow-growing masses that may become large and destructive over time. the prognosis is excellent after complete excision and malignant transformation has not yet been documented.2 recurrence rates are as high as 30 to 58%.3 a google scholar and pubmed search of medline using the keywords “ossifying fibroma,” “frontoethmoid,” and “frontal-ethmoid” suggests that this is the third reported case of an ossifying fibroma of the frontoethmoid sinus in the english literature and the only account of an ossifying fibroma causing a large craniofacial defect and significant orbital displacement. a local literature search suggests that this is the first account of a frontoethmoid sinus ossifying fibroma in the philippines. the atypical presentation of the mass posed several surgical challenges, including difficult wide extirpation of the mass, preservation of the brain and eye and formidable reconstruction of the large defect. the ossifying fibroma appeared in the ct scan as a single large, irregularly shaped multicystic heterogenous entity causing surrounding osteolytic changes. but on mri, it appeared as a round, well encapsulated cystic mass surrounded by an expansile osteolytic mucocele that may have originated from an obstruction of the frontal recess. there are only a few reports of mucoceles caused by ossifying fibromas4,5 and this case is the first to show its formation in the frontal sinus. the high recurrence rate of ossifying fibromas necessitates complete excision of the mass including involved orbital structures, frontal bone and dura. although this radical extirpation can lead to debilitating complications like blindness, brain herniation, bleeding, cerebrospinal fluid leak and intracranial infections, the latter mri findings of mucocele formation led to a more conservative surgical approach. this experience emphasizes the need for sufficient diagnostic imaging. orbital exenteration is an indicated treatment for malignant tumors, but there are indications for exenteration in benign orbital disease, including uncontrollable pain, blindness, cosmetic disfiguration and tendency of infiltration and malignant transformation.6 in this case, exenteration could address the possibility of orbital infiltration and cosmetically unacceptable proptosis but would also cause iatrogenic blindness. ultimately, the orbit was preserved despite its inferior displacement because ophthalmological evaluation showed an intact globe, optic nerve and extraocular muscles. there are no reports known to us of an ossifying fibroma causing direct intradural extension, although excision of a frontal sinus ossifying fibroma can cause iatrogenic csf leak.7 mucoceles associated with acknowledgment the authors are grateful to drs. fp nolasco, na almazan, am chiong, ja malanyaon, jf david, em donato, aa monroy and az alcarde for their general support and useful critiques. our special thanks are also extended to dr. jf lapeña for his patient and thorough supervision in the review of this work. references cardesa a, slootweg pj. pathology of the head and neck. new york berlin heidelberg: springer; 1. 2006. ghom ag. textbook of oral radiology. india: elsevier; 2008.2. shekhar mg, bokhari k. juvenile aggressive ossifying fibroma of the maxilla3. . j indian soc pedod prev dent 2009;27(3):170-4. vaidya am, chow jm, goldberg k, stankiewicz ja. juvenile aggressive ossifying fibroma pre-4. senting as an ethmoid sinus mucocele. otolaryngol head neck surg 1998;119(6):665–8. gezici ar, ergün r. giant ossifying fibroma complicated by mucocele of sphenoid sinus--case 5. report. neurol neurochir pol. 2008 sep-oct; 42(5):467-9. domínguez-polo a, castillo-laguarta j, cristóbal-bescós ja, salinas-alamán a, mateo-orobia 6. a. exenteration in benign orbital pathology: report of a case. arch soc esp oftalmol 2002 mar; 77(3):151-4. gotlib t, krzeski a, balcerzak j, niemczyk k. iatrogenic csf leak as a complication of osteoplastic 7. flap surgery of the frontal sinus. otolaryngol pol 2009 may-jun; 63(3):242-4. manaka h, tokoro k, sakata k, ono a, yamamoto i. intradural extension of mucocele complicat-8. ing frontoethmoid sinus osteoma: case report. surg neurol 1998 nov;50(5):453-6. ilankovan v, jackson it. experience in the use of calvarial bone grafts in orbital reconstruction. 9. br j oral maxillofac surg 1992 apr;30(2):92-6. chan e., khoo jl, lee jc, yu dk. primary dermis fat graft as orbital implant after evisceration. 10. hkjophthalmol 2010 dec; 16(1):14-18. suárez c, ferlito a, lund vj, silver ce, fagan jj, rodrigo jp, llorente jl, cantù g, politi m, wei 11. wi, rinaldo a. management of the orbit in malignant sinonasal tumors. head neck 2008 feb;30(2):242-50. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 case reports 20 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2012; 27 (2): 20-23 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to describe a case of juvenile angiofibroma with unusual protrusion out of the nasal cavity, and its management with surgery and radiotherapy. methods: design: case report setting: tertiary public referral centre patient: one results: a 17-year-old gentleman presented with a huge tumor protruding from his left nostril, diagnosed with juvenile angiofibroma stage iiia by mri and angiography. following successful pre-operative embolization, the protruding mass was ligated and truncated, followed by surgical resection via external approach. post-operative residual tumor was treated with adjuvant radiotherapy. there was no evidence of recurrence after nine months. conclusion: a high index of suspicion is of paramount importance in the diagnosis of ja and avoids the possibility of an unwarranted biopsy which could spell disaster. the most useful tools for diagnosis are mri and arterial angiography. treatment is primarily surgical. irradiation therapy has been reported to achieve satisfactory outcomes, especially for unresectable residual disease and/or intracranial extension, where total surgical resection is unlikely to be attained without unacceptable morbidity. keywords: juvenile angiofibroma, juvenile nasopharyngeal angiofibroma, head and neck tumor juvenile angiofibroma (ja) is a benign, highly vascular neoplasm affecting primarily male adolescents1 and accounts for 0.5% of all head and neck tumors.2 it often originates from the superior margin of the sphenopalatine foramen.3 the tumor may extend backwards into the nasal cavity and nasopharynx, laterally to the pterygopalatine fossa, involving the paranasal sinuses and infratemporal fossa. it may even invade the skull base and extend to cavernous sinus and pituitary fossa.4 the common clinical features include recurrent epistaxis and persistent nasal obstruction.5 we report a case of ja with unusual protrusion out of the nasal cavity. juvenile angiofibroma protruding from the nasal cavity voon hoong fong, md mohd razif mohamad yunus, mbbs, ms (orl-hns) department of otorhinolaryngology head and neck surgery faculty of medicine universiti kebangsaan malaysia medical centre kuala lumpur, malaysia correspondence: dr. voon hoong fong department of otorhinolaryngology head and neck surgery faculty of medicine universiti kebangsaan malaysia medical centre jalan yaakob latiff, bandar tun razak 56000 cheras, kuala lumpur, malaysia phone: (+601) 2613 6564 fax: (+603) 9145 6675 email: daihoong@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 case reports philippine journal of otolaryngology-head and neck surgery 21 case report a 17-year-old sabahan man presented with a one-year history of left nasal obstruction with recurrent epistaxis. examination revealed a brownish well defined mass measuring 6x5 cm protruding from his left nostril (figure 1). the rest of the physical examination was noncontributory. contrast-enhanced computed tomography (ct) scan showed a heterogenous mass occupying the left pterygopalatine fossa with anterior extension through the left nasal cavity protruding through the nose, lateral extension to the left infratemporal fossa, superior extension to the left ethmoidal and sphenoidal sinuses as well as the posterior part of the left orbit. (figure 2) magnetic resonance imaging (mri) further characterized the tumor as an enhancing mass with small intracranial extension to left middle cranial fossa and dural involvement. (figure 3) the radiographic features were suggestive of ja. angiography of both internal (ica) and external carotid artery (eca) revealed the tumor supplied by branches of both ica and maxillary arteries from both eca. seventy percent (70%) of the tumor-feeding vessels were successfully embolized. figure 4a and b shows the arteriogram before and after embolization. the definitive surgical procedure was performed the next day. the external nasal mass was first ligated and truncated from the nose. the internal portion of the tumor was resected via a weber ferguson figure 1. tumor protruding from the left nostril. figure 2. contrast ct scan (axial view) revealing the extent of the disease. figure 3. mri scan characterizing the tumor and showing intracranial involvement philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 22 philippine journal of otolaryngology-head and neck surgery case reports incision and canine approach. he made an uneventful recovery. histopathological examination showed that the tumor was made up of variably sized blood vessels set in a delicate fibrocollagenous background, consistent with ja. a post-operative ct scan showed residual enhancing mass in the left pterygopalatine fossa, infratemporal fossa, sphenoid sinus, and superior orbital fissure. he subsequently figure 4. angiogramsa, pre-embolization; b, post-embolization. figure 5. post-radiotherapy ct scan (axial view) revealing no evidence of recurrence. received 50gy radiotherapy given in 25 fractions over five weeks which eradicated the residual lesion. at nine months post-irradiation, nasal endoscopy and ct scan revealed no recurrence. (figure 5) discussion the diagnosis of ja was almost certain in view of the patient’s gender, age and clinical presentation. a tumor protruding from the nasal cavity can be very tempting for a tissue biopsy, but doing so in an unprepared circumstance could spell disaster. the diagnosis could have been easily missed were it not for the initial evaluation with imaging studies because ja does not usually present as a mass protruding from the nose. angiography further established the diagnosis and allowed embolization to be done in the same setting, the fisch6 classification (table 1) has been commonly used for staging the disease. there are three other commonly employed staging systems (table 2).7-9 none of these classifications mention tumor extension out of the nostril. staging is important to the surgeon to predict the outcome, to ascertain the chance of complete excision as well as to determine the approach to tumor resection. not counting the extranasal tumor extension, the patient in this case was stage iiia based on radkowski classification. he underwent selective angiography to establish a definite diagnosis and to embolize the feeding vessels. this method has been widely recognized to reduce intraoperative blood loss which in turn facilitates the removal of tumor.10 ungkanont et al. reported in a study with 43 cases that morbidity, recurrence and intraoperative complications decreased with embolization.11 however, there are several risks of embolization including bleeding, allergic reactions and a b philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 case reports philippine journal of otolaryngology-head and neck surgery 23 table 1. stages of the fisch classification6 references 1. tang ip, shashinder s, gopala krishnan g, narayanan p. juvenile nasopharyngeal angiofibroma in a tertiary centre: ten-year experience. singapore med j 2009 mar;50(3): 261-264. 2. bales c, kotapka m, loevner la, al-rawi m, weinstein g, hurst r, et al. craniofacial resection of advanced juvenile nasopharyngeal angiofibroma. arch otolaryngol head neck surg 2002 sep;128(9):1071-1078. 3. sennes lu, butugan o, sanchez tg, bento rf, tsuji dh. juvenile nasopharyngeal angiofibroma: the routes of invasion. rhinology 2003 dec;41(4):235– 40. 4. tewfik tl, tan ak, al noury k, chowdhury k, tampieri d, raymond j, et al. juvenile nasopharyngeal angiofibroma. j otolaryngol 1999 jun;28(3):145-51. 5. mendenhall wm, werning jw, hinerman rw, amdur rj, villaret db. juvenile nasopharyngeal angiofibroma. j hk coll radiol 2003;6(1):15-19. 6. andrews jc, fisch u, valavanis a, aeppli u, makek ms. the surgical management of extensive nasopharyngeal angiofibromas with the infratemporal fossa approach. laryngoscope 1989 apr;99(4):429-37. 7. chandler jr, goulding r, moskowitz l, quencer rm. nasopharyngeal angiofibromas: staging and management. ann otol rhinol laryngol 1984 jul-aug;93(4 pt 1):322-9. 8. sessions rb, bryan rn, naclerio rm, alford br. radiographic staging of juvenile angiofibroma. head neck surg mar-apr;3(4):279-83. 9. radkowski d, mcgill t, healy gb, ohlms l, jones dt. angiofibroma. changes in staging and treatment. arch otolaryngol head neck surg 1996 feb;122(2):122-129. 10. mann wj, jecker p, amedee rg. juvenile angiofibromas: changing surgical concept over the last 20 years. laryngoscope 2004 feb;114(2):291-3. 11. ungkanont k, byers rm, weber rs, callender dl, wolf pf, goepfert h. juvenile nasopharyngeal angiofibroma: an update of therapeutic management. head neck 1996 jan-feb;18(1):60-6. 12. cummings bj, blend r, keane t, fitzpatrick p, beale f, clark r et al. primary radiation therapy for juvenile nasopharyngeal angiofibroma. laryngoscope 1984 dec;94(12 pt 1):1599-605. 13. nicolai p, berlucchi m, tomenzoli d, cappiello j, trimarchi m, maroldi r, et al. endoscopic surgery for juvenile angiofibroma: when and how. laryngoscope 2003 may;113(5):775-82. strokes. the patient in this case was free from these complications. there are several modalities of treatment for ja, with surgical resection and irradiation therapy being the most successful. it is generally accepted that surgery is the treatment of choice while radiotherapy is best for recurrence post surgery or extensive tumor with significant intracranial extension (where total resection with acceptable morbidity is unlikely). there is also a relatively large series of 55 patients with ja, where 42 underwent radiotherapy as the primary therapy and 80% were successfully treated.12 surgical resection was essential for the patient in this case because he had a huge tumor protruding from his nostril, which was unlikely to regress with other treatments. it is also generally accepted that external approaches are superior in advanced tumors.13 in view of the tumor extent, the open approach was adopted. however, resection was incomplete due to intracranial extension. hence, adjuvant radiotherapy was given for residual disease. mendenhall et al. summarized six studies on the outcome of radiotherapy for ja.5 most patients in these series were those who exhibited recurrence after prior surgery or had intracranial extension. after completing radiotherapy, local control rates ranged from 73% to 100%. almost all those with recurrence after radiotherapy were successfully treated with another surgery or a second course of radiotherapy. hence, the ultimate local control was nearly 100%. our case shows that a high index of suspicion is of paramount importance in the diagnosis of ja and alleviates the possibility of an unwarranted biopsy, as an indiscriminate biopsy could spell disaster. the most useful tools are mri and arterial angiography. once the definite diagnosis is established, the treatment plan has to be mapped out which is primarily surgical. irradiation therapy has been reported to achieve satisfactory outcome, especially for unresectable residual disease and/or intracranial extension, where total surgical resection is unlikely to be attained without unacceptable morbidity. stage description i tumors limited to the nasal cavity nasopharynx with no bony destruction. ii tumors invading the pterygomaxillary fossa, paranasal sinuses with bony destruction. iii tumors invading the infratemporal fossa, orbit and parasellar region remaining lateral to the cavernous sinus. iv tumors with invasion to the cavernous sinus, optic chiasmal region and pituitary fossa. table 2. other staging systems for juvenile angiofibroma chandler et al, 19847 i tumor confined to nasopharyngeal vault ii tumor extending into nasal cavity or sphenoid sinus iii tumor extending into antrum, ethmoid sinus, pmf, orbit, and/or cheek iv intracranial tumor sessions et al, 19818 ia limited to nose and/or nasopharyngeal vault ib extension into ≥1 sinus iia minimal extension into pmf iib full occupation of pmf with or without erosion of orbital bones iic infratemporal fossa with or without cheek erosion iii intracranial extension radkowski et al, 19969 ia limited to nose and/or nasopharyngeal vault ib extension into ≥1 sinus iia minimal extension into pmf iib full occupation of pmf with or without erosion of orbital bones iic or posterior to pterygoid plates iiia erosion of skull base — minimal intracranial extension iiib erosion of skull base — extensive intracranial extension with or without cavernous sinus invasion philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports philippine journal of otolaryngology-head and neck surgery 21 abstract objective: to describe a rare case of nonkeratinizing carcinoma of the sinonasal tract and review the literature on the nomenclature of its many synonyms. methods: design: case report setting: tertiary referral center patient: one results: a 45-year-old female presented with a 6-month history of left nasal obstruction associated with epistaxis. computed tomography revealed a mass expanding the left nasal cavity with the epicenter arising from the anterior ethmoidal air cells. endoscopic resection of the tumor was carried out but as there was residual tumor, she then underwent endoscopic-assisted medial maxillectomy via a lateral rhinotomy. a subsequent computed tomography scan showed residual tumor adhering to the ipsilateral periorbita. the patient has so far declined intensity modulated radiotherapy that was advised though she is still under regular follow-up. conclusion: nonkeratinizing carcinoma of the sinonasal tract is a rare entity and there are very few reports concerning this type of malignancy. this may be partly due to its many synonyms, such as cylindrical cell carcinoma, schneiderian carcinoma and transitional cell carcinoma. nomenclature of this tumor should be standardized to avoid confusion and misdocumentation. keywords: nonkeratinizing carcinoma, schneiderian carcinoma, transitional cell carcinoma, cylindrical cell carcinoma, ringertz carcinoma, respiratory epithelial carcinoma non-keratinizing carcinoma of the sinonasal cavity is a rare entity. there are very few reports concerning this type of malignancy.1,2,3 this may be partly due to the many different terminologies by which it has been referred to, such as cylindrical cell carcinoma, schneiderian carcinoma and transitional cell carcinoma. we present a case of a sinonasal non-keratinizing carcinoma. the nomenclature and cytological aspects of this tumor will be discussed in detail. nonkeratinizing carcinoma of the sinonasal tract: a diagnosis of confusing nomenclature nur hashima abdul rashid, mbbs1 suria hayati md pauzi, md2 geok chin tan, mbbs, mpath2 salina husain, mbbs, ms (orl-hns)1 mohd razif mohammad yunus, mbbs, ms (orl-hns)1 balwant singh gendeh, mbbs, ms (orl-hns)1 1department of otorhinolaryngology head and neck surgery universiti kebangsaan malaysia medical center cheras, kuala lumpur, malaysia 2department of pathology universiti kebangsaan malaysia medical centre jalan yaacob latif, 56000 cheras kuala lumpur, malaysia correspondence: dr nur hashima abdul rashid department of otorhinolaryngology and head and neck surgery universiti kebangsaan malaysia medical centre jalan yaacob latif, 56000 cheras, kuala lumpur malaysia phone: 603-91456054/6045 fax: 603-91737840 e-mail: nurhashima@gmail.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (2): 21-24 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 22 philippine journal of otolaryngology-head and neck surgery case reports case report a 45-year-old female schoolteacher of chinese descent presented to a private hospital with a 6-month history of progressively worsening left nasal obstruction associated with epistaxis. there were no other symptoms in this previously well lady. clinical examination showed a friable mass occupying the left nasal cavity pushing the nasal septum to the opposite side. a complete head and neck examination did not reveal any evidence of cervical lymphadenopathy. a computed tomography scan of the paranasal sinuses showed a predominantly homogeneously-enhancing mass expanding the left nasal cavity and pushing the nasal septum to the right with inferior compression of the ipsilateral inferior turbinate. the epicenter of the mass appeared to be within the left anterior ethmoidal air cells. there was also thinning and displacement of the ipsilateral lamina papyracea noted but no evidence of subperiosteal or extraconal extension within the left orbit. a partial medial maxillectomy via lateral rhinotomy was aborted due to excessive intraoperative bleeding from the tumor. a month later, the patient was referred to us for further management of the residual tumor. histopathologic examination revealed a non-keratinizing (transitional cell) carcinoma. post-operative computed tomography of the paranasal sinuses showed an enhancing soft tissue mass occupying the left nasal cavity, extending antero-superiorly into the ethmoid and frontal sinuses and encroaching postero-superiorly the sphenoid sinus ostium. the left medial rectus muscle was pushed toward the orbit although the fat plane between mass and the muscle was preserved. there was dehiscence of the anterior and medial walls of the maxillary sinus and lamina papyracea (figure 1). we proceeded with a biopsy of the tumor in the outpatient clinic which was reported as non-keratinizing (transitional cell) carcinoma. endoscopic removal of the tumour was planned and an angiogram performed in view of the previous intraoperative bleeding. the feeding vessel was found to be the left internal maxillary artery (a branch of the sphenopalatine artery) and this was subsequently embolized. intraoperatively there was dehiscence of the medial wall of the maxillary sinus and the ipsilateral lamina papyracea was absent. ethmoidectomy, sphenoidectomy and frontal sinustomy were performed. the tumor occupying the maxillary, ethmoid, frontal and sphenoid sinuses was removed completely. tumor adhering to the periorbita was curetted. despite embolization, bleeding was profuse and the patient was nursed in the intensive care unit with blood and fluid resuscitation and recovery was uneventful. the patient was asymptomatic during post-operative followup, until ten weeks later when she reported a recurring epistaxis. endoscopic examination revealed a fleshy mass over the left periorbita. ophthalmologic assessment was unremarkable. the patient underwent another ct scan to assess the extent of the residual tumor which showed a mass adhering to the periorbita, extending to the frontal ethmoidal recess. a repeat angiogram demonstrated that the feeding vessel of the tumor was the left ophthlamic artery and embolization was abandoned in view of the high risk of blindness. the patient subsequently underwent an endoscopic assisted medial maxillectomy via lateral rhinotomy. histopathologic examination revealed nonkeratinizing (transitional) cell carcinoma of all tissue from the retrobullar area, frontal recess and cribiform plate. consequently the patient was advised to undergo intensity modulated radiotherapy in view of the residual tumor. since the risk of complications was inevitable to such a vital sense organ, the patient declined. she is nevertheless under close regular follow-up. discussion nonkeratinizing carcinoma (nkca) is a rare malignancy of the nose and paranasal sinuses. the incidence of sinonasal malignancy is approximately 3.5 per 100,000 population per year.4 of this, 15-20% are nonkeratinizing carcinoma.1 according to the who classification, it has many synonyms including schneiderian carcinoma, transitional cell carcinoma, cylindrical cell carcinoma, ringertz carcinoma and respiratory epithelial carcinoma.5 in the 1600s, victor conrad schneider first described the mucosal figure 1. contrast computed tomography scan, coronal section. a predominantly homogeneouslyenhancing mass (margins marked by arrowheads) is seen expanding the left nasal cavity, with minimal bulging of the nasal septum to the right and inferior compression of the ipsilateral inferior turbinate. the epicenter of the mass appears to be within the left anterior ethmoidal air cells. thinning and displacement of ipsilateral lamina papyracea is noted (white arrow). no evidence of subperiosteal or extraconal extension is seen within the left orbit. obliteration of the left maxillary ostium and infundibulum by the inferolateral aspect of the mass can be observed (black dotted line). retained fluid within the left frontal & maxillary sinuses from ostiomeatal complex obstruction is evident. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports philippine journal of otolaryngology-head and neck surgery 23 epithelium lining of the nasal cavity and the paranasal sinuses as ectodermal in origin.6 it is derived from nasal placodes that invaginate to form the primitive nasal sacs and ultimately the sinonasal cavities and lacrimal apparatus. the posterior boundary of this lining is the posterior choanae although it is continuous with the rest of the nasopharynx which is endodermally-derived i.e. from the foregut respiratory epithelium. therefore, the use of the term schneiderian distinguishes the boundaries of this epithelium and avoids confusion with any other anatomically-located tumors.7 the who classification also lists nkca as a variant of squamous cell carcinoma. it is described as a tumor of the sinonasal tract characterized by a plexiform or ribbon-like growth pattern with occasional mucuscontaining cells.5 although identified as nonkeratinizing, there are often small keratin pearls interspersed within the proliferations and some may form surface keratin that fills cystic spaces.5,8 in our patient, histopathological examination showed tissue partly lined by respiratory epithelium with the underlying stroma infiltrated by malignant cells forming islands and ribbon-like patterns. the cells displayed large nuclei with moderate pleomorphism, vesicular nuclei and prominent large nuclei. some of the cells had 2 to 3 nucleoli. mitoses were frequently seen. bone trabeculae, areas of haemorrhage and necrosis were also present. no evidence of keratinisation was seen (figures 2 and 3). amelanotic mucosal malignant melanoma was ruled out by immunohistochemistry where there was negativity to melan-a, hmb45 and s100. the ribbon-like invasive architecture and monomorphic nuclear cytology of nonkeratinizing carcinoma may mimic inverted papilloma. thus, osborn called inverted papillomas as transitional papillomas and sinonasal nonkeratinizing carcinoma as transitional carcinomas.2 however, the focal keratin pearl formation, increased mitotic activity and nuclear pleomorphism distinguish the nonkeratinizing carcinoma.8 it may be impossible to identify nkca from a carcinoma-ex-inverted papilloma characterized by diffuse dysplasia of the epithelium unless there is residual, better differentiated underlying inverted papilloma present.8 as reported by robin et al. in 1979 and svane-knudsen et al. in 1998, a small percentage of transitional-type carcinomas may arise in pre-existing transitional cell papillomas.1,9 most nonkeratinizing carcinomas are well-differentiated resembling transitional epithelium reminiscent of urothelium. some are poorly-differentiated, composing layers of disordered small anaplastic cells though others show pseudostratified tall cylindrical cells with a basal palisade of columnar cells.8 the designation of cylindrical cell carcinoma as a synonym on the other hand is misleading as it may suggest a relationship to the cylindrical cell papilloma (oncocytic schnederian papilloma). the latter is microscopically distinct characterized by surface oncocytic columnar and mucus cells and is unrelated to nkca.3 the many different terminologies and synonyms that have been used frequently in the international literature may have lead to some confusion and perhaps misdocumentation of this rare tumor. in a series reported by osborn in 1970 there were 57 cases of transitional cell carcinomas seen and treated in the royal national throat and ear hospital between 1948 and 1968 accounting for approximately 20% of all carcinomas of the nose and sinuses.2 a review by robin et al. in 1979 illustrated a series obtained from registrations in the birmingham regional cancer registry from 1957 to 1972 inclusive of figure 2. histopathologic section. hematoxylin and eosin, low-power view (40x). respiratory epithelium with the underlying stroma infiltrated by malignant cells forming islands and ribbon-like patterns. figure 3. histopathologic section. hematoxylin and eosin, high-power view (400x). the cells display large nuclei with moderate pleomorphism, vesicular nuclei and prominent large nuclei, some with 2 to 3 nucleoli and frequent mitoses. no evidence of keratinisation is seen. (hematoxylin-eosin, 40x) (hematoxylin-eosin, 400x) philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 24 philippine journal of otolaryngology-head and neck surgery case reports references 1. robin p, powell dj, stansbie jm. carcinoma of the nasal cavity and paranasal sinuses: incidence and presentation of different histologic types. clin otolaryngol allied sci. 1979 dec; 4(6):431-56. 2. osborn da. nature and behavior of transitional tumors of the upper respiratory tract. cancer. 1970 jan; 25(1):50-60. 3. el-mofty s, lu dw. prevalence of high-risk human papillomavirus dna in nonkeratinizing (cylindrical cell) carcinoma of the sinonasal tract. am j surg pathol. 2005 oct; 29(10):1367-72. 4. muir cs, nectoux j. descriptive epidemiology of malignant neoplasms of nose, nasal cavities, middle ear and accessory sinuses. clin otolaryngol allied sci. 1980 jun; 5(3):195-211. 5. pilch bz, bouquot j, thompson ldr. squamous cell carcinoma. in: barnes l, eveson jw, reichart p, sidransky d, editors. world health organization classification of tumors. pathology and genetics of head and neck tumors. lyon: iarc press; 2005.p.15-7. 6. batsakis jg. pathology consultation. nasal (schneiderian) papillomas. ann otol rhinol laryngol. 1981 mar-apr; 90(2 pt 1):190-1. 7. batsakis jg, suarez p. schneiderian papillomas and carcinomas: a review. adv anat pathol. 2001 mar; 8(2):53-64. 8. zarbo rj, torres fx, gomez j. nasal cavity and paranasal sinuses: embryology, anatomy, histology and pathology. in: pilch bz, editor. head and neck surgical pathology. philadelphia: lippincott williams & wilkins; 2000.p.80-156. 9. svane-knudsen v, jorgensen ke, hansen o, lindgren a, marker p. cancer of the nasal cavity and the paranasal sinuses: a series of 115 patients. rhinology. 1998 mar; 36(1):12-4. 10. manivel c, wick mr, dehner lp. transitional (cylindric) cell carcinoma with endodermal sinus tumor-like features of the nasopharynx and paranasal sinuses. clinicopathologic and immunohistochemical study of two cases. arch pathol lab med. 1986 mar; 110(3):198-202. 11. calderon-garciduenas l, delgado r, calderon-garciduenas a, meneses a, ruiz lm, de la garza j, et al. malignant neoplasms of the nasal cavity and paranasal sinuses: a series of 256 patients in mexico city and monterrey. is air pollution the missing link? otolaryngol head neck surg. 2000 apr; 122(4):499-508. 12. zhang tm, fang jg, chen xh, zhang jl, zhao jw. [trans-cranio-naso-orbital approach in treatment of ethmoid sinus malignant tumors: analysis of 39 cases]. zhonghua yi xue za zhi. 2007 jan; 87(5):304-7. 13. ahossi v, vincent s, duvillard c. sinonasal undifferentiated carcinoma, or schneiderian carcinoma arising from an aspergillosis: a case history. br j oral maxillofac surg. 2009 jun; 47(4):316-7. 14. friedmann i, osborn da. carcinoma of the surface epithelium. in: freidmann i, editor. pathology of granulomas and neoplasms of the nose and paranasal sinuses. edinburgh: churchill livingstone; 1982.p.118-82. only 48 cases of transitional cell carcinomas constituting merely 7.7% of all malignant tumors of the nose and paranasal sinuses.1 manivel et al. in 1986 reported two cases of transitional (cylindric) cell carcinoma with endodermal simus tumor-like features of the nasopharynx and paranasal sinuses.10 in 2000, calderon-garciduenas et al. published their series obtained from a major oncology hospital in metropolitan mexico city from 1976-1997 which listed schneiderian carcinoma as one of the diagnosis in their 256 patients.11 el-mofty and lu in 2005 reported only eight cases of nonkeratinizing carcinomas retrieved from the department of pathology and immunology at washington university school of medicine, st. louis missouri, though they did not specify when they were diagnosed.3 another series published in a chinese journal reported one case of schneiderian carcinoma from 39 ethmoidal malignancies.12 a recent case report evidently demonstrated incorrect terminology where the author used “sinonasal undifferentiated carcinoma” interchangeably with “schneiderian carcinoma.”13 some authors also regard nkca as a distinct clinicopathologic entity. justification for a separate classification is based on various significant observations.1,3 robin et al. found a difference in the mean age of presentation between men and women in nkca which was 57.8 years and 70.4 years, respectively.1 this difference was statistically significant and was greater than in other histological groups. they also found a marked contrast in the distribution of sites among the different types of carcinomas. squamous cell carcinomas were seen predominantly in the maxillary antrum, adenocarcinomas were predominantly in the ethmoid while nkcas was more evenly spread. another observation was that nkca in men carried a better prognosis than in women where the five-year survival rates were 40% and 13% respectively. other studies have found that it emerges more favorably with the five year survival rate of 37.5% compared to kscc of 10% and is more sensitive to radiation but has a greater tendency to local recurrence.2,14 a recent study has also shown that nkcas of the sinonasal tract have a higher prevalence of high risk hpv dna than other types of carcinomas in this region.3 nkca is a rare malignancy of the nose and paranasal sinuses and should be recognized as a distinct clinicopathologic entity to determine the best treatment modality and to better predict the outcome of treatment. nomenclature of this tumor should be standardized to avoid confusion and misdocumentation. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 editorial 4 philippine journal of otolaryngology-head and neck surgery in 2013, multiple articles reporting the clinical trial of valsartan, an antihypertensive drug of more than us$ 1 billion annual sales from novartis, were retracted due to data falsification.1,2 these included the kyoto heart study presented by dr. hiroaki matsubara at the european society of cardiology 2009 congress and subsequently published in the european heart journal (ehj).3,4 aside from retraction of this article by ehj, the american heart association (aha) also retracted five papers published in three of its journals -circulation, circulation research, and hypertension.4 novartis employees were involved in the conduct and analysis of the kyoto heart study and a second investigator-initiated trial, the jikei heart study,5 although their participation was not acknowledged in publications and presentations of the data, while a novartis employee who allegedly manipulated statistical data was listed as one of the academic authors, without disclosing the relation with the company.4,6 this scandal has severely damaged scientific integrity in japan and set the stage for the “tokyo declaration on research integrity and ethical publication in science and medicine in the asia pacific region” adopted at the 2013 convention of the asia pacific association of medical journal editors (apame) held in tokyo from 2 to 4 august 2013, and co-published by journals linked to apame and listed in the index medicus for the south east asian region (imsear) and the western pacific region index medicus (wprim), including the philippine journal of otolaryngology head and neck surgery, with a special announcement in this issue.7 at the core of research integrity and ethical publication is responsible and accountable authorship. the icmje “uniform requirements for manuscripts submitted to biomedical journals” has been replaced by the “recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals.”8 an important change under these new guidelines is an additional criterion for authorship, totaling four (4) instead of three (3) criteria. the icmje recommends that authorship be based on the following 4 criteria:8 • substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; and • drafting the work or revising it critically for important intellectual content; and • final approval of the version to be published; and • agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. in addition to being accountable for the parts of the work he or she has done, an author should be able to identify which co-authors are responsible for specific other parts of the work. in addition, authors should have confidence in the integrity of the contributions of their co-authors. one cannot be listed as a co-author for the credit it brings, without being equally accountable in case of discredit. for example, consultant advisers and seniors who would consider adding their correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft ave., ermita, manila 1000 philippines phone: (632) 526 4360 telefax: (632) 524 4455 email: lapenajf@upm.edu.ph reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines on research integrity and ethical publication, authorship and accreditation philipp j otolaryngol head neck surg 2013; 28 (2): 4-6 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 5 philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 editorial names as co-authors of a junior resident, are equally accountable for research misconduct (such as data fabrication, falsification, plagiarism), and cannot lay the blame on one (usually junior) author. while all those designated as authors should meet all four criteria for authorship, and all who meet the four criteria should be identified as authors, those who do not meet all four criteria should be acknowledged. hence, it is more appropriate for consultant advisers and seniors who do not meet all four criteria for authorship to be acknowledged in this manner. our journal seeks to maintain the highest standards of biomedical publication, and fully supports the apame tokyo declaration on research integrity and ethical publication in science and medicine in the asia – pacific region as well as the icmje recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals. multiple accreditations and indexing are testimony to these standards. it was surprising therefore, that a letter from the commission on higher education journal accreditation system dated 26 april 2013, which we received 26 may 2013, informed us of our reaccreditation under category b based on the “recommendation of the panel of evaluators” who “pointed out the need to improve the journal’s refereeing system, regularity of publication/circulation and timeliness.”9 i respectfully responded to these remarks10 stating that: the philipp j otolaryngol head neck surg is one of the few consistently compliant journals accredited by the national journal selection committee of the philippine council for health research and development, department of science and technology. our journal has a reputable loco-regional stature evidenced by international contributions from the usa, japan, turkey, malaysia, india and brunei, and has consistently been recognized as a benchmark journal by the philippine association of medical journal editors and asia pacific association of medical journal editors. it functions as the de facto asean journal in the field of otolaryngology head and neck surgery. it is always regularly published on time, and indexed in the health research and development network (herdin-neon) supported by the pchrd-dost; philippine journals on line (philjol) and asia journals on line (asiajol) supported by the international network for the availability of scientific publications (inasp); the western pacific region index medicus (wprim) of the world health organization (who), apamed central and the index copernicus™ journals master list. it has always met the accreditation criteria of these services. the journal’s online peer review system is used as an example for other local journals, including in national medical writing and reviewing workshops organized by the pchrd (2012 cebu and davao, 2013 baguio and iloilo), in the philippine national health research system week (2011 bacolod, 2012 manila, 2013 laoag) as well as for regional journals in medical writing and review workshops held in brunei, singapore, malaysia, vietnam and cambodia. several local and regional journals have been thus assisted by us in their editing and peer review systems. as a category a accredited research journal (batch 1) for 2009 – 2012 per commission on higher education (ched) memorandum order no. 09 s. 2010 and resolution no. 477-2009, effective december 9, 2009 (signed may 26, 2010), our journal has faithfully complied with all the terms of the jas, including “acknowledgement in the published journal that the publication thereof was a product of the journal accreditation service project of the commission on higher education” in the inside front cover of every issue. moreover, we have gone beyond the dissemination requirement by providing a complimentary copy of each issue to every medical school library in the philippines. i ended by reiterating that our journal “has more than complied with the requirements of the journal accreditation service of the commission on higher education for reaccreditation as a category a accredited research journal, and beg(ged) the honorable review panel to reconsider its recommendation.”10 it turned out that previously-submitted copies of our journal had been inadvertently misplaced, leading to our downgrade from category a to b. expecting full reinstatement, i was surprised to receive a response dated 23 july 2013 on 23 august 2013, informing us that: “the technical evaluators decided to classify the said journal as ‘conditional category a’ pending submission of enhanced volumes with sober and serious formats to project scientific/ scholarly image. while refereed journals often contain many graphs and charts, these do not normally include glossy pages (e.g. advertisements) or exciting pictures (e.g. captoons) which noticeably appeared in the issues that you submitted.”11 i again respectfully responded to these remarks by citing12 the international committee of medical journal editors recommendations for the conduct, reporting, editing, and philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 6 philippine journal of otolaryngology-head and neck surgery editorial references retraction of: effects of valsartan on morbidity and mortality in uncontrolled hypertensive 1. patients with high cardiovascular risks: kyoto heart study [eur heart j (2009) 30: 2461—69, doi:10.1093/eurheartj/ehp363]. eur heart j 2013; 34: 1023. retraction—valsartan in a japanese population with hypertension and other cardiovascular 2. disease (jikei heart study): a randomised, open-label, blinded endpoint morbidity-mortality study. lancet 2013 sep; 382(9895):843. sawada t, yamada h, dahlof b, matsubara h. effects of valsartan on morbidity and mortality in 3. uncontrolled hypertensive patients with high cardiovascular risks: kyoto heart study. eur heart j 2009; 30: 2461-2469. wood s. diovan data-manipulation scandal touches novartis in japan. heartwire. the heart.4. org medscape cardiology [homepage on the internet]. july 19, 2013. [cited 2013 november 9]. available fromhttp://www.medscape.com/viewarticle/808152?t=1 mochizuki s, dahlof b, shimizu m, et al. valsartan in a japanese population with hypertension 5. and other cardiovascular disease (jikei heart study): a randomised, open-label, blinded endpoint morbidity-mortality study. lancet 2007; 369: 1431-1439. husten l. novartis acknowledges employees participated in ‘independent trials’ forbes. 6. [homepage on the internet]. [cited 2013 november 9]. available from http://www.forbes. com/sites/larryhusten/2013/05/23/novartis-acknowledges-its-employees-participated-inindependent-trials/ asia pacific association of medical journal editors. “tokyo declaration on 7. research integrity and ethical publication in science and medicine in the asia pacific region.” special announcement in philipp j otolaryngol head neck surg 2013 jul-dec; 28(2): __. international committee of medical journal editors recommendations for the conduct, 8. reporting, editing, and publication of scholarly work in medical journals (icmje recommendations) [homepage on the internet].updated august 2013. [cited 2013 august 29]. available from http://www.icmje.org/urm_main.html tayag jc. [director, office of policy, planning, research and information, commission on higher 9. education, office of the president, republic of the philippines]. letter dated april 26, 2013 to inform (us) that the philippine journal of otolaryngology head and neck surgery has been reaccredited under category b. lapena jf. [editor-in-chief, philippine journal of otolaryngology head and neck surgery, 10. philippine society of otolaryngology head and neck surgery inc.] letter dated may 29, 2013 requesting reconsideration of the accreditation status of the philippine journal of otolaryngology head and neck surgery from category b to category a. tayag jc. [director, office of policy, planning, research and information, commission on higher 11. education, office of the president, republic of the philippines]. letter dated july 23, 2013 in reference to request for reconsideration of the accreditation status of the philippine journal of otolaryngology head and neck surgery from category b to category a. lapena jf.12. [editor-in-chief, philippine journal of otolaryngology head and neck surgery, philippine society of otolaryngology head and neck surgery inc.] letter dated august 30, 2013 regarding conditional category a status of the philippine journal of otolaryngology head and neck surgery. international committee of medical journal editors: journals following icmje 13. recommendations. [homepage on the internet]. [cited 2013 august 29]; available from http:// www.icmje.org/journals.html bennett hj. humor in medicine. 14. south med j. 2003 dec;96(12):1257-61. publication of scholarly work in medical journals (icmje recommendations) updated august 2013, cited 29 august 2013 available at http://www.icmje.org/urm_main.html8 the recommendations have clear guidelines on advertising, and do not forbid exciting pictures and cartoons. nowhere do they constrain scholarly medical journals to maintain “sober and serious formats to project scientific/scholarly image.” the philippine journal of otolaryngology head and neck surgery is listed among the journals following icmje recommendations http://www.icmje.org/journals.html13 the top-tier journals in medicine (bmj, jama, lancet and nejm) as well as science and nature all have advertising in glossy pages and exciting pictures and cartoons, even on their covers. the same is true for our major journals in the field of otolaryngology head and neck surgery. i provided the technical panel with copies of the instructions to authors of these journals, as well as photographs of actual caricatures from their covers and inside pages. finally, i also attached an excerpt from: bennett hj. humor in medicine. south med j. 2003;96(12)14 for the perusal of the honourable technical panel. as of press time, we have not received a reply from the technical panel, but have received advise from the office of policy, planning, research and information of the commission on higher education to withhold, in the meantime, our inside front cover acknowledgement that the publication of this issue “was a product of the journal accreditation service project of the commission on higher education.” however, we shall continue to provide a complimentary copy of this issue to every medical school library in the philippines as a valuable service of our society and journal as we await the resolution of this situation. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports philippine journal of otolaryngology-head and neck surgery 15 philipp j otolaryngol head neck surg 2013; 28 (1): 15-18 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to present a case of vocal cord paralysis and dysphagia developing in gradenigo syndrome and to discuss its clinical presentation, differential diagnosis and therapeutic approach. methods: design: case report setting: tertiary government hospital patient: one results: a 54-year-old lady was admitted with a six-month history of left-sided otorrhea, cheek and jaw pain, three months otalgia, and recent-onset hoarseness, dysphagia and diplopia on a background of mastoidectomy at age six. otoscopy revealed granulation tissue and chlolesteatoma occupying the left external auditory canal. there was left vocal cord paralysis with pooling of saliva in the pyriform sinus, left lateral gaze paralysis and left facial nerve paralysis. ct scan revealed sclerosis of the left petrous apex and leptomeningeal enhancement on the left temporal lobe. chronic suppurative otitis media with cholesteatoma and gradenigo syndrome was diagnosed, and canal wall down mastoidectomy was performed. postoperatively, the otalgia and pain over the left jaw diminished in intensity while hoarseness and left lateral gaze palsy remained. conclusion: gradenigo syndrome is known for its triad of retro-orbital pain, lateral gaze paralysis, and chronic middle ear infection due to petrous apicitis. although rare, vocal cord paralysis and dysphagia may develop when infection traverses and encroaches on the jugular foramen where cranial nerves ix, x, and xi are lodged. knowledge of the syndrome should not be limited or confined to the classic triad. practicing ear specialists should be vigilant and cognizant of the clinical manifestations and sequelae of chronic middle ear infection. prompt surgical intervention is crucial while resolution of the disease may vary for different individuals. keywords: chronic otitis media, gradenigo syndrome, vocal cord paralysis, petrous apicitis dealing with chronic suppurative otitis media requires utmost attention and care because of the clever and sometimes elusive nature of the disease. life threatening complications include meningitis, brain abscess, lateral sinus thrombophlebitis and petrous apicitis which may manifest with gradenigo’s syndrome. a recent grand rounds discussion of gradenigo syndrome in a 17-year-old patient with nuchal rigidity and anisocoria was reported in this journal.1 the literature has several reports about the syndrome manifesting with the classic triad1-10 but vocal cord paralysis and dysphagia are not usually mentioned sequelae.2 vocal cord paralysis and dysphagia as sequelae of gradenigo syndrome mary ann v. macasaet, md emmanuel tadeus s. cruz, md department of otorhinolaryngology head & neck surgery quezon city general hospital and medical center quezon city, philippines correspondence: dr. mary ann v. macasaet department of otorhinolaryngology head & neck surgery quezon city general hospital and medical center seminary road, munoz, quezon city 1106 philippines phone: (632) 426 1314 local 232 fax: (632) 920 7081; 920 6270 email: orl_hns_qcgh@yahoo.com.ph reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at: interesting case contest (3rd place), philippine society of otolaryngology head and neck surgery, best western hotel, a venue, makati city, may 27, 2013. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports 16 philippine journal of otolaryngology-head and neck surgery case report a 54-year-old lady from pampanga was admitted because of diplopia. six months prior, she experienced left ear discharge which was treated with oral antibiotics and otic drops. three months later, she experienced left jaw and left eye pain radiating to the left frontal and occipital areas. she was diagnosed with trigeminal neuralgia but steroid injection in the left lower alveolar area afforded no relief. two weeks before admission, she developed hoarseness, difficulty of swallowing (especially liquids) and doubling of vision prompting this consult. review of history disclosed that a left facial palsy developed after mastoidectomy at age six, with occasional ear problems thereafter. otoscopy showed a dry 30% central tympanic membrane (tm) perforation on the right while no tympanic membrane was appreciated on the left because of granulation tissue and cholesteatoma occupying the left mastoidectomy cavity. (figure 1) videolaryngoscopy revealed left vocal cord paramedian paralysis with pooling of saliva in the left pyriform sinus. (figure 2) there was lateral gaze palsy of the left eye (figure 3) with left facial nerve paralysis house-brackmann grade v. topognostic exam showed loss of taste on the anterior 2/3 of the left side of the tongue and decreased lacrimation of the left eye on schirmer’s test suggesting pathology in the mastoid segment of the facial nerve. plain and contrast cranial and temporal bone ct scans showed evidence of previous left mastoidectomy with mastoiditis, cholesteatoma formation, abnormal enhancement of the meninges in the left temporal region and sclerosis of the left petrous apex. (figures 4 and 5) pure tone audiometry revealed profound hearing loss on the left and moderate mixed hearing loss on the right. figure 3. extraocular muscle movements, (left photo) on right gaze, and (right photo) on (l) gaze, showing left lateral gaze palsy of the left eye. figure 1. (leftmost photo): right tympanic membrane with 30% central perforation, (middle photo) left ear granulation tissue and (right photo) cholesteatoma occupying the middle ear. figure 2. left vocal cord paralyzed in paramedian position with pooling of saliva in the left pyriform sinus (left photo) in phonation, (right photo) in inspiration. figure 4. ct scan showing (left) moderate enhancement of the meninges in the left temporal lobe (arrow) adjacent to (right) the cortical defect in tegmen tympani (upper arrow) and mastoidectomy defect in the left mastoid with soft tissue density representing cholesteatoma and granulation tissue (lower arrow). philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports philippine journal of otolaryngology-head and neck surgery 17 the clinical impression was post-mastoidectomy recurrent chronic suppurative otitis media with cholesteatoma formation and gradenigo syndrome. intravenous ceftriaxone was started and a canal wall-down mastoidectomy with translabyrinthine approach to the petrous bone was commenced but difficulty drilling the sclerotic bony labyrinth hindered access to the petrous apex. postoperatively, the left jaw, cheek and retro-orbital pain diminished within 24 hours but the hoarseness and lateral gaze palsy remained. discussion although rarely encountered, complications of chronic suppurative otitis media continue to develop, perhaps because of neglect, complacency, poor patient education or inadequate treatment. dreaded intracranial complications include brain abscess, meningitis, lateral sigmoid sinus thrombophlebitis, cavernous sinus thrombosis and petrous apicitis. petrous apicitis may be defined as an extension of infection from the mastoid air cell tract into a pneumatized anterior or posterior petrous apex.3 with involvement of cranial nerves located near the vicinity of the petrous apex, gradenigo syndrome may develop which includes the clinical triad of acute inflammation of the middle ear, pain in the temporal and parietal areas and paralysis of the abducens nerve.1-10 these three cardinal features were observed during the course of illness of our patient. the left vocal cord paralysis and dysphagia are unusual, and need to be explained. petrous apicitis rarely occurs because infection in sclerotic or petrous apices containing marrow is uncommon and the prevalence of pneumatization is low. when it occurs, infection in the petrous apex may persist even if mastoid disease responds to treatment.3 petrous apicitis may develop due to direct extension of acute otitis media into a pneumatized petrous apex. when drainage from the petrous apex to the middle ear is compromised, it promotes growth of microorganisms. common etiologic agents include streptococcus pneumoniae, haemophilus influenzae, and staphylococcus aureus11 while tuberculous and fungal petrous apicitis have also been reported.12 because of proximity of the petrous apex to the venous sinuses, the risk of developing venous sinus thrombosis is high. when infection reaches dorello’s canal which transmits the abducens nerve (cn vi) and the gasserian ganglion (cn v), the patient may manifest with lateral rectus palsy and hemifacial pain ipsilateral to the involved ear.12 this explains the pain in the left eye, cheek and jaw which may mimic trigeminal neuralgia. a discerning clinician should evaluate and analyze the pain alongside other signs and symptoms. the dysphagia felt for two weeks when hoarseness and diplopia developed was accompanied by coughing, choking sensations and aspiration. despite this, she was able to tolerate feeding with some difficulty and had no significant weight loss for the past three months. her dysphagia maybe classified as neurogenic and may be secondary to involvement of the ix and x cranial nerve. while symptoms of acute petrositis are subtle and may be attributed to sudden obstruction of the pneumatized petrous apex air cell system resulting from acute mastoid inflammation, chronic apicitis follows a more indolent course. patients with chronic apicitis may not appear acutely ill compared to those suffering from acute petrositis.12 as mentioned earlier, the patient had a childhood mastoid operation because of the intermittent ear infections spanning 50 years, may have developed chronic petrositis. involvement of the abducens nerve and gasserian ganglion may be secondary to local pachymeningitis as a consequence of acute petrous apicitis.5 other possible routes include spread of infection via pneumatized air cell tracts and vascular channels, or via direct extension beneath fascial planes.6 symptoms of petrous apicitis may be attributed to middle ear and mastoid infection, and symptoms coming from the apex which include deep or retro-orbital pain (from irritation of the trigeminal ganglion in meckel’s cave), paralysis of the abducens nerve as it passes through dorello’s canal abutting the petrous apex, dysfunction of cranial nerves vii and viii, or labyrinthitis.1-10 in a study of 22 patients by chole and donald, otalgia was the most consistent symptom followed by deep pain and headache, and otorrhea.2 only one patient presented with cn ix and x involvement because of its proximity to the petrous apex.2 the patient met the diagnostic criteria for gradenigo syndrome but the left vocal cord paralysis and dysphagia need further explanation. was this a case of gradenigo versus vernet syndrome? the latter occurs figure 5. ct scan axial bone window, showing sclerotic left petrous apex. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports 18 philippine journal of otolaryngology-head and neck surgery acknowledgment the authors would like to thank drs. raymond g. belmonte, antonio g. talapian, agnes f. marcelino and princess jehann p. arimao who participated in the surgery and management of the patient, and contributed valuable comments and suggestions in the course of preparing the manuscript. references santiago mrg, aguilar na. gradenigo’s syndrome. 1. philipp j otolaryngol head neck surg. 2008 jul – dec; 23(2):46-48. chole ra, donald pj. petrous apicitis. clinical considerations. 2. ann otol rhinol laryngol. 1983 nov-dec;92(6 pt 1);544-51. harker la, shelton c. complications of temporal bone infections. in: cummings cw, flint 3. pw, harker la, haughey bh, richardson ma, robbins kt, schuller de, thomas jr, editors. otolaryngology head and neck surgery. 4th edition, vol. 4. philadelphia: elsevier mosby; 2005. p. 3013-3039. piron k, gordts f, herzeel r. gradenigo syndrome: a case report. 4. bull soc belge ophtalmol. 2003;(290) 43-47. back gw. atypical gradenigo’s syndrome complicated by meningitis and sphenoiditis, a case-5. report. cme bulletin otorhinolaryngology, head and neck surgery. 2000; 4:114-116. [cited 2013 mar 6] available from: http://www.rila.co.uk/issues/full/download/51c78af3db56edea91d7d0 1d8b3183a2377734.pdf. motamed m, kalan a. gradenigo’s syndrome. 6. postgrad med j. 2000 sep;76(899):559-560. kantas i, papadopoulou a, balatsouras dg, aspris a, marangos n. therapeutic approach to 7. gradenigo’s syndrome:a case report. j med case reports. 2010 may; 4:151 scardapene a, del torto m, nozzi m, elio c, breda l, chiarelli f. gradenigo’s syndrome with 8. lateral venous sinus thrombosis: successful conservative treatment. eur j pediatr. 2010 apr,169(4):437-440. felix f, domingues de olivaes mc, gismondi ra, belmont h, de p. felix ja,9. conservative treatment of gradenigo’s syndrome. braz j otorhinolaryngol. 2003, 382;69(2):256-259. [cited 2013 feb 18] available from: http://www.bjorl.org/conteudo/acervo/print_acervo_english. asp?id=382. jacobsen cl, bruhn ma, yavarian y, gaihede ml. mastoiditis and gradenigo’s syndrome with 10. anaerobic bacteria. bmc ear nose throat disord. 2012 sep14;12:10. razek aa ,huang by. lesions of the petrous apex: classification and findings at ct and mr 11. imaging. radiographics. 2012 jan-feb:32(1):151–173 yeung ah, lustig lr. skull base, petrous apex infections. medscape reference article on the 12. internet. [cited 2013 feb 25] available from http://emedicine.medscape.com/article/883256overview. lee yh, lee nj, kim jh, song jj. ct, mri and gallium spect in the diagnosis and treatment of 13. petrous apicitis presenting as multiple cranial neuropathies. br j radiol. 2005 oct;78(934):948951. mathew l, singh s, rejee r, varghese am. gradenigo’s syndrome: findings on computed 14. tomography and magnetic resonance imaging. j postgrad med. 2002 oct-dec;48(4):314-6. [cited 2008 oct 29] available from: http://www.jpgmonline.com/text.asp?2002/48/4/314/68. adams gl, boies lr jr., paparella mm, eds. boies’s fundamentals of otolaryngology: a textbook 15. of ear, nose and throat diseases 5th ed., philadelphia, london, toronto: wb saunders company 1978, p. 157-159. when lesions affect the jugular foramen where cranial nerves ix, x, xi are lodged. a stroke or cerebrovascular event was unlikely with no history of hypertension and negative cranial ct scan results. the proximity of various venous sinuses to the petrous apex has been implicated as the cause of various complications following gradenigo syndrome such as venous sinus thrombosis,8 meningitis, intracranial abscess, involvement of cn ix, x, xi (vernet syndrome), involvement of the sympathetic plexus around the carotid sheath (horner syndrome), and prevertebral and parapharyngeal abscesses.6 this is the possible mechanism by which the patient developed hoarseness and dysphagia after manifesting the gradenigo triad. the diagnostic procedure of choice are ct scans which show details of the petrous apex and provide important anatomical blueprints for surgical access.13 if the ct scans indicate potential apicitis, magnetic resonance imaging (mri) may add details about the nature of the fluid or tissue within the apex while a gallium bone scan may show high signal intensity on the side of the apicitis.3 ideally, combination of mri and ct scans are necessary to evaluate normal anatomic variations and to eliminate other disease entities. diagnostic findings of petrous apicitis on ct scan include opacification of the mastoid air cell system and the petrous apex, enhancement of the cavernous sinus and bony erosion within the petrous apex. with contrast media, cavernous sinus enhancement may be seen.12 contrary to acute petrous apicitis which may appear as an expanding lesion with irregular margins, chronic petrous apicitis may demonstrate hypopneumatization and sclerosis.14 sclerosis of the mastoid and petrous bone may be secondary to lack of development in which no pneumatization occurs or it may be due to new bone formation in a previously pneumatized area as a result of middle ear infection.15 because of the complex anatomy and the need to dissect around delicate structures such as the labyrinth, cranial nerves and carotid artery, diseased petrous air cells cannot be totally removed by surgery and establishment of drainage and antibiotics are essential components of the treatment regimen. indications for surgical drainage include failure to respond to antimicrobial therapy, cranial nerve deficits, brain abscess, and development of life-threatening complications.12 a transmastoid, infralabyrinthine, suprajugular approach has been advocated to provide drainage and ventilation of the petrous apex with preservation of hearing.7 prolonged postoperative antibiotics are recommended for 2-3 weeks after surgery, and for patients that may have accompanying osteomyelitis, 3-6 weeks of iv antibiotics may be required.12 pain caused by trigeminal nerve irritation usually resolves within one week of intravenous antibiotic therapy.9 other reports showed resolution of cranial nerve palsies within 3-4 weeks when adequately treated. rapid resolution of cranial deficits can result if surgery is combined with antibiotics than with antibiotics alone.12 gradenigo syndrome is well known for its triad of retro-orbital pain, lateral rectus (cn vi) paralysis and chronic middle ear infection due to petrous apicitis. although rare, vocal cord paralysis and dysphagia may develop when infection traverses and encroaches on the jugular foramen where cranial nerves ix, x, and xi are lodged. knowledge of the syndrome should not be limited or confined to the classic triad. practicing ear specialists should be vigilant and cognizant of the clinical manifestations and sequelae of chronic middle ear disease. prompt surgical intervention is crucial while resolution of the disease may vary for different individuals. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles 10 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2011; 26 (2): 10-12 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: this study aimed to measure the dimensions of the nasal septal cartilage in adult filipino malay cadavers and calculate the cartilage area as well as the amount of graft material that can be harvested from the septal cartilage. methods: design: descriptive, cross-sectional setting: pamantasan ng lungsod ng maynila college of medicine anatomy laboratory subjects: ten preserved adult cadavers dissected within a period from september 2010 to october 2010. the septal cartilages were harvested and the lengths of the cephalic margin, dorsal margin, caudal margin and ventral margin were measured. from these measurements, the total area of the cartilage and the amount of graft material that can be harvested were calculated. results: the mean length of each margin of the septal cartilage was 25.9mm (cephalic edge), 22.3 mm (dorsal edge), 21.4mm (caudal edge) and 33.1 mm (ventral edge). the area of the septal cartilage had a mean value of 652.5 mm2. the amount of septal cartilage which can be harvested had a mean area of 403mm2. conclusion: this study showed a slight decrease in septal cartilage area to 652.5 mm2 and in available graft material to 403 mm2. while this decrease may reflect the apparently smaller noses of native southeast asians compared to east asians and south asians, the difference in values can also be due to the difference in the number of subjects or in methods of measurement and further studies are recommended to determine the extent of inter-racial variability. keywords: septal cartilage, autologous graft the septal cartilage is a widely used autologous graft and is generally accepted as the gold standard of grafting materials.1 its main use is in septorhinoplasty and as a spreader graft to widen the internal nasal valve to treat nasal obstruction.2 the effects of cartilage tympanoplasties on tympanic membrane closure, hearing improvement and prevention of retraction pockets have been well documented.3,4,5 it can even be applied to reconstruction of the orbital floor.6 the dimensions of the nasal septal cartilage: a preliminary study in adult filipino malay cadavers niña eliza r. pernia, md1 joseph amado c. galvez, md1,2 francisco a.victoria, md1,3,4 1department of otorhinolaryngology head and neck surgery ospital ng maynila medical center 2department of otorhinolaryngology head and neck surgery the medical city 3department of otorhinolaryngology head and neck surgery quezon city general hospital 4department of otorhinolaryngology head and neck surgery medical center manila correspondence: dr. niña eliza r. pernia department of otorhinolaryngology ospital ng maynila medical center roxas blvd cor. quirino ave., malate, manila 1000 philippines phone: 524 6061 local 220 fax: 523 6681 reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the descriptive research contest, philippine society of otolaryngology head and neck surgery, glaxo smith kline (gsk) bldg., chino roces ave., makati city philippines, october 11, 2010. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles philippine journal of otolaryngology-head and neck surgery 11 studies on the dimensions of the septal cartilage have been done in several countries using both cadavers and radiographic images to establish a baseline measurement distinct to their race. in 1997, godley collected anatomic data from 60 cadavers, mostly caucasians.7 another study in korea used mri images to determine the area of the nasal septum and grouped them according to age7. however, despite the increasing popularity of autologous grafts in our country, we are not aware of locally published studies on the subject. for instance, the generally smaller southeast asian noses of many malay filipinos may not yield as much septal cartilage as the noses of east (north china, japan, korea) and south (india) asians or caucasians. this study aimed to measure the dimensions of the nasal septal cartilage in filipino malay cadavers and calculate the cartilage area and the amount of graft material that can be harvested from the septal cartilage. methods this was a cross-sectional study. ten adult preserved cadavers (6 males, 4 females) were dissected in the pamantasan ng lungsod ng maynila anatomy laboratory between september and october 2010 by two orl residents. in each cadaver, an open sky rhinoplasty technique was used. a small incision was made in the columella, the columellar flap was then elevated to expose the alar and septal cartilages. the septal cartilages were dissected from the perichondrium and harvested. the cephalic, dorsal, caudal and ventral lengths were measured accordingly using a standard ruler in millimeters (figure 1), the area figure 3. septal cartilage with l strut 1 cm dorsal-caudal strut (l strut) figure 2. computation of nasalseptal area area of irregular shapes find regular shapes = 2 triangles area of triangle = 1/2bh t1 t2 figure 1. the margins of the nasal septum dorsal caudal margin cephalic margin ventral of each septum was measured (figure 2) by dividing the septum into two triangles and applying the formula for area of a triangle to each. from these values, the amount of graft material that can be harvested (excluding the 1 cm. dorsal-caudal l-strut) was computed using the formula for determining the area of irregular shapes, derived from the pythagorean theorem (bh/2) (figure 3). philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles 12 philippine journal of otolaryngology-head and neck surgery results the mean lengths of the margins of the septal cartilage were: 25.9 mm, cephalic margin (range: 23 – 28mm), 22.3 mm dorsal margin (range 20 – 26 mm), 21.4 mm caudal margin (range: 19 – 25 mm) and 33.1mm ventral margin (range: 30 – 36 mm). the mean area of the septal cartilage was 652.5 mm2 and the mean amount of cartilage which can be harvested was 403mm2. discussion this study measured the dimensions of the nasal septal cartilage in filipino malay cadavers and calculated the cartilage area and the amount of graft material that can be harvested from the septal cartilage. the cartilage area of the septum includes the whole quadrangular cartilage dissected from all its attachments. the amount of available graft material is the area of the septum without the 1 cm dorsal-caudal strut (or l strut). a recent study measuring nasal cartilage by kim, et al in korea used mri sagittal sections of 280 patients.7 the adult septum was noted to have a mean measurement of 692mm2 with a maximal amount of graft material of 427 mm2.7 this is not far from the value of 420mm2 of graft material (excluding the l strut) obtained by miles et al.8 our study showed a slight decrease in septal cartilage area to 652.5 mm2 and in available graft material to 403 mm2. while this decrease may reflect the apparently smaller noses of native southeast asians compared to east asians and south asians, the difference in values can also be due to the difference in the number of subjects, as this study only utilized 10 cadavers. in addition, the study done in korea was based on radiologic images rather than cadaver dissection. in 1997, godley et al. studied the noses of 60 adult cadavers and reported the cartilaginous dorsal length to be 21±5 mm on average (shorter in females by approximately 5±4 mm).7 kim’s study which was based on radiological measurements yielded a cartilage dorsal length in adults of 26±4 mm on average with no significant differences in dorsal length between males and females.7 in this study, the mean dorsal length was 22.3 mm, closer to the cadaver values reported by godley. septal cartilage may be available in different populations as graft material if less than 400 mm2 is needed and further studies can determine the extent of inter-racial variability. surgeons can then decide if septal cartilage is enough or additional donor sites are needed and patients can be oriented regarding these additional surgeries preoperatively. in addition, knowledge of the area available to the surgeon can lessen the possibility of extensive resection of the nasal septum. too much resection can lead to weakening of the structural support of the nose which can bring about saddle nose deformity and problems in airway function. studies such as this are valuable to basic and applied medical science. this study was limited to the 2-dimensional plane of the nasal septum and was not able to determine its actual surface area and thickness which can be valuable in nasal airflow studies. the computation for the area of irregular shapes used in this study only yields approximate values and future studies may employ more accurate centimeter grids to measure area. thickness, which varies from caudal edge to posterior attachment can also be evaluated. areas based on cadaver dissection can also be compared with those obtained from imaging modalities. the limited number of subjects in this study did not allow stratification according to age or sex. the observation that the septum is actually bigger in younger populations (who are also generally taller than previous generations) and in noses with long columellas (especially in mestizos or those of mixed-heritage) can be validated. while the data gathered in this study is comparable to that available in the literature, further studies with more subjects utilizing harvested septal cartilage are needed to validate existing data and posit predictive parameters for the size of the septum. acknowledgements the author would like to acknowledge dr. jenny catignas for her assistance in the dissections. references 1. lin g, lawson w. complications using grafts and implants in rhinoplasty. operative techniques in otolaryngology. 2007 dec; 18:315-23. 2. fischer h, gubisch w. nasal valves--importance and and surgical procedures. facial plast surg. 2006 nov;22(4):266-80. 2006 nov;22(4):266-80. 3. yung m. cartilage tympanoplasty: literature review. j laryngol otol. 2008 jul; 122(7): 663-72. epub 2008 mar 3. 4. aarnisalo aa, cheng jt, ravicz me, hulli n, harrington ej, hernandez-montes ms , et al. middle ear mechanics of cartilage tympanoplasty evaluated by laser holography and vibrometry, otol neurotol 2009 dec; 30(8): 1209-14. 5. ozbek c, ciftçi o, ozdem c. long-term anatomic and functional results of cartilage tympanoplasty in atelectatic ears. eur arch otorhinolaryngol. 2010 apr; 267(4): 507-13. epub 2009 sep 2. 6. cavusoglu,t, vargel i, yaziqi i, cavusoglu m, vural ac. reconstruction of orbital floor fractures using autologous nasal septal bone graft. ann plast surg 2010 jan ;64 (1):41-6. 7. kim is, lee my, lee ki, kim,hy, chung yj. analysis of the development of the nasal septum according to age and gender using mri. clin exp otorhinolaryngol. 2008 mar; 1(1): 29–34. epub 2008 march 20. [cited 2010 august]. available from: http://www.ncbi.nlm.nih.gov/pmc/articles/ pmc2671753 8. miles ba, petrisor d, kao h, finn ra, throckmorton gs. anatomical variation of the nasal septum: analysis of 57 cadaver specimens. otolaryngol head neck surg. 2007 mar;136(3):362–368. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 original articles 10 philippine journal of otolaryngology-head and neck surgery abstract objective: using preand post-treatment otoacoustic emission (oae) tests, this study aimed to assess the ototoxic effect of meropenem, amikacin and meropenem plus amikacin among neonates treated for sepsis neonatorum in a neonatal intensive care unit versus untreated outpatient controls. methods: design: prospective quasi-experimental controlled clinical trial setting: tertiary government hospital subjects: neonates treated for sepsis neonatorum in the neonatal intensive care unit between august to october 2012 who met inclusion criteria were included in this study. controls were neonates born in the same institution who were not admitted and did not receive any antibiotic treatment. excluded were those with apgar < 5 at first minute, birth weight < 1000 grams, clinically evident congenital anomalies and initial “refer” results on oae. neonates were subjected to oae testing before and after seven days treatment with amikacin, meropenem or a combination of both drugs. results were analysed using chi-square test. maternal drug intake, family history of hearing impairment and clinical outcomes (whether expired or discharged improved) were not included in this study. assessment of ototoxic effects were limited to oae alone and not confirmed by abr. results: oae “refer” rates were as follows: no amikacin and no meropenem, 0% (0/42); amikacin only, 33.3% (3/9); meropenem only, 25% (2/8) and amikacin and meropenem, 50% (10/20). statistical analysis showed that hearing loss was dependent on treatment (c2 =23.741, p = < 0.001). overall, statistical analysis showed that there is an increased risk of hearing loss when treated with amikacin and/or meropenem as compared to no treatment. conclusion: there is an increased risk of ototoxicity when amikacin, meropenem or a combination of both drugs is administered to neonates. while the ototoxic effects of amikacin have been elucidated, further studies involving meropenem and its potential ototoxic effect are recommended. keywords: ototoxicity, amikacin, meropenem, otoacoustic emission testing, neonatal hearing loss assessment of the ototoxic effects of amikacin and meropenem among neonates in a tertiary government hospital edgar jake a. agullo, md francisco a. victoria, md department of otolaryngology -head and neck surgery ospital ng maynila medical center correspondence: dr. francisco a. victoria department of otolaryngology -head and neck surgery ospital ng maynila medical center quirino ave. cor. roxas blvd., malate, manila 1004 philippines phone: (632) 524 6061 local 220 e-mail: ommc_enthns@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or in electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2014; 29 (2): 10-14 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 original articles philippine journal of otolaryngology-head and neck surgery 11 ototoxicity refers to the injurious effect of a drug or any chemical substance on the organ of hearing or balance.1 drugs that could inflict such damage include aminoglycoside antibiotics, vancomycin, erythromycin iv, minocycline, amphotericin b, quinine, salicylates, cisplatin and loop diuretics among others.2 these drugs can cause auditory and/or vestibular dysfunction. the damage is usually permanent hearing loss and tinnitus secondary to sensorineural degradation. generally, the site of lesion is almost exclusively cochlear and balance dysfunction may derive from comparable degeneration.3 the mechanism of cell damage is mainly through apoptosis particularly on the outer hair cells.4 severe neonatal infections can be treated by various types of antimicrobials. ideally, culture-guided therapy is recommended to prevent production of multidrug resistant strains. however, empiric therapy is usually initiated in order to facilitate prompt and immediate treatment. as documented by a previous study,5 common pathogens in sepsis neonatorum are frequently susceptible to aminoglycosides particularly gentamicin and amikacin as well as to carbapenems such as meropenem and imipenem. aminoglycosides are well-known and regarded as a successful class of antibiotics. the first aminoglycoside was streptomycin which was isolated from streptomyces griseus. this provided treatment for tuberculosis and was found to be effective against gram-negative bacteria. years after, other aminoglycosides were also isolated from members of the streptomyces spp. in addition to their potent antimicrobial efficacy, all aminoglycosides can cause toxic side effects on the kidneys and inner ear. while damage inflicted on the kidney is usually temporary, damage to the inner ear is irreversible.6 carbapenems are beta-lactams with the broadest antibacterial spectrum currently available. they are generally well-tolerated and there are only few reports of drug-related adverse events. they have a definite role in empiric and definitive therapy of serious and multi drug resistant bacterial infections.9 interestingly, this group of drugs was developed from a drug called thienamycin which was first detected from a culture of streptomyces cattleya, a member of the streptomyces family where aminoglycosides were first isolated from.7 the most frequently reported adverse events were diarrhea, rash, nausea and vomiting, thrombocytosis, eosinophilia and changes in hepatic biochemistry.8 no data can suggest its possible ototoxic effect. the american academy of audiology released its position statement and policy guidelines in ototoxicity monitoring.3 the set of guidelines recommended audiologic monitoring for ototoxicity to be primarily performed for two purposes: “early detection of changes to hearing status presumably attributed to a drug/treatment regime so that changes in the drug regimen may be considered and audiologic intervention when handicapping hearing impairment has occurred.” audiologic monitoring is suggested in cases of treatment using platinum coordination complexes, aminoglycosides, loop diuretics and nonsteroidal anti-inflammatory agents. audiological methods possibly of value in ototoxicity monitoring include basic audiologic assessment, high frequency audiometry (hfa) and otoacoustic emission (oae) measurement. these may be used separately or in combination and may vary in utility, reliability and purpose and applicability to specific patient populations. regardless of the method to be used, it is highly recommended that a baseline evaluation be carried out so that future results will have a good basis of interpretation. to date, the best approach in evaluating newborn hearing is through otoacoustic emissions (oae) or auditory brainstem response (abr) testing.10 otoacoustic emission test equipment is more accessible and mild degrees of motion artifact do not interfere with test results. moreover, transient-evoked otoacoustic emissions (teoae) can be used as a powerful, sensitive and reliable test in evaluation of cochlear damage.14 auditory brainstem response offers a more complete evaluation of the hearing pathway but motion artifacts may affect the test results and if the test cannot be performed because of motion artifacts, sedation may be necessary.11 this study aims to assess the ototoxic effect of meropenem, amikacin, and meropenem plus amikacin among admitted neonates treated for sepsis neonatorum in a tertiary government hospital neonatal intensive care unit through preand post-treatement otoacoustic emission testing versus outpatient controls. the results of this study may be used in guiding the clinician in administering the involved drugs in order to maximize efficacy and minimize the possible adverse outcomes. methods study design: prospective quasi-experimental controlled clinical trial setting: tertiary government hospital subjects: neonates admitted to the neonatal intensive care unit between august to october 2012 for possible sepsis neonatorum and met inclusion criteria were included in this study. the control group was composed of neonates born in the same institution who were not admitted and did not receive any antibiotic treatment. neonates with poor apgar score <5 at first minute, extremely low birth weight <1000 grams, clinically evident congenital anomalies, and initial “refer” results on oae were not included to ensure that all subjects were presumed to be of normal hearing function before commencement of the treatment intervention. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 original articles 12 philippine journal of otolaryngology-head and neck surgery intervention neonates were systematically assigned to three groups at the time of admission. this was based on the severity of the clinical and laboratory findings as assessed by pediatric residents. group a neonates (least severe) were given an aminoglycoside (amikacin at 15 mg/kg/ day), group b neonates (moderately severe) were given a carbapenem (meropenem at 20 mg/kg/dose q12), group c neonates (severe) were given combination of amikacin at 15 mg/kg/day and meropenem at 20 mg/kg/dose q12. informed consent was secured from the parents after informing them the need for admission. risks and benefits of undergoing the proposed treatment plan were explained to the parents as part of the consent. otoacaustic emission test using madsen accuscreen® pro v. 1.16e1m (gn otometrics, denmark) was performed on all these neonates prior to the start of antibiotics and after seven days of antibiotics and on controls. neonates were subjected to oae testing before and after seven days treatment with amikacin, meropenem or a combination of both drugs. results were analysed using chi-square test. maternal drug intake, family history of hearing impairment and clinical outcomes (whether expired or discharged improved) were not included in this study. assessment of ototoxic effects was limited to oae alone and not confirmed by abr. main and secondary outcome measure a grade of pass or refer in both ears were assigned to each subject after the hearing test. data and statistical analysis data were processed using spss v11.5 (spss inc., south wacker drive, chicago, il 60606-6412) for windows. results were analyzed using chi square test. descriptive statistics were applied on demographic profiles. cross tabulation of hearing loss before and after treatment on each group was done. results a total of 79 neonates were included in the study; 47 (59.5%) were male and 32 (40.5%) were female. nine neonates (9 male, no female) were in group a (least severe, amikacin group), 8 neonates (4 male, 4 female) were in group b (moderately severe, meropenem group), 20 neonates (6 male, 14 female) were in group c (severe, amikacin + meropenem group) and 42 (28 male, 14 female) were outpatient controls. for the overall age of gestation based on ballard’s score, 42 neonates (53%) belonged to the age group of 37-39 weeks. seventeen (17) of 37 neonates (46%) from the treatment group had ages of gestation of 3436 weeks while most (74%) of the babies from the control group had a ballards score of 37-39 weeks. (figure 2) the birth weight among the subjects was also noted and grouped (figure 2) where 14 neonates (37.8%) from the treatment group had normal birthweight (2.5kg – 3.0kg) and 18 neonates (48.6%) had low birthweight. thirty one (31) neonates (73.8%) from the control group had normal birthweight. baseline oae results of all subjects were “pass.” hearing tests were repeated after treatment with antibiotic. (table 1) oae “refer” rates were as follows: no amikacin and no meropenem, 0% (0/42); amikacin only, 33.3% (3/9); meropenem only, 25% (2/8) and amikacin and meropenem, 50% (10/20). statistical analysis showed that risk of developing hearing loss is dependent on treatment (c2 =23.741, p = < 0.001). (table 2) the chi-square test revealed that there was a significant difference between the proportion of neonates who developed hearing loss after treatment compared with the control group. figure 1. distribution of neonates based on sex between group a (amikacin), b (meropenem), c (meropenem and amikacin) and control group (no treatment) figure 2. distribution of neonates based on birthweight between group a (amikacin), b (meropenem), c (meropenem and amikacin) and control group (no treatment) philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 original articles philippine journal of otolaryngology-head and neck surgery 13 overall, statistical analysis showed that there was an increased risk of developing hearing loss as suggested by a “refer” oae result when treated with amikacin and/or meropenem as compared to no treatment (c2 = 1.242, p = 0.265). (table 3) there was an increased risk of developing hearing loss when treated with amikacin (group a) as compared to no treatment. for group b, there was an increased risk of having hearing loss when treated with meropenem as compared to no treatment. for group c, there was an increased risk of having hearing loss when treated with both meropenem and amikacin as compared to no treatment. table 1. oae results after treatment tragal pointer treatment total no treatment meropenem amikacin amikacin + meropenem 42 6 6 10 64 0 2 3 10 15 42 8 9 20 79 “pass” “refer” total table 2. computed relative risks using chi-square test among the treatment groups meropenem amikacin meropenem and amikacin p-value= 0.02 95% ci [-455.485 to -0.25] [-0.587 to -0.058] [-2 to -17] [456.485 to 1.25] p-value = 0.003 95% ci [-536.383 to -0.686] [-0.635 to -0.107] [-2 to -9] [537.383 to 1.686] p-value < 0.001 95% ci [-698.132 to -1.645] [-0.685 to -0.272] [-1 to -4] [699.132 to 2.645] chi-squared rrr arr nnt rr chi-squared rrr arr nnt rr chi-squared rrr arr nnt rr =5.419 estimate -22.889 -0.266 -4 23.889 =8.905 estimate -29.1 -0.338 -3 30.1 =20.336 estimate -42 -0.488 -3 43 table 3. computed relative risks using chi-square test among treatment versus nontreatment groups treatment vs no treatment p-value < 0.001 95% ci [-565.652 to -1.172] [-0.554 to -0.229] [-2 to -4] [665.652 to 101.172] chi-squared rrr arr nnt rr =17.562 estimate -34.079 -0.396 -3 134.079 discussion the ototoxic effects of amikacin have long been proven. among the aminoglycosides, amikacin has been found to have higher rates of cochleotoxicity.12 previous studies documented the toxic effects of amikacin on high frequencies particularly on levels of 8,000 hz, 4,000 hz and even 2,000 hz.13 as such, careful monitoring of ototoxicity is recommended whenever the drug is used. concentration of the drug is initially highest at the basal level of the cochlea thus exerting its effect in this region.14 within this area, outer hair cells are usually the ones that receive the harmful effect. damage to the outer hair cells can be documented through otoacoustic emissions testing. the oae device utilized in this study analyzed frequencies of 1500 hz, 2000 hz, 3000 hz and 4000 hz.15 meropenem, as a member of the class of drugs called carbapenems, can induce cns toxicity usually presented as seizures.16 meropenem levels have been quantified in different tissues and body fluids such as csf, respiratory tract, urinary tract and even in gynecologic tissues but no reports have been made regarding its presence in the inner ear.17 furthermore, no reports have been established for its possible effect on the vestibulocochlear system. owing to the fact that carbapenems and aminoglycosides have the same origin on streptomyces spp.,6,7 we assumed that there may be some similarities in their pharmacokinetics. one possible hint is the nephrotoxicity which is a common characteristic of these groups of drugs.6,22,24 in this study, monotherapy with both amikacin and meropenem showed an increased risk of developing hearing loss after seven days of treatment. this is expected of amikacin but not of meropenem. no available literature has been found to explain the possible mechanism of ototoxicity brought about by meropenem. amikacin stimulates generation of reactive oxygen species (ros) in the inner ear. reactive oxygen species can activate cell-death pathways thereby causing irreversible injury to the outer hair cell that could ultimately lead to hearing loss.4 on the other hand, meropenem’s structure, believed to be the factor responsible for its epileptogenic activity, has not been probed for its possible ototoxic effects. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 original articles 14 philippine journal of otolaryngology-head and neck surgery references 1. world health organization: programme for the prevention of deafness and hearing impairment. report of an informal consultation on strategies for prevention of hearing impairment from otottoxic drugs. geneva, 1994 nov 21-23. 2. fairbanks d. pocket guide to antimicrobial therapy in otolaryngology – head and neck surgery. 13th ed. american academy of otolaryngology--head & neck surgery foundation, inc. one prince street alexandria, va 22314-3357, u.s.a. 2007. 3. durrant j, campbell k, fausti s, guthrie o, jacobson g, lonsbury-martin b, poling g. american academy of audiology position statement and clinical practice guidelines: ototoxicity monitoring. american academy of audiology. 2009 oct. 4. tabuchi k, nishimura b, nakamagoe m, hayashi k, nakayama m, hara a. ototoxicity: mechanisms of cochlear impairment and its prevention. curr med chem. 2011; 18(31):4866-71. 5. querimit em. “outcome of neonates with burkholderia cepacia growth on blood culture in a tertiary government hospital from 2009-2011”. presented at ospital ng maynila department of pediatrics descriptive research presentation, 2012. (unpublished) 6. huth me, ricci aj, cheng ag. mechanisms of aminoglycoside ototoxicity and targets of hair cell protection. int j otolaryngol. 2011; 2011: 937861. 7. shah pm. parenteral carbapenems. clin microbiol infect. 2008 jan; 14 suppl 1: 175–180. 8. norrby sr, newell pa, faulkner kl, lesky w. safety profile of meropenem: international clinical experience based on the first 3125 patients treated with meropenem. j antimicrob chemother. 1995 jul; 36 suppl a: 207-223. 9. baldwin cm, lyseng-williamson ka, keam sj. meropenem : a review of its use in the treatment of serious bacterial infections. drugs. 2008; 68(6): 803-38. 10. world health organization. newborn and infant hearing screening: current issues and guiding principles for action. world health organization 2010. geneva 27, switzerland. 11. harlor ad jr, bower c. hearing assessment in infants and children: recommendations beyond neonatal screening. pediatrics. 2009 oct; 124(4):1252-63. epub 2009 sep 28. 12. javadi mr, abtahi b, gholamia k, safari moghadam b, tabarsi p, salamzadeh j. the incidence of amikacin ototoxicity in multidrug-resistant tuberculosis patients. iran j pharm res. 2011 fall; 10 (4): 905-911. 13. black re, lau wk, weinstein rj, young ls, hewitt wl. ototoxicity of amikacin. antimicrob agents chemother. 1976 jun; 9(6): 956-961. 14. naemi m, maamouri g, boskabadi h. assessment of aminoglycoside-induced hearing impairment in hospitalized neonates by teoae. indian j otolaryngol head neck surg. 2009 dec; 61 (4):256-261. 15. madsen accuscreen pro datasheet. product insert. fischer-zoth diagnosesysteme gmbh. walter-kolbenhoff-st. 34 d – 82110 germering 16. papp-wallace km, endimiani a, taracila ma, bonomo ra. carbapenems: past, present, and future. antimicrob agents chemother. 2011 nov; 55(11): 4943–4960. 17. craig wa. the pharmacology of meropenem, a new carbapenem antibiotic. clin infect dis. 1997 feb; 24 suppl 2: s266-75. monotherapy with amikacin and combination therapy with amikacin plus meropenem carries the same risk of developing hearing loss. following this, it may be hypothesized that there is possibly no synergistic effect on ototoxicity of the two drugs. this study suggested the possible ototoxic effect of meropenem and confirmed that of amikacin on neonates. however, the specific area of the inner ear as predicted by the frequency of hearing impairment where meropenem might have been taking its effect was not established due to the limitation of equipment. it is recommended to test for possible ototoxic effects of meropenem on a larger sample size using equipment that could determine the specific frequency of possible area of injury. further biochemical studies can also be recommended for meropenem in order to verify the possible mechanism of injury it can induce in the inner ear. 28 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports abstract objective: to report a case of a gastrointestinal stromal tumor presenting as a recurrent tongue mass methods: study design: case report setting: tertiary public military hospital participant: one patient results: a 40-year-old filipino soldier from camarines sur presented with a recurrent tongue mass two years after excision of a progressively-enlarging, firm, fixed, non-tender mass at the left posterior third of the tongue diagnosed as a schwannoma. repeat surgery involved partial glossectomy via midline mandibular swing. final histopathologic report after immunohistochemical studies for cd117, sma, and s100 was extraintestinal gastrointestinal stromal tumor of the tongue. the patient was started on the c-kit tyrosine kinase inhibitor imatinib with no recurrence 10 months post treatment. conclusion: gastrointestinal stromal tumor may be considered when presented with a recurrent tongue mass despite complete surgical resection. surgical removal is curative for most lesions. post-operative chemotherapy with the use of imatinib is valuable. keywords: recurrent tongue mass, gastrointestinal stromal tumor, immunohistochemistry, c-kit tyrosine kinase inhibitor a 40-year-old filipino soldier from camarines sur presented with a recurrent mass over the posterior third of the tongue. his condition started two years earlier, with a progressively enlarging, firm, fixed, non-tender mass at the left posterior third of the tongue of one month duration, associated with difficulty in speech and dysphagia for solid food. there was no history of trauma, weight loss or taste disturbances. initial physical examination revealed a 5 x 5 x 3cm, non-hyperemic, non-tender, firm, fixed mass involving the left posterior third of the tongue with no limitation of tongue movement. there were no palpable cervical lymphadenopathies, and the rest of the physical examination findings were unremarkable. incision biopsy revealed capillary hemangioma, and intralesional triamcinolone injection at 1.5cc once a week for four weeks was started. a decrease in size of the mass to 4 x 3 x 3 cm was noted, and wedge excision biopsy with 0.5 cm margins and primary repair was performed under general anesthesia. histopathological examination showed tissue composed of spindle-shaped cells with indistinct cellular borders disposed in fascicles while others exhibit rows of cells with gastrointestinal stromal tumor of the tongueandrie jeremy formanez, md grace naomi b. galvan-bravo, md department of otorhinolaryngology head and neck surgery armed forces of the philippines medical center quezon city, philippines correspondence: dr. andrie jeremy formanez department of otolaryngology head and neck surgery armed forces of the philippines medical center 7th floor, armed forces of the philippines medical center, v. luna avenue, quezon city, 0840 philippines mobile: +63917 842 3142 phone: (632) 426 2701 local 6172 email: docdrie@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the interesting case contest, philippine society of otolaryngology head and neck surgery, best western hotel, a venue, makati city, may 27, 2013. philipp j otolaryngol head neck surg 2013; 28 (1): 28-33 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 29 philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports nuclear palisading alternating with anuclear fibrillar zones; and chronic inflammation of the surrounding muscular stroma. the histopathologic interpretation was schwannoma with chronic glossitis. two years later, a month prior to this admission, he noted recurrence of the mass in the same area of the tongue with associated dysphagia, odynophagia and slurring of speech. physical examination revealed a 5 x 4 x 2 cm exophytic, nonhyperemic, nontender, firm mass over the midline of the posterior 3rd of the tongue. (figure 1). there were figure 1. 5 x 4 x 2 cm exophytic, nonerythematous, nonhyperemic, nontender, firm mass over the midline of the posterior third of the tongue (arrow) no palpable cervical lymphadenopathies and the rest of the physical examination was again unremarkable. contrast ct scans of the oropharynx and neck revealed a fairly well-defined solid tumor in the posterior half of the left and right tongue causing secondary narrowing of the oral cavity and oropharynx. (figure 2 a, b) a partial glossectomy excised the mass with 0.5 cm margins via a midline mandibular swing with titanium plate restorative fixation. resection borders extended past the sulcus terminalis anteriorly and approached tongue base posteriorly. the gross specimen was a firm encapsulated 7 x 7 x 8 cm mass. (figure 3 a, b) figure 2. contrast ct scan of oropharynx, a. axial view, b. coronal view, showing a fairly well-defined contrast-enhancing mass involving the posterior half of the left tongue which crosses to the right, measuring 5 x 4 x 5 cm (arrow) a b histopathological examination showed mostly bundles of normal skeletal muscle tissues with some portions of stroma noted to have densely cellular fascicles and intersecting bundles of spindle shaped cells, exhibiting vesicular to hyperchromatic nuclei, some wavy, with pinpoint nucleoli and scanty pinkish cytoplasm. the tumor cells were pleomorphic, exhibiting fusiform vesicular to hyperchromatic nuclei, pinpoint nucleoli, and eosinophilic cytoplasm; other cells appeared asymmetrically tapered, spindly with irregular nuclei in palisading form; still other tumor cells were monotonous, oval shaped with illdefined borders. areas of necrosis and inflammation were noted in 30 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports figure 3. firm encapsulated 7 x 7 x 8 cm mass, a, intraoperative view and b. gross specimen figure 4a. low power magnification (100x), h&e, showing densely cellular fascicles and intersecting bundles of spindle shaped cells (arrow) a b (hematoxylin eosin, 100x ) figure 4b. high power magnifaction (400x), h&e, showing spindle shaped cells exhibiting wavy hyperchromatic nuclei with pinpoint nucleoli and scanty pinkish cytoplasm (arrow) (hematoxylin eosin, (400x) initial histopathological interpretation was a malignant spindle cell tumor with the following considerations: 1) malignant peripheral nerve sheath tumor; 2) myofibroblastic sarcoma; and 3) spindle cell (sarcomatoid) carcinoma. immunohistochemical studies for s-100, smooth muscle actin, desmin, cd34, factor viii and cytokeratin were conducted, cd117, s100 and sma were positive (figure 4 c – e). the final histopathological and immunohistochemical diagnosis was extraintestinal gastrointestinal stromal tumor. on the 24th post-operative day, a 2 x 2 x 0.5 cm exophytic, nonerythematous, firm, nontender, fixed recurrent mass was noted over the midline of the anterior tongue. (figure 5) the oncology service started imatinib 100 mg/tab, 4 tablets once daily, with regression of the mass, and no recurrence until 10 months post treatment. some portions of the overlying epithelium. mitotic figures were seen at 1-3/high power field. the portions of distal margins of resection were negative for tumor metastases. (figure 4 a b) philippine journal of otolaryngology-head and neck surgery 31 philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports discussion gastrointestinal stromal tumors (gist) are nonepithelial neoplasms which arise from connective tissue. these are said to arise from the interstitial cells of cajal.1 such cells are normally part of the autonomic nervous system of the lower digestive tract and serve a pacemaker function in controlling motility. figure 5. recurrent 2 x 2 x 0.5 cm exophytic, nonerythematous, firm, nontender, fixed mass over the midline of the anterior tongue (arrow) figure 4c. low power magnifaction (400x), immunohistochemical stain, showing positive, diffuse strong cytoplasmic expression in neoplastic cells for smooth muscle actin (sma) (arrow) figure 4d. low power magnifaction (400x), immunohistochemical stain, showing positive, diffuse cytoplasmic expression in neoplastic cells for cd117 (arrow) (immunohistochemical stain, 400x) (immunohistochemical stain, 400x) figure 4e. immunohistochemical stian, 400x showing positive, cytoplasmic and nuclear staining in neoplastic cells for s100 (arrow) (s100 stain, 400x ) 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports although gist are among the most common mesenchymal tumors of the digestive tract, they rarely occur in the tongue. approximately 70% arise in the stomach, 20% in the small intestine, and less than 10% in the esophagus.2 to the best of our knowledge, there has been only one previous report in the english literature of a malignant gist of the tongue in a 60-year old woman in kuwait.3 differential diagnosis in this patient presenting with a recurrent tongue mass include schwannoma, squamous cell carcinoma of the tongue, and malignant peripheral nerve sheath tumor. a schwannoma is a benign encapsulated tumor which can arise anywhere in the body with a high predilection for the head and neck region that usually occurs in persons between 40 – 70 years of age.4 microscopic examination reveals antoni a and b patterns with elongated cells with cytoplasmic processes arranged in fascicles in areas of moderate to high cellularity with little stromal matrix.4 however, it is slightly more common in women and is usually found at the base of the tongue, and recurrence upon complete resection of the mass is rare. with a 4 pack-year smoking history, squamous cell carcinoma of the tongue can be considered. it usually presents as a painless, ulcerative or infiltrative lesion at the ventrolateral aspect of the mid and posterior tongue,5 but can also present as an exophytic lesion with symptoms of dysphagia, odynophagia, and difficulty of speech. squamous cell carcinoma can recur with inadequate resection and/or adjuvant medical treatment. however, it was ruled out by our histopathologic results. malignant peripheral nerve sheath tumors arise from cells associated with the nerve sheath namely schwann cells, perineural cells, or fibroblasts.6 although these commonly present as enlarging masses near the sciatic, brachial and sacral plexuses, they may also present as intraoral masses and may involve the tongue.6 their etiology is unknown, but their incidence is increased in patients with a history of radiation exposure.6 they usually occur in adults 20 – 50 years of age and symptoms are usually related to impingement of the involved nerve or mass effect.6 histologically, these may appear as dense cellular fascicles containing spindle shaped cells and may have a nuclear palisading as was seen in the patient.6 however, they are not positive for cd117 on immunohistochemistry, hence this entity was ruled out. symptoms in patients with gist may be related to mass effects. they may present with difficulty in swallowing, vague abdominal pain or discomfort, or gastrointestinal hemorrhage in cases of mucosal ulceration. only the first symptom was observed in our patient due to the location of the tumor on the tongue. most gist arise because of a mutation in a gene which is responsible for encoding a transmembrane receptor for a growth factor called stem cell factor (scf ).1 this gene is called c-kit and its product cd117 is expressed on the interstitial cells of cajal, mast cells, melanocytes and bone marrow cells.1 activating mutations of c-kit and platelet derived growth factor alpha (pdgfra) permit the phosphorylation of the receptor tyrosine kinases perpetuating the receptor-initiated signal and causing activation of the downstream effectors. the end result of such activation is increase in cellular proliferation and decrease in apoptosis, ultimately leading to neoplasia, probably following other, currently unknown genetic events.1 due to the sparsity of data regarding extraintestinal gist, particularly the tongue in this case, histogenesis is not yet defined. for primary gist of mesentery, omentum, and retroperitoneum, where interstitial cells of cajal are not known to be present, it has been suggested that a new type of c-kit positive mesenchymal cell may be present7 and this could also be a possibility in explaining the development of gist in the tongue of our patient. gist typically originate from within the muscle wall of the gastrointestinal tract, ranging from 1 – 40 cm in size with an average size of approximately 5 cm. small gist usually form subsolid intramural masses but may also have polypoid morphology. when present in the abdominal cavity, as is usually the case, large gist are usually exophytic with an outward pattern of growth.8 for the most part, the etiology for gist remains unknown at present. the vast majority of gist are sporadic.9 familial gist occurs rarely and is associated with a mutation in the c-kit or even more rarely in succinate dehydrogenase genes in carney-stratakis syndrome.10 mutation of the pdgfra gene is an alternative oncogenic event, and is found in 35% to 40% of gist lacking a c-kit mutation.9 gist has an incidence of 10 – 20 per 1 million people.11 this would make the gist the most common form of mesenchymal tumor. there is a slight male predominance. in gist of the stomach, the peak age of diagnosis is at 60 years with fewer than 10% occurring in individuals under 40 years of age.8 it is equally distributed across all geographic and ethnic groups.4 current classifications do not characterize gist as benign or malignant.8 rather, these classify tumors according to the probability of recurrence into very low risk, low risk, moderate risk, and high risk. factors that affect recurrence include tumor size, mitotic index, and tumor location.1 local invasion and metastases indicate aggressive tumor behavior and increases the risk of tumor recurrence.8 in the abdomen, spread to the liver, omentum, and peritoneum is usually seen. metastases to the bone, pleura, lungs, and retroperitoneum may also occur. occasionally, malignant lymphadenopathy is seen in <10% of cases.13 radiologic findings that are suggestive of malignancy include heterogeneous enhancement after contrast enhancement, philippine journal of otolaryngology-head and neck surgery 33 philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports references 1. miettinen m, lasota j. gastrointestinal stromal tumors: review on morphology, molecular pathology, prognosis, and differential diagnosis. arch pathol lab med 2006 oct;130(10):1466– 78. 2. miettinen m, lasota j. gastrointestinal stromal tumors--definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis. virchows arch 2001 jan; 438(1):1–12. 3. ibrahim hh, ahmad ms, eskaf wa, schuutz p. malignant gastrointestinal stromal tumor of the tongue: case report and review of the literature. oral surg oral med oral pathol oral radiol endod. 2011 may;111(5): e24-9. 4. anthony a, frosch m, girolami u. the central nervous system. in: kumar v, abbas a, fausto n, aster j. robbins and cotran pathologic basis of disease. 7th edition, 2005. philadelphia: saunders elsevier. page 1411. 5. becker m. oral cavity and oropharynx. in: mafee m, valbasson g, becker m, lewin js, nour sg, weber al. imaging of the head and neck.” 2nd edition, 2005. stuttgart: thieme medical publishers. page 689. 6. guo a, liu a, wei l, song x. malignant peripheral nerve sheath tumors: differentiation patterns and immunohistochemical features a mini-review and our new findings. j cancer 2012;3:303309. 7. sakurai s, hishima t, takazawa y, sano t, nakajima t, saito k, et al. gastrointestinal stromal tumors and kit-positive mesenchymal cells in the omentum. pathol int. 2001 jul;51(7):524-31. 8. tran t, davila ja, el-seraq hb. the epidemiology of malignant gastrointestinal stromal tumors: an analysis of 1,458 cases from 1992 to 2000. am j gastroenterol 2005 jan;100(1):162-8. 9. rubin bp, singer s, tsao c, duensing a, lux ml, ruiz r, et al. kit activation is a ubiquitous feature of gastrointestinal stromal tumors. cancer res. 2001 nov;61(22):8118-8121. 10. nowain a, bhakta h, pais s, kanel g, verma s. gastrointestinal stromal tumors: clinical profile, pathogenesis, treatment strategies and prognosis. j gastroenterol hepatol 2005 jun;20(6):81824. 11. nishida t, hirota s. biological and clinical review of stromal tumors in the gastrointestinal tract. histol histopathol 2000 oct;15(4):1293–301. 12. pidhorecky i, cheney rt, kraybill wg, gibbs jf. gastrointestinal stromal tumors: current diagnosis, biologic behavior, and management. ann surg oncol 2000 oct;7(9):705–12. 13. hersh mr, choi j, garrett c, clark r. imaging gastrointestinal stromal tumors. cancer control 2005 apr;12(2):111–115. 14. ulusan s, koc z, kayaselcuk f. gastrointestinal stromal tumours: ct findings. br j radiol 2008 aug;81(968):618–623. 15. graadt van roggen jf, van velthuysen ml, hogendoorn pc. the histopathological differential diagnosis of gastrointestinal stromal tumours. j clin pathol 2001 feb;54(2):96-102. 16. mazur mt, clark hb. gastric stromal tumors. reappraisal of histogenesis. am j surg pathol 1983 sep;7(6):507-519. 17. lehnert t. gastrointestinal sarcoma (gist)--a review of surgical management. ann chir gynaecol 1988;87(4):297–305. 18. patel sr, wong p. the efficacy of imatinib in unresectable/metastatic gastrointestinal tumors. us oncological review 2009;5(1):61-4. [serial on the internet] cited 2013 february 17.available from: http://www.touchoncology.com/articles/efficacy-imatinib-unresectablemetastaticgastrointestinal-stromal-tumors. 19. din os, woll pj. treatment of gastrointestinal stromal tumor: focus on imatinib mesylate. ther clin risk manag 2008 feb;4(1):149 – 162. 20. okuno sh. the use of tyrosine kinase inhibtors for gastrointestinal stromal tumors (gist). contemporary oncology.2011 mar. [serial on the internet] cited 2013 february 17. available from: http://www.onclive.com/publications/contemporary-oncology/2011/spring-2011/theuse-of-tyrosine-kinase-inhibitors-for-gastrointestinal-stomal-tumors-gist/1. ulcerations and size > 5 cm.14 based on criteria for gist propounded by miettinen and lasota1 with tumor size at >5 cm ≤ 10 cm and mitotic figures at 1 – 3/ high powered field, this tumor is placed in group 3a which for extragastric tumors would signify a high incidence of recurrence. histologically, gist may exhibit two patterns. tumors composed of thin elongated cells are classified as spindle cell type while those dominated by epithelial appearing cells are termed epithelioid type.15 the spindle cell type may exhibit a palisading architecture and may either have an amphophilic, basophilic or eosinophilic cytoplasm;1 the latter being true in the patient. nucleoli are of variable prominence. areas of necrosis and inflammation are also seen. immunohistochemistry for gist would be positive for cd117 and s100.16 these markers were positive for this patient. mazur and clark first recognized gist as a distinct clinicopathologic syndrome in 1983.16 previously, gist were often diagnosed as smooth muscle cell tumors, paragangliomas, fibromatoses, nerve sheath tumors and carcinomas.1 this is due to the relatively broad histomorphologic spectrum which gist represents. surgical removal is the mainstay of treatment for nonmetastatic gist.17 lymph node metastases are rare hence routine removal of lymph nodes is typically not necessary. prognosis correlates with tumor size, mitotic index, and location.1 gastric gist are less aggressive than those arising from the small intestine. recurrence is rare for gastric gist under 5 cm but common for mitotically active tumors larger than 10 cm.8 imatinib, a c-kit tyrosine kinase inhibitor originally used to treat chronic myelogenous leukemia, has been found to be valuable in treating gist.18 imatinib is used for inoperable or metastatic cases with a 40 – 70% response rate. the two-year survival of patients with advanced disease has risen to 75 – 80% following imatinib treatment.19 patients who developed resistance to imatinib may respond to the multiple tyrosinase inhibitor sunitinib.20 in summary, gastrointestinal stromal tumors of the tongue should be considered in the differential diagnosis of a recurrent tongue mass which has been previously resected. although gist of the tongue is rare with only one case from kuwait previously published, this entity should still be considered especially because gist have previously been misdiagnosed as fibromatoses, nerve sheath tumors or carcinomas. histopathologic and immunohistochemical studies, wherein cd117 is generally positive, aid diagnosis. complete surgical excision is curative for most lesions. the c-kit tyrosine kinase inhibitor imatinib is used to treat inoperable or metastatic cases. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports 12 philippine journal of otolaryngology-head and neck surgery abstract objective: to describe an unusual presentation of undifferentiated nasopharyngeal malignancy with immunohistochemical features of both diffuse b-cell lymphoma and undifferentiated carcinoma. methods: design: case report setting: tertiary private university hospital patient: one results: a 49-year-old female whose initial nasopharyngeal biopsy interpretation was diffuse large b-cell lymphoma underwent three cycles of rituximab, cyclophosphamide, hydroxydaunomycin, oncovin and prednisone (r-chop). post-chemotherapy computed tomography (ct) scan of the nasopharynx revealed no change in tumor size or appearance. repeat nasopharyngeal (np) biopsy findings suggested an epithelial tumor lineage or post-chemotherapy reactive mucosal epithelial cells. no residual lymphoma was noted and immunostaining was positive for cytokeratin. the patient underwent 35 fractions of radiotherapy. re-evaluation by magnetic resonance imaging (mri) with contrast after four months showed significant tumor shrinkage. repeat np biopsy revealed necrotic tissues with foci of high-grade squamous cell carcinoma. two months after the biopsy, repeat mri with contrast of the nasopharynx and neck showed increase in the bulk of the nasopharyngeal tumor with inferior extension to the level of the orophaynx and possible contralateral involvement. a nasopharyngectomy via left maxillary swing was performed and the final histopathology was undifferentiated carcinoma. conclusion: undifferentiated malignancies of the nasopharynx may contain lymphoma or carcinoma and rarely, both lineages in coexistence. in such cases, the possibility of a collision tumor should be considered. immunohistochemical distinction is important for treatment and prognostication. keywords: nasopharyngeal carcinoma, undifferentiated tumor, undifferentiated carcinoma, nasopharyngeal lymphoma, collision tumors, immunohistochemistry, diffuse large b-cell lymphoma, secondary malignancy the term “undifferentiated tumor” has been used in reference to a heterogeneous group of tumors with little or no evidence of differentiation. these tumors lack evidence of lineage differentiation on the basis of routine light microscopic morphology, and immunohistochemical evaluation is employed to differentiate between malignant lymphoma (lca) lymphoid lineage, nasopharyngeal carcinoma (cytokeratin) epithelial lineage, rhabdomyosarcoma (vimentin) messenchymal lineage and yolk sac tumor (α-fetoprotein) germ cell lineage.1 undifferentiated nasopharyngeal malignancy with immunohistochemical features of diffuse large b cell lymphoma and undifferentiated carcinoma: a collision tumor? january e. gelera, m.d. norberto v. martinez, m.d. department of otorhinolaryngology head and neck surgery university of santo tomas hospital manila, philippines correspondence: dr. january e. gelera university of santo tomas hospital españa street, sampaloc, manila 1015 philippines phone: 731 3001 local 2224 email: janjanmd@yahoo.com reprints will not be available from the authors the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2012; 27 (1): 12-17 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports philippine journal of otolaryngology-head and neck surgery 13 distinction between these lineages is important for treatment and prognostication. for an undifferentiated tumor, the diagnosis of lymphoma generally predicts a better clinical outcome than a diagnosis of carcinoma.2 on the other hand, the occurrence of collision tumors in the human body is extremely rare. the term refers to coexistent but histologically independent tumors occurring in the same organ. the biological behavior of these tumors is difficult to ascertain and clinical awareness and recognition will oftentimes determine the final outcome in terms of disease-free survival time. this case report will illustrate the significance of immunohistochemistry in identifying the true identity of undifferentiated tumors and the possibility of collision tumors of carcinoma and lymphoma of the nasopharynx or development of secondary malignancy. case report a 49-year-old female consulted due to one-year progressive hearing loss, aural fullness and occasional tinnitus in the left ear with weight loss. otoscopy revealed otitis media with effusion and nasal figure 1. hematoxylin – eosin stain. a. 100x magnification b. 200x magnification. microsections disclose np tissue with a malignant neoplasm composed of polyhedral cell nests infiltrating the lymphoid stroma. tumor cells exhibit round to ovoid hyperchromatic nuclei, prominent nycleoli and scanty cytoplasm. figure 2. leukocyte common antigen (cd45). a. 100x magnification b. 200x magnification. positive in sheets of large lymphoid endoscopy showed a nasopharyngeal mass, both on the left. no cervical lymph node enlargement was appreciated. nasopharyngeal (np) biopsy was interpreted as undifferentiated malignancy. (figure 1) immunohistochemical evaluation was positive for lymphoma and b-cell lineage (figure 2, 3) and negative for t-cell lineage and carcinoma. (figure 4, 5) the results were consistent with diffuse large b-cell lymphoma (dlbcl) and three cycles of rituximab, cyclophosphamide, hydroxydaunomycin, oncovin and prednisone (r-chop) were started. after three months of treatment repeat contrast-enhanced ct scan showed no apparent change in tumor size (figure 6) and a second np biopsy was read as undifferentiated carcinoma. immunostaining was positive for cytokeratin (figure 7) and negative for lca. (figure 8) management was shifted to concurrent chemoradiotherapy (crt) of high-dose 3-weekly cisplatin and simultaneous integrated boost intensity modulated radiotherapy (sib imrt) of 70gy in 35 fractions. four months after concurrent crt, contrast mri showed decrease in nasopharyngeal tumor size and absence of cervical adenopathies. (figure 9) a third np biopsy revealed necrotic tissues with foci of highgrade squamous cell carcinoma. unfortunately, the patient was lost to follow-up until two months after, when another contrast mri showed (hematoxylin-eosin, 100x) (hematoxylin-eosin,200x) (leukocyte common antigen (cd45), 100x) (leukocyte common antigen (cd45)200x) philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports 14 philippine journal of otolaryngology-head and neck surgery figure 4. t-cell specific marker (cd3). a. 100x magnification b. 200x magnification. negative in sheets of large cells; positive in scattered small mature t-lymphocytes figure 5. cytokeratin 100x magnification. epithelial cells staining negatively for cytokeratin discussion the first np biopsy histophathology reading was an undifferentiated malignancy. the term undifferentiated malignancy refers to a heterogenous group of tumors with little or no evidence of differentiation. the term undifferentiated also refers to tumors lacking evidence of lineage differentiation on the basis of routine light microscopic morphology. the characterization of epithelial, mesenchymal, melanocytic or hematopoeitic origin is crucial for treatment planning and prognostication.3,4 undifferentiated malignancies of the nasopharynx may resemble large cell or immunoblastic types of malignant lymphoma and may be distinguished from a carcinoma by a positive immunoreactivity for lca and negative reaction for cytokeratin.4,5 this identification is important in undifferentiated tumors because the diagnosis of lymphoma generally predicts a better clinical outcome than diagnosis of carcinoma.5 studies have demonstrated a greater incidence of lymphomas in cases of undifferentiated nasopharyngeal malignancy. gatter et al. further illustrated that when a pathologist is uncertain about the origin of a neoplasm, the tumor is likely (by a factor of 3 to 1) to be lymphoid in origin.6 in cases where a diagnosis of carcinoma is figure 3. b-cell specific marker (cd20). a. 100x magnification b. 200x magnification. positive in sheets of large b-cells (b-cell specific marker (cd20), 100x) (b-cell specific marker (cd20), 200x) (t-cell specific marker (cd3), 100x) (t-cell specific marker (cd3), 200x) (cytokeratin, 100x) increase in the bulk of the nasopharyngeal tumor on the left with inferior extension to the level of the orophaynx and possible contralateral involvement. (figure 10) based on the consensus at a multidisciplinary meeting, a nasopharyngectomy via left maxillary swing was performed, and the final histopathology report was undifferentiated carcinoma. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports philippine journal of otolaryngology-head and neck surgery 15 figure 8. repeat np biopsy. leukocyte common antigen. a. 100x magnification. b. 200x magnification. negative immunostainingg of the cytoplasm indicates negativity for lymphoma lineage. figure 6. a. september 2008. b. january 2009. no apparent interval change in size appearance and configuration compared with the previous ct. figure 7. repeat np biopsy cytokeratin a. 100x magnification. b. 200x magnification. epithelial cells stained positively for cytokeratin indicating a carcinoma lineage. (cytokeratin, 100x) (cytokeratin, 200x) (leukocyte common antigen., 100x) (leukocyte common antigen., 200x) philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports 16 philippine journal of otolaryngology-head and neck surgery favored, the frequency of it being a lymphoma is higher.6,7 immunostaining was done in this case to reveal the true identity of the tumor. the specimens from the first np biopsy were immunopositive for lca and cd20 while cytokeratin and cd3 were immunonegative. lca antibody for lymphoma and keratin antibody for carcinoma are useful immunohistochemical tools in the differential diagnosis of undifferentiated neoplasms.7,8 non-hodgkins lymphoma of b and t cell types are immunoreactive to lca in 93% to 100%.7,8 prior to the start of chemotherapy, numerous laboratory and metastatic evaluations all indicated that the primary tumor was present only in the nasopharynx. following r-chop every three weeks for three cycles, repeat ct scans of the nasopharynx and neck showed no evidence of tumor regression or change in appearance and configuration. could this have been a residual mass or another tumor entity? positron emission tomography combined with a radiotracer 18f-fluoro-2deoxyglucose (pet-fdg) would have been very useful in detecting the activity of this residual tumor because malignant cells have increased glycolytic activity.9 in this case, a tissue sample was still a reasonable choice because it can correctly identify the tumor and is cost-effective. figure 10. mri with contrast june 2010. increase in the bulk of the nasopharyngeal tumor on the left with inferior extension to the level of the orophaynx and possible contralateral involvement. figure 9. a. ct july 2009 scan b. mri july 2009. four months after completion of radiotherapy a significant decrease in the size of left nasopharyngeal mass was observed. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports philippine journal of otolaryngology-head and neck surgery 17 acknowledgement we acknowledge ma. karen a. capuz, m.d., rolando a. lopez, m.d., and alita b. santos, m.d. for their support, literature contributions and advise in finishing this case report. references bahrami a, truong ld, ro jy. undifferentiated tumor; true identity by immunohistochemistry. 1. arch pathol lab med. 2008 mar;132 (3):326–348. allam w, ismaili n, elmajjaoui s, elgueddari b, ismaili m, errihani1 h. primary nasopharyngeal 2. non-hodgkin lymphomas: a retrospective review of 26 moroccan patients. bmc ear nose throat disord. 2009 nov 17; 9:11. zong ys, zhang rf, he sy, qiu h. histopathologic types and incidence of malignant 3. nasopharyngeal tumors in zhongshan county. chin med j (engl). 1983 jul;96(7):511 – 6. ensani f, karimi sk. nasopharyngeal carcinoma: the role of immunohistochemistry in 4. differentiation between undifferentiated carcinoma and malignant lymphoma: report of 10 cases and review of literature. acta med iran. 38 (1); 55-60: 2000. senba m, zhong xy, itakura h. immunohistochemical investigation of nasopharyngeal 5. carcinoma using keratin, ema, laminin, fibronectin, collagen type iv, laminin receptor, and laminin/collagen receptor antibodies. acta med nagasaki.1993; 38(2): 182-185. gatter kc, abdulaziz z, beverley p, corvalan jr, ford c, lane eb. use of monoclonal antibodies 6. for the histopathological diagnosis of human malignancy. j clin pathol. 1982 nov; 35(11): 125367. gatter kc, heryet a, alock c, mason dy. clinical importance of analyzing malignant tumours of 7. uncertain origin with immunohistological techniques. lancet. 1985 jun 8; 1(8441): 1302-5. michels s, swanson pe, frizzera g, wick mr. immunostaining for leukocyte common antigen 8. using an amplified avidin-biotin-peroxidase complex method and paraffin sections: a study of 735 hematopoietic and nonhematopoietic human neoplasms. arch pathol lab med. 1987 nov;111(11):1035–1039. raani p, shasha y, perry c, metser u, naparstek e, apter s, 9. et al. is ct scan still necessary for staging in hodgkin and non-hodgkin lymphoma patients in the pet/ct era? ann oncol. 2006 jan; 17(1):117-122. sacchi s, marcheselli l, bari a, marchesseli r, pozzi s, gobbi pg 10. et al. second malignancies after treatment of diffuse large b-cell non hodgkin’s lymphoma: a gisl cohort study. haematologica 2008; 93:1335-1342. lasota j, hyjek e, koo ch, blonski j, miettinen m. cytokeratin-positive large-cell lymphomas 11. of b-cell lineage: a study of five phenotypically unusual cases verified by polymerase chain reaction. am j surg pathol. 1996 mar; 20(3): 346-354. tezer ms, tuncel u, özlügedik s, uzun m, kulaçoglu s, ünal a. coexistence of laryngeal 12. squamous cell carcinoma and non-hodgkin’s lymphoma with nasopharyngeal involvement. j laryngol otol .2006 feb; 120(2):e2 1-4. brahmania m, kanthan cs, kanthan r. collision tumor of the colon – colonic adenocarcinoma 13. and ovarian granulosa cell tumor. world j surg oncol. 2007 oct 20; 5:118. walvekar rr, kane sv, d’cruz ak. collision tumor of the thyroid: follicular variant of papillary 14. carcinoma and squamous carcinoma. world j surg oncol. 2006 sep 19; 4: 65. could this have been a secondary malignancy after chemotherapy? the success in combating non-hodgkin’s lymphoma with r-chop during the last decade cannot be overemphasized. this successful treatment resulted in long-term survival of patients, putting them at risk for late sequelae, particularly secondary malignancy. a secondary malignancy is a new cancer that occurs in an individual as a result of previous treatment with radiotherapy and chemotherapy that may occur months or years from initial treatment. sacchi et al., estimated the average development of secondary malignancy at 51 months. among 1280 patients with dlbcl eligible for their study, 48 (3.8%, crude rate 7.6 per 1000 person-years) developed secondary malignancy. of these, 35 developed solid tumors such as colorectal (8), lung (8) and others (19) while the rest were hematologic malignancies (8).10 notably, none developed nasopharyngeal malignancy. our case is unlikely to have been a secondary malignancy because any mitotic changes caused by initial treatment would have taken months or years to manifest. moreover, the first and second np biopsy results were reviewed by pathologists from three different tertiary hospitals in metro manila and the reviews were consistent with our previous findings. now, could this still be a lymphoma with an unusual immunohistochemistry result? lasota et al. reported five cases of clinically aggressive, keratin-positive malignant lymphomas of b-cell type that showed unusual immunophenotypes. two of the cases lacked reactivity to lca while three were immunopositive for cytokeratin. all five were documented as b-cell lymphoma on the basis of polymerase chain reaction suggesting that some b-cell lymphomas can have confusing immunophenotypes with keratin positivity and leukocyte antigen negativity.11 such a possibility may have been considered given the increased nasopharyngeal tumor size after crt treatment. molecular genetic studies would have been a logical next step, but the multidisciplinary consensus was to treat the persistence as radioresistance, hence the nasopharyngectomy. could this have been an immunohistochemistry error from the beginning? we believe this case underwent a reasonable immunohistochemistry panel. the tissue samples were routinely fixed with 10% (v/v) phosphate-buffered formalin embedded in paraffin and cut at 5 um. standard immunohistochemistry staining techniques were performed with a dako envision flex™ kit (dako cytomation, denmark). sources of error in immunohistochemistry include denatured antibody, loss of antigen due to poor fixation, antigen level below detection, cross-reactivity and non-specific binding of antibody. our institution followed strict guidelines to avoid such errors, including preliminary evaluation of some slides to ensure optimal quality. furthermore, the first np biopsy was processed and reviewed by two experienced pathologists with one being a hemapathologist. these slides were subsequently reviewed at three tertiary private institutions in metro manila and the results were the same. could this have been a case of collision tumor on the same site? reports of co-existence are not uncommon because the risk of multiple malignancies in the head and neck region are reported at 2–11 per cent.21 collision tumors represent a coexistence of two adjacent but histologically-different malignant neoplasms occurring in the same organ without histological admixture or an intermediate cell population zone.13 theories include: 1) “chance accidental meeting” of two primary tumors; 2) presence of the first tumor alters the microenvironment facilitating the development of the second primary tumor or seeding of metastatic tumor cells; 3) simultaneous proliferation of two different cell lines.23 the occurrence of two primary tumors in the nasopharynx is possible because it is primarily lined with stratified squamous epithelium and is rich in lymphoid cells. the residual tumor in our case may have been undifferentiated carcinoma following resolution of lymphoma after rchop treatment. we can only hypothesize the possibility of a collision tumor because it can only be diagnosed if the resected specimen showed different histological findings. though collision tumors are very rare, their existence in the nasopharynx has yet to be reported. in the name of academic curiosity, we hope that this possibility heightens clinical awareness because recognition of such tumors is important as it will dictate appropriate treatment strategies, overall prognosis and survival rates. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles 16 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2011; 26 (1): 16-20 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: the study aimed to evaluate mandibular fractures in a tertiary military hospital, to determine the age group in which injury occurred most often, to examine the various mechanisms of injury, to determine the anatomical part of the mandible most frequently affected and to determine if there were significant relationships between the various mechanisms of injury and the different fracture sites. methods: design: cross-sectional retrospective study setting: tertiary public military hospital patients: medical records of 328 active military personnel and their dependents, treated for mandibular fracture at the department of otorhinolaryngology – head and neck surgery, armed forces of the philippines medical center from january 1999 – december 2009 were retrospectively reviewed for data regarding sex, age, various mechanisms of injury and fractured anatomical part of the mandible. the number of fractures per site according to mechanism of injury was tabulated and prevalence ratios (95% confidence intervals) and p values were computed for the different fracture sites among the various mechanisms of injury. the probability or risk of sustaining fractures in these sites based on mechanism of injury was then computed. results: the most fractured anatomical part of the mandible was the body (28%), followed by the parasymphysis (24%), angle (17%), symphysis (12%), ramus (8%), condyle (7%), alveolar ridge (3%) and coronoid (1%). there were associated injuries in 54% of those with mandibular fractures. in these patients, zygomaticomaxillary complex fractures occurred in 25%, head and neck abrasions and lacerations in 30%, head injuries in 28%, ocular injuries in 10%, nasal fractures in 8% and cervical spine fractures in 5%. other injuries present were extremity trauma evaluation of mandibular fractures in a tertiary military hospital: a 10-year retrospective study grace naomi b. galvan, m.d. department of otolaryngology head and neck surgery armed forces of the philippines medical center correspondence: dr. grace naomi b. galvan department of otolaryngology head and neck surgery armed forces of the philippines medical center v. luna avenue, quezon city 0840 philippines phone: (632) 426 2701 local 8872 e-mail: gracenaomigalvanmd@yahoo.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the 12th annual north east manila ent consortium research contest, valdes hall, veteran’s memorial medical center, august 18, 2010. presented at the descriptive research contest, philippine society of otorhinolaryngology-head and neck surgery, glaxo smith kline (gsk) bldg., chino roces ave., makati city, philippines, october 11, 2010. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles philippine journal of otolaryngology-head and neck surgery 17 in 60%, thoracic trauma in 5% and abdominal trauma in 3%. males dominated with a ratio of 99:1. males 21 to 30 years of age sustained the most mandible fractures. most fractures were caused by vehicular accidents (60%), followed by gunshot wounds (31%), falls (4%), violent assault (4%) and sports activities (1%). alcohol was a contributing factor at the time of injury in 20.6% of fractures. all cases were treated by open reduction and internal fixation with plating or wiring. conclusion: the body was the most commonly fractured anatomic region of the mandible in this series. there appeared to be a statistically significant relationship between violent assault and fractures of the ramus, but not between the other mechanisms of injury and the site of fracture. its prevalence ratio of 3.32 (95% confidence interval: 1.13; 9.74, p value 0.039) suggests that the prevalence of fractures of the ramus among those exposed to violent assault was 3 times higher than those who were not. keywords: mandibular fractures, etiology, maxillofacial injuries, trauma the mandible occupying a very prominent and vulnerable position on the face is the 2nd most commonly fractured bone of the face and the 10th most fractured bone in the whole body. 1 surveys of mandible fractures have shown that the etiology varies from one country to another and even within the same country depending on the prevailing socioeconomic, cultural and environmental factors.2 however, different sources list differing anatomic regions of the mandible that are commonly fractured. the aim of this study was to determine the age group, etiology, frequency and classification of mandibular fractures seen in a tertiary military hospital, and to determine if there are significant relationships between the various mechanisms of injury and the different fracture sites. methods this study was a cross-sectional retrospective analysis of all mandibular fractures treated at the armed forces medical center over a 10-year period (1999-2009). data regarding sex, age, various mechanisms of injury and fractured anatomical part of the mandible were gathered from hospital inpatient records and radiographic examinations. the specific anatomic region of the mandible fracture was determined and sites were classified according to the fractured anatomical part of the mandible as parasymphysis, body, angle, symphysis, alveolar ridge, condyle, ramus and coronoid fractures. each fracture line was counted separately. the number of fractures per site according to mechanism of injury was tabulated, and prevalence ratios (95% confidence intervals) and p values were computed for the different fracture sites among the various mechanisms of injury using the statistical software epi info™ version 3.5.3 (centers for disease control, atlanta ga, usa).the probability or risk of sustaining fractures in these sites based on mechanism of injury was then computed using the same statistical software. results a total of 328 patients aged 21 to 45 were treated for mandibular fracture during the study period. most (282) of those treated belonged to the 21-30 year old group with a mean age of 26.98 ± 4.12 years (range 22.86 to 31.1 years). as expected in a military setting, most of the patients were male (99.1%), with females accounting for only 0.9% of the cases. among males, the highest prevalence of mandibular fractures occurred in the 21-30 year-old group, whereas only women constituted the above 40-year-old group. the causes of mandibular fracture were varied (table 1); however, the primary causative factor was vehicular accidents which were not workrelated in 190 cases (57.9%). combat-related injuries resulting from table 1. frequency of mandibular fractures according to site and mechanism of injury among the 328 patients treated at the afp medical center (1999-2009) site vehicular accident combatrelated fall violent assault sportsrelated total (%) number of fractures according to mechanism of injury body parasymphysis angle symphysis ramus condyle alveolar ridge coronoid total 103 95 75 42 30 32 12 3 392 65 56 32 25 14 11 7 2 212 11 6 6 3 3 4 2 0 35 5 7 2 5 5 2 0 0 26 4 2 4 1 0 1 0 0 126 188 (27.77%) 166 (24.52) 119 (17.58) 76 (11.23) 52 (7.68) 50 (7.38) 21 (3.10) 5 (0.74) 677 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles 18 philippine journal of otolaryngology-head and neck surgery gunshots were the second most frequent cause of fracture in 102 cases (31.1%), followed by accidental falls (17 or 5.2%), violent assault (13 or 4.0%) and sports-related injuries (6 or 1.8%). on closer examination, obvious differences between sexes in the causes of fracture were readily apparent (table 1). males most frequently sustained fractures as the result of vehicular accidents involving the use of motorcycles (190 cases or 58.5% of the male population), followed by combat-related injuries secondary to gunshot (101 cases or 31.3% of the males). in contrast, two of the three female cases reported falls as the cause of injury. of the 328 patients included in this study, 300 (91.50%) sustained multiple fracture sites while only 28 (8.50%) had a single fracture site. overall, a total of 677 fractures were noted. in this study, the most commonly fractured site was the body of the mandible (188 cases or 27.77% of all fractures), followed by the parasymphysis (166 of the cases or 24.52% of all fractures). the angle, symphysis, ramus and condyle had prevalence rates of 17.58%, 11.23%, 7.68%, and 7.38%, respectively. the least commonly affected sites were the alveolar ridge and the coronoid being seen in only 21 and 5 cases, respectively. among the various mechanisms of injury, the body of the mandible was still the most frequently affected site. even among those patients who suffered a single fracture, the body was still noted to be the most affected area of the mandible. among those with multiple fracture sites, the most commonly encountered combination involved the body and parasymphysis. to determine if there was a relationship between the various mechanisms of injury and the site of mandibular fracture, prevalence ratios were computed and are summarized in table 2. it appears that violent assault and fractures of the ramus have a statistically significant relationship. its prevalence ratio of 3.32 (95% confidence interval: 1.13; 9.74, p value 0.039) shows that the prevalence of fractures of the ramus among those exposed to violent assault was three times higher than those who were not. associated injuries were present among 43% of those with mandible fractures. among these patients, zygomaticomaxillary complex fractures occurred in 25%, head and neck abrasions and lacerations in 30%, head injuries in 28%, ocular injuries in 10%, nasal fractures in 8% and cervical spine fractures in 5%. other injuries present in this group were extremity trauma in 60%, thoracic trauma in 10% and abdominal trauma in 5%. the mandible fractures were managed by open reduction and internal fixation with wires (2%) or titanium plates (98%). discussion the management of fractures to the maxillofacial complex remains a challenge for oral and maxillofacial surgeons demanding both skill and a high level of expertise. in our institution, mandibular fractures account for 45% of all maxillofacial fractures. the results of this investigation of patients with mandible fractures who were treated at the armed forces of the philippines medical center differ from other series’ in the literature, particularly with regard to the most commonly involved anatomic region in mandible fractures. table 3 summarizes other studies that reveal mandible fracture sites that differ from our findings.3,4,5,6 the results of this study show consistency with that of other studies with regards to the predominant age group sustaining mandibular fractures, which was the 21-30 year-old group.7 a possible explanation for the higher frequency of fractures in this group is that the second table 2. prevalence ratios (95% confidence intervals) and p values of different sites of mandibular fracture among the various mechanisms of injury site of fracture vehicular accident combatrelated fall violent assault sportsrelated mechanism of injury body p value parasymphysis p value angle p value symphysis p value ramus p value condyle p value alveolar ridge p value coronoid p value 0.88 (0.73; 1.06) 0.22 0.97 (0.78; 1.21) 0.88 1.24 (0.92; 1.67) 0.20 0.90 (0.60; 1.33) 0.69 0.99 (0.60; 1.64) 0.91 1.29 (0.76; 2.20) 0.43 0.97 (0.42; 2.23) 0.88 1.09 (0.18; 6.43) 1.00 1.16 (0.96; 1.41) 0.16 1.13 (0.90; 1.41) 0.35 0.81 (0.59; 1.13) 0.26 1.09 (0.72; 1.65) 0.81 0.82 (0.46; 1.44) 0.58 0.62 (0.33; 1.17) 0.18 1.11 (0.46; 2.66) 0.99 1.48 (0.25; 8.71) 0.65 1.14 (0.79; 1.64) 0.70 0.69 (0.36; 1.32) 0.29 0.97 (0.50; 1.88) 0.86 0.75 (0.26; 2.14) 0.77 1.12 (0.39; 3.23) 0.74 1.59 (0.65; 3.90) 0.31 1.93 (0.49; 7.60) 0.30 0.47 (0.16; 1.39) 0.26 1.14 (0.39; 3.32) 0.96 0.32 (0.07; 1.42) 0.14 2.07 (0.70; 6.15) 0.19 3.32 (1.13; 9.74) 0.039 1.01 (0.23; 4.42) 1.00 1.49 (0.28; 8.02) 1.00 0.49 (0.09; 2.63) 0.44 3.51 (0.65; 18.89) 0.19 1.11 (0.13; 9.32) 1.00 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles philippine journal of otolaryngology-head and neck surgery 19 and third decades of life are the most active, making people in these age groups vulnerable to trauma. it has also been consistently shown that the frequency of mandible fractures among males is far greater than for females.8 previous epidemiologic studies reported road traffic accidents9,10 followed by falls as the leading cause of mandibular fractures in developing countries, others have reported assault as the main causative factor.8 the reported findings of certain aspects of mandible trauma have been widely substantiated. for example, investigators in countries such as jordan,11 singapore,12 nigeria,13,14 new zealand,15 denmark16 and japan17 have found that motor vehicle accidents represent the most common cause of mandible fractures in those countries, while others in finland,18 scotland19 and sweden20 have reported assault as the most common etiology. in our setting, motor vehicle accidents were the single most frequent cause of mandible fractures (60%). those suffering trauma as a result of violence were mainly males; females reported assault as the second most frequent reason for their injuries, after falls. in all too many cases, however, the clinical findings did not corroborate the history of a fall, and health care providers often suspect domestic violence. it is highly possible that a good number of females who received their injuries as a result of assault may have reported a fall as the cause. 9 alcohol was a contributing factor at the time of injury in 21% of fractures for which this information was available in our institution. this may reflect the deleterious effects of alcohol on psychomotor skills and the lack of preventive mechanisms to respond to situational hazards.21 in australia, alcohol involvement in mandible fractures has been reported to be as high as 41.4%, and most of the cases associated with violence (73%) were linked to alcohol abuse.22 in a study conducted in finland, 44% of mandible fractures were associated with alcohol abuse. 22 in our study, alcohol was associated with about 20.6% of mandible fractures a proportion significantly lower than figures reported elsewhere. however, this discrepancy may also be explained by underreporting by hospital staff. the mandible fracture site depends upon the mechanism of injury, magnitude and direction of impact force, prominence of the mandible and anatomy of site. 3 its resistance to compression is greater but tends to fracture at the site of tensile strain. 3 in addition, it is more sensitive to lateral impact especially the body and ramus. 3 in our setting, the body of the mandible was the most commonly fractured part of the mandible. fractures of the mandible body often are unfavorable because the actions of the masseter, temporalis and medial pterygoid muscles distract the proximal segment supero-medially20 while the mylohyoid and anterior belly of the digrastic muscles displace the fractured segment posteriorly and inferiorly.23 prevalence ratios were computed to determine if there was a relationship between the various mechanisms of injury and the site of mandibular fracture. statistical analysis showed that even if the body was the most frequent site affected, the relationship between the various mechanisms of injury and the site of fracture were not statistically significant. however, there was a statistically significant relationship between violent assault and fractures of the ramus. its prevalence ratio of 3.32 (95% confidence interval: 1.13; 9.74, p value 0.039) shows that the prevalence of fractures of the ramus among those exposed to violent assault was 3 times higher than those who were not. our study has determined the body as the most common region involved in mandible fractures in the armed forces of the philippines medical center. mandible fractures occur in people of all ages and races, in a wide range of social settings. their causes often reflect shifts in trauma patterns over time. it is hoped that assessments such as the one presented here will be valuable to the armed forces of the philippines and military surgeons involved in planning future programs of prevention and treatment. further studies among non-military hospitals will be valuable in extending our findings to the general population. table 3. comparison of the literature on the most commonly fractured part of mandible symphysis parasymphysis body angle ramus condyle coronoid caparas et al.6 (1993) sirimaharaj & pyungtanasup5 (2008) khan et al.3 (2009) kamali & pohchi4 (2009) this study galvan 2001 14% 13.24% 11.1% 16.7% 12% __ 45.3% 27.4% 23% 24% 21% 3.83% 22.2% 20.1% 28% 20% 19.51% 23.3% 23% 17% 3% 2.09% 2.3% 1.7% 8% 36% 15.68% 12.8% 15.5% 7% 2% __ 0.5% __ 1% philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles 20 philippine journal of otolaryngology-head and neck surgery acknowledgements the author thanks her mentor, dr. ma sheila p. jardiolin, dr. maribel m. develos for statistical analysis and dr. michael b. bravo for data collection. references 1. stanley rb. pathogenesis and evaluation of mandibular fracture. in: mathog rh, editor. maxillofacial trauma. baltimore: williams and wilkins; 1984. p. 136-147. 2. adeyemo wl, ladeinde al, ogunlewe mo, james o. trends and characteristics of oral and maxillofacial injuries in nigeria: a review of the literature. head face med. 2005; 1:7-15. 3. khan a, salam a, khitab u, tariqkhan m. pattern of mandibular fractures – a study. pakistan oral and dental journal. 2009[cited 2011 april 14]; 29(2):221-224. available from:http://www.podj. com.pk/dec_2009/article-8.pdf. 4. kamali u, pohchi a. mandibular fracture at husm: a 5-year retrospective study. arch orofac sci. 2009; 4(2):33-35. 5. sirimaharaj w, pyungtanasup k. the epidemiology of mandibular fractures treated at chiang mai university hospital: a review of 198 cases. j med assoc thai 2008;91(6): 868-874. 6. caparas mb, lim mg, enriquez a, jamir j, ejercito n, chiong a, et al., editors. maxillofacial trauma. basic otolaryngology. manila: university of the philippines; 1993. p. 225-229. 7. manson pn. facial fractures. in: mathes sj, editor. plastic surgery. vol 3. 2nd ed. philadelphia: saunders elsevier; 2006. p 77-380. 8. dibaie a, raissian s, ghafarzadeh s. evaluation of maxillofacial traumatic injuries of forensic medical center of ahwaz, iran in 2005. pak j med sci 2009; 25(1):79-82. 9. sojat aj, meisami t, sandor gk, clokie cm. the epidemiology of mandibular fractures treated at the toronto general hospital. a review of 246 cases. j can dent assoc. 2001; 67:640-4. 10. sigua rg, palmiano hs, editors. assessment of road safety in the asean region. proceedings of the eastern asia society for transportation sudies. 2005;5:2032-2045. 11. bataineh ab. etiology and incidence of maxillofacial fractures in the north of jordan. oral surg oral med oral pathol oral radiol endod. jul 1998;86(1):31-5. 12. tay ag, yeow vk, tan bk, sng k, huang mh, foo cl. a review of mandibular fractures in a craniomaxillofacial trauma centre. ann acad med singapore. sep 1999;28(5):630-3. 13. adekeye eo. the pattern of fractures of the facial skeleton in kaduna, nigeria. a survey of 1,447 cases. oral surg oral med oral pathol. jun 1980;49(6):491-5. 14. ugboko vi, odusanya sa, fagade oo. maxillofacial fractures in a semi-urban nigerian teaching hospital. a review of 442 cases. int j oral maxillofac surg. aug 1998;27(4):286-9. 15. adams cd, januszkiewcz js, judson j. changing patterns of severe craniomaxillofacial trauma in auckland over eight years. aust n z j surg. jun 2000;70(6):401-4. 16. marker p, nielsen a, bastian hl. fractures of the mandibular condyle. part 1: patterns of distribution of types and causes of fractures in 348 patients. br j oral maxillofac surg. oct 2000;38(5):417-21. 17. tanaka n, tomitsuka k, shionoya k, andou h, kimijima y, tashiro t, et al. aetiology of maxillofacial fracture. br j oral maxillofac surg. feb 1994;32(1):19-23. 18. oikarinen k, ignatius e, silvennoinen u. treatment of mandibular fractures in the 1980s. j craniomaxillofac surg. sep 1993;21(6):245-50. 19. adi m, ogden gr, chisholm dm. an analysis of mandibular fractures in dundee, scotland (1977 to 1985). br j oral maxillofac surg. jun 1990;28(3):194-9. 20. strom c, nordenram a, fischer k. jaw fractures in the county of kopparberg and stockholm 1979-1988. a retrospective comparative study of frequency and cause with special reference to assault. swed dent j. 1991;15(6):285-9. 21. dongas p, hall gm. mandibular fracture patterns in tasmania, australia. australian dental journal. 2002; 47(2):131-137. 22. savola o, niemela o, hillbom m. alcohol intake and the pattern of trauma in young adults and working aged people admitted after trauma. alcohol and alcoholism. 2005;40:269-273. 23. barrera je. mandibular angle fracture [updated 2010july 9; cited 2010 july 30] available from: http://emedicine.medscape.com/article/868517-overview philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 34 philippine journal of otolaryngology-head and neck surgery case reports abstract objectives: to describe a rare case of chemodectoma, its clinical features and management and to discuss its relationship chronic hypoxia from tetralogy of fallot. methods: design: case report setting: tertiary government hospital patient: one results: a 23-year-old woman presented with a painless, slow growing, movable right submandibular mass, initially diagnosed as a lipoma by fine needle aspiration biopsy. computed tomography scan showed a solid nodule with ill-defined margins from the angle of the mandible to the level of the hyoid bone along the carotid sheath. there was also an incidental finding of patent ductus arteriosus and tetralogy of fallot on pre-operative clearance. excision of the mass under general anesthesia revealed adherence to the posterior portion of the carotid trunk enveloping both the internal & external carotid artery. final histopathological diagnosis was chemodectoma. conclusion: although rare, chemodectoma should be considered as one of the differentials in a patient with a submandibular mass. hyperplastic chemodectoma may result from chronic hypoxia due to tetralogy of fallot. surgical excision is the treatment of choice. keywords: carotid body tumor, chemodectoma, paraganglioma, tetralogy of fallot paragangliomas arise from extra-adrenal paraganglionic cells of the neural crest.1 various terminologies have been used to describe these tumors based on their location and histology. a chemodectoma is a paraganglioma arising from the chemoreceptors of the carotid body. it is a rare carotid body tumor, accounting for 0.5% of masses occurring in the head and neck region.2,3 we present a case of chemodectoma initially diagnosed as a lipoma by fine needle aspiration biopsy and discuss its clinical features, management and its relationship with chronic hypoxia from tetralogy of fallot. case report a 23-year-old woman presented with a painless, slow-growing right submandibular mass that started seven years before as a 2 x 2 cm soft, non-tender, mobile mass with well-circumscribed borders. no consult was sought nor medications taken until she visited a physician five years prior to admission due to a progressive enlargement of the mass. chemodectoma and tetralogy of fallotkathleen joy b. santiago, md lian melissa r. samio, md rodante a. roldan, md samantha s. castañeda, md department of otorhinolaryngology head and neck surgery rizal medical center correspondence: dr. kathleen joy b. santiago department of otorhinolaryngology – head and neck surgery rizal medical center pasig boulevard barangay pineda, pasig city 1603 philippines phone: (632) 671 9740 to 43 local 186 email: ent.hns_rmc@yahoo.com reprints will not be available from the authors. the authors declare that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest philipp j otolaryngol head neck surg 2015; 30 (2): 34-37 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports philippine journal of otolaryngology-head and neck surgery 35 anesthesia care unit (pacu), several bouts of oxygen desaturation resolved with oxygenation and completion of the blood transfusion. hoarseness on the 1st post-operative day was attributed to right vocal cord paralysis diagnosed by indirect video laryngoscopy. the rest of the post-operative course was unremarkable and the patient was discharged on the 5th post-operative day. figure 1. ct scan of the neck, axial view, at the level of the a. mandible b. hyoid bone, showing an illdefined mass with intact nasopharyngeal retropharyngeal spaces. carotid sheath not seen. a b figure 2. fine needle aspiration biopsy photomicrograph (high power magnification, 40x) showing clusters of adipose tissue (yellow arrow) in a background of pink amorphous material, interpreted as lipoma. figure 3 a. intraoperative view showing reddish-brown mass (arrow) attached to the carotid bifurcation (dotted arrow). b. gross specimen after excision. b a figure 4. common carotid artery bifurcation (arrow) after excision of the mass showing preserved external carotid (dotted arrow) and internal carotid arteries (star). ct scan revealed a solid nodule measuring 5.0 x 3.0 x 4.0 cm in the right neck with ill-defined margins extending from the mandibular angle to the level of the hyoid bone along the carotid sheath (figure 1). a fine needle aspiration biopsy revealed lipoma (figure 2) but she did not follow-up until seventeen months prior to admission, when she was finally admitted for surgery. on routine pre-operative cardiopulmonary examination, a patent ductus arteriosus (pda) and a tetralogy of fallot (tof) were discovered. she was started on carvedilol and was cleared for surgery. intraoperatively, a 5 x 4cm, dark brown, rubbery mass was seen attached to the carotid bifurcation (figure 3). despite careful dissection of the mass from the carotid, massive blood loss amounting to 1.8l ensued. as the working diagnosis was a lipoma, no blood had been prepared for perioperative use and the procedure was aborted. four days later, reoperation resulted in complete gross excision of the mass with preservation of the carotid arteries (figure 4). blood loss of 1.7l was replaced by transfusion of 2 units prbc. at the post philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 36 philippine journal of otolaryngology-head and neck surgery case reports or lymphoma. fine needle aspiration cytology revealed lipoma ruling out our other considerations. review of the aspirate by another cytopathologist still diagnosed a lipoma. in our case, “a chemodectoma was not entertained due to the absence of typical signs such as (1) a pulsatile slow growing mass that would have been mobile laterally and less mobile in a cranio-caudal direction because of its adherence to the carotid arteries (positive fontaine sign), and (2) a bruit on auscultation.”1 although our fine-needle biopsy may have aspirated subcutaneous fat or cervical fibrofatty tissue, the aspirate of a chemodectoma, according to masilamani et al., is hemorrhagic with clusters of round to oval cells showing anisokaryosis.4 delicate fibrous strands with spindle cells are observed within these clusters. these round to oval cells are seen as balloon-like which on poor fixation with ethyl alcohol and longer exposure to air-drying may result in poor slide quality and cellular degeneration. this can be read as a lipoma aspirate as by a cytopathologist. according to o’neill et al. “biopsy of a chemodectoma is rarely employed because of the risk of carotid injury or hemorrhage in these highly vascular tumors and open biopsy is clearly contraindicated due to the risk of catastrophic hemorrhage.”3 also, according to tayyab et al., fine needle aspiration cytology for chemodectomas is usually inconclusive.2 o’neill et al. opined that “diagnostic modalities such as a magnetic resonance imaging (mri) and ct scan are useful for determining the extent of tumor and demarcating soft tissue planes to provide the anatomic detail crucial for planning the surgical approach.”3 a crucial, and curiously absent finding on the ct scans of our patient was the lack of enhancement typically found in chemodectomas (since they are intensely enhancing due to their extensive vascularity). neither was splaying of the internal and external carotid arteries (the so-called “lyre sign”) seen. our working diagnosis was a submandibular pleomorphic adenoma since the physical examination was not consistent with a lipoma. it was only intraoperatively when we noted that the mass surrounded the common carotid, internal & external carotid arteries that a chemodectoma was considered. there are three treatment modalities for carotid body tumor-tumor embolization, radiotherapy and surgical excision. according to tayyab et al., “tumor embolization has been questioned because of potential neurologic complications. radiotherapy has been used in patients with metastatic lesions or tumors presumed to be malignant in certain series but recurrence has been observed after initial control.”2 thus, rekha et al. state “surgical excision is the best option but tumors with greater than 5 cm diameter have a 67% risk of complications versus 15% for tumors less than 5 cm in diameter.”5 tayyab et al. further say “cranial nerve palsies still remain one of the figure 5 a. histopathologic section, hematoxylin-eosin (low-power,10x) showing epitheliod cells in an organoid pattern seen in chemodectoma (arrow). b. high-power magnification (40x) shows cells exhibiting pleomorphism, with coarse chromatin pattern and scanty cytoplasm (dotted arrow). histopathologic gross examination revealed light to dark brown, irregular and rubbery tissue measuring 4.5 x 3 x 2.5 cm. microsections disclosed epithelioid cells arranged in an organoid pattern exhibiting pleomorphism with course chromatin pattern, prominent nucleoli and scanty to ample cytoplasm in a fibrocollagenous stroma. mitotic figures were rare (figure 5). these findings were interpreted as consistent with a chemodectoma. the patient was seen every 6 months for a year after her surgery with improvement of hoarseness in just 3 months post-operatively. there was no aspiration or recurrence of the mass. discussion the priority in our case of a submandibular mass that was mobile, slow growing, soft, painless and non-pulsatile was to establish the diagnosis. our differentials based on location and presentation included branchial cleft cyst, tb adenitis, a submandibular new growth, (hematoxylin and eosin, low-power 10x) a (hematoxylin and eosin, high-power magnification , 40x) b philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports philippine journal of otolaryngology-head and neck surgery 37 major complications and occur in 10-40% of cases.”2 they found “that 0.6% resulted in mortality, stroke in 2.3%, and postoperative peripheral nerve dysfunction in 29% of patients.”2 our patient manifested with hoarseness, aspiration and right vocal cord palsy as a result of vagus nerve injury. duran et al. reported that “paragangliomas arising from the carotid bodies account for 60% of all head and neck paragangliomas.”6 according to rekha et al., “there is an increased incidence of these tumors in high altitude dwellers,” which is not exactly seen in our patient, “and an in increased preponderance in females with a female to male ratio of 5:1.”5 according to rekha et al. and aydogan et al., “there are three types of chemodectomas-sporadic, which is the most common, familial, and hyperplastic. chemodectomas are generally sporadic in nature, accounting for 85% of carotid body tumors and are more frequently multicentric in 30% 40 % of cases. familial cases occur in 7% to 10%. the inheritance pattern is autosomal dominant and passed on by the father.”5,8 there was no known family history of a similar tumor in our patient. as sajid et al. state, “the hyperplastic form is very common in patients with chronic hypoxia which includes patients living at high altitude (>5,000 feet above sea level) and in those with cyanotic heart disease.”9 our patient was diagnosed with congenital heart disease-a patent ductus arteriosus and tetralogy of fallot (tof). the development of her carotid body tumor may be attributed to these congenital heart diseases. several authors agree that “patients with congenital heart disease particularly tof suffer chronic hypoxia. this can overburden the carotid body leading to hypertrophy, hyperplasia and neoplasia of the chief cells.”10-13 as lopez-barneo and colleagues said, “the carotid body is a peripheral chemoreceptor whose primary function is to detect changes in arterial oxygen tension in hypoxia. it is composed of neuron-like glomus, type i cells, which are enveloped by processes of glia-like sustentacular, type ii cells that have the ability to proliferate and differentiate into glomus cells in response to hypoxia. these type i cells are the chemoreceptive elements that contain o 2 sensitive k+ channels whose open probability decreases during hypoxia.”16 exposure to chronic hypoxia predisposes these glomus cells to undergo mitosis with resultant marked enlargement of the carotid body caused by dilatation and multiplication of blood vessels, as well as expansion of the parenchyma, with increased number of glomus cell clusters, thus resulting in hypertrophy and cellular hyperplasia of the carotid body. tumorigenesis has been attributed to a defect in sensing environmental o 2 levels which is due to a decrease by 50% mitochondrial comples ii activity.16 post-operatively, it is recommended to follow-up the patient and monitor for tumor recurrence both on the ipsilateral and contralateral carotid body. the question of treating the patent ductus arteriosus and tetralogy of fallot arises because they might cause regrowth of a chemodectoma. this relationship is just an association at present and not entirely proven due to lack of published documents supporting this theory. this case report, however, supports this association. the question of whether the chemodectoma of this patient was brought about by the presence of a cardiac problem or was just merely coincidental remains unanswered. chemodectoma is a rare vascular neoplasm of the head and neck and it should be considered as one of the differentials in a patient with a submandibular mass particularly in the background of congenital heart disease. chronic hypoxia brought about by tof may have an association with hyperplasia of the chief cells of the carotid body leading to neoplasia and chemodectoma development. surgical excision is the treatment of choice. massive blood loss and cranial nerve damage are common complications of surgical excision and should be anticipated. references 1. day t, buchmann l, rumboldt z, joe j. neoplasms of the neck. in: flint p, haughey b, lund v, niparko j, richardson m, robbins kt, editors. cummings otolaryngolgy head and neck surgery. philadelphia:elsevier; 2010. p.1659. 2. tayyab m, khan mr, sophie z. presentation and management of carotid body tumors. jpma. 2003 jul. 53(7): 227-231. 3. o’ neill s, o’ donnell m, harkin d, loughrey m, lee b, blair p. a 22-year northern irish experience of carotid body tumours. ulster med j. 2011 sep; 80(3): 133-140. 4. masilamani s, duvuru p, sundaram s. fine needle aspiration cytology diagnosis of a case of carotid body tumor. singapore med j. 2012 feb; 53(2): 35-7. 5. rekha a, ravi a, vijayaraghavan ks. paraganglioma neck – a neuroendocrine tumour revisited. int j angiol. 2008 fall; 17(3): 162-165. 6. duran ctb, co jm, nolasco fp. paraganglioma presenting as a parotid mass. philipp j otolaryngol head neck surg. 2001; 16 (3) 153-157. 7. godwins e, matthew t, olugbenga s, ayuba d, agabus m, barnabas m, samuel a. chemodectoma on the highland of jos, nigeria: three cases with review of the literature. biomedicine international. 2011; 2(1): 32-35 8. aydogan h, orhan g, aykut-aka s, albeyoglu s, yucel o, sargin m, goksel o, filizcan u, eren ee. carotid body tumors. asian cardiovasc thorac ann. 2002 jun; 10(2):173-5. 9. sajid ms, hamilton g, baker d. joint vascular research group. a multicenter review of carotid body tumour management. eur j vasc endovasc surg. 2007aug; 34(2); 127-130. 10. nissenblatt, mj. cyanotic heart disease: “low altitude” risk for carotid body tumor? johns hopkins med j. 1978 jan; 142(1):18-22. 11. lack ee. carotid body hypertrophy in patients with cystic fibrosis and cyanotic congenital heart disease. hum pathol.1977 jan; 8(1): 39-51. 12. gabhane sk, gangane nm, sinha rt. pentalogy of fallot and cardiac paraganglioma: a case report. cases j. 2009 dec 23; 2: 9392. 13. baysal be, myers en. etiopathogenesis and clinical presentation of carotid body tumors. microsc. res. tech. 2002 nov 1; 59(3): 256–261. 14. moskovic dj, smolarz jr, stanley d, jimenez c, williams md, hanna ey, kupferman me. malignant head and neck paragangliomas: is there an optimal treatment strategy? head neck oncol. 2010 sep 23; 2: 23. 15. dias da silva a, o’ donnel s, gillespie d, goff j, shriver c, rich n. malignant carotid body tumor: a case report. j vasc surg. 2000 oct;32(4): 821-3. 16. lopez-barneo j, ortega-sáenz p, pardal r, pascual a, piruat ji. carotid body oxygen sensing. eur respir j .2008 nov; 32(5):1386-1398. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 6 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: the study aims to compare the maximum sound output capabilities of different earphone types/music style combinations. the study also intends to assess the preferred listening levels (pll) of test subjects using different earphone types with background noise accession. the study also seeks to determine the presence or absence of a threshold shift on headphone/music style combination plls that exceed the recommended noise limit. methods: design: experimental study setting: tertiary government hospital subjects: thirty (30) hearing healthy volunteers were sampled from hospital staff aged 18-40 years with no known history of ear pathology and/or use of any known ototoxic drugs, with normal otoscopy, audiograms of less than 20db from 125hz to 8000hz and no exposure to loud noise from any source within the previous three days. the sound pressure levels (spl) delivered by three (3) types of earphones (earbud type, in-ear type, supra-aural type) were measured at maximum volume setting of a personal media player (ipod, apple inc.), while playing different music genres. the test subjects were asked to listen at their preferred listening levels (pll) using the different types of earphones at increasing background noise accession. results: the earbud type averaged the greatest spl among the earphone types and pop music averaged the greatest spl among the music styles. comparison of the maximum output capabilities revealed that there was a significant difference among different brands of earphones of the same type. however, no significant difference were found among songs of similar music style and across different music styles in all earphones except the in-ear type. pll average was at 90.4db in a silent environment with increasing intensity as background noise accentuated. supra-aural earphones registered the least increase in pll in a loud environment due to its higher background noise-attenuating capabilities. conclusion: having a significant difference among earphone types with regard their maximum output capabilities, it is recommended to check the specifications of the earphone type one intends to use. in using personal media players (pmp), the volume should be set at the lowest comfortable level. while choice of music style remains the discretion of the listener, the choice of music style should be considered for long periods of listening. because the pll of test an experimental study on maximum sound output capabilities and preferred listening levels using different earphone types waynn-nielsen c. destriza, md roderick b. de castro, md howard m. enriquez, md department of otolaryngology head and neck surgery ospital ng makati correspondence: dr. howard m. enriquez department of otolaryngology head and neck surgery 5th floor, ospital ng makati sampaguita street, brgy. pembo, makati city 1208 philippines phone: (632) 882 6316 local 309 email: osmakenthns@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2015; 30 (1): 6-13 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 7 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles subjects were alarmingly high, the authors recommend intervention in their listening habits. background noise attenuating capabilities of earphones play a factor in reducing excessive sound energy from reaching the ear reducing the pll and decreasing the risk for noiseinduced hearing loss. keywords: earphones, music styles, personal media players, preferred listening levels, recreational noise, noise-induced hearing loss sound is a sensory perception and noise is commonly designated as an undesirable sound. however, this meaning may be obscured by subjective opinions especially in this day and age when loud sounds may be desirable for some we clinically define noise as any excessively loud sound that has potential harm to hearing.1 noise-induced hearing loss (nihl) is the second most common type of hearing loss next only to age-related hearing loss. nihl has been well studied in the past decades and a relationship with noise exposure from occupational environment has been established. since then, noise regulations in workplaces have been legislated to prevent nihl. with the passage of time, the age of noisy factories has been reduced and we enter a new, digital age. machines have been replaced by computers and the risk of nihl from occupational noise has tremendously fallen. however, a new noise risk emerges from this evolution of mankind, recreational noise. recreational noise is the term for noise exposure during leisure hours which includes but is not limited to noise from clubs or discos, concerts, orchestra, cinema, television and personal media players (pmp). in comparison to occupational noise, recreational noise is more difficult to quantify because the intensity of sound is user dependent and there is no definite amount of time exposure. hence, no local regulation has been imposed on recreational noise giving it a greater risk for nihl. of alarming concern among recreational noise sources are pmps which have been widely available to the public with the advent of the ipod (apple, inc.). because of this, a greater number of the population is exposed with no knowledge of its potential risk for nihl. moreover, the age of individuals with free access to pmps has been getting younger and younger. this study aims to compare the maximum sound output capabilities of different earphone types /music style combinations. the study also intends to assess the preferred listening levels of test subjects using different earphone types with background noise accession. the study also sought to determine the presence or absence of a threshold shift on headphone/music style combination plls that exceed the recommended noise limit. assessment and analysis of the results may help outline recommendations to prevent noise-induced hearing loss and guidelines for safe use of personal media players. methods this was an experimental study on maximal output capabilities of three (3) types of earphones (earbud type, in-ear type and supraaural type) using an ipodtouch 4th generation mc008zp (apple, inc., california, usa) as the sound source across five music styles (pop, country, hiphop, r&b and rock). three (3) earphone models/brands of each earphone type (table 1) and five (5) songs of each music style (based on the top 5 songs of www.billboard.com, see (table 2) were used in the experiment. the study was approved by our institutional ethical review board and divided in two phases. the first phase table 1. earphone types and modelsa earphone type model description earbud type (a) earbud type (b) earbud type (c) in-ear type (a) in-ear type (b) in-ear type (c) supra-aural type( a) supra-aural type (b) supra-aural type (c) cdr-king ep-030-v ipod mpn: ma662g/b philips she2670gn/98 cdr-king eb-101-lc philips she3570gn/98 sennheiser cx270 cdr-king hp-060-la sennheiser hd201 philips shl3100/00 speaker: ø10mm, impedance: 32ω, frequency: 18-20 000hz, sensitivity: 108db ± 3db impedance: 32ω, frequency: 20-20 000hz speaker: ø13.5mm, impedance: 16ω, frequency: 12-22 000hz, sensitivity: 103db speaker: ø9.5mm, impedance: 32ω, frequency: 10-20 000hz, sensitivity: 115db ± 3db impedance: 16ω, frequency: 12-23 500hz, sensitivity: 102db impedance: 16ω, frequency: 19-20 000hz speaker: ø30mm, impedance: 32ω, frequency: 20-20 000hz, sensitivity: 108db ± 3db impedance: 24ω, frequency: 21-18 000hz impedance: 32ω, frequency: 18-20 000hz, sensitivity: 107db determined the a-weighted sound pressure level (spl-a) delivered by each earphone/music style combination to a sound level meter (extech instruments digital sound level meter, model 407768; frequency bandwidth: 31.5hz to 8 khz, applicable standards: ansi s1.4 1983 type 2, iec 61672 class 2, ce). an artificial ear construct was built that held the sound level meter on one side and the earphone on the opposite side. the distance between the sound level meter and the earphone was approximately 2cm to simulate the relationship of the earphone to the tympanic membrane. the construct was made of foam moulding allowing the earphones to fit snugly into the device and minimizing aall earphones were wired and with no sound cancelling function philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles 8 philippine journal of otolaryngology-head and neck surgery the second phase included thirty (30) hearing healthy volunteers aged 18-40 years old gathered from hospital staff and employees from whom informed consent was obtained. participants had no known history of ear disease and no pathologic findings on otoscopy. an audiogram of <20db from 125hz to 8000hz frequency had to be obtained to ensure normal hearing in all volunteers. pregnant women and those taking any ototoxic drugs were excluded from the study. participants were advised to avoid exposure to loud noise either from work or other recreational activities (clubbing, concerts, etc.) three (3) days prior to the test. participants gave written informed consent and were asked to fill out and answer a set questionnaire for demographics and information on their habits using pmps. one model/brand of each earphone type was chosen and one song among the music samples was chosen based on which gave the least variance of sound pressure throughout the duration of the song and least difference from the whole sample’s sound pressure mean. the subjects underwent baseline audiometry prior to the experiment. using an earphone splitter, one set ! 2cm spl meter earphone figure 1. pictures of the spl meter and ear construct with schematic diagram of the ear construct table 2. songs per music style music style song title song artist country hiphop r & b pop rock i want crazy highway don’t care wagon wheel boys ‘round here cruise u.o.e.n.o feel this moment bad power trip thrift shop fine china suit and tie body party #beautiful blurred lines can’t hold us come and get it just give me a reason i love it get lucky lego house sail gone, gone, gone ho hey my songs know what you did in the dark (light ‘em up) hunter hayes tim mcgraw feat. taylor swift darius rucker blake shelton feat. pistol annies & friends florida georgia line rocko feat. future and rick ross pitbull feat. christina aguilera wale feat. tiara thomas j. cole feat. miguel macklemore and ryan lewis feat. wanz chris brown justin timberlake feat. jay z ciara mariah carey feat. miguel robin thicke feat. t.i. and pharrell williams macklemore and ryan lewis feat. ray dalton selena gomez pink feat. nate ruess icona pop daft punk feat. pharrell williams ed sheeran awoination phillip phillips the lumineers fall out boy the outside noise approximating the fit in a normal-hearing ear. (figure 1) all experiments were done inside a sound treated booth. the sound source was at full battery and plugged to an electric outlet at all times during the experiment. set at maximum volume setting the spl delivered by each model of each earphone type was recorded while playing the song samples from each music style. this was to determine the maximum output capabilities of each earphone model of each earphone type. data was gathered using the extech instruments bundled data acquisition software (model 407768 v.0509a) at a reading rate of 2 seconds. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 9 of earphones was fitted by the patient and the other set of the same type and model fitted to the ear construct. the pmps initial volume was set at 50% and could be adjusted by the subject to his or her preferred listening level. the first round was recorded with no background noise although having an spl average of around 44dba. using loudspeakers surrounding the participant, speech background noise was introduced into the room from another sound source at 50% volume setting delivering a free field spl of around 70dba and preferred listening levels with background noise accession were recorded. after amplifying the background noise at 75% volume setting delivering a free field spl of around 85dba, another recording was made. sound pressure levels registered by the patients preferred volume setting were recorded using each type of earphones. a post-test audiometry was done to determine any threshold shift. data was gathered and analysed using the extech instruments bundled data acquisition software, microsoft excel 2013 (microsoft corporation, redmond, washington) and spss version 20 (spss, inc., chicago). all data was tested for normality of distrubution using kolmogorov-smirnov (ks) test for normality (for phase 1 subgroups, earbud type p=0.20, in-ear type p=0.83, supra-aural type p=0.16 and phase 2 subgroups, earbud type p=0.20, in-ear type 0.20, supra-aural type p=0.16) and levene’s test for homoscedasticity (phase 1 subgroups p=0.497 and phase 2 subgroups p=0.595), thus, parametric tests were preferred. a b c d figure 2 a-e. comparison of mean spl of songs per music style delivered by each earphone model of each earphone type e philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles 10 philippine journal of otolaryngology-head and neck surgery results the first phase of the experiment recorded the spl delivered by each earphone type using different music styles at maximal volume setting. the earbud-type earphone playing a rock music style delivered the greatest intensity at 126.1dba. the mean spl delivered by a model/brand of earphone type using five songs of similar music style is depicted in figure 2a-e. comparison of mean spl delivered by each earphone type of songs using a similar music style revealed no significant difference in both earbud type and supra-aural type of earphones. however in-ear earphones revealed a significant difference of spl among all songs of similar music style (hiphop p=2.42e-05, r&b p=0.000755, pop p=0.000267 and rock p=0.005951) except country music (p=0.199). it was found that there was a significant difference in the spl delivered among the different models (a, b and c) of similar earphone type (figure 3). this finding was constant in all earphone type/music style combinations except for two songs in the country style music (p=0.045 and p=0.08) using in-ear type of earphone. among the earphone types the earbud type delivered the greatest intensity of sound (112dba). however, the mean spl of all earphone models per earphone type set against the different music styles (figure 4) revealed no significant difference among earphone type (earbud, inear and supra-aural types) in all music styles. moreover, the mean spl of all songs in a similar music style set against the different earphone types revealed no significant difference among the songs of the same music style. analysis of mean spl per music style using different earphone models of the same earphone type revealed no significant difference in using earbud type and supra-aural type of earphones. however, using in-ear type of earphones revealed a significant difference when using different models of earphone even of the same type. additionally, comparing the mean spl per earphone type across music styles revealed no significant difference in what earphone type was used. the second phase of the experiment recorded the preferred listening levels (pll) of subjects using different types of earphones at different background attenuations. there were 30 participants, 12 males and 18 females aged 18 to 36 (mean age 26 years-old). participants of the study were mostly female (60%) aged 25-30 years (50%). all of them listened to a pmp (100%); the most common was an iphone (apple, inc.) using an in-ear type of earphone (83%). sixty-six percent (66%) listened to pmp at least twice a week while 16% of the participants listened to it everyday. the most commonly preferred music style was r&b music (50%) and the usual volume setting fell around 75-99% (83%). in terms of awareness, 66% of the participants believed that use of pmp can lead to hearing problems. figure 5. comparison of mean spl at preferred listening levels at increasing background noise according to earphone type figure 4. comparison of the mean spl delivered by each earphone type using different music styles figure 3. comparison on mean spl of different music styles per earphone model of each earphone type there was a noted trend of increase in pll with increasing background noise in all earphone types. (figure 5) using paired t-test analysis comparing the pll from (1) no background noise to a background noise of 50% volume setting; (2) background noise of 50% philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 11 volume setting to a 75% volume setting; and (3) no background noise to background noise of 75% volume setting, only the pll while using the earbud type earphone revealed a statistically significant difference in comparison to 50% background volume setting to 75% background volume setting and no background noise to 75% background volume setting (p=0.004 and p=0.017, respectively). the pll of the other two types did not show any significant difference across the background volume settings. (figure 6) comparing the 3 earphone types on the same background volume setting revealed that the supra-aural type earphone registered the least pll although it was not statistically significant (no background noise p=0.66; 50% background noise p=0.75; 75% background noise p=0.73). the post-experiment pure tone audiometry to find out if a threshold shift could be noted in the participants took about an hour each to complete with noted pll going beyond 85dba. only seven percent (7%) of the participants were noted to have a clinically significant threshold shift of beyond 10db. the average threshold shift for the entire sample was a 3db shift. discussion sound is quantified by its air vibrations measured in sound pressure levels (l) measured on a logarithmic scale with units of decibels (db) to indicate the loudness of sound. the human ear is not equally sensitive to sound at different frequencies; thus a spectral sensitivity factor (a-filter) is used to weight the sound pressure level at different frequencies to account for the perceived loudness of sound. the a-weighted sound pressure is averaged over a period of time (t) and is designated by laeq,t (a common exposure period is 8 hours, hence the parameter is designated by the symbol laeq,8h).2 sound pressure levels delivered from earphones set at maximum figure 6. comparison of mean spl at preferred listening levels delivered by different earphone types grouped by background noise volume volume setting can go higher than 125dba which is in the range of a jet engine at 100m (110-140db).3 at this level, potential for hearing damage increases as the sound goes beyond 120db and is just below the threshold of pain which is 130db.4 repeated exposure at this range of spl can harm the ear and lead to permanent threshold shift in hearing. however, in reality few persons listen at maximum volume setting as listeners often adjust their volume setting to levels which they are most comfortable with-hence, the study measured the preferred listening levels of test subjects. in a silent environment, 61% of our volunteers preferred to listen at <90db intensity and the average pll was 90.7dba. as expected, this further increased as the background noise became louder. the ear tries to differentiate among sound signal variations between the sound it wants to listen to (signal) in contrast to the unwanted sound (noise). this is commonly known as signal-noise relationship concept.5 hence, to maintain this ratio (signal/noise) the psychoacoustic response to increasing background noise is to increase the pll of the listener. this experiment simulates the environment wherein a listener is exposed to a noisy environment like public transport. in public transportation, noise can reach up to 80-90db in a traffic roadway and it is common for commuters to travel while listening to a pmp using their preferred earphones. the recommended noise dose in the philippines is less than 90db spl(a) for 8 hours6 with the amount of time decreased by half every 3db increment excess noise level. extrapolating our data at 75% volume setting background noise (~85db), the average pll is at 94.5dba and taking into consideration the travel time of approximately one hour, most of the listeners will exceed the set daily noise dose. a major part of our knowledge about noise-induced hearing loss relates to occupational noise exposure. international standards recommended the equivalent sound pressure level (laeq, 8h) of 85db(a) as the exposure limit for occupational noise (iso 1999:1990; niosh revised criteria 1998).7 in the philippines, the department of labor and employment (dole) issued occupational safety and health (osh) standards stating that in an 8-hour work day the noise exposure should not exceed 90db(a).6 outside the workplace, a high risk of hearing impairment arises from participating in concerts and clubs using personal media players (pmp), exercising or attending noisy sports or from exposure to military noises. these exposures have been collectively termed recreational noise. the first effects of exposure to excessive sound is a threshold shift.2 a threshold shift can either be a reversible damage known as temporary threshold shift (tts) or a permanent damage known as permanent threshold shift (pts) to the peripheral auditory end organ.1 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles 12 philippine journal of otolaryngology-head and neck surgery the pathophysiology of tts was correlated with a buckling of the supporting pillar cell bodies in the frequency region of the maximal exposure effect while pts was consistently correlated with a focal loss of hair cells and a complete degeneration of the corresponding population of nerve fiber endings.8 the precise relationship between tts and pts stages of hearing loss caused by noise exposure is still unknown.1 threshold shift is the precursor of noise-induced hearing loss (nihl). the problem with this type of hearing loss is that the impairment is gradual, the affected individual will not notice changes in hearing ability until a large threshold shift has occurred. the impairment occurs predominantly at higher frequencies (3 to 6khz frequencies) with the largest effect at 4khz frequency.2 hearing impairment was defined by the world health organization (who) in 2008 as hearing level with audiometric iso value greater than 25db on the better ear.5 global statistics show an increase in prevalence of this disease yearly, continually affecting the quality of life and productivity of majority of the general population. who estimates show that there were 250 million persons worldwide with disabling hearing impairment in 2000 comprising about 4.2% of the world’s population.9 two-thirds of the hearing impaired population come from developing countries such as indonesia, india, myanmar, sri lanka, thailand and the philippines. in the third national health and nutrition examination survey of 1988-1994 in the usa it was found that among children aged 6-19years, 12.5% had noise-induced threshold shift (nits) in one or both ears, with higher prevalence in boys (14.2%) compared to girls (10.1%), and in older aged children 12-19 (15.5%) compared to 6-11 years olds (8.5%).9 a recent local study entitled the philippine disability survey, listed the prevalence rate of disability at 2.9% covering a total sample population of 59,443.9 out of the 2.9%, hearing impairment ranked second comprising 33% of all persons with disabilities.9 the national statistics office conducted a disability survey in 1995 registering 919,292 persons with disabilities (pwd), 115,375 persons (12%) had hearing impairment.10 in 1997, according to the doh national registry, hearing impairment was said to have a prevalence rate of 17% out of 597,345 individuals with disabilities were listed in varying forms of hearing impairment.11 among the music styles studied, pop and country music gave the highest intensity of sound (108dba); however, choice of music style is of trivial importance only as it contradicts the purpose of listening to music if we choose to listen to a different music style just to reduce the risk. music style choice should still be considered specially when planning to listen to pmp over long periods of time or at high intensities. the supra-aural earphones averaged the least pll at 75% background noise volume setting. this is expected due to the built of the earphone which covers the most of the area of the pinna, thus adding the earphone’s background noise attenuation capability. next was the in-ear type, which delivers the signal more directly than the other types, thus maintaining a higher signal-to-noise ratio, hence the lower pll. assuming that a lower pll reflects a lower acoustic energy reaching the tympanic membrane, maintaining a high signal-to-noise ratio is of utmost importance in reducing the risk of nihl. therefore, proper selection of earphones which provides better quality or clarity (increased signal) and with good background noise attenuation (decreased noise) may be the most effective measure in risk reduction for nihl due to recreational noise (pmp). taking into consideration the model/brand of earphones, there is a significant difference when using different brands of earphones, hence the choice of earphone model is also of importance in reducing the risk of potential damage to the ear. bearing in mind the recommended daily noise dose and inferring our data from the spl output findings, we estimated the time of exposure a person should listen to a distinct music style using a distinct earphone type at maximal volume setting. (table 3) additional data can be gathered using different volume settings but this was not included in this study. future studies could further delineate the limits of time exposure with a distinct earphone type and music style to recommend legislation on guidelines for proper use of pmps. these time exposures can be applied only in a silent environment which limits its use. the presence of background noise may shorten the computed time limit due to additional noise reaching the ear. although the actual sound pressure that the reaches the ear in a silent environment is only 2-4dba above the pll estimation even in a loud environment with near 8085dba of background noise,12 this minimal difference has to be taken in consideration. the attenuating capabilities of the earphone used also country pop rock hiphop r & b earbud in-ear supra earbud in-ear supra earbud in-ear supra earbud in-ear supra earbud in-ear supra 100% 1.9 15 15 1.9 15 15 3.8 30 15 3.8 15 15 3.8 60 30 table 3. personal media player recommended exposure time for safetya,b atime is measured in minutes bfollowing the local legislature of the recommended daily noise dose of less than 90dba for 8 hours. the time required to meet the exposure level decreases in half for each 3db increment extra noise. this limits are only applicable in silent environment and may be lower in areas with background noise. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 13 references 1. lonsbury-martin b, martin g. noise-induced hearing loss. in: flint pw, haughey bh, lund vj, richardson ma, robbins kt, thomas jr, et al. cummings’ otolaryngology head and neck surgery. 5th ed. 2010; 151:2140-2152. 2. concha-barrientos m, campbell-lendrum d, steenland k. occupational noise: assessing the burden of disease from work-related hearing impairment at national and local levels. geneva, world health organization, 2004. (who environmental burden of disease series, no. 9). 3. stevens ss, warshofsky f and the editors of time-life books, sound and hearing, life science library. time-life books, alexandria, va, 1965. p. 173. 4. nave cr. “threshold of pain”. hyperphysics. scilinks. 2006. [retrieved 2009 jun 16]. available from: http://hyperphysics.phy-astr.gsu.edu/hbase/hph.html#hph 5. scenhir (scientific committee on emerging and newly identified health risks). scientific opinion on the potential health risks of exposure to noise form personal music players and mobile phones including a music playing function. 2008 sep 23 [cited 2013 may 12]. available from: (http://ec.europa.eu/health/opinions/en/hearing-loss-personal-music-player-mp3) 6. department of labor and employment, philippines. occupational safety and health standards. amended 1989. intramuros, manila: occupational safety and health center, department of labor and employment; february 2005 may 2013. 7. niosh. criteria for a recommended standard: occupational noise exposure. revised criteria 1998. cincinnati, oh, national institute for occupational safety and health. 8. nordmann as, bohne ba, harding gw. histopathological differences between temporary and permanent threshold shift. hear res. 2000 jan; 139 (1-2):13-30. 9. guzman cz. the philippine disability survey. in: baltazar jp, mancao bd, baquilod mm, trinidad fe. strategic planning workshop on the national ear and hearing health care program (2003 mar 27-29, manila, philippines). 2003; p. 32. 10. japan international cooperative agency, planning and evaluation department. country profile on disablity: republic of the philippines. march 2002. pp. 3-9. [cited 2015 apr 30]. available from: http://siteresources.worldbank.org/disability/resources/regions/east-asia-pacific/ jica_philippine.pdf. 11. del prado j, martinez n, ramos h. prevalence of hearing impairment in the philippines. “philippine statistics”. 2005. p. 16 [cited 2015 apr 30].available from: http://www.bhphil.org/ downloads/prevalence_of_ear.pdf. 12. breinbauer ha, anabalon jl, gutierrez d, carcamo r, olivares c, caro j. output capabilities of personal music players and assesment of preferred listening levels of test subjects: outlining recommendations for preventing music-induced hearing loss. laryngoscope. 2012 nov; 122 (11): 2549-2556. affects the sound energy reaching the ear. summarizing our findings, we recommend using pmps at the lowest comfortable volume possible. in selecting earphone types, a clearer signal output and higher background noise attenuation capability should be taken into consideration. supra-aural earphones are recommended since they tend to have the highest background noise attenuation capabilities among earphone types. the brand/model of earphones among similar earphone types is also important since they have been shown to differ significantly. it is recommended to check the audio specifications (frequency response: 20-20khz, sensitivity: 92-110db, lower impedance) of the earphone you intend to buy and use. time limits of exposure should be further explored and setting of recommended guidelines for use of pmp should be initiated. however, maximal time exposure is not reliable in a loud environment and may depend on the background noise attenuation of the earphone. the recommendation of using noise attenuating or noise cancelling earphones are mainly based on the audiological data and findings on this study. precautions should still be advised among listeners since background noise attenuation includes the dampening not only of noise but also of warning sounds and/or alarms such as approaching vehicles or fire alarms. the authors hope that the study can awaken public awareness of the risk brought about by the increasing use of pmps and initiate the development of guidelines and recommendations for proper use of pmps, to lessen the risk for recreational nihl at least in pmp usage. philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery featured grand rounds immobility, fixation or paralysis of the vocal folds is an ominous sign when encountered in the clinics. this may be due to a variety of diseases, lesions, injuries or vascular compromise which may affect the integrity and physiologic mechanism of the vocal folds. the common etiologies include infectious processes such as laryngeal or pulmonary tuberculosis (ptb), malignancy or neoplasms, central problems such as cerebrovascular accidents (cva), stroke and others.1,2,3 the problem should be addressed immediately because this potentially life threatening and imminent narrowing of the glottic opening may lead to respiratory distress. vocal fold paralysis due to compression of the recurrent laryngeal nerve from ptb and laryngeal cancer are perennially seen in clinical practice, but immobility of the vocal folds due to cricoarytenoid joint fixation or ankylosis is seldom seen and appreciated. hence, we present a case of bilateral cricoarytenoid joint ankylosis and discuss its etiology, pathophysiology, differential diagnoses, ancillary procedures and management. case report a 60-year-old man was admitted for the first time because of difficulty of breathing and stridor. one week prior to admission, he started to experience difficult breathing associated with productive cough and colds. he consulted in a primary private hospital and was managed as a case of bronchial asthma in exacerbation. nebulization with salbutamol afforded temporary relief. a few hours prior to admission, difficulty of breathing and productive cough worsened, prompting emergency room consult. he was referred to us for further evaluation of stridor. the patient had no diabetes mellitus, hypertension or allergies to food and drugs. he was diagnosed with refractory bronchial asthma during childhood and had frequent hospitalizations for pulmonary infections. he had no maintenance medication for bronchial asthma and was nebulized with salbutamol during exacerbations. he had ptb and completed six months’ anti-tb medications in 2013. the patient claimed that he had no dyspneic episodes during routine daily activities or upon exertion. no history of hoarseness or joint pain was noted either. a golf caddy, he was a previous 15-pack-year smoker, occasional alcoholic beverage drinker and denied use of illicit drugs. upon admission, the patient was awake, coherent, not in cardiorespiratory distress. blood pressure was 110/70 mmhg, pulse rate was 74/minute, respiration was tachypneic at 24 cycles per minute, afebrile. ear examination showed normal pinnae, no tragal tenderness, patent external auditory canals with no discharge and 80-90% dry central perforations of both tympanic membranes. anterior rhinoscopy, nasal endoscopy and the oral cavity examination bilateral cricoarytenoid joint ankylosis with a perplexing etiology correspondence: dr. emmanuel tadeus s. cruz department of otorhinolaryngology head & neck surgery quezon city general hospital and medical center seminary road, muñoz, quezon city 1106 philippines phone: (632) 863 0800 local 401 fax: (632) 920 7081; 920 6270 email: emancrz@yahoo.com (contact details may be published) the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest presented at the quezon city general hospital 33rd interesting case contest (3rd place). 17 august 2016 qcgh, muñoz, quezon city. joyce rodvie m. sagun, md emmanuel tadeus s. cruz, md department of otorhinolaryngology head and neck surgery quezon city general hospital and medical center philipp j otolaryngol head neck surg 2018; 33 (1): 51-55 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery featured grand rounds figure 1. video laryngoscopy using a 70° rigid scope showed vocal folds fixed in paramedian position with 1-2 mm glottic opening on inspiration (arrow). were unremarkable. head and neck examination showed no cervical lymphadenopathy or palpable mass. video laryngoscopy showed both vocal folds were immobile and fixed in paramedian position upon inspiration with a 1–2 mm glottic opening and no mass or lesion appreciated. (figure 1) the initial impression was impending upper airway obstruction figure 2. direct laryngoscopy and passive mobility test using a 3 mm laryngeal suction tip showing limitation of movement of the cricoarytenoid joints. lateralization of the (a) left arytenoid and (b) right arytenoid, with noted fixation at midline; inspection of the left (c) and right (d) cricoarytenoid area with no noted adhesions or swelling. secondary to bilateral vocal fold paralysis. under general anesthesia, direct laryngoscopy revealed no mass or lesion on both vocal folds and passive mobility test demonstrated resistance and limitation of lateral rotation and movement of the arytenoids on both sides. (figure 2) the vocal folds did not abduct on lateral retraction of the arytenoids. tracheostomy was performed and he was discharged after a few days. a b c d philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery featured grand rounds a subsequent laryngeal electromyography (emg) study showed no signs of myopathy or acute or chronic denervation changes of the thyroarytenoid muscles and rheumatoid factor was normal. at this point, bilateral cricoarytenoid fixation or ankylosis was considered and posterior interarytenoid web and bilateral vocal fold paralysis were ruled out. we recommended a lateralization procedure such as unilateral arytenoidectomy with cordectomy. the patient is currently well while he and his family are still contemplating whether he will undergo the surgical procedure. discussion respiratory stridor is always considered an ominous sign which implies upper airway obstruction. if severe, stridor may compromise breathing and in some instances is life threatening and a telltale sign of imminent danger requiring immediate endotracheal intubation. stridor is a musical, high-pitched sound which may be elicited in the presence of laryngeal and upper tracheal obstruction while wheezes are defined as high-pitched, continuous, adventitious lung sounds.4,5 stridor may be due to several reasons such as immaturity of the laryngeal structures seen in laryngomalacia in newborns, laryngeal infection, foreign body in the airway and chronic obstructive pulmonary disease.3,6 this may be the reason why bronchial asthma was entertained in the clinical course of our patient and initially at the emergency room. it is unfortunate that despite the non-responsiveness of bronchial asthma to medical therapy and persistence of stridor, no ent referral to evaluate the upper airway was made until recently. it should be emphasized that patients who develop stridor need to be evaluated by otolaryngologists specifically to ascertain the status of the vocal folds, which in this case turned out to be fixed or ankylosed, a condition which is rarely seen and encountered in clinical practice. among the differential diagnoses considered in this case were laryngeal cancer, vocal fold paralysis, interarytenoid web and arthritis.7,8,9 initially, laryngeal cancer was entertained because of his age, however no mass or suspicious lesion was appreciated on video laryngoscopy and this was ruled out. because the vocal folds were immobile and fixed in paramedian position upon inspiration, bilateral vocal fold paralysis was considered with the etiology to be determined. vocal fold paralysis occurs when nerve impulses to the laryngeal muscles are disrupted in case of cva or stroke, recurrent nerve injury after thyroid surgery or compression of the inferior laryngeal nerve due to pulmonary tb or lung cancer.8,11 on the other hand, vocal fold fixation occurs when movement of the cricoarytenoid joint is compromised in cases of rheumatoid arthritis provided that the innervation is intact.10,11 another common differential diagnosis which may be entertained is laryngeal tb in which nodular lesions may be seen in the vocal folds, granulation tissues are usually present in the posterior commissure and histopathology shows langhans cells and caseation necrosis.8 paralysis is oftentimes unilateral due to compression of the recurrent laryngeal nerve from apical ptb. although the patient has a history of tb, he was asymptomatic and close examination of the vocal folds revealed no lesions except for bilateral fixation, and this was ruled out. direct laryngoscopy (dl), the gold standard in the evaluation of laryngeal anatomy especially when dealing with the vocal folds,3 showed smooth, normal-looking vocal folds with no lesions. the passive mobility test is done to differentiate vocal fold paralysis from cricoarytenoid ankylosis by retracting or pushing the arytenoid laterally. if there is limitation of rotation and movement of the arytenoid laterally and the vocal folds do not abduct, then cricoarytenoid ankylosis or fixation is considered. on the contrary, if the arytenoid rotates and abducts laterally when retracted by forceps, then vocal fold paralysis is considered.1,6 hence, because there was limitation of rotation and movement of the arytenoids, cricoarytenoid joint fixation was entertained and vocal fold paralysis was ruled out. interarytenoid web was excluded because the vocal folds had no mucosal adhesions, synechiae or any scarring within the posterior portion of the glottis. in addition, although the patient’s glottic opening was restricted, no difficulty was encountered during endotracheal intubation since a smaller caliber tube was used. to further confirm the diagnosis of cricoarytenoid fixation, laryngeal electromyography (emg) revealed no paralysis of the thyroarytenoid muscles with no signs of myopathy and acute or chronic denervation, making bilateral vocal fold paralysis unlikely in this case. laryngeal emg is indicated to determine the integrity of the laryngeal muscles and innervation especially in cases of vocal fold paralysis.11 in postthyroidectomy patients, laryngeal emg is done 6 months after surgery to determine if the laryngeal nerve injury may recover or is irreversible. the 6-month waiting period is to allow swelling or inflammation to subside and to observe whether the injured nerve will recover prior to further intervention.12 the findings on direct laryngoscopy, passive mobility test and laryngeal electromyography clearly favor the diagnosis of cricoarytenoid joint ankylosis. other ancillary procedures such as a ct scan may show sclerosis of the arytenoids1,11 in elderly patients and videostroboscopy may be useful in determining the relative vertical height and tension of the vocal folds for assessing the cricoarytenoid philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery featured grand rounds function.1 a ct scan was not done because there was no palpable neck mass and no other lesion was entertained that would warrant ct imaging. videostroboscopy may help and may further show and magnify the movement of the vocal folds for observation however, the findings seen on direct laryngoscopy and laryngeal emg were deemed enough to support and confirm the diagnosis. the patient may be classified under type iv posterior glottic stenosis congenital or acquired bilateral cricoarytenoid fixation with or without interarytenoid scarring based on the classification by bogdasarian and olson which was later modified by irving and associates.3 interarytenoid web and scarring presents as bilateral impaired abduction but adduction is normal and patients affected tend to have a normal voice while the main presenting symptom is airway compromise. in cricoarytenoid joint ankylosis, adduction and abduction of the vocal folds are limited.3 as previously mentioned, to distinguish cricoarytenoid joint ankylosis from vocal fold paralysis, palpation of the cricoarytenoid joint on rigid endoscopy and laryngeal emg are necessary for definitive diagnosis.6 the patient’s voice was normal because the vocal folds approximate each other with a 1 to 2 mm glottic opening while no history of aspiration was apparent because the vocal folds are fixed in paramedian position which may prevent fluid from entering the larynx during swallowing. although the patient’s voice is normal, respiration is compromised manifested as stridor and difficulty of breathing requiring tracheostomy. in contrast, patients with acute or recent unilateral vocal fold paralysis in post-thyroidectomy or post-cva (stroke) conditions may initially manifest with aspiration. this is because the vocal fold assumes an intermediate position in which the glottic opening is relatively wider compared with the paramedian position. in a few months’ time, the paralyzed fold will compensate, move medially, and assume a paramedian position and aspiration may eventually resolve.13 cricoarytenoid ankylosis has several etiologies which include arthritides, bacterial infection and trauma. rheumatoid arthritis may account for numerous clinical diagnoses of cricoarytenoid ankylosis.2 other causes include gout, reiter syndrome and ankylosing spondylitis. some anecdotal evidence suggests a mump-associated laryngeal arthritis and fixation secondary to radiation therapy.2, 8 bacterial involvement of the joint space with infectious microorganisms such as streptococcal species with resultant ankylosis is also well established.8 external and direct laryngeal trauma may also result in cricoarytenoid joint injury.8 documented and retrospective studies suggest intubation-related joint injury and posterior or anterior arytenoid displacement secondary to the distal tip of the endotracheal tube engaging the arytenoid during intubation.8 traumatic obstetric delivery using forceps and postpartum newborn care through vigorous cleansing and suctioning the mouth and pharynx of the newborn are also mentioned in the literature.11 posterior dislocation resulting from extubation with a partially inflated endotracheal tube cuff is another probable cause.7, 8 another potential etiology is arytenoid chondritis secondary to prolonged endotracheal intubation which results in fibrosis.8,16 reviewing the patient’s history, however, showed no history of trauma, previous intubation, signs and symptoms of arthritis and serious laryngeal infections. the patient was delivered via normal spontaneous delivery by a traditional birth attendant (“hilot”) and no apparent respiratory distress or postpartum hospitalization was known of by the patient. cricoarytenoid ankylosis is usually associated with cases of rheumatoid arthritis with 17 to 33% incidence among ra patients.9 house et al. in 2010 described approximately 0.1% incidence of cricoarytenoid joint ankylosis in endotracheal intubations.16 most cases of vocal fold immobility seen under the service is secondary to vocal fold paralysis due to cerebrovascular accident (stroke), pulmonary problems such as ptb or laryngeal malignancy and to our knowledge, this is the first reported case of cricoarytenoid joint ankylosis in our institution. chronic cricoarytenoid joint ankylosis may be mistaken for asthma or chronic bronchitis, with symptoms of dyspnea, hoarseness or stridor.3 in rheumatoid arthritis, laryngoscopy may show rough and thick mucosa and narrowed glottic chink which were contrary to the recent endoscopic findings. if the etiology is bacterial, there is direct involvement of the joint space with infectious agents such as streptococcal species which leads to scarring and thickening of the cricoarytenoid joints.8 airway compromise occurs most commonly in patients with long-standing cricoarytenoid ankylosis and laryngeal stridor has been described as the sole presentation of the disease as manifested in this case.8, 14, 17 to rule out ra in this case, rheumatoid factor (rf) was done with negative results. finally, when it comes to upper airway obstruction, the glottic opening or opening of the vocal folds should be thoroughly evaluated. the normal glottic opening in newborns opens approximately 4 mm in a lateral direction. congenital subglottic stenosis is defined as a subglottic diameter of less than 4 mm.13 in retrospect, it may be presumed that the patient’s glottis may not be seriously compromised since birth because he was able to thrive and breathe with no apparent difficulty. it may be conjectured that narrowing of the glottic opening occurred only later in life. although asymptomatic, rheumatoid factor was negative, and the etiology of the patient’s ankylosis remains perplexing and elusive. the management of cricoarytenoid ankylosis includes tracheostomy to address the upper airway obstruction. surgical management philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery featured grand rounds acknowledgements we acknowledge antonio g. talapian, md, fpsohns, francisco a. victoria, md, fpsohns, and emmanuel samson, md, fpsohns, for their scientific advise. references 1. woo peak m. laryngeal trauma in woo peak stroboscopy. 1st ed. california: plural publishing inc. 2010. p. 221-226. 2. bryson pc, buckmire ra. medscape. arytenoid fixation. [updated 2016 mar 30; cited 2013 apr]. retrieved from: https://emedicine.medscape.com/article/866384-overview#a6. 3. albert d, boardman s, soma m. evaluation and management of the stridulous child. in flint pw, haughey bh, lung vj, niparko jk, richardson ma, robbins t, et al (editors). cummings otorhinolarynglogy head and neck surgery. 5th ed. philadelphia: mosby elsevier. 2010. p. 28962897. 4. lechtzin nm. stridor. merck manual professional. 2014 [cited 2014 apr]. retrieved from merck manuals: http://www.merckmanuals.com/professional/pulmonary-disorders/symptoms-ofpulmonary-disorders/stridor. 5. lechtzin nm. wheezing. merck manual professional. 2014 [cited 2014 apr]. retrieved from merck manuals: http://www.merckmanuals.com/professional/pulmonary-disorders/symptoms-ofpulmonary-disorders/wheezing. 6. jackson c, jackson cl. direct laryngoscopy in bronchoesophagology. 5th ed. philadelphia: w.b. saunders. 1950. p. 116-117. 7. cooper r. extubation and changing endotracheal tubes. in benumof j, hagberg ca (editors). benumof ’s airway management: principles and practice. 2nd ed. philadelphia: mosby elsevier. 2007. p. 1160. 8. heman-ackah y, kelleher k, sataloff r. inferior glottic ridges that prevent vocal cord closure. in sataloff rt, chowdhury f, joglekar s, hawkshaw mj (editors). atlas of endoscopic laryngeal surgery. 1st ed. new delhi: jaypee brothers medical publishers. 2011. p. 45. 9. kamanli a, gok u, sahin s, kaygusuz i, ardicoglu o yalcin s. bilateral cricoarytenoid joint involvement in rheumatoid arthritis: a case report. rheumatology (oxford). 2001 may; 40 (5): 593-594. pmid: 11371675. 10. zakaria hm, al awad na, al kreedes as, al-mulhim am, al-sharway ma, hadi ma, et al. recurrent laryngeal nerve injury in thyroid surgery. oman med j. 2011 jan; 26(1): 34–38. doi: 10.5001/omj.2011.09; pmid: 22043377 pmcid: pmc3191623. 11. remacle m, sandhu g. bilateral vocal fold immobility. in oswal v, remacle m, jovanvic s, zeitels sm, krespi jp, hopper c (editors). principles and practice of lasers in otorhinolaryngology and head and neck surgery. 2nd ed. amsterdam: kugler publication. 2014. p. 250-251. 12. chauhan a, badhwar s, patel m, tiwari s. post intubation bilateral arytenoid dislocation with acute respiratory distress. j anaesth clin pharmacol. 2009 aug; 25(3):361-62. 13. banovetz j. benign laryngeal disorders. in adams gl, boies lr (editors). boies fundamentals of otolaryngology a textbook of ear, nose, and throat diseases. 6th ed. singapore: w.b. saunders. 1989. p. 406-408. 14. stojanovic sp, zivic l, stojanovic j, belic b. total fixation of cricoarytenoid joint of a patient with rheumatoid arthritis and hashimoto thyroiditis. srp arh celok lek. 2010 mar-apr; 138(3-4): 230-2. pmid: 20499506. 15. hamdan al, sarieddine d. laryngeal manifestations of rheumatoid arthritis. hindawi autoimmune diseases. 2013; 2013: 4-6. doi:10.1155/2013/103081. 16. polisar ia, burbank b, levitt lm, katz hm, morrione tg. bilateral midline fixation of cricoarytenoid joints as a serious medical emergency. jama. 1960; 172(9): 901-906. doi:10.1001/ jama.1960.03020090013003. 17. burkey b, goudy s, rohde s. airway control and laryngotracheal stenosis in adults. in snow jb, ballenger jj (editors). ballenger’s manual of otorhinolaryngology head and neck surgery. 17th ed. ontario: bc decker. 2009. p. 911. includes open arytenoidectomy, arytenoidpexy and endoscopic arytenoidectomy or transverse cordectomy and all have their advantages and disadvantages.6, 11, 16 these are lateralization procedures which aim to widen the glottic opening and wean the patient from tracheostomy afterwards. in closing, when bronchial asthma remains refractory to treatment, the physician should not hesitate to refer to otolaryngologists to rule out other probable upper airway pathologies. although rare, ankyloses of the cricoarytenoid joint should be considered especially when the movement of the vocal folds is compromised. although direct laryngoscopy, passive mobility tests and laryngeal emg are indispensable in clinching the diagnosis, the clinical history is important in determining etiology which in this case remains elusive and perplexing. philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to translate the sino-nasal outcome test (snot) 22 into filipino and establish the validity and reliability of the filipino version of the sino-nasal outcome test (snot) 22. methods: design: prospective cohort setting: tertiary government training hospital participants: twenty one (21) patients with rhinosinusitis with or without nasal polyposis were administered the filipino snot 22 to determine reliability. sixty three (63) patients with rhinosinusitis with or without nasal polyps and forty eight (48) controls were recruited for the validity study. results: the filipino snot 22 had a pearson correlation of 0.618 significant at the 0.01 level and a cronbach’s alpha of 0.76. the calculated z-score was 7.21 with p-value < .00001 significant at p < .05. the value of u was 300 with a critical u value at 1512. conclusion: the self administered filipino snot 22 is a reliable and valid tool for measuring qol among filipino patients with rhinosinusitis. keywords: sinusitis, reliability and validity, quality of life, sino-nasal outcome test 22 according to the european position paper on rhinosinusitis and nasal polyps 2012, rhinosinusitis is an inflammation of the mucosa of the nose and paranasal sinuses characterized by 2 or more of the following symptoms: nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip) ± facial pain/pressure ± reduction or loss of smell and either endoscopic signs of: nasal polyps and/or mucopurulent discharge primarily from middle meatus and/or edema/mucosal obstruction primarily in middle meatus and/or ct changes: mucosal changes within the ostiomeatal complex and/or sinuses. it may be acute if it lasts for less than 12 weeks with complete resolution of symptoms or chronic if it lasts 12 or more weeks without complete resolution of symptoms.1 because symptomatology drives treatment in conditions such as rhinosinusitis, it is imperative to establish the baseline symptoms of patients to better gauge the effect of medical or surgical treatment.2,3 the snot 22 is a disease-specific health related quality of life (qol) reliability and validity of the filipino sino-nasal outcome test (snot) 22 christine anne c. maningding, md rodante a. roldan, md department of otolaryngology head and neck surgery rizal medical center correspondence: dr. rodante a. roldan department of otolaryngology head and neck surgery rizal medical center pasig blvd., pasig city 1600 philippines phone: (632) 865 8400 local 106 email: ent.hns_rmc@yahoo.com the authors declared that this represents original material that is not being considered for publication, or has not been published or accepted for publication elsewhere in full or in part in in print or electric media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual, passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery analytical research contest (2nd place), november 9, 2017, menarini office, bonifacio high street, taguig city. philipp j otolaryngol head neck surg 2018; 33 (1): 17-20 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery original articles questionnaire that is considered the most suitable tool for assessing chronic rhinosinusitis with or without nasal polyps4 that was validated in 2009.5 it has been translated into brazilian portuguese,4 greek,6,7 turkish,8 danish,9 and thai,10 and the reliability and validity of these translations have been established.4,6-10 however, the snot 22 has not been translated into filipino, a development that could provide better health care for many filipinos in the country and overseas. we aimed to translate the sino-nasal outcome test (snot) 22 into filipino and establish the validity and reliability of the filipino version of the sino-nasal outcome test (snot) 22, among patients with rhinosinusitis with or without nasal polyposis compared to asymptomatic controls. methods instrument development to develop the filipino snot 22, a snot 22 form in english was sent to two (2) independent interpreters who translated it into filipino. each translated snot 22 form was then back-translated into english by another group of individuals who were knowledgeable in filipino and english as well as in ear, nose and throat (ent) concepts. the 2 filipino translations were then consolidated into one questionnaire by this group. reliability assessment with institutional ethics review board approval, the consolidated questionnaire was administered to patients seen at the ent outpatient clinic who were 19 years or older, could read and write in filipino, were diagnosed to have rhinosinusitis with or without nasal polyps and consented to be part of the study. after obtaining consent, the questionnaire was administered on the first consult and then again on follow up. each time, the questionnaire was provided with a pen or pencil by a resident physician, with no additional instructions or guidance in answering. accomplished forms were collected after a maximum of thirty (30) minutes and collated by the primary investigator over a period of 8 weeks, from december 2016 to february 2017. validity assessment after the test-retest period, the filipino snot 22 was administered to patients seen at the ent outpatient clinic who were 19 years or older, could read and write in filipino, were diagnosed to have rhinosinusitis with or without nasal polyps and consented to be part of the study. the control group was composed of volunteers meeting the same criteria except rhinosinusitis. after written consent was obtained, each test form and a pencil was given to participants and controls by a resident physician with instructions for their accomplishment in a designated area within the clinic. no further guidance was given and questionnaires were collected within thirty (30) minutes of administration. accomplished forms were collated by the primary investigator over the test period of 24 weeks from march 2017 to august 2017. statistical analysis data was tabulated using microsoft® excel for mac version 16.12 (180410) (microsoft corporation redmond, wa, usa) and analyzed using ibm spss statistics software for windows, version 24.0 released 2015 (armonk, ny, usa). reliability and internal consistency were measured by cronbach alpha and test-retest reliability measured by pearson correlation coefficient. a pearson correlation coefficient of ≥0.60 was deemed acceptable10 while the minimum acceptable value of cronbach alpha was set at ≥0.7. validity was determined using the mann-whitney u test calculator available from http://www. socscistatistics.com/tests/mannwhitney/default3.aspx. results instrument development the consolidated filipino snot 22 is shown in figure 1. reliability assessment twenty one (21) patients, 11 (52%) males and 10 (48%) females completed the test and retest phase of the filipino snot 22. the mean age was 43 years (range, 19-79 years). the mean follow-up interval was 16 days (range, 7-49 days). table 1 shows the mean snot 22 scores of these patients on first consult and on follow up. table 1. test-retest reliability snot 22 score n mean (sd) first consult follow-up 21 21 38.4286 (28.0866) 30.2381 (25.7738) the filipino snot 22 had good internal consistency and good testretest reliability with a pearson correlation of 0.618 significant at the 0.01 level and a cronbach alpha of 0.76. we did not perform individual item analysis because the pearson correlation and cronbach alpha were acceptable and there was no need to remove items to improve internal consistency and test-retest reliability. validity assessment for validity assessment, a total of 63 patients with rhinosinusitis with or without nasal polyposis and 48 controls participated in the philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery original articles makikita sa baba ang listahan ng mga sintomas at panlipunan/emosyonal na epekto ng iyong rhinosinusitis. sagutin ang mga sumusunod sa abot ng iyong makakaya. walang tama o maling kasagutan. ikaw lamang ang maaaring makakapagbigay impormasyon tungkol dito. lagyan ng marka ang halaga ng iyong nararanasan na problema batay sa nakaraang dalawang linggo. maraming salamat sa iyong pagsagot. huwag mag-atubiling magtanong o humingi ng tulong kung kailangan. study. of the 63 rhinosinusitis patients, 32 (51%) were male and 31 (49%) were female. the mean age was 39 years (range, 19-69 years). of the 48 controls, 21 (44%) were male and 27 (56%) were female. the mean age was 40 years (range, 22-72 years). table 2 shows the snot 22 scores of these patients. table 2. validity (mann-whitney u test) snot 22 score n mean (sd) patients with crs controls 63 48 39.1270 (18.4544) 11.9375 (10.5516) 1. lagyan ng marka kung gaano kalala ang iyong nararanasan at kung gano ito kadalas mangyari sa pamamagitan ng pagbilog ng bilang na katumbas ng iyong nararamdaman. 2. lagyan ng marka ang pinakamahalagang karamdaman o problema na nakakaapekto sa iyong kalusugan (pinakamataas/ pinakamaraming punto na ang 5) w alang problem a h indi m asyadong problem a 5 pinakam ahalagang karam dam an/ problem a bahagyang iniindang problem a iniindang problem a m alalang problem a m asidhing problem a 1. pagsinga 2. baradong ilong 3. pagbabahing 4. hindi tumitigil na pagtulo ng sipon 5. ubo 6. sipon na hindi lumalabas sa ilong 7. malapot na sipon 8. pagbabara ng tenga 9. pagkahilo 10. pananakit ng tenga 11. pananakit ng mukha 12. pagkawala/pagkabawas ng panlasa/pang-amoy 13. hirap sa pagtulog 14. nagigising sa gabi 15. kakulangan sa mahimbing na tulog 16. paggising nang pagod 17. pagkapagod 18. pagkabawas ng pagka prodaktibo 19. pagkabawas ng pokus sa pag-iisip 20. pagiging irritable/pagkainis 21. malungkot 22. nahihiya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 m m m m m m m m m m m m m m m m m m m m m m figure 1. filipino sino-nasal outcome test (snot) 22 philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles references 1. fokkens wj, lund vj, mullol j, bachert c, alobid i, baroody f, et al. european position paper on rhinosinusitis and nasal polyps. rhinol suppl. 2012 mar; 23:3 p preceding table of contents, 1-305. pmid: 22764607. 2. steele to, rudmik l, mace jc, deconde as, alt ja, smith tl. patient-centered decision making: the role of the baseline snot-22 in predicting outcomes for medical management of chronic rhinosinusitis. int forum allergy rhinol. 2016 jun; 6(6): 590-596. doi: 10.1002/alr.21721; pmid: 26852743 pmcid: pmc4921291. 3. rudmik l, soler zm, mace jc, deconde as, schlosser rj, smith tl. using preoperative snot22 score to inform patient decision for endoscopic sinus surgery. laryngoscope. 2015 jul; 125(7):1517-1522. doi: 10.1002/lary.25108; pmid: 25546168 pmcid: pmc4481170. 4. kosugi em, chen vg, fonseca vm, cursino mm, mendes neto ja, gregório lc. translation, cross-cultural adaptation and validation of sinonasal outcome test (snot): 22 to brazilian portuguese. braz j otorhinolaryngol. 2011 sep-oct; 77(5): 663-669. pmid: 22030978. 5. hopkins c, gillett s, slack r, lund vj, browne jp. psychometric validity of the 22-item sinonasal outcome test. clin otolaryngol. 2009 oct; 34(5): 447-454. doi: 10.1111/j.17494486.2009.01995.x; pmid: 19793277. 6. lachanas va, tsea m, tsiouvaka s, hajiioannou jk, skoulakis ce, bizakis jg. the sino-nasal outcome test (snot)-22: validation for greek patients. eur arch otorhinolaryngol. 2014 oct; 271(10): 2723-2728. doi: 10.1007/s00405-014-2969-7; pmid: 24595707. 7. seferlis f, proimos e, chimona ts, asimakopoulou p, papadakis ce. snot-22 validation in greek patients. orl j otorhinolaryngol relat spec. 2014; 76(4): 207-211. doi: 10.1159/000365995; pmid: 25195715. 8. hancı d, altun h, şahin e, altıntoprak n, cingi c. turkish translation, cross-cultural adaptation and validation of the sinonasal outcome test (snot)-22. ent updates. 2015; 5(2): 51-57. 9. lange b, thilsing t, al-kalemiji a, baelum j, martinussen t, kjeldsen a. the sino-nasal outcome test 22 validated for danish patients. dan med bull. 2011 feb; 58(2): a4235. pmid: 21299922. 10. numthavaj p, bhongmakapat t, roongpuwabaht b, ingsathit a, thakkinstian a. the validity and reliability of thai sinonasal outcome test-22. eur arch otorhinolaryngol. 2017 jan; 274(1): 289295. doi: 10.1007/s00405-016-4234-8; pmid: 27535841. 11. world health organization. [internet]. process of translation and adaptation of instruments. 2016[cited 2015 aug]. available from: http://www.who.int/substance_abuse/research_tools/ translation/en/. the filipino snot-22 is a valid measuring tool with a calculated z-score of 7.21 with p-value < .00001 significant at p < 0.05. the mannwhitney u value was 300. discussion this study has found that the filipino snot 22 is a valid and reliable tool to measure symptoms in adult filipino patients suffering from chronic rhinosinusitis with or without nasal polyps. reliability of a disease-specific questionnaire can be measured through its internal consistency and test-retest reliability. the filipino snot 22 showed a cronbach’s alpha of 0.76, and a pearson correlation coefficient of 0.618 significant at the 0.01 level, comparable with findings of other studies.4, 6-10 validity is demonstrated by being able to discriminate patients with crs as oppposed to those without crs. using a mann-whitney calculator, the u value was determined to be 300 with a z-score of 7.21 and a p-value of < .00001 significant at p <0.05. the computed u value is statistically significant as it is lower than the critical value set at 1512. this means there was a significant difference between the scores of those with rhinosinusitis with or without nasal polyposis and those without rhinosinusitis. this is also comparable to the results of previously cited studies.4,6-10 part of the limitations of our study would be the unpredictability of follow-up as patients can opt not to follow-up promptly and this delay may have an impact on the symptoms and scores being experienced by patients. we recommend the use of the filipino snot 22 among preoperative and postoperative patients so that responsiveness of the tool can be further quantified. future studies with larger samples may further establish its reliability and validity. in conclusion, the filipino snot 22 is a reliable and valid measuring tool for use among filipino patients suffering from rhinosinusitis with or without nasal polyposis. it can make it easier for patients to communicate their subjective complaints as the questionnaire is in a language that they can understand better. it may also serve as a more reliable guide to clinicians in decision-making and monitoring patient response to treatment. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 6 philippine journal of otolaryngology-head and neck surgery original articles abstract objectives: to assess effects of type 3 thyroplasty on outcomes of voice quality in puberphonia. methods: design: prospective cohort setting: tertiary referral hospital participants: six patients with puberphonia who failed voice therapy, aged 16-25 years, who consulted at the ent outpatient department between september 2010 and september 2012, underwent type 3 thyroplasty. pre-operative and 6-month post-operative voice analysis by voice recordings, voice handicap index (vhi), grbas score and real time acoustic analysis (perturbation) using dr speech software (university version 4.0, voice tech corporation, usa [tiger electronics]) with habitual fundamental frequency (f0), jitter % and shimmer % as parameters were performed. results: mean pre-operative vhi and grbas scores were 53 and 75.67, respectively, whereas post-operative scores were 29 and 25.00, respectively. (p-value for vhi was 0.004 and that of grbas was 0.00). on acoustic analysis, mean pre-operative habitual fundamental frequency (f0), jitter % and shimmer % was 245.82 hz, 0.21 and 2.34, respectively, whereas post-operative mean was 140.78 hz (p = 0.00), 0.19 (p = 0.04) and 1.52 (p = 0.00), respectively. conclusion: the mainstay of treatment of puberphonia is voice therapy. thyroplasty provides a suitable management option in those cases who fail to respond by voice therapy. keywords: puberphonia, thyroplasty, laryngeal framework surgery, voice analysis puberphonia is a condition affecting young men between ages 11-15 with an incidence of 1/900,000 per year.1, 2 it presents with increased pitch or fundamental frequency, weak, breathy, hoarse voice, pitch breaks, low intensity and psychological symptoms.1 at puberty, the voice needs to be retrained in order to cope with the larger larynx. most boys adjust to this new change of voice. but a few do not make the transition into using their deeper voice and continue to use the high-pitched voice. this is labeled ‘puberphonia.’ so puberphonia, also called mutational falsetto, functional falsetto or persistent falsetto is defined as a post-adolescent male continuing to have a pre-adolescent voice.3, 4 effects of type 3 thyroplasty on voice quality outcomes in puberphoniakanishka chowdhury,1 mbbs, ms ent, somnath saha,mbbs, ms ent, sudipta pal,1 mbbs, ms ent, indranil chatterjee2 maslp 1department of ent, r.g.kar medical college & hospital, kolkata 2ali yavar jung national institute for the hearing handicapped, kolkata correspondence: dr kanishka chowdhury 27 nilmoni mitra street kolkata700006 india phone: 91 9674172144 email: drkanishka@gmail.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2014; 29 (1): 6-10 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 7 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles outcome assessment of results of puberphonia therapy can be done in terms of different aspects of voice evaluation which includes subjective evaluation of voice, perceptual evaluation of voice and acoustic analysis along with traditional voice recordings.3 subjective evaluation is basically a patient scale. patient scales typically measure patient satisfaction, quality of life, general health, handicap or loss as a result of the voice disorder or some aspect of voice production.3 several scales specific to voice have been used such as voice handicap index (vhi) and voice-related quality of life (v-rqol). perceptual evaluation of voice can be done using various scales such as grbas, cape-v and buffalo iii. there are various parameters such as fundamental frequency, intensity, perturbation measures (shimmer%, jitter %) which are measured as part of acoustic analysis. in the present study, we tried to evaluate the effects of type 3 thyroplasty on voice outcome in puberphonia using these tools of voice analysis along with conventional recording of voice. methods this was a prospective cohort of puberphonia patients attending the ent outpatient department of a tertiary referral hospital in eastern india between september 2010 and september 2012. institutional ethical review board approval as well as informed consent was taken. patients 15 years of age and above were included in the study. all patients were given voice therapy (primal sound production with cough and digital manipulation thrice weekly, each session for 30 minutes over three months) by three speech pathologists. as the results of voice improvement were not satisfactory, six patients underwent type 3 thyroplasty. the voice improvement was unsatisfactory in terms of: 1) shifting of fundamental frequency (f0) was not stable: 2) threemonth therapy sessions (30 minutes daily) did not give them adequate improvement in conversational speech: and 3) lack of motivation that affected improvement pattern. patients included in the study were those who failed after voice therapy, without any psychological abnormality including transsexualism, no endocrine abnormality, no chronic pulmonary problems and no anesthetic contraindications. all operations were performed under local anesthesia. after thyroid cartilage exposure via midline approach, the thyroid cartilage midline was identified. (figure 1) perichondrium was elevated from the thyroid cartilage. a parallel incision to midline was made on both sides up to the inner perichondrium without incising it and 1.5 mm strips of cartilage were incised on either side of the midline of the thyroid cartilage with a knife. (figure 2) peri-operative voice assessment was made after pushing the mid portion of the cartilage. the free borders of the thyroid cartilage were approximated with 2-0 prolene sutures and the wound was closed in layers. (figure 3) pre-operative and 6-month post-operative comparison of voice recordings was performed by three trained listeners consisting of one otorhinolaryngologist with five years of experience in phonosurgery and two post-graduate speech language pathologists with five years of experience, vhi score, grbas score (we extra-plotted the grbas score into a 100 point visual analogue scale to increase specificity) and real time acoustic analysis (perturbation) of voice using dr speech software (university version 4.0, voice tech corporation, usa [tiger electronics]) (habitual fundamental frequency (f0), jitter % and shimmer % as parameters). statistical analysis was done using paired-t test with finite population correction (as sample size was small) using spss software (version 17.0, ibm, usa). figure 1. delineation of midline of thyroid cartilage figure 2. making incision lateral to midline of thyroid cartilage philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles 8 philippine journal of otolaryngology-head and neck surgery results a total of six patients underwent surgery. their ages ranged from 16-25 years (mean age 19 years). the mean pre-operative vhi score was 53 and post-operative was 29. paired t test result showed that t = 0.004 (p < 0.05) which was significant. the mean pre-operative grbas score was 75.67 whereas post-operative score was 25.00. paired t test result showed that t = 0.000 (p < 0.05) which was significant. results of acoustic analysis of voice revealed mean pre operative habitual fundamental frequency; jitter % and shimmer % 245.82 hz, 0.21 and 2.34, respectively. (table 1) the mean post-operative values for the same parameters showed 140.78 hz, 0.19 and 1.52, respectively. paired t test result of habitual fundamental frequency showed that t = 0.00 (p < 0.05) which was significant. paired t test result of jitter % showed that t = 0.04 (p < 0.05) which was significant. paired t test result of shimmer % showed that t = 0.00 (p < 0.05) which was significant. there were no early or late postoperative complications. the post-operative voice was improved in all patients. discussion puberphonia, also called mutational falsetto, functional falsetto or persistent falsetto is a disorder of adolescent males and can be defined as a post adolescent male continuing to have a pre adolescent voice. 3,4 during infancy the laryngo-tracheal complex is situated at a higher level that gradually descends throughout life.2 the descent of larynx is most pronounced during puberty when there is also a sudden increase in the size of larynx under the influence of testosterone. this results in a voice change in the males during adolescence between 12 and 15 years of age. this voice change can be well appreciated as it changes from a high-pitched voice to a low-pitched voice. at puberty the voice thus needs to be retrained in order to cope with the larger larynx. most boys adjust to this new change of voice. but a few do not make the transition into using their deeper voice and continue to use the prepubertal highpitched voice. this is labeled as ‘puberphonia’ where the larynx fails to descend and tends to be held high in the neck. the etiologies of puberphonia have been posited to include resisting change of puberty, habitual pitch, disliking new pitch after puberty, new pitch not matching personality, wanting to remain young, more identification with females, singing voice, embarrassment and anatomical differences.5, 6 the treatment of choice for puberphonia is voice therapy with which most of the patients improve.7,8 however, patients who fail to improve with conservative management should be considered for other modalities of treatment as delayed treatment and denial of the problem causes the disorder to become recalcitrant to behavioral treatment. direct laryngoscopic manipulation has been described by vaidya et al. where pressure was applied onto the valleculae internally by laryngoscope and externally on the thyroid cartilage with immediate improvement of pitch.9 isshiki type 3 thyroplasty can be considered to be a definitive treatment for puberphonia as vocal pitch has been shown to be effectively lowered by this surgery without distorting the vocal quality.10 pau and murty (2001) were the first to report a surgically corrected case of puberphonia where they attempted surgical lowering of the hyoid and larynx in a 24-year-old male resulting in lowering of pitch from 175hz to 142hz.2 they mobilized the hyoid and superior halves of thyroid cartilage and reduced cricothyroid distance by apposing mobile hyoid to fixed cartilage by two non-absorbable figure of 8 sutures. however, in the classic isshiki type 3 thyroplasty, 2 – 3 mm of vertical strips of cartilage were excised on each side of midline of thyroid cartilage.10 this procedure caused retrusion of the middle portion of the thyroid cartilage causing a reduction in the length of the vocal folds. the procedure is termed as relaxation thyroplasty by a medial approach (anterior commissure retrusion) as proposed by the phonosurgery committee of the european laryngological society.11 according to isshiki et al. vocal cord stiffness is seen in dysphonia that is suggested by a breathy, high pitched and strained voice. surgical a-p table 1. results of acoustic analysis using dr speech software (university version 4.0) pre op habitual f0 (hz) post op habitual f0 (hz) pre op jitter % pre op shimmer % post op jitter % post op shimmer % 249.07 244.98 252.67 250.24 229.32 248.64 0.21 0.19 0.24 0.22 0.18 0.24 2.16 2.62 2.24 2.62 2.22 2.18 128.51 180.24 136.68 140.24 128.38 130.64 0.22 0.18 0.19 0.2 0.14 0.19 1.48 1.6 1.42 1.64 1.4 1.58 figure 3. suturing two sides of ala of thyroid cartilage philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles philippine journal of otolaryngology-head and neck surgery 9 shortening of thyroid ala reduced the stiffness of the cord thus treating it successfully.12 in our study, we performed the classic isshiki type 3 thyroplasty in six puberphonia patients with high pitched voice who failed to improve with voice therapy. postoperatively there was successful lowering of the vocal pitch. remacle et al. has shown type 3 thyroplasty to be a successful treatment option for lowering vocal pitch in cases of mutational falsetto voice recalcitrant to conservative therapy.13 li et al. performed acoustic evaluation of isshiki type 3 thyroplasty for treatment of mutational voice disorders in 11 male patients and concluded that the pre-operative high pitched voices of all the male patients were lowered up to the normal value by type 3 thyroplasty.14 slavith et al. assessed the role of type 3 thyroplasty using preoperative and postoperative voice recordings as well as electroglottography and photoglottography.15 analysis of the preoperative and postoperative data from two patients with over one year follow-up showed a decrease in frequency of vibration. postoperatively, the vocal folds still vibrated in a regular pattern as described by the myoelastic-aerodynamic theory without any increase in jitter or shimmer quotient. they concluded that type 3 thyroplasty is capable of lowering the fundamental frequency of speech without adversely affecting the vibratory mode of the vocal folds. different modifications of type 3 isshiki thyroplasty have been proposed by various authors. tucker’s procedure is less invasive whereby a superiorly based cartilage window is created at the level of anterior commissure and is pushed behind causing relaxation of the vocal folds.16 this surgical procedure is very useful in treating patients in whom psychological counseling and voice therapy have failed. kocak et al. assessed the success rate of a less invasive modification of isshiki type 3 thyroplasty by performing window anterior commissure relaxation laryngoplasty technique in patients with high-pitched voice disorders.17 among 21 patients with a mean age of 30.5 years, the most frequent cause of high-pitched voice was sulcus vocalis (n = 14), followed by constitutional causes (n = 5), mutational falsetto (n = 1) and severe glottic scarring secondary to childhood diphtheria (n = 1). after surgery, the fundamental frequency dropped significantly from a mean of 213.81 hz to 149.86 hz (p < 0.001) equaling a mean postoperative semitone drop of 6.23. garcía-lópez et al. presented a case of a patient with dysphonia by tone elevation in relation to gender treated by type 3 thyroplasty and an updated review of the surgical technique and its outcome.18 chandra et al. also performed issiki’s type 3 thyroplasty in seven patients with puberphonia.19 average pre and post-operative mean pitch was 224.42 and 137, hz respectively. in the present series, we included only patients whose voice did not improved even after extensive voice therapy sessions. after type 3 thyroplasty, there was improvement of all the parameters of acoustic analysis. though jitter and shimmer percentage improved, the most table 2. results of type 3 thyroplasty on puberphonic patients in different studies author(s) / year journal subjects parameters results post operative voice frequencies were significantly decreased (p<0.05) without any statistically significant differences in the preand postoperative measures of vocal intensity (p > 0.5). all scores of the vhi showed significant improvements (p=0.001). among acoustic parameters, only the mean fundamental frequency showed a significant change from 246 hz to 134 hz after treatment (p=0.001) fundamental frequency dropped significantly from a mean of 213.81 hz to 149.86 hz (p < .001). misperception leading to an abnormal body image was reduced by 86%. diplophonia with subharmonic signals was reduced or disappeared in 6 cases. mean fundamental frequency was lowered from 187 hz to 104 hz (p < 0.001), and the mean voice handicap index was improved from 70 to 21. average pre and post-operative mean pitch was 224.42 and 137 hz respectively mean pre-operative vhi and grbas score were 53 and 75.67 respectively whereas post-operative score were 29 and 25 respectively. mean pre-operative habitual fundamental frequency (f0), jitter % and shimmer % was 245.82 hz, 0.21 and 2.34 respectively whereas post-operative mean was 140.78 hz, 0.19 and 1.52 respectively. voice recordings, electroglottography, photoglottography fundamental frequency (fo), voice frequencies, and vocal intensity obtained from a sustained vowel /i/ during different phonatory tasks voice handicap index (vhi) and videolaryngostroboscopy (vls), fundamental frequency(f0), jitter, shimmer and normalized noise energy(nne) fundamental frequency (f0), diplophonia, perception of body image and pitch and subjective ratings of comfort during vocalization. fundamental frequency (f0) of the voice and voice handicap index (vhi) mean pitch in hz voice recording by trained listener, vhi score, grbas and real time acoustic analysis (perturbation) of voice using dr speech software (university version 4.0) (habitual fundamental frequency (f0), jitter % and shimmer % 2 male patients 11 male patients 16 male patients (treatment given mainly voice therapy. thyroplasty was done in 1 patient who failed after voice therapy) 21 patients with high-pitched voice including 1 patient with puberphopnia 7 male patients with a mean age of 21 years 7 male patients 6 male patients with a mean age of 19 years laryngoscope journal of laryngology & otology turkish journal of ear nose and throat archives of otolaryngology head and neck surgery the annals of otology, rhinology, and laryngology international journal of phonosurgery and laryngology philippine journal of otolaryngology head and neck surgery slavit dh, maragos ne, lipton rj. /1990 li gd, mu l, yang s. /1999 kizilay a, firat y /2008 kocak i, dogan m, tadihan e, alkan cakir z, bengisu s, akpinar m. /2008 remacle m, matar n, verduyckt i, lawson g /2010 chandra st, rao sm, kumar ay, murty psn /2011 chowdhury k, saha s, pal s, chatterjee i/ 2014(present study) philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles 10 philippine journal of otolaryngology-head and neck surgery references dagli m, sati i, acar a, stone re jr, dursun g, eryilmaz a. mutational falsetto: intervention 1. outcomes in 45 patients. j laryngol otol.2008 mar; 122(3):277-281. pau h, murty ge. first case of surgically corrected puberphonia. 2. j laryngol otol. 2001 jan; 115(1):60-61. flint pw, haughey bh, lund vj, niparko jk, richardson ma, robbins kt, thomas jr, editors. 3. cummings otolaryngology–head and neck surgery. 5th ed. ny: elsevier; 2010. stemple jc, glaze le, klaben bg. clinical voice pathology: theory and management. 3rd ed. ny: 4. delmar cengage learning; 2000. nicolosi l, harryman e, kresheck j. terminology of communication disorders: speech-language-5. hearing. 5th ed. baltimore: lippincott williams & wikins; 2004. hedge mn. introduction to communicative disorders, 3rd ed. austin, tx: pro-ed; 2001.6. harris s. speech therapy for dysphonia. in: harris t, harris s, rubin js, howard dm, editors. the 7. voice clinic handbook. london: whurr publishers ltd. 1998;139-206. carlson e. electrolaryngography in the assessment and treatment of incomplete mutation 8. (puberphonia) in adults. eur j disord commun. 1995; 30(2): 140-8. vaidya s, vyas g. puberphonia: a novel approach to treatment. 9. indian j otolaryngol head neck surg. 2006 jan; 58(1):20-1. isshiki n, taira t, tanabe m. surgical alteration of the vocal pitch. 10. j otolaryngol. 1983 oct; 12(5): 335-40. friedrich g, de jong fi, mahieu hf, benninger ms, isshiki n. laryngeal framework surgery: a 11. proposal for classification and nomenclature by the phonosurgery committee of the european laryngological society. eur arch otorhinolaryngol. 2001 oct; 258(8): 389–396. isshiki n, ohkawa m, goto m. stiffness of the vocal cord in dysphoniaits assessment and 12. treatment. acta otolaryngol suppl. 1984; 419:167–174. remacle m, matar n, verduyckt i, lawson g. 13. relaxation thyroplasty for mutational falsetto treatment. ann otol rhinol laryngol. 2010 feb; 119(2):105-9. li gd, mu l, yang s. 14. acoustic evaluation of isshiki type iii thyroplasty for treatment of mutational voice disorders. j laryngol otol. 1999 jan; 113(1):31-4. slavit dh, maragos ne, lipton rj. 15. physiologic assessment of isshiki type iii thyroplasty. laryngoscope. 1990 aug; 100(8): 844-8. tucker hm, editor. the larynx. 216. nd ed. new york: thieme; 1992. kocak i, dogan m, tadihan e, alkan cakir z, bengisu s, akpinar m. 17. window anterior commissure relaxation laryngoplasty in the management of high-pitched voice disorders. arch otolaryngol head neck surg. 2008 dec; 134(12):1263-9. garcía-lópez i, peñarrocha j, gavilan j.18. [type iii thyroplasty for the treatment of high-pitched voice disorder]. ]. acta otorrinolaringol esp. 2010 jul-aug; 61(4): 318-20. chandra st, rao sm, kumar ay, murthy psn. puberphonia. 19. int j phonosurg laryngol. 2011 janjun; 1(1): 19-20. kizilay a, firat y. 20. treatment algorithm for patients with puberphonia. turkish j ear nose throat. 2008 nov-dec; 18(6): 335-42. significant change was with fundamental frequency (mean preoperative 245.82 to mean post-operative 140.78 hz, p = 0.001). there was also significant subjective improvement of the patients as evident by vhi score (from pre-operative 53 to post-operative 29, p=0.004). results of type 3 thyroplasty on puberphonic patients in different studies are summarized in table 2. the treatment of choice for puberphonia is voice therapy. the main difficulties encountered in the treatment of puberphonia with voice therapy include stabilization of the attained fundamental frequency (f0) and widening the frequency range. type 3 thyroplasty can offer a suitable management option in those cases that fail to respond to voice therapy or fail to sustain the results. outcomes of surgery can be assessed by subjective improvement scales (e.g. vhi), perceptual scales (e.g. grbas) as well as real time acoustic analysis apart from traditional voice recordings. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 passages 44 philippine journal of otolaryngology-head and neck surgery dr. tomas carvajal at 76 years old, practiced for over 40 years as an emeritus consultant at our lady of lourdes hospital in sta. mesa, manila, where he started his residency training. early on, he learned to love the ent specialty and underwent preceptorship under the wing of dr. ariston bautista. at that time, there was no training program in the philippines. he went abroad and was accepted to train in berlin, germany at the rodolf virchow krankenhaus department of ear nose and throat under professor peffniz. after his training, to further hone his knowledge and skills, he underwent post graduate training at the royal national ear, nose and throat hospital in london, england and wakayama medical center in osaka, japan specializing in nasal allergy. on returning to manila, he was invited to be an assistant professor in otorhinolaryngology at the far eastern university – college of medicine and a consultant at the feu hospital then in morayta, manila. he was also appointed medical specialist examiner under the then ministry of health. later, he became the first chairman of the department of ear nose throat – head and neck surgery (1986-1993) at the feu hospital. during the same time, he was also chairman at the quirino medical center department of eye ear nose and throat (eent). since then he had helped a lot of people including colleagues, friends and neighbors and was thus invited by former president erap estrada and senator jinggoy estrada to run for city councilor in san juan city where he served for two consecutive terms (2000-2006). my father lived a fruitful and blessed life. he was loved and praised by everyone. it was he who inspired me to become an ent doctor. it was he who guided me, giving me pointers during my residency training, and it was he who taught me too about life…. “thank you dad!” tomas c. carvajal, md (1936 2013) “my mentor… my inspiration… my dad” theodore m. carvajal, md “the righteous who walks in his integrity—blessed are his children after him! ” proverbs 20:7 philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 special announcement philippine journal of otolaryngology-head and neck surgery 7 we, the participants in the joint meeting of the asia pacific association of medical journal editors (apame), the index medicus for the south-east asian region (imsear), and the western pacific region index medicus (wprim) held in tokyo from 2 to 4 august 2013: considering that overwhelming data in science and medicine may differ in their reliability and that quality control is important for compiling scientific and health information; that equitable circulation of scientific and health information is facilitated by fair collaboration among policy makers, researchers, and industry sectors including pharmaceuticals and publishers; that apame, imsear, and wprim are important collaborative initiatives that can implement global guidelines for publication and dissemination of scientific and medical knowledge in an equitable and ethical manner; confirm our commitment to endorse that scientific and medical knowledge is imperishable and should not be assessed or evaluated by only economic or temporal considerations; our commitment to improve quality and reliability of scientific and medical knowledge through the imsear and wprim; our commitment to publish reliable and high-quality information by education of researchers, implementation of fair review processes, and organization of networks through apame; our commitment to collaborate with publishers, academic or public libraries, and research bodies to achieve equitable and tokyo declaration on research integrity and ethical publication in science and medicine in the asia pacific region ethical publication and dissemination of scientific and medical knowledge; commit ourselves, to publishing reliable and high-quality information, thereby setting the ethical standard for our colleagues, editors, and librarians in the region; our publishers, to disseminating scientific and medical knowledge fairly and impartially through digital library services including, but not limited to, imsear, wprim, and the global health library; our organization, apame, to building further networks, convening conferences, and organizing events to educate and empower editors, peer reviewers, and authors to achieve internationally acceptable, but regionally realistic, scholarly standards. 4 august 2013, tokyo this declaration was adopted at the 2013 convention of the asia pacific association of medical journal editors (apame) held in tokyo from 2 to 4 august 2013. it is concurrently published by journals linked to apame and listed in the index medicus for the south east asian region (imsear) and the western pacific region index medicus ( wprim). copyright © apame. www.wpro.who.int/apame apame@wpro.who.int philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 philippine journal of otolaryngology-head and neck surgery 39 under the microscope a 60-year-old woman with a 3-year history of a gingivoalveopalatal mass underwent an incision biopsy. microscopically, the lesion centered in the stroma is infiltrative (figure 1) and architecturally diverse, having cystic (figure 2), linear or “indian file” (figure 3), solid and tubular (figure 4) patterns. the cells are uniform in size, round to oval and have bland cytologic features with vesicular nuclei and inconspicuous nucleoli (figure 4). the clinical data and histomorphologic features characterized by architectural diversity yet cytologic blandness lead us to the diagnosis of polymorphous low-grade adenocarcinoma. polymorphous low-grade adenocarcinoma correspondence: dr. jose m. carnate, jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st. ermita, manila, 1000 philippines phone (632) 526 4450 telefax (632) 400 3638 email: jmcjpath@gmail.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believes that the manuscript represent honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to conflict of interest. philipp j otolaryngol head neck surg 2014; 29 (2):39-40 c philippine society of otolaryngology – head and neck surgery, inc. joy b. bernido, md1 jose m. carnate, jr., md2 1department of laboratories philippine general hospital university of the philippines manila 2department of pathology college of medicine university of the philippines manila figure 1. hematoxylin and eosin (40x) tumor within the stroma with an infiltrating growth pattern figure 2. hematoxylin and eosin (100x) tumor showing tubules and small cystic structures. (hematoxylin and eosin, 40x) (hematoxylin and eosin, 100x) philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 under the microscope 40 philippine journal of otolaryngology-head and neck surgery references luna ma, wenig bm. polymorphous low-grade adenocarcinoma. in: barnes l, eveson jw, 1. reichart p, sidransky d, editors. world health organization classification of tumors: pathology and genetics of head and neck tumors. lyon, france: international agency for research on cancer press, 2005. pintor mf, figueroa l, martinez b. polymorphous low-grade adenocarcinoma: review and case 2. report. med oral patol oral cir bucal. 2007 dec 1; 12(8):e549-51. thompson ldr. polymorphous low-grade adenocarcinoma. 3. pathology case reviews 2004 novdec;9(6): 259-263. doi: 10.1097/01.pcr.0000143777.ea olusanya aa, akadiri oa, akinmoladun vi, adeyemi bf. polymorphous low grade 4. adenocarcinoma: literature review and report of lower lip lesion with suspected lung metastasis. j maxillofac oral surg. 2011 mar; 10(1): 60-63. doi: 10.1007/s12663-011-0185-1. seethala rr, johnson jt, barnes el, myers en. polymorphous low-grade adenocarcinoma: the 5. university of pittsburgh experience. arch otolaryngol head neck surg 2010 apr;136(4):385-92. doi: 10.1001/archoto.2010.39. de araujo vc, passador-santos f, turssi c, soares ab, de araujo ns6. . polymorphous low-grade adenocarcinoma: an analysis of epidemiological studies and hints for pathologists. diagn pathol 2013 jan 15;8:6. doi: 10.1186/1746-1596-8-6. potluri a, prasad j, levine s, bastaki j. polymorphous low-grade adenocarcinoma: a case report. 7. dentomaxillofac radiol 2013;42(2):14804843. doi: 10.1259/dmfr/14804843. gnepp dr, editor. diagnostic surgical pathology of the head and neck. 28. nd ed. philadelphia: saunders elsevier, 2009, p. 486-489. polymorphous low-grade adenocarcinoma (plga) is a malignant epithelial tumor characterized by cytologic uniformity, morphologic diversity, an infiltrative growth pattern and low metastatic potential.1 it is the second most common intraoral malignant salivary gland tumor1 following mucoepidermoid carcinoma. the tumor is found almost exclusively in minor salivary glands and is rare in extraoral locations including major salivary glands.2 the tumor affects a wide age range (16 – 95 years; mean 60 years) with only two pediatric cases reported1 and has a female predilection.3,4 it usually presents as a painless mass located within the oral cavity3 60% of which are located in the palate.1 they are characteristically unencapsulated although well-circumscribed.3 this entity is architecturally diverse (“polymorphous”) even within a single tumor, with solid, tubular, trabecular, cribriform, papillary and figure 3. hematoxylin and eosin (100x) tumor cells showing a linear (“indian-file”) arrangement (hematoxylin and eosin, 100x) figure 4. hematoxylin and eosin (400x) the round to oval tumor cells are uniform in size with bland nuclei and inconspicuous nucleoli (hematoxylin and eosin, 400x) linear patterns being described. perineural invasion is common although it was not seen in this case. the tumor cells are small to medium sized and uniformly round to polygonal. the nuclei are bland and vesicular with occasional small inconspicuous nucleoli. mitotic figures can be found occasionally but are never numerous.3, 8 the morphologic heterogeneity in small biopsies and frozen section samples can be confused with pleomorphic adenoma and adenoid cystic carcinoma.6,7 glial fibrillary acid protein may help as plga is typically non-reactive in contrast to pleomorphic adenoma.2 de araujo and others site that uniformly positive vimentin, ck7 and s100 staining favors plga over adenoid cystic carcinoma.6 tumor cytology and histology are quite characteristic recognizing the constant cytological appearance despite the diversity of architectural tumor patterns should aid one in diagnosing plga. plga, despite its infiltrative growth pattern and propensity for perineural invasion usually runs an indolent course. nodal metastasis and distant spread are rare, occurring in less than 1% of cases.4 seethala and others report that extrapalatal location is associated with a more aggressive clinical course.5 complete surgical excision is the primary treatment with neck dissection reserved for nodal metastasis.1 onethird of patients may have a local recurrence and lifelong monitoring is suggested. re-excision is amenable in these cases.5,6 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 philippine journal of otolaryngology-head and neck surgery 65 from the viewbox this young adult man presented to ent clinic with a complaint of left facial weakness and persistent left retro-auricular pain. high resolution ct of the mastoids was performed following clinical assessment. in this case, there is extensive sclerotic bony expansion with a ground-glass appearance involving the left zygoma, sphenoid and petrous temporal bone. the bony expansion is centred on the medullary bone and has an abrupt zonal transition (figure 1). the bone involvement encompasses almost complete bony stenosis of the left external auditory meatus down to 1-2mm with consequential fluid in the external auditory canal and middle ears (figure 2). the bony expansion involves both the tympanic and mastoid segments of the facial canal which are stenosed. the ossicular chain remains intact. the left mastoid air cells are under-pneumatised and completely occupied by fluid. facial palsy and mastoiditis from fibrous dysplasia correspondence: dr. ian c bickle consultant radiologist department of radiology ripas hospital bandar seri begawan ba1710 brunei darussalam phone: + 00 673 224 2424 fax: + 00 673 224 2690 email: firbeckkona@gmail.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2015; 30 (2): 65-66 c philippine society of otolaryngology – head and neck surgery, inc. ian c. bickle, mb, bch, bao, frcr department of radiology ripas hospital bandar seri begawan brunei figure 1. axial high resolution ct of the mastoids: diffusely sclerotic, expansile left temporal bone with a ground-glass appearance (**) and sharp transition to normal bone (wide black arrow). this involves the temporal component of the facial nerve canal with narrowing of the mastoid segment of the facial canal (thin black arrow). the mastoid air cells are opacified with fluid (white arrow). philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 from the viewbox 66 philippine journal of otolaryngology-head and neck surgery references 1. lo acc, nemec sf. opacification of the middle ear and mastoid: imaging findings and clues to differential diagnosis. clin radiol 2015 may 6;70(5):e1-e13. 2. valentini v, cassoni a, marianetti tm, terenzi v, fadda mt, iannetti g. craniomaxillofacial fibrous dysplasia: conservative treatment or radical surgery? a retrospective study on 68 patients. plast reconstr surg. 2009 feb; 123(2):653–660. 3. lee js, fitzgibbon ej, chen yr, kim hj, lustig lr, akintoye so, collins mt, kaban lb. clinical guidelines for the management of craniofacial fibrous dysplasia. orphanet j rare dis. 2012 may 24; 7(suppl 1): s2. figure 2. coronal high resolution ct of the mastoids: almost complete bony stenosis of the left external auditory canal (white arrows) with post obstructive fluid in auditory canal and middle ear. discussion fibrous dysplasia (fd) is a benign congenital process that typical manifests itself as a localized defect in osteoblastic differentiation and maturation. normal bone is replaced with haphazard fibrous tissue and immature woven bone.1 fibrous dysplasia is predominantly a condition of children and young adults (those less than 30 years of age). disease growth usually halts after the third decade of life. fd may be a monostotic or polyostotic in nature and in some cases is part of a syndrome such as mccune-albright.2 the zygomatic maxillary complex is the most commonly reported location for fibrous dysplasia. the temporal bone is a typical site in polyostotic disease in up to 70%, but less often observed in monoostotic disease. disease of the temporal bone most typically results in hearing impairment due to bony stenosis of the external auditory canal. facial nerve involvement is a less frequent feature, resulting in facial nerve paralysis, due to involvement of the nerve as it exits through the petrous temporal bone.2 the anatomical location of the facial nerve compression is hard to access and treat surgically.3 ct is the imaging investigation of choice giving the most exquisite bony definition. typical ct features (as shown in this case) are: • a diffuse ground-glass appearance to the affected bone • homogeneously sclerotic bone • well-defined borders between the diseased and unaffected bone (abrupt zone of transition) • bony expansion with overlying cortical bone intact the ct appearances apply equally to the anatomical site involved, however the combination of imaging appearances can be variable presenting a diagnostic dilemma, which may merit a confirmatory bone biopsy. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports philippine journal of otolaryngology-head and neck surgery 25 abstract objective: dacrocystorhinostomy (dcr) with silicone tube stenting is a common procedure for congenital nasolacrimal duct obstruction (nldo). the incidence of congenital nldo is about 6% in the newborn. the duration the tube is left in place varies depending on surgeon preference. cheese wiring is one of the tube-related complications when the tube is left behind for a long duration. the term cheese wiring refers to the silicone stent or tubing cutting through soft tissue close to the punctum or canaliculi like wire cuts through cheese. we present a case of tube extrusion with cheese wiring five years post dcr. methods: design: case report setting: tertiary referral center patient: one results: a 16-year-old indian male with congenital bilateral nldo underwent right and left dcr at ages 9 and 11, respectively. the patient presented with smelly nasal discharge five years later to the ent clinic. on initial examination the right tube was in place but the left tube was not visualized. nasal endoscopy however revealed that both tubes were still there and were subsequently removed. conclusion: dcr with silicone intubation is a common practice. early follow up is essential to prevent complications. if tube extrusion is suspected, early endoscopic examination is essential to confirm it. keywords: nasolacrimal duct obstruction, dacrocystorhinostomy, tube extrusion, cheese wiring dacrocystorhinostomy (dcr) with silicone tube stenting is a common procedure for congenital nasolacrimal duct obstruction after failed conservative management including lacrimal apparatus probing and irrigation. the incidence of congenital nasolacrimal duct obstruction (nldo) is about 6% in the newborn.1 the duration the tube is left in place varies depending on surgeon preference, from several weeks up to more than 12 months. cheese wiring is one of the complications when the tube is left behind for a long duration. we report a case of cheese wiring five years post dcr. tube extrusion and cheese wiring five years post dacryocystorhinostomy khairullah bin anuar mbchb balwant singh gendeh mbbs, ms (orl-hns) department of otorhinolaryngology head and neck surgery universiti kebangsaan malaysia medical center cheras, kuala lumpur, malaysia correspondence: dr khairullah bin anuar department of otorhinolaryngology medical faculty, universiti kebangsaan malaysia jalan yaakub latif 56000 cheras, kuala lumpur malaysia phone: 603-91455555 ext 6838 fax: 603-91737840 email: khairullah4195@yahoo.co.nz reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (2): 25-27 c philippine society of otolaryngology – head and neck surgery, inc. 26 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports case report a 16-year-old indian male presented with history of bilateral epiphora associated with yellowish discharge since birth. he had previous probing and syringing under general anaesthesia in 2002 and early 2003 at the age of 8 years and 9 years, respectively. a dacrocystogram (dcg) in april 2003 showed complete obstruction at the right lacrimal sac and left inferior canaliculus. an ophthalmologist performed right external dacrocystorhinostomy (dcr) with bordeaux tube in september 2003 and left external dcr with bordeaux tube in 2005. on subsequent visits to the outpatient eye department it was thought that the left tube was dislodged. an ent referral was made for occasional epistaxis and smelly nasal discharge of two months duration. on examination of the eye, the right bordeaux tube was in situ (figure 1). however on the left eye, the tube could not be visualized with evidence of cheese wiring of the inferior canaliculus (figure 2). endoscopic examination revealed that the tubes were covered with greenish encrusted secretions (figures 3 & 4). both tubes were removed (figures 5 & 6). the patient was treated with an oral antibiotic, intranasal steroid and oral antihistamine. on follow up at three months, there was no more epiphora or evidence of foul smelly discharge or epistaxis. clinically he had a patent canaliculus with no mucopus or polyp seen. discussion obstruction of the nasolacrimal duct results in disturbed outflow of tears, commonly known as epiphora. although epiphora is a benign condition, it has social implications. adeo toti introduced an operation which he called dacryocystorhinostomy (dcr) for the treatment of epiphora.2 after creating an external approach to the lacrimal figure 1. right eye, tube in situ figure 2. left eye cheese wiring figure 3. right nasoendoscopic view, tube in situ figure 4. left nasoendoscopic view, tube in situ philippine journal of otolaryngology-head and neck surgery 27 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports references 1. charmaine sl, martin f, beckenham t, cumming rg .nasolacrimal duct obstruction in children: outcome of intubation. j american association for pediatric opthalmology and strabismus. 2004 oct; 8(5):466-472. 2. dolman pj. comparison of external dacrocystorhinostomy with non laser endonasal dacrocystorhinostomy. ophthalmology 2003 jan;110(1):78-84. 3. onerci m. diagnosis and treatment of nasolacrimal canal obstructions. rhinology. 2002 june; 40 (2):49-65. 4. wormald pj. powered endonasal dacryocystorhinostomy. laryngoscope. 2002 jan;112(1):69-71 5. saiju r, morse lj, weinberg d, shrestha mk, ruit s. prospective randomized comparison of external dcr with and without silicone intubation. br j opthalmol. 2009 june; 93(9.):12201222. 6. gauba v. the practice of dacryocystorhinostomy (dcr) surgery by ophthalmologists in the united kingdom (uk). orbit. 2008 jan; 27(4):279–83. 7. nemet ay, fung a, martin pa, benger r, kourt g, danks jj et al. lacrimal drainage obstruction and dacryocystorhinostomy in children. eye. 2008 july; 22 (7):918-24. 8. kashkouli mb, parvaresh m, modarreszadeh m, hashemi m, beigi b. factors affecting the success of external dacryocystorhinostomy. orbit. 2003 dec; 22(4):247–55. 9. hartikainen j, gremnan r, puukka p, seppä h. prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy. ophthalmology. 1998 june; 105(6):1106–13. 10. charalampidou s, fulcher t. does the timing of silicone tube removal following external dacryocystorhinostomy affect patients’ symptoms? orbit. 2009 april; 28 (2):115-119. 11. anderson rl, edwards jj. indications, complications and results with silicone stents. ophthalmology .1979 aug; 86(8): 1474–87. sac, its portion near the canaliculi should be preserved and absorbed into the nose by creating a window in the lateral wall of the nose. an endonasal approach was introduced by caldwell in 1893.3 its use was initially limited by the difficulty of visualizing endonasal structures during surgery. the development of operating microscopes and subsequent rigid endoscopes aroused more interest for the endonasal approach. powered endoscopic dcr was subsequently popularized by pj wormald.4 the current gold standard for treating epiphora by ophthalmologists is external dcr. beginning in the 1970’s, surgeons began to favour dcr with intubation tubes over dcr without intubation tubes.5 a recent survey of ophthalmologists in the uk showed that the insertion of silicone tubes for external dcr was routine.6 for congenital nldo, dcr with nasolacrimal silicone tube intubation is the treatment of choice after failed probing and irrigation.7 the necessity of intubation in dcr remains controversial even though its use is common practice. some studies found that silicone intubation improves success rates in children while other studies showed no difference in outcome .7,8 the time frame for silicone tube removal varied in the literature from as early as 3 to 7 weeks to as late as over a year.3,9 charalampidou et al. reviewed a retrospective study of external dcr and found that out of 180 cases, 94 tubes were removed between 2 to 4 months, 24 tubes were removed before the planned 2 – month period and 62 tubes were removed after the 4 month period.10 the survey of ophthalmologists also found out that the tubes were removed as early as 4 weeks.6 complications of silicone tube insertion include marsupialization of canaliculi, granuloma formation, corneal abrasion, fistula formation, chronic mucopurulent discharge and nasal irritation. punctal and canalicular complications include punctal stretch, erosion and cheese wiring. the incidence of cheese wiring has been reported to be 2.6% for external dcr and 1.5% for endoscopic dcr.2 the etiology of cheese wiring results from the tube being placed under tension and left behind for a long duration. another possible explanation for cheese wiring is that wiping the eye when the eyelids are closed, the stent loop is immobilized such that outward wiping of the eyelid pulls the punctum against the fixed stents. other causes of cheese wiring may include unintentional trauma during probing or chronic irritation from the tube itself.11 in this case the patient had congenital nldo and needed a longer time for tube placement which may have resulted in migration of the tube and cheese wiring. charalampidou et al. suggested for early review of the tube within a week and anticipation of cheese wiring if the tubes were too tight.10 in such cases, early follow up is essential to prevent complications. if tube extrusion is suspected, early endoscopic examination is essential to confirm it. figure 5. left nasoendoscopic view, post removal of tube figure 6. right nasoendoscopic view, post removal of tube philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 from the viewbox 34 philippine journal of otolaryngology-head and neck surgery this 8-year-old girl presented to a tertiary surgical centre with a history from birth of an absent left and a malformed right pinna, and associated bilateral hearing impairment. on clinical examination, the left pinna was absent and the right dysplastic. no penetrable external auditory meati were evident. bilateral hearing impairment, more pronounced on the left, was confirmed with auditory testing. prior to surgery high resolution ct imaging of the temporal bones was performed. in addition a ct of the lower thoracic cavity was undertaken to assess the costal cartilage for surgical planning. (figure 1) ct 3d reformatting technique to aid microtia reconstruction procedure planning correspondence: dr ian c bickle department of radiology ripas hospital bandar seri begawan ba1710 brunei darussalam phone: (673) 8 612182 fax: (673) 224 2690 email: firbeckkona@gmail.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2013; 28 (1): 34-35 c philippine society of otolaryngology – head and neck surgery, inc. ian c. bickle, mb bch bao, frcr department of radiology ripas hospital, bandar seri begawan brunei figure 1: coronal ct chest (non-contrast) with 3d in-space (siemens, erlangen, germany) reformatting. (r= bony rib, s = sternum, cc = costal cartilage) philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 philippine journal of otolaryngology-head and neck surgery 35 from the viewbox references aase,jm, tegtmeier, re. microtia in new mexico: evidence for multifactorial causation. 1. birth defects, 1977; 13:113-116. romo t 32. rd, presti,pm, yalamanchili hr. medpor alternative for microtia repair. facial plast surg clin north am, 2006. 14(2):129-36. brent, b. ear reconstruction with an expansile framework of autogenous rib cartilage. 3. plast reconstr surg, 1974. 53(6):619-628. yanai,a, fukuda, o, nagata, s, tanaka, h. a new method utilising the bipedicle flap for 4. reconstruction of the external auditory canal in mircotia. plast reconstr surg. 1985. 76(3):464-8. discussion microtia is a congenital deformity of the pinna, with a wide spectrum of abnormalities ranging from complete absence (anotia) to a relatively, well formed but dysplastic pinna (figure 2). it occurs in one in every 6,000 births, with a higher preponderance in select racial groups such as the japanese.1 for decades surgical procedures have been performed and evolved for the treatment of microtia. in contemporary practice these may either be autogenous, using costal cartilage or alloplastic, using the likes of porous high density polyethylene (medpor).2 the key autogenous surgical techniques in common practice are those described by the brent and nagata.3,4 autogenous costal cartilage is utilised in one of the key stages in reconstructing the pinna to fabricate the auricular framework. the age at which the procedure is performed is typically in childhood (8 – 10 years of age), when costal cartilage is believed to be well formed and fusion may have occurred at the mid-lower ribs levels (7th – 9th). traditionally no pre-operative imaging has been undertaken given the difficulties with visualising cartilage at this age. on standard ct chest with traditional viewing methods the costal cartilage is poorly if at all seen in children. however, utilising some of the more advanced 3d software algorithms on contemporary ct scanners, accurate figure 3: coronal ct chest (non-contrast) with 3d in-space reformatting. a: using the arterial algorithm illustrating with line annotation a suitable costal cartilage segment for surgical harvest for auricular reconstruction. b: using a soft tissue algorithm with width and distance annotations applied. figure 2: high resolution ct of the temporal bones: a: axial images illustrating bilateral microtia, with an absent left pinna (*) and dysplastic right pinna (white arrow). in addition the left ossicular chain is absent with soft tissue filling the middle ear (black arrow). b: coronal images showing the absent left pinna (*) and absence of the external auditory canals (diamond). assessment to aid the surgeon prior to scheduling a procedure can be performed (figure 1). the configuration of costal cartilage may be reviewed and if adequate fusion has occurred. a potential framework can then be outlined (figure3a). in addition selective dimensions can be recorded to the nearest millimeter (figure 3b). this post-processing work is undertaken with the reporting radiologist and surgical lead for the procedures. *images in our institutions were acquired on a siemens somatom 64 slice scanner with radiographic parameters of kv 120, mas 46, slice thickness 0.6mm and dlp of 68 without the use of intravenous contrast. coronal 3d reformatting was performed using the inspace software, using an arterial algorithm (figures 1 and 3a). alternatives employed include the use of soft tissue algorithm (figure 3b). 34 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 featured grand rounds arterio-venous malformations (avms) are congenital vascular defects1 and are most commonly located in the head and neck area (81%).2 the majority of these were localized over the cheek (31%) , ear(16%), nose (10%), forehead(10%), upper lip (7%), mandible (5%), neck (5%), and scalp and maxilla (4%).2 there is equal predominance in males and females and no racial predilection.2 in general, there is “sparse literature about avm in the external ear,”3 let alone its occurrence in a pregnant patient. arterio-venous malformations are composed of a central nidus with anomalous arteriovenous shunts and a network of surrounding collateral vessels.4 the short circuit or shunting between the high pressure arterial and low pressure venous system accounts for much of the clinical presentation, anatomical changes and progression of the lesions. they are usually present at birth but commonly manifest in childhood or adolescence with gradual onset and progression and rarely can be associated with an enlarged heart and high output cardiac failure.3,5 the size of avms may increase rapidly secondary to infection, trauma, ligation or attempted excision and hormonal influences like pregnancy and puberty.3 we present the case of an avm occurring in the external ear of a pregnant patient. case report a 31-year-old g1p0 patient consulted with a uterine pregnancy of 24 weeks and two days age of gestation for an enlarging left external ear mass of approximately two years duration. the patient characterized the mass as initially “pimple-like”, erythematous and nontender. there were no other associated signs and symptoms. the mass persisted despite taking ciprofloxacin 500 mg twice daily and mefenamic acid 500 mg thrice daily for a week. four months prior to consult, on one of her pre-natal check-ups, the mass was now more visible with an increase in size to about 1.5 x 1.5 x 1.5 cm. she noticed that her hearing was also decreased in the left ear. there were no other associated signs or symptoms. against her obstetrician’s advice to consult an otolaryngologist she decided to ignore the mass. a month before consult, the mass was about 2 x 2 x 1.5 cm, was more erythematous but nontender and had bled once (less than 3 ml) after traumatic manipulation. the patient sought an ent specialist and was advised to consult in our institution. on examination the left external ear had a 2 x 2 x 1.5 cm. erythematous, non-ulcerating mass of the external ear from tragus to external auditory canal. it was soft, compressible, nodular, nontender and pulsatile with a thrill and bruit. an av malformation was considered. (figure1) computed tomography axial and coronal sections revealed a soft tissue mass from tragus to external auditory canal with calcifications. (figure 2) the rest of the ear structures were normal. color doppler ultrasonography showed a 2 x 1.4 x 1.8 cm. congregation of small tubular structures in the subcutaneous area with the tubular mesh showing a diameter of 1.1 and 1.7mm. there was blood flow in the tubular structures with spectral tracing showing mixed arterial and venous flow arterio-venous malformation in the external ear in pregnancy normita s. pangan, md department of otorhinolaryngology head and neck surgery east avenue medical center correspondence: dr. normita s. pangan department of otorhinolaryngologyhead and neck surgery 6th floor, east avenue medical center east avenue, diliman, quezon city 1100 philippines phone: (632) 928 0611 loc 324 fax: (632) 435 6988 email: normitap@yahoo.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (2): 34-36 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 35 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 featured grand rounds she was closely monitored through her 39th week of pregnancy when she delivered a healthy baby girl via caesarean section. no other complications or problems were encountered after and she was discharged on the eighth hospital day. we recommended excision of the av malformation with reconstruction as a future treatment option. dicussion it has been estimated that the coexistence of pregnancy and avm may result in a 150% increase in cardiac output above normal levels.5 several cases of high output cardiac failure have been reported in pregnancies related to avm and beginning a pregnancy with a figure 1. a 2 x 2 x 1.5 cms erythematous, non-ulcerating mass of the external ear from tragus to external auditory canal. it was soft, compressible, nodular, nontender and pulsatile with a note of thrill and bruit figure 2-b. magnified mra of the left ear mass of the patient showing a central nidus of arterial and venous serpentine vessels. figure 3. temporal bone with contrast ct scan , coronal section (1 mm cut) showing left soft tissue mass from tragus to external auditory canal with noted calcifications figure 2-a. magnetic resonance angiography of the left ear mass of the patient showing serpentine feeding vessels around the mass coming from external carotid artery. (arterio-venous malformation was considered). magnetic resonance angiography (mra) revealed a feeding vessel possibly from the external carotid artery. (figure 3) other examinations (2-d echocardiography and 12-lead ecg) were normal. pure tone audiometry showed a moderately severe mixed hearing loss on the affected ear (left) and normal hearing on the contralateral side. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 36 philippine journal of otolaryngology-head and neck surgery featured grand rounds references 1. bailey b and johnson j. head and neck surgery – otolaryngology. 4th edition. pennsylvania: lippinkott, williams and wilkins: 2006. volume 1.125: 1813. 2. pollock be, gorman da, coffey rj. patient outcomes after arteriovenous malformation radiosurgical management: results based on a 5to 14-year follow-up study. neurosurgery [serial on the internet]. 2003 jun [cited 2011 sep 9]; 52(6):1296-7. available from: http://www. ncbi.nlm.nih.gov/pubmed/12762874 3. erdmann m, davis d, jackson j, allison d. multidisciplinary approach to the management of head and neck arterio-venous malformations. ann r coll surg eng. 1995. jan: 77(1):53-59. 4. ogilvy cs, stieg pe, awad i, brown rd jr., kondziolka d, rosenwasser r et al. aha scientific statement. recommendations for the management of intracranial arteriovenous malformations: a statement for health care professionals from a special writing group of the stroke council, american stroke association. stroke [serial on the internet]. 2001 [cited 2011 sep 9]; 32: 145871. available from: http://stroke.ahajournals.org/cgi/content/full/32/6/1458 5. prager j, mcclay j, elluru r, zapalac j, bromwich m. skin tumors, vascular lesions, face and neck. medscape. updated 2009 sep 15 [cited 2011 sep 9]. available from : http://emedicine. medscape.com/article/846692-overview. pre-existing avm can be dangerous. progesterone increases venous distensibility during pregnancy and the menstrual cycle and may explain the relationship of avm and pregnancy. the risk of avm bleeding is 2 to 3% per year although we have found no record of bleeding risks in avm of the external ear in pregnancy. thus, our patient was closely monitored and was co-managed with her obstetrician on out-patient care.3,4 women with avms in pregnancy that were most likely to bleed tended to be younger (20-25 years) and were usually primiparous. hemorrhages are most common between 15 and 20 weeks of gestation and could occur at any stage including during labour and in the puerperium.4 there is really no conclusive data regarding avm hemorrhage risk during pregnancy. according to ogilvy et al., the incidence of hemorrhage in pregnancy in patients with a prior history of hemorrhage is 5.8% during the year after the last menstrual period, but the number of patients with hemorrhage was small which made the data nondefinitive. neither of these rates was significantly different from similar nonpregnant populations.4 color doppler ultrasonography may be helpful in determining between highand lowflow lesions in avm. magnetic resonance imaging (mri) is said to be the diagnosis of choice since it depicts the extent and lack of invasion of these lesions providing multi-planar images and differentiating between highand low-flow lesions. a magnetic resonance angiogram (mra) is the same non-invasive study but also examines the blood vessels as well as the structures of the brain, which is very advantageous as a guide if surgery is contemplated.5 options for definitive management of avm include observation, corticosteroid therapy, surgery and interferon (inf) therapy. because the vast majority of avm are small, well circumscribed and involute with no sequelae and acceptable cosmetic results, observation remains the preferred management option. other treatments include surgery, endovascular therapy and radiosurgery. the latter can be used alone or in combination to treat an avm. superselective arterial or retrograde venous embolization may also be used as first choice treatment for avm not amenable to surgery.3,5 aside from conservative observation, none of these are advisable in pregnant patients.3,5 hemorrhage during delivery has been a major concern of obstetricians and patients. however, the available data would suggest that in most cases, vaginal delivery does not carry a higher risk for hemorrhage than delivery by cesarean section. there are no data available to address whether cesarean section helps to reduce the already low incidence of avm-associated complications during delivery, although there is evidence that increased venous pressure during a valsalva maneuver is not directly transmitted to the draining veins.4 to our knowledge, there is no existing management guideline for avm in the external ear area in pregnancy. treatment should be individually planned to minimize further avm enlargement and cardiovascular complications, utilizing conservative means rather than surgery as a primary option until after the pregnancy has been carried to term. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 philippine journal of otolaryngology-head and neck surgery 35 under the microscope a 58-year-old filipino man with a two-year history of a left external auditory canal mass associated with ipsilateral hearing loss underwent polypectomy for a clinical impression of aural polyp. we received several cream tan, irregular tissue fragments with an aggregate diameter of 1.4 cm. histopathologic examination shows clusters of tumor cells forming variably sized ducts and glands some of which are cystically dilated; many of these structures have irregular lumina. (figure 1) higher magnification shows a dual cell population: an outer layer of round to ovoid cells with clear cytoplasm corresponding to basal myoepithelial cells; and an inner layer of cuboidal to columnar cells that have eosinophilic and granular cytoplasm with decapitating apical ends, corresponding to luminal epithelial cells with apocrine morphology. (figure 2) nuclear pleomorphism is mild to moderate, nucleoli are not prominent and mitoses, perineural invasion and necrosis are not seen. in some glands a yellow to golden brown, coarse pigment is seen at the cytoplasm of the luminal cells. (figure 3) the tumor does not involve the epidermis and there is a variable amount of chronic inflammation. (figure 4) based on these features we diagnosed it as ceruminous adenoma. ceruminous neoplasms are uncommon tumors found in the external auditory canal. benign ceruminous tumors include ceruminous adenoma, ceruminous pleomorphic adenoma and ceruminous syringocystadenoma papilliferum.1 most common among these is the ceruminous adenoma; making up 88% in one thirty-year review of benign ceruminous neoplasms.1 these tumors occur in a wide age range, most commonly in the sixth decade, and have no sex ceruminous adenoma correspondence: dr. jose m. carnate jr., department of pathology college of medicine, university of the philippines manila 547 pedro gil st., ermita, manila 1000 philippines phone (632) 526 4450 telefax (632) 400 3638 email: jmcjpath@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2014; 29 (1):35-36 c philippine society of otolaryngology – head and neck surgery, inc. albert joseph b. lupisan, md1 jose m. carnate, jr., md2 1department of laboratories, university of the philippines philippine general hospital 2department of pathology, university of the philippines college of medicine philippine general hospital figure 1. hematoxylin and eosin (100x) neoplastic cells with a glandular and cystic architecture. (hematoxylin and eosin, 100x) philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 under the microscope 36 philippine journal of otolaryngology-head and neck surgery references thompson ldr, nelson bl, barnes el. ceruminous adenomas: a clinicopathologic study of 41 1. cases with a review of literature. am j surg pathol. 2004 mar; 28(3):308-318. thompson ldr. in: thompson ldr, editor. foundations in diagnostic pathology. head and 2. neck pathology. philadelphia, pa: elsevier, inc.; 2006. p.397-340. srivalli m, qaiyum ha, moorthy pns, srikanth k. adenomatous neoplasia presenting as aural 3. polyp. indian j otolaryngol head neck surg. 2012 jan-mar; 64(1):87-89. doi: 10.1007/s12070011-0128-7. michaels l, thompson ldr. in: barnes l, eveson jw, reichart p, sidransky d, editors. world 4. health organization classification of tumours. pathology and genetics of head and neck tumours. 2005; lyon: iarc press. p.331. lassaletta l, patron m, oloriz j, perez r, gavilan j. avoiding misdiagnosis in ceruminous gland 5. tumours. auris nasus larynx. 2003 aug; 30(3):287-290. doi: 10.1016/s0385-8146(03)00055-5. gnepp dr. diagnostic surgical pathology of the head and neck. 26. nd edition. philadelphia, pa: saunders; 2009. in our case. the main differential diagnosis of ceruminous adenoma is a ceruminous adenocarcinoma.1,2,5,6 marked pleomorphism, brisk mitoses, necrosis, invasion (e.g. perineural), and loss of the two-cell population favor a diagnosis of ceruminous adenocarcinoma but some well-differentiated cases can be confused with an adenoma. in these cases, sometimes the only clue of malignancy is invasion especially at the surgical margins.6 lassaletta et al.5 stressed the importance of adequate tumor excision for a more accurate diagnosis. the presence of a dual cell population and the absence of malignant features led us to a diagnosis of ceruminous adenoma. immunohistochemical staining for cytokeratin (specifically ck7) which highlight the luminal cells and for basal/myoepithelial cell markers like ck 5/6, s-100 and p63 may be done to further demonstrate the dual cell population.2 complete or adequate local excision is the treatment of choice; however, residual tumor often remains because of the difficulty of surgery at this location leading to recurrence. subsequent repeat surgery to completely remove the tumor leads to cure.1,2,6 figure 2. hematoxylin and eosin (400x) glands and ducts have a dual cell population of basal myoepithelial cells and luminal epithelial cells with apocrine features. (hematoxylin and eosin, 400x) figure 4. hematoxylin and eosin (100x) chronic inflammation is variably present, sometimes peritumorally. the tumor does not involve the skin. (hematoxylin and eosin, 1000x) figure 3. hematoxylin and eosin (1000x) yellow to golden brown, granular “ceroid” material present in cytoplasm of the luminal epithelial cells (marked by black arrows). (hematoxylin and eosin, 100x) predilection.2 they present as masses in the outer half of the external auditory canal with hearing changes and pain.2 they can be mistaken for aural polyps especially when there is associated chronic suppurative otitis media.3 ceruminous adenomas arise from ceruminous glands4 which are modified sweat glands of the outer one half of the external auditory canal.1 these are well-circumscribed tumors with glandular architecture composed of two populations of cells with apocrine features as described above. two microscopic features reinforce the ceruminous nature of the glands: the apocrine morphology and presence of “ceroid” material which are lipofuscin-like pigment granules seen in the cytoplasm of ceruminous gland luminal cells.1,2 both are evident philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 letters to the editor 46 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2014; 29 (2): 46-47 c philippine society of otolaryngology – head and neck surgery, inc. dear editor, foreign bodies in the paranasal sinuses are not so common but are still possible. the structures most often involved are maxillary and the frontal sinuses.1 in our case, the sphenoid sinus which is posterior and deep was involved. having a foreign body lodged in the sphenoid sinus, and considering how it got there put the patient at great risk of possible involvement of the optic nerve and the carotid artery. accessing the sphenoid sinus and removing the foreign body lodged in it would be a big challenge to any surgeon. we report one such case. case report a 22-year-old man was accidentaly shot in the face by a fellow criminology student while playing with a polyvinyl chloride (pvc) handmade gun two weeks prior to admission. the patient, who was conscious, coherent and ambulatory at that time, was brought to a local government hospital where facial ct scans revealed a radio-opaque, well rounded foreign body, approximately measuring 1.5 cm x 1. 5 cm in diameter lodged in the sphenoid sinus. (figure 1 a &b) foreign body in the sphenoid sinus alvin b. javierto, md josefino g. hernandez, md rodante a. roldan, md department of otolaryngology head and neck surgery rizal medical center correspondence: dr. alvin b. javierto department of otorhinolaryngology head and neck surgery rizal medical center pasig blvd., pasig city 1600 philippines phone: (632) 671 9740 telefax: (632) 671 4216 email: info@rizalmedicalcenter.gov.ph the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. figures 1a. axial ct showing a radio-opaque foreign body at the level of the right sphenoid sinus; b. coronal ct showing a radio-opaque foreign body in the right sphenoid sinus a b philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 philippine journal of otolaryngology-head and neck surgery 47 letters to the editor references 1. wani na, khan aq. foreign body within sphenoid sinus: multidetector-row computed tomography (mdct) demonstration. turk neurosurg. 2010 oct; 20 (4): 547-549. 2. stammberger h, hawke m. surgical operative technique. hurley r editor. essentials of functional endoscopic sinus surgery. missouri: mosby; 1993. p. 172. he was subsequently admitted on penicillin g and was eventually discharged. on his fourth post-injury day, he had profuse epistaxis from the right nostril and consulted at the emergency room of our medical center. anterior nasal packing did not control the bleeding and was converted to a posterior nasal pack. a sutured wound with a scab on the left lateral nasal root was also noted. (figure 2) the rhinology service consultants advised endoscopic removal of the foreign body under general anesthesia. intraoperatively, the nasal cavity was congested with slight septal deviation to the right and a collapsed posterosuperior septal wall. behind the postero-superior third segment of the middle meatus, the sphenoethmoidal recess was appreciated. on further exploration, a 1.5 cm x 1.5 cm green marble was seen lodged in the sphenoid sinus. an initial attempt to remove the foreign body using a nasal foreign body extractor failed. an improvised large metallic paper clip, molded to the shape of a curved foreign body extractor was also unsuccessful. a cotton pledget tip dipped in cyanoacrylate (super glue) also failed to have the marble attach to it. two angulated sharp foreign body extractors insinuated using the four hand technique yet again failed. the collapsed posterior end of the nasal septum was removed using a cutting forceps for better visualization and access and on the last attempt, a bent spoon used to scoop the marble out of the sphenoid sinus was successful. (figure 3) full extraction of the foreign body was achieved by dislodging the marble towards the nasopharynx and into the oral cavity without compromising the optic nerve and the carotid artery. (figure 4) discussion it is very common to see a foreign body in the nasal cavity or in the external ear canal but seeing it in unlikely places like the sphenoid sinus is such a surprise. many factors need to be considered in the decision to extract it. one factor to consider is the approach to the sphenoid sinus. there are two different approaches to the sphenoid sinus: external and internal. the external, trans-ethmoidal approach involves subperiosteal elevation and ethmoidectomy.2 internal approaches such as the transseptal and trans-nasal are less-invasive ways to access the sphenoid sinus. because of ease in access, minimal damage to surrounding mucosa and good exposure, the trans-nasal approach was used. whatever approach the surgeon chooses, it is important to be familiar with the surgical anatomy to prevent unwanted complications. creativity also played a role in this procedure and quick thinking was needed since the foreign body was a round object and extracting it from such a limited space with utmost care using makeshift instrumentsmwas critically challenging. sincerely, alvin b. javierto, md josefino g. hernandez, md rodante a. roldan, md department of otolaryngology head and neck surgery rizal medical center figure 2 sutured point of entry with scab, left lateral nasal root figure 3. instruments used during the removal of foreign body figure 4. the 1.7 x 1.7 cm glass marble 26 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 case reports abstract objective: to present a rare case of congenital maxillomandibular fusion or syngnathia. methods: study design: case report setting: tertiary public teaching hospital participant: one patient results: a 3-year-old girl with oral adhesion (syngnathia) caused by a mandibular to maxillary fibrous band with bony fusion underwent successful surgical division and release. subsequent monitoring and serial oral dilations were performed post operatively, resulting in mouth opening of 24mm over a period of three months. currently, the patient is able to tolerate a general liquid diet. conclusion: congenital maxillomandibular fusion is a very rare condition with few cases reported. we hope this report contributes to its diagnosis and management in other children. keywords: congenital maxillomandibular fusion, syngnathia from birth, the upper aerodigestive tract of neonates plays an important role in simultaneous nose-breathing, suckling and swallowing. it is crucial for this mechanism to function properly to ensure survival. problems that interfere with this design, such as bilateral choanal atresia, may result in death, unless attended to emergently. this report a case that could have had similar consequences over a slightly longer course. case report a newborn girl from nueva ecija, philippines was noted to have maxillo-mandibular fusion after full-term spontaneous home delivery to a 31-year-old g3p3 (3003) mother attended by a midwife. the mother was a non-smoker and non-alcoholic beverage drinker with irregular prenatal check-ups but had multivitamins and ferrous sulfate during pregnancy. she took unrecalled medications for an upper respiratory tract infection at 1 to 2 months of pregnancy and denied exposure to viral exanthems, chemicals, radiation or teratogenic drugs. on examination, there was complete bilateral fusion of the bony upper and lower jaws. a nasogastric tube was inserted through the right nasal cavity. the rest of the physical examination findings were normal. complete blood count revealed a white cell count of 18.45 with segmenter predominance. she was started on ampicillin 60 mg/iv every 8 hours, gentamicin 14 mg/iv congenital maxillomandibular fusion: a rare case of isolated true bony syngnathia patrick o. aguiling, md1 nikki lorraine y. king-chao, md1 lyra v. veloro, md1,2 1department of otorhinolaryngology head and neck surgery the medical city 2department of child neuroscience section of pediatric otorhinolaryngology philippine children’s medical center correspondence: dr. patrick aguiling department of otolaryngologyhead and neck surgery the medical city ortigas avenue, pasig city 1600 philippines phone (632) 6356789 local 6250 email: patrickaguiling@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or in electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2013; 28 (2): 26-28 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 27 philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 case reports od, vitamin k 0.5 mg/im and oxytetracycline eye ointment, and she eventually improved. the assessment was congenital maxillomandibular fusion or syngnathia. (figure 1) ct scan of the facial bones with 3d reconstruction showed complete bony fusion of the maxilla and the mandible with hypoplasia of the temporomandibular joints. (figure 2) radiographs showed no definite lung infiltrates, cardiothymic shadow within normal limits, intact diaphragm and costophrenic angles, gastrointestinal tract patterns within normal, no abnormal mass or calcifications, no pneumoperitoneum or organomegaly and no osseous, joint space or soft tissue abnormalities appreciated. at two months of age, elective tracheostomy under local anesthesia was performed due to dyspneic episodes associated with desaturations exacerbated by recurrent upper respiratory tract infections. anesthesia was maintained through the tracheostomy tube while a gastrostomy was carried out. she tolerated the procedure well and was eventually discharged, breathing spontaneously and well oxygenated. several follow-up visits included a repeat ct scan of the facial bones with 3d reconstruction (including reference markers) at 1 year and 5 months of age, but she was not seen again until 3 years of age. at 3 years and 6 months of age, she underwent surgical division of the bony fusion. an extended right pre-auricular incision and dissection of the superficial temporal fascia over root of zygoma were carried to the fascia and periosteum which were incised over the zygomatic root. the skin flap and parotid were retracted anteriorly and the coronoid process and zygomatico-maxillo-mandibular area were exposed. with maximum retraction to facilitate optimal exposure of a long tunnel medial to the masseter muscle, the mandibular fusion was released and the mucosal incision was gradually extended to the midline. the bony fusion was exposed by dissecting the mucosa away from the bone using a periosteal and freer elevator. osteotomy of zygomatico-maxillomandibular fusion was achieved by tunneling from the zygomatic area to the midline by alternately using an osteotome, oscillating saw and high-speed surgical drill with different-sized cutting bur tips. the same procedure was replicated on the left side up to the midline until the division from the right side was reached. the bony division was then pried open until all fibrous bands were detached. sharp edges were smoothened using a surgical drill with diamond bur tips. avulsed central and lateral incisors were removed. the oral cavity was established and packed with medicated gauze impregnated with antibiotic ointment. the patient underwent serial oral dilation on succeeding follow-ups, eventually achieving mouth opening of 24mm within 3 months. (figures 3, 4) currently, the patient is able to tolerate a general liquid diet. figure 1. complete bilateral fusion of the bony and soft-tissue components of the upper and lower jaws. figure 2. 3d reconstruction ct scan of the facial bones showing complete bony fusion of the maxilla and the mandible with hypoplasia of the temporomandibular joints. figure 3. oral dilation at 15mm (4 weeks postoperative) 28 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 case reports references 1. mir m, iqbal s, hafeez a, zargar h, rasool a, mohsin m, darzi a. syngnathia without any other associated anomaly: a very rare case report. the internet journal of plastic surgery. 2006;4(1). cited 2013 march 24. available at:http://ispub.com/ijps/4/1/13380. 2. bali r, sharma p, jain s, thapar d. congenital fibrous maxillomandibular fusion. j maxillofac oral surg. 2010 sep; 9(3): 277–279. 3. puvabanditsin s, garrow e, sitburana o, avila fm, nabong my, biswas a. syngnathia and van der woude syndrome: a case report and literature review. cleft palate craniofac j. 2003 jan; 40(1): 104-6. 4. dawson kh, gruss js, myall rw. congenital bony syngnathia: a proposed classification. cleft palate craniofac j. 1997 mar; 34(2):141–146. 5. goodacre te, wallace af. congenital alveolar fusion. br j plast surg. 1990 mar; 43(2): 203–209. 6. poovazhagi v, vijayakumar v, kumudha j, balachandran k. congenital fusion of maxilla and mandible (bony syngnathia). pediatric oncall 2009. cited 2009 december 1; 6(12) art 63. available at http://www.pediatriconcall.com/fordoctor/casereports/syngnathia.asp discussion congenital causes of limited mouth opening involving fusion of the maxilla and mandible (syngnathia) are a rare group of anomalies. cases are classified into those involving bony tissue and those involving soft tissue alone. occurrence may be unilateral or bilateral, partial or complete.1,2 among the abovementioned classifications, cases involving solely soft tissue and bilateral fusion in the posterior region are more common.2 isolated occurrence of bony syngnathia is a very rare condition with few reported cases. in the literature, the congenital defect is associated with other anomalies like van der woude syndrome, popliteal pterygium syndrome2,3 and aglossia–adactylia syndrome. our patient has none of these syndromes or any other intraoral or maxillofacial abnormalities. no sex predilection has been reported. 2,4 however, it is interesting to note that eight out of 11 cases reviewed for this study have male subjects. the exact pathogenesis of congenital bony fusion is unknown. some of the etiologic hypotheses proposed by goodacre and wallace5 include “persistence of buccopharyngeal membrane, amniotic constriction bands in the region of the developing first branchial arch, environmental insults, drugs such as meclozine and large doses of vitamin a.”1,2 according to a review by dawson et al., there is no familial tendency, history of drug or toxin exposure and consanguinity.1,2,4 however, there is a possibility of autosomal recessive inheritance. mir et al. and poovazhagi et al. reported cases which revealed a history of consanguinity.1,6 our patient presented with maxillomandibular fusion discovered immediately after birth. physically, oral cavity deformity was evident and the baby was not able to open her mouth or feed normally. once recognized, the diagnosis was confirmed by ct scan. these events are congruent with the observation that congenital bony fusion is clinically diagnosed soon or after birth as the neonate presents with airway and feeding difficulties.1 the modality of choice is high resolution or spiral ct scan which has the advantage of revealing the condition of the temporomandibular joints or any hypoplasia of the other facial bones.1 the usual accompanying problems in such patients include airway and respiratory impairment, feeding difficulties, speech limitation, poor oral hygiene, interference with salivation and mastication, and induction of anesthesia.1 in spite of these complications, studies show that functional results especially in isolated occurrence are likely to be good.1 for our patient, feeding problems were addressed initially by insertion of nasogastric tube and subsequently, by gastrostomy tube. treatment consists of surgical division of the maxillomandibular fusion under anesthesia.1,6 awake blind nasal intubation is the ideal manner of inducing anesthesia, although a tracheostomy may be required if blind intubation fails.1,2 a less invasive technique using fiberoptic nasotracheal intubation may also be administered.3,6 our patient underwent tracheostomy insertion for maintenance of airway and anesthesia. following surgery, active physical therapy is recommended and the infant should be encouraged to feed normally as soon as possible1,3,4 to achieve adequate mandibular range or motion and function. acceptable mouth opening may be appreciated 1-2 weeks post operatively. 6 the mother of our patient was advised to perform such manual therapy techniques as carefully opening the baby’s mouth with a tongue depressor and rotating fingers to press the gums. indeed, congenital maxillomandibular fusion is a very rare condition with few cases reported. we hope this report contributes to its diagnosis and management in other children. figure 4. mouth opening of 22 mm (8 weeks postoperative) philippine journal of otolaryngology head and neck surgery vol. 32 no. 2 july– december 2017 editorial 4 philippine journal of otolaryngology head and neck surgery philippine journal of otolaryngology head and neck surgery 5 millenials or generation y physicians (born 1977/1980-1995) today form the majority of medical personnel, from medical students and residents in their early twenties and thirties to young attending physicians hitting forty; practicing side-by-side with generation x (19651976/1980) in their late thirties to early fifties; baby boomers (1946-1964) in their mid-fifties, sixties and early seventies; and the last of the silent generation or traditionalists (1925-1945) in their mid-seventies, eighties and nineties.2,3 among 734 fellows of the philippine society of otolaryngology – head and neck surgery alone, there are currently 18 traditionalists, 192 boomers, 360 generation x, and 164 millenials. assuming the 862 board-certified diplomates waiting to become full-fledged fellows and 182 residents-in-training are also millenials, there are a total of 1,208 millenials in the field of otolaryngology head and neck surgery in the philippines. with four distinct generations simultaneously in the workforce, it is not unusual to hear older physicians gripe about “these millenials,” and how different they are from previous generations. the so-called generation gap has been used to characterize inter-generational relations, wherein the preceding generation historically puts down the younger, and the succeeding generation usually complains about the older one. i posit that central to this conflict is a clash between tradition -the way things should be done (as perceived by the older generation) - and disruption, the way things can be done differently (from the perspective of the younger generation). in particular (meaning no offense to the “in-between” generation x, and at risk of being overly simplistic), this is highlighted by the supposed looming showdown between baby boomers who are not yet ready to leave and millenials who can hardly wait to take over.4 tradition, a “statement, belief or practice handed down from generation to generation” comes from the old french tradicion “transmission, presentation, handing over” and directly from the latin traditionem “delivery, surrender, a handing down, a giving up,” from tradere “deliver, hand over,” derived from trans – “over” + dare “to give.”5 although older generations may like to think they uphold tradition (giving them the right and duty to pass it on to succeeding ones), a large part of what defines each generation in the first place is their departure from the statements, beliefs or practices of their predecessors. such a transition may have been gradual or sudden, and more pronounced in some generations than in others. our post-war boomer generation grew up in a world where face-to-face communication was supplemented by the written (handwritten, typewritten, typeset or telegraphed) and spoken (rotary-dial telephone) word. in medicine and medical education, history and physical examination were taught through lectures (with overhead and opaque projectors, slides on carousels and filmstrips) and live demonstrations on patients and on one another. the correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 554 8467 telefax: (632) 524 4455 email: lapenajf@upm.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines millenials in medicine: tradition and disruption philipp j otolaryngol head neck surg 2017; 32 (2): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international “i suppose in reality not a leaf goes yellow in autumn without ceasing to care about its sap and making the parent tree very uncomfortable by long growling and grumbling but surely nature might find some less irritating way of carrying on business if she would give her mind to it. why should the generations overlap one another at all? samuel butler, the way of all flesh1 philippine journal of otolaryngology head and neck surgery vol. 32 no. 2 july– december 2017 4 philippine journal of otolaryngology head and neck surgery philippine journal of otolaryngology head and neck surgery 5 editorial advent of word processing and advances in telecommunications and technology that became available to generation x (who in the philippines include “martial law babies” oblivious to our “wonder years” of the sixties) gradually changed the landscape of medical education and practice, but it would take the digital and internet revolution to finally, drastically change the world-and millenials were the primary beneficiaries of this change. disruption, from the latin disruptionem “a breaking asunder,” which comes from disrumpere “break apart, split, shatter, break to pieces,” from dis“apart” + rumpere “to break”6 perhaps best describes the baby boomer generation’s experience of the technological revolution that millenials grew up with. suddenly, everything could be had in a split-second and the world was connected in real time. no longer did one have to master penmanship, typing and speed-reading, and homes no longer displayed dictionaries and encyclopedias. even the library card catalogue and periodicals index became obsolete, as most anything became instantly available and accessible – including information, fast food and relationships. millenials grew up with this transition, and readily mastered the rapidly changing technology. the locus of socialization was no longer face-to-face interaction within the family, but the worldwide web and social media. in medical education, lectures gave way to podcasts and webinars; heavy textbooks gave way to electronic references; and even dissection gave way to 3d virtual human anatomy. the millenials’ expertise in, and dependence on, technology can both be their boon and bane – as i often note when residents and students automatically search their peripheral brains (a.k.a. mobile devices) to answer a ward round question. but they are also as quick to intuitively master the diagnostic and therapeutic tools that did not exist when their older colleagues were in residency.7 the early access that millenials and generation x had to computer resources in childhood certainly laid “a critical foundation for use of these systems later in life,” compared to baby boomers and traditionalists whose “lack of early experience may limit their enthusiasm” for such tools.3 as cole puts it, “baby boomers don’t react well to a 20-something coming in and disrupting the way things have ‘always been’ while millennials don’t react well when they’re told to shoot for the moon and ‘do big things,’ references 1. butler s. the way of all flesh. new york: dover publications, 2004. 315 pages. the center for generational kinetics. how to determine generational birth years. november 28, 2. 2016 ©2016 [cited 2017 nov 2.] available from: http://genhq.com/generational_birth_years/ mohr nm, moreno-walton l, mills am, brunett ph, promes sb. generational influences in 3. academic emergency medicine: teaching and learning, mentoring, and technology (part i). acad emerg med. 2011 feb;18(2):190-199. doi: 10.1111/j.1553-2712.2010.00985.x pmid: 21314779 pmcid: pmc3076332. taylor p, pew research center. the next america: boomers, millenials, and the looming 4. generational showdown. new york: publicaffairs, 2016. 384 pages. harper d. online etymology dictionary © 2001-2017 [cited 2017 november 2.] available from: 5. https://www.etymonline.com/word/tradition. harper d. online etymology dictionary © 2001-2017 [cited 2017 november 2.] available from: 6. https://www.etymonline.com/word/disruption. sopher m. how millenial doctors will shape the future of health care. blog on the internet, 7. baltimore: rendia, 2016 october 26. [cited 2017 november 2.] available from: : https://blog. rendia.com/millennials/. cole n. the real reason baby boomers and millenials don’t see eye to eye (written by a 8. millenial). inc. southeast asia. 2017 jan 20 [cited 2017 november 2] available from: : https:// www.inc.com/nicolas-cole/the-real-reason-baby-boomers-and-millennials-dont-see-eye-toeye-written-by-a-mi.html. seabrook m. intimidation in medical education: students’ and teachers’ perspectives. 9. studies higher educ. 2004;29(1):59–74. http://dx.doi.org/10.1080/1234567032000164877. feiertag j, berge zl. training generation n: how educators should approach the net generation. 10. education and training. 2008 september;50(6):457–64. doi: 10.1108/00400910810901782. mangold k. educating a new generation: teaching baby boomer faculty about millennial 11. students. nurse educ. 2007 jan-feb;32(1):21-23. pmid: 17220763. and then when they walk in the door with new ideas ready to disrupt age-old models, get told to know their place.”8 thus, older generations of physicians may question how the stock knowledge and clinical eye of millenials can compare to theirs, who learned medicine without these tools, and wonder how millenials would fare in conflict and catastrophic situations when technology fails, or in lowand middle-income rural settings where technology is scarce. conversely, millenials wonder why boomers insist on their old ways and just don’t get it! perhaps we can learn from mohr et al.3 about bridging generational issues in medical and surgical education—for instance, between the socratic method whereby boomers may appear to intimidate learners9 versus the millenial expectation that presentation of information be tailored to their needs, individually or via available technology.10 it could be helpful for millenials who are “outcomes-oriented and value doing more than knowing”11 “to realize that traditionalists and boomers ‘know how to do’ and are ready and able to teach.”3 on the other hand, “when instructing boomers in new technology or information,” the millenial teacher “should recognize that this role reversal is uncomfortable to older generations” and “mitigate discomfort … by focus(ing) on the relevance of the information and creat(ing) an environment in which it is ‘safe’ to ask questions and challenge the teacher.”3 indeed, if inter-generational differences could be surmounted, there is much that boomers can learn from millenials, and vice versa. if as cole observes, “this great debate is hauntingly similar to a parent/child argument,”8 it is because boomers and millennials are “also each other’s children and parents, bound together in an intricate web of love, support, anxiety, resentment, and interdependence.”4 perhaps by involving generation x in bridging the great divide, and fostering an environment that allows for inter-generational differences in teaching and learning styles, non-disruptive disruption of tradition can take place. each generation must have the humility (as opposed to intellectual arrogance) to accept that they can learn from other generations – younger or older—for truly meaningful medical progress to take place. we cannot do otherwise, for generation z (born after 1995, and about to enter medical school) is already poised to join the fray. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 letter to the editor 56 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2015; 30 (2): 56-58 c philippine society of otolaryngology – head and neck surgery, inc. dear editor, the tympanic membrane and the ossicular chain contribute roughly 28 db in hearing gain. in chronic suppurative otitis media, loss of tympanic membrane and lysis of the ossicular chain are significant causes of hearing loss.1 through the years, hearing impairment has been augmented using various devices such as ear trumpets, carbon hearing aids, vacuum tube and transistor hearing aids, bone anchored hearing aids and cochlear implants.2 this case report describes how a cotton wick was used to amplify sound. case report a 65-year-old man consulted for hearing loss. he had a childhood history of recurrent ear discharge and hearing loss and was diagnosed with chronic suppurative otitis media. at age 55, he underwent tympanomastoidectomy of the left ear. while surgery stopped the left ear discharge, there was complete hearing loss in this ear. for this reason, he opted not to have surgery on the right ear. there was subsequent recurrent ear disease of the right ear. he would clean his ear with a cotton wick and apply antibiotic drops during bouts of ear discharge. he observed that leaving the ear wick with a few drops of topical otic preparations (polymyxin-neomycin-steroid or ofloxacin) would lessen the frequency of ear discharge and improve his hearing. he found that morning application and positioning of the cotton wick in his right ear using tweezers and a toothpick allowed him to hear adequately to conduct his daily activities as an architect. (figure 1, 2) the fear of hearing loss from another surgery, cost of a commercial hearing aid and great utility of a simple cotton wick made him continue his practice for these ten years. examination of the right middle ear without the cotton wick showed thickened mucosa, absent malleus and incus structures, a patent eustachian tube and a near – total tympanic membrane perforation. there was no keratinous material or foul smelling discharge. (figure 3) pure tone audiometry confirmed that with the cotton wick, the right air-bone gap decreased at 500 hz, 1khz, 2kh and 4khz by 30db, 40db, 35db and 25db, respectively. (table 1) a cotton wick improves hearing in a patient with profound hearing loss ryner jose d. carrillo, md, msc1,2 precious eunice r. grullo, md, mph1 maria luz m. san agustin, rn, mclinaudio1,3 1department of otorhinolaryngology philippine general hospital, university of the philippines manila 2department of anatomy college of medicine, university of the philippines manila 3philippine national ear institute national institutes of health, university of the philippines manila correspondence: dr. ryner jose d. carrillo department of otorhinolaryngology ward 10 philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 554 8467 email: ryner_c@yahoo.com reprints will not be available from the authors. the authors declare that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 philippine journal of otolaryngology-head and neck surgery 57 letter to the editor figure 1. cotton wick is shaped using a toothpick and tweezers applied in the ear canal and repositioned using the same tools while performing a valsalva maneuver. figure 2. cotton wick positioned in right ear canal. figure 3. right middle ear with absent malleus-incus ossicles, thickened middle ear mucosa and patent eustachian tube. no “cotton wick” 500 hz 500 hz1khz 1khz2khz 2khz4khz 4khz with “cotton wick” air conduction ad pure tone average bone conduction ad air bone gap abg gain abg average db 80 107.5 25 55 56.25 120 50 70 110 65 45 120 nr at 65 55 50 75 25 25 30 23.75 80 50 30 40 75 65 10 35 95 nr at 65 30 25 table 1. pure tone audiometry without and with the “cotton wick” philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 letter to the editor 58 philippine journal of otolaryngology-head and neck surgery references 1. chien w, lee d. physiology of the auditory system. in: flint p, haughey b, lund v, niparko j, robbins t, thomas r, lesperance m, editors. cummings otolaryngology head and neck surgery. 6th ed. canada: saunders; 2015. p1995. 2. hearing aid museum.com [homepage in the internet]. philadelphia: center for hearing; c20062015. [cited 2015 aug 10]. available from: http://www.hearingaidmuseum.com/gallery.htm 3. schlauch r, nelson p. basic test and procedures. in: katz j editor. handbook of clinical audiology, 7th ed. philadelphia: wolters kluwer health; 2015. p30. 4. carrillo rjc, yang nw, abes gt. relationship of pure tone audiometry and ossicular discontinuity in chronic suppurative otitis media. philipp j otolaryngol head neck surg. 2006; 21(1-2):5-10. 5. triana r. revision tympanoplasty. in: carrasco v and pillsbury h. revision otologic surgery. new york: thieme medical publishing; 1997. p.81-82. discussion at different anatomic levels, mechanical sound energy is amplified and transmitted to the functional parts of the ear. the tympanic membrane and oval window ratio of 21:1 and malleus-incus lever mechanism ratio of 1.3:1 provide a 28 db amplification of conductive hearing.1 this gain is reflected by frequency specific air-bone gaps which can range between 25-40 db. with the contribution from the external ear, the overall conductive gain is 60 db.1,3 damage to the auditory system often results in a loss of hearing sensitivity that is frequency – specific. the presence of a frequency – specific wide airbone gap suggests ossicular chain discontinuity among patients with chronic otitis media.4 narrowing of the air-bone gap which in this case was provided by insertion of the cotton wick may lead to at least partial restoration of ossicular coupling. the ability of the cotton wick to improve hearing may be attributed to its possession of characteristics for sound conduction and acoustic impedance such as stiffness, resistance and mass. the effectiveness of the cotton wick was reported to be dependent on its positioning in the ear; the patient would have to insert the wick down to the level of the promontory or oval window occasionally blow his nose or reposition the cotton wick to achieve an acceptable hearing level. however, for a patient with completely deaf contralateral ear, a 32.5 db gain in hearing is very pronounced and significant. the hearing gain produced by the cotton wick only amplified the air conductive component of hearing but not bone conduction. while it afforded amplification of sound and a route of medicine administration, it may also have contributed to sensorineural hearing loss brought about by ototoxicity of medications and thickening of the oval and round window from chronic irritation. for this reason, utmost caution must be advised before considering use of a “cotton wick” to amplify hearing in this manner-a practice we do not endorse. the cotton wick may have served as a vibrating piston on top of the oval window which amplified hearing. such a mechanism may conceivably prognosticate potential gain from a contemplated tympanoplasty in the same way that the “paper patch test”5 predicts simple myringoplasty outcomes. having said that, the diagnostic utility of such a cotton wick requires further investigation before potential clinical applications such as prognostication of tympanoplasty are theorized. could future studies show that a preoperative cotton wick (or equivalent device) may approximate potential gains from a good tympanoplasty with ossiculoplasty in a patient with total tympanic perforation and ossicular chain loss? sincerely, ryner jose d. carrillo, md, msc precious eunice r. grullo, md, mph maria luz m. san agustin, rn, mclinaudio philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 philippine journal of otolaryngology-head and neck surgery 63 featured grand rounds in 1863, the term odontoma was introduced by paul broca which he described as a tumor formed by overgrowth of transitory or complete dental tissue. the world health organization classified them under mixed benign odontogenic tumors because of their origin from epithelial and mesenchymal cells exhibiting different structures of dental tissue (enamel, dentin, cementum and pulp).1 there are two distinct types: compound and complex. compound odontoma is composed of all odontogenic tissue in an orderly fashion resulting in many teeth-like structures but with no morphological resemblance to normal teeth whereas a complex odontoma appears as an irregular mass with no similarity even to rudimentary teeth.2,3,4 the pathogenesis of odontomas has not been completely established although the most accepted etiology is related to trauma, infection, growth pressure and genetic mutations in one or more genes that cause disturbances in the mechanism controlling tooth development.1,5 patients with compound odontoma are often asymptomatic. it is usually detected on routine radiography upon examination of an unerrupted tooth.6 odontomas can occur anywhere in the jaws and are usually found associated with or within the alveolar process.7 however, the presence of an odontoma in the maxillary sinus is very rare. we present a female patient with a compound odontoma in the maxillary sinus initially managed as nasal vestibulitis with maxillary sinusitis. case report a 63-year-old woman from cavite city, philippines consulted in our institution due to perception of foul odor. six weeks prior to admission, she experienced right alar pain, facial fullness and swelling with associated undocumented fever. she consulted an ent specialist and was diagnosed with nasal vestibulitis with maxillary sinusitis. she was given cefixime 200mg, one tablet twice a day and metronidazole 500mg, one tablet every six hours for seven days. five weeks prior to admission, despite resolution of the nasal and maxillary swelling and pain, she started to perceive a foul odor. there was no associated nasal congestion and nasal discharge, fever, no nasal itchiness nor frequent sneezing. her physician requested an orthopantomogram hat revealed a suspicious mass and haziness in the right maxillary sinus and an impacted tooth in the left maxillary sinus. (figure 1) she was advised surgery but opted for a second opinion. compound odontoma of the maxillary sinus correspondence: dr. lei-joan vital department of otorhinolaryngology head and neck surgery veterans memorial medical center north avenue, diliman, quezon city 0870 philippines phone: (632) 426 9775 email: enthns_vmmc@yahoo.com reprints will not be available with the author the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. ma. melizza s. villalon, md lei-joan vital, md department of otorhinolaryngology head and neck surgery veterans memorial medical center philipp j otolaryngol head neck surg 2015; 30 (1): 63-66 c philippine society of otolaryngology – head and neck surgery, inc. figure 1. orthopantomogram of the paranasal sinuses showing a suspicious mass and haziness in the right maxillary sinus and an impacted tooth in the left maxillary sinus. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 featured grand rounds 64 philippine journal of otolaryngology-head and neck surgery two weeks prior to admission and still with perception of foul odor, she consulted another ent specialist and was given co-amoxiclav 625mg, one tablet every eight hours. a ct scan of the paranasal sinuses revealed mucoperiosteal thickening and calcific density within the opacified right maxillary sinus. (figure 2 a, b) the patient was advised surgery. the patient had pulmonary tuberculosis in 1983 but was treated for six months. she does not recall having any un-erupted teeth and claimed that her previous dental extractions were unremarkable. she had a family history of bronchial asthma and colon cancer. she did not drink alcoholic beverages but she previously smoked for one packyear. anterior rhinoscopy revealed scant clear mucoid discharge in both nasal cavities, noncongested and nonhyperemic turbinates and no figure 2. ct scan of the paranasal sinuses. a. axial view and b. coronal view showing mucoperiosteal thickening and calcific density within the opacified right maxillary sinus. a b figure 3. caldwell-luc procedure exposing the right maxillary antrum figure 4. macroscopic appearance of compound odondoma located in the maxillary sinus as seen in the patient—a 2 x 2 x 2.1 cm tan, white, ovoid hard mass partially covered by black fragments. intranasal mass. she was edentulous with no facial mass or swelling. the rest of the examination was unremarkable. with an assessment of a right maxillary mass (odontogenic tumor versus foreign body) with right maxillary sinusitis and an impacted tooth in the left maxilla she underwent a caldwell-luc procedure. antrotomy was performed through the canine fossa via a gingivolabial incision overlying the anterior maxillary wall. thick clear mucous was seen oozing out and eventually drained and suctioned out. (figure 3) a 2 cm x 2 cm x 2.1 cm ovoid, whitish to tan colored hard mass partially covered by black fragments was carefully extracted. (figure 4) irrigation of the maxillary sinus was performed using normal saline solution and the natural maxillary ostium was widened. the incision was closed with interrupted mattress sutures using chromic 3.0 and the mass was submitted for histopathological analysis. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 philippine journal of otolaryngology-head and neck surgery 65 featured grand rounds microscopic sections revealed misshapen teeth or denticles with a coordinated pattern of calcification such as enamel, dentin and cementum. (figure 5a-c) the final histopathologic report was a compound odontoma of the right maxillary sinus. the postoperative follow-up was satisfactory. our patient developed no oro-antral fistula and showed no signs of maxillary sinusitis and the perception of foul odor resolved. figure 5. microscopic appearance of compound odondoma located in the maxillary sinus. a. enamel, dentin and cementum (h&e; 200x) b. denticles (h&e); 20x c. enamel, dentin and cementum (h&e; 200x) a (hematoxylin and eosin, 200x) b (hematoxylin and eosin, 20x) c (hematoxylin and eosin, 200x) discussion odontoma is a generally asymptomatic, slowly progressing tumor that may pass unnoticed. it is usually detected by routine radiograph. this may be associated with un-erupted tooth mainly the mandibular third molar followed by the upper canine and upper central incisor. the prevalence of odontoma associated with impacted canine is 1.5 %.8 the maxillary sinus is a frequent site for pathologies of odontogenic origin because of its close anatomical relationship with teeth and periodontal tissues. this makes a frequent but not a common site for inflammatory diseases as well as neoplastic lesions.6 the patient initially presented with right alar pain and right facial swelling. she did not recall having an un-erupted tooth and claimed that her previous dental extractions were unremarkable. after treatment, the pain and swelling resolved but she started to perceive a malodorous smell. commonly, clinicians arrive at the diagnosis of sinusitis when failure of its resolution despite antibiotic treatment prompts warning bells that warrant further radiographic investigation. the radiographic appearance of odontoma is almost always diagnostic3 as in the presented case. panoramic and periapical images usually show well-defined borders of a similar density to calcified dental tissue, having a ground-glass appearance, and a radiopaque mass occupying the affected maxillary sinus.9 this was evident in the patient’s panoramic radiograph. additional radiographic evaluation with computed tomography was necessary to determine the extension and features of the lesion because periapical and panoramic images do not provide complete visualization of the maxillofacial complex. ct scans serve as a guide not only for evaluation of the lesion itself but also for localization of associated pathology and proper treatment planning.10 in this case, the computed tomography scan of the paranasal sinuses revealed mucoperiosteal thickening and calcific density within the opacified right maxillary sinus suggesting odontogenic origin with concomitant maxillary sinusitis. due to its asymptomatic course, it can be surmised that the patient might have had the asymptomatic compound odontoma for a long time. the mass in her maxillary sinus was seen freely floating in her ct scan. it may be hypothesized that obstruction by the odontoma could have altered the ventilation and drainage of the maxillary sinus causing the symptoms of the patient. cabov, et al. reported that odontomas in the maxillary sinus may also cause pain, facial asymmetry and chronic congestion of the sinus.11 management for this case was surgical removal of the mass with drainage of trapped mucus as well as medical treatment of the maxillary sinus infection. the caldwell-luc procedure was the favored approach to this case because it offered easy access to the mass that could not be extracted trans-nasally because of its size and solid nature. restoring philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 featured grand rounds 66 philippine journal of otolaryngology-head and neck surgery references 1. ajike so, adekeye eo. multiple odontomas in the facial bones. a case report. int j oral maxillofac surg. 2000 dec: 29(6):443-4. 2. hanemann ja, oliveira dt, garcia ng, santos mr, pereira aa. peripheral compound odontoma erupting in the gingiva. head face med. 2013 jun 11; 9:15. 3. prabhakar c, haldavnekar s, hegde s. compoundcomplex odontoma an important clinical entity. j int oral health. 2012; 4(1)49-53. 4. kramer irh, pindborg jj, shear m. histological typing of odontogenic tumours. 2nd ed. berlin: springer-verlag. 1992: 16-21. 5. hidalgo-sánchez o, leco-berrocal mi, martinez-gonzález jm. metaanalysis of the epidemiology and cinical manifestations of odontomas. med oral p patol oral cir bucal. 2008 nov 1:13(11); 730-4. 6. tan ty, shashinder s, subrayan v, krishnan g. silent sinus syndrome due to a maxillary mucocele. auris nasus larynx. 2008 jun; 35(2): 285–287. 7. caton rb, marble hb jr, topazian rg. complex odontoma in the maxillary sinus. oral surg oral med oral pathol. 1973 nov; 36(5): 658–662. 8. malhotra k, namdev r, rohilla m, dutta s. unerupted maxillary central incisor associated with compound composite odontoma: a case report. j oral health comm dent. 2012; 6(1) 43-46. 9. au-yeung km, ahuja at, ching as, metreweli c. dentascan in oral imaging. clin radiol. 2001 sep; 56(9): 700–713. 10. dagistan s, cakur b, goregen m. a dentigerous cyst containing an ectopic canine tooth below the floor of the maxillary sinus: a case report. j oral sci. 2007 sep; 49(3): 249–252. 11. cabov t, krmpotic m, grgurevic j, peric b, jokic d, spomenka manojlovic s . large complex odontoma of the left maxillary sinus. wien klin wochenschr. 2005 nov; 117(21-22):780-3. the drainage of the maxillary sinus was also essential and this was done by widening the natural maxillary sinus ostium. the histological characteristics of the mass extracted from the patient consisted of denticles with a coordinated pattern of calcification such as enamel, dentin and cementum compatible with a compound odontoma. the rarity of odontomas makes them easy to miss should a radiographic examination not have been done. despite their being usually asymptomatic, our patient had chronic perception of foul odor that was bothersome and frustrating. a clinician relying on medical history and physical examination alone could not have arrived at the correct diagnosis. in this case, it was shown that radiographic imaging was very crucial in catching a hidden and rare tumor. philipp j otolaryngol head neck surg 2011; 26 (1): 6-9 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles 6 philippine journal of otolaryngology-head and neck surgery abstract objective: to describe the cochlear anatomy among filipinos through high resolution computed tomography (hrct) imaging. methods: design: retrospective study setting: tertiary private university hospital patients: cochlear images retrospectively obtained from computed tomography (ct) scans of subjects who underwent cranial, facial, paranasal sinus and temporal bone computed tomography from october 2009 to july 2010 were reconstructed and analyzed. results: 388 cochlear images were obtained from the scans of 194 subjects (101 males and 93 females, aged 1 to 90 years old, mean = 52 years) and reconstructed for analysis. the mean coiled cochlear height measured 4.36 mm on the right (a.d.) and 4.34 mm on the left (a.s.). measurement from the oval window to the distal end of the basal turn (equivalent to the horizontal dimension of the cochlea or the mean length of the basal turn) was 7.55 mm a.d. and 7.60 mm a.s. the vertical and horizontal dimensions of right and left cochleas were identical in all subjects (s.d. = 0.35). the right and left cochlear turns were identical in each subject, exhibiting 2 ½ turns in 92.3% of subjects and 2 ¾ turns in 7.7% of subjects.the cochlear dimensions were similar in all subjects, regardless of age. no cochlear ossification or malformation was noted on any ct image. conclusion: the 7.55 mm mean length of the cochlear basal turn among filipinos in this study was 1.24 mm shorter than the average length of the basal turn of 8.81 mm reported elsewhere. further studies of the cochlear dimensions in specific age groups and its correlation to audiometric status are recommended to determine other significant physiologic correlations. keywords: cochlea, cochlear turn, high-resolution computed tomography (hrct ), magnetic resonance imaging (mri) the cochlea and its anatomic details are difficult to study due to its minute size and remote location. it is surrounded almost entirely by dense bone of the otic capsule and has 2 ½ to 2 ¾ coils. before the advent of high resolution ct imaging, anatomical studies of the human cochlea an anatomical study of the cochlea among filipinos using high-resolution computed tomography scans adrian f. fernando, md1 brian joseph dg. de jesus, md2 alejandro p. opulencia, md1 gil m. maglalang, jr., md2 antonio h. chua, md1,3 1department of otorhinolaryngology head and neck surgery university of the east – ramon magsaysay memorial medical center inc. 2department of radiology university of the east – ramon magsaysay memorial medical center inc. 3department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. adrian f. fernando department of otorhinolarynglogy head and neck surgery rm. 463, hospital service bldg., uermmmci 64 aurora blvd., quezon city 1113 philippines telefax: (632) 716 1789 e-mail: ianfernando_md@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the descriptive research contest, philippine society of otolaryngology – head and neck surgery, glaxo smith kline (gsk) bldg., chino roces ave., makati city, philippines, october 11, 2010. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles philippine journal of otolaryngology-head and neck surgery 7 were mostly cadaveric, making comprehension of human cochlear details and correlating histological findings with cochlear functional status more difficult.1 today, computed tomography and magnetic resonance imaging can provide quality cochlear and temporal bone images indispensible in the practice of otology, but no local studies have been reported. because further information and knowledge of cochlear dimensions among filipinos is important especially in cochlear implantation, we aimed to describe the cochlear anatomy among filipinos through high resolution computed tomography (ct) scan. methods computed tomography (ct) scans of 194 subjects who underwent cranial, facial, temporal bone, paranasal sinus and orbital examinations for different indications between october 2009 to june 2010 at the university of the east ramon magsaysay memorial medical center were retrospectively obtained for temporal bone image isolation, in compliance with the hospital ethics committee. all scans used the same 64 detector-row aquilon 64 (toshiba medical systems corp., tokyo, japan) employing 120 kv, 350 ma, 512 x 512 matrix dimension, 0.5 mm section thickness, 0.85 pitch and 70 mm field of view parameters. one hundred ninety four (194) temporal bone images with these parameters were obtained from 137 cranial, 24 temporal bone, 22 paranasal, 8 orbital, 2 facial and 1 mandibular scan(s) and were transferred to the vitrea® 2: version 4.1.20 (vital images, inc., minnesota, usa) workstation for further image isolation. multi-planar reconstruction (mpr) and 3d reconstruction of the cochlea were done with a 4000 window width and 700 window levels. multi-planar reconstruction with double oblique coronal and single oblique settings were employed along the short and long axis of the cochlea as standard cochlear imaging.2 (figure 1) reconstructed cochlear images were trimmed and sculpted manually with the vitrea® 2 workstation for optimal 3d visualization. the horizontal and vertical dimensions of each reconstructed coiled cochlea were measured with the vitrea® 2 workstation internal scale along its orthogonal views (figure 2.a). the widest horizontal dimension of the coiled cochlea was measured on axial view from the highest point of the helicotrema to the inferior margin of the basal turn while the widest vertical dimension was measured on axial view from the oval window to the widest margin of the basal turn which is equivalent to the length of the cochlear basal turn (figure 2.b). conversely, the cochlear turn was measured on the axial-oblique view of the reconstructed cochlear image from the helecotrema to the round window (figure 3). a line created through the reference point acted as the center of the modiolus and a complete cochlear turn was defined as the reference line run parallel to the basal and apical segments of the cochlea.3 data gathered were tabulated for comparison of the vertical dimension, horizontal dimension and turns of the left and right cochlea. presence or absence of cochlear deformities, ossification and other anomalies were also noted. results a total of 388 cochlear images were obtained from the ct scan images of 194 subjects (101 males and 93 females, aged 1 to 90 years, mean age = 52 years) and reconstructed for analysis. the vertical dimension of the cochlea equivalent to the coiled cochlear height ranged from 3.30 mm to 5.10 mm on the right (mean = 4.37 mm) and 3.40 mm to 5.20 mm on the left (mean = 4.34 mm) with a difference of 0.02 mm (s.d. = 0.38, ad and 0.36, as). the coiled cochlear widest dimension which is equivalent to the length of the basal turn ranged from 7.00 mm to 8.00 mm on the right (mean = 7.55 mm) and 6.00 mm to 8.00 mm on the left (mean = 7.60 mm) with a difference of 0.05 mm (s.d. = 0.33, ad and 0.36, as). the number of turns of the right and left cochlea in each of the subjects was identical, exhibiting 2 ½ turns in 92.3% of the subjects (n = 179) and 2 ¾ turns in 7.7% of the subjects (n = 15). the cochlear dimensions were similar in all subjects, regardless of age. no cochlear ossification or malformation was noted in any image. discussion inner ear surgery has become more frequent and continues to advance over the past decade requiring otolaryngologists particularly neuro-otologists to have more detailed knowledge of cochlear anatomy. detailed comprehension of the anatomy of the human cochlea has lagged behind that of other sensory systems because of technical difficulties in examining inner ear structures. previous cadaveric model studies were time consuming, expensive and did not permit physiological correlation. the mean length of the cochlea is about 33.01 mm (s.d. 2.31 mm)4 and is normally known to demonstrate 2 ½ to 2 ¾ turns to allow its full dimensions to be accommodated in the temporal bone. a study comparing eight adult cochleas with eighteen formalin-fixed fetal specimens at the carnegie embryological collection of normal fetuses using plain radiography, computed tomography (ct) and magnetic resonance (mr) imaging showed that the mean length of the cochlear basal turn is 7.86 mm and 8.81 mm in the fetal and adult subjects respectively which is 0.29 mm to 1.24 mm longer than the cochlear basal turn length noted in this study.5 in the present local clinical setting, ct and mri are the imaging modalities used for assessing the cochlea, with mri as the imaging method of choice for assessing the spiral canal, especially in cochlear implant candidates.6 however, recent improvements in ct imaging philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles 8 philippine journal of otolaryngology-head and neck surgery figure 1. double oblique coronal view of the r temporal bone showing the cochlear dimensions. a. apical turn; b. middle turn c. basal turn. d. cochlear base figure 2. measurement of the coiled cochlear dimensions. a. orthogonal view of the 3d reconstructed cochlea showing the measurement of the coiled cochlear vertical dimension from the helicotrema to the lowest margin of the basal turn. b. coronal view of the cochlea showing the measurement of the coiled cochlear horizontal dimension from the promontory to the most lateral portion of the basal turn. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles philippine journal of otolaryngology-head and neck surgery 9 references 1. manoussaki d, chadwick rs, ketten dr, arruda j, dimitriadis ek, o’malley jt. the influence of cochlear shape on low-frequency hearing. proc natl acad sci u s a. 2008 apr 22;105(16):6162-6. epub 2008 apr 14. 2. lane ji, lindell ep, witte rj, delone dr, driscoll cl. improved depiction with multiplanar reconstruction of volumetric ct data. radiographics. 2006 jan-feb; 26(1):115-24. 3. rebscher sj, hetherington a, bonham b, wardrop p, whinney d, leake pa. j rehabil res dev. 2008;45(5):731-47. 4. takagi a, sando i. computer-aided three-dimensional reconstruction: a method of measuring temporal bone structures including the length of the cochlea. ann otol rhinol laryngol. 1989 jul;98(7 pt 1):515-22. 5. nemzek wr, brodie ha, chong bw, babcook cj, hecht st, salamat s, et al. imaging findings of the developing temporal bone in fetal specimens. ajnr am j neuroradiol. 1996 sep;17(8):1467-77. 6. baumgartner wd, youssefzadeh s, hamzavi j, czerny c, gstoettner w. clinical application of magnetic resonance imaging in 30 cochlear implant patients. otol neurotol. 2001 nov;22(6):818-22. 7. purcell d, johnson j, fischbein n, lalwani ak. establishment of normative cochlear and vestibular measurements to aid in the diagnosis of inner ear malformations. otolaryngol head neck surg. 2003 jan;128(1):78-87. 8. purcell dd, fischbein nj, patel a, johnson j, lalwani ak. two temporal bone computed tomography measurements increase recognition of malformations and predict sensorineural hearing loss. laryngoscope. 2006 aug;116(8):1439-46. 9. lan my, shiao jy, ho cy, hung hc. measurements of normal inner ear on computed tomography in children with congenital sensorineural hearing loss. eur arch otorhinolaryngol. 2009 sep;266(9):1361-4. epub 2009 feb 24. 10. mallo wm, giordanengo c, bertona c, bertona jj, gigena c, florez mp. ear study with 64 slices multidetector ct. the international society of radiology [serial on the internet] 2010 [cited 2010 february 4]; 74(4): [about 7 p.] available from: http://isradiology.org/ gorad/docs/rard_art_oido_en.pdf. 11. bogar m, bento rf, tsuji rk. cochlear anatomy study used to design surgical instruments for cochlear implants with two bundles of electrodes in ossified cochleas. braz j otorhinolaryngol. 2008 mar-apr;74(2):194-9. 12. chen jl, gittleman a, barnes pd, chang kw. utility of temporal bone computed tomographic measurements in the evaluation of inner ear malformations. arch otolaryngol head neck surg. 2008 jan;134(1):50-6. technology may now facilitate visualization of the inner ear at resolutions sufficient to assess the basic structural anatomy of the coiled cochlea at lower costs than mri providing opportunities to validate existing knowledge on human cochlear dimensions, turns, details, variations and anomalies. recent anatomical studies of the human cochlea with ct scans have also increased recognition of inner ear malformations in subjects with normal hearing and in those with hearing impairment.7 the use of high-resolution ct in studying the cochlear anatomy is a feasible and relatively inexpensive means that may be correlated with other functional or audiometric studies and experiments, an aspect that is difficult to match with cadaveric cochlear studies. the measurements of coronal cochlear height and other bony inner ear structures particularly the lateral semicircular canal have excellent reproducibility and sensitivity in detecting inner ear malformations.8,9 high-resolution ct also avoids image artifices with an acquisition of submillimetrical slices with optimum resolution10 and may be valuable in the advancement of cochlear implantation and engineering future implants.11 it is recommended that in future studies, the age and audiometric status be stratified and classified for better correlation with the minute inner ear structures and to minimize systemic biases.12 further studies with better comparison of the cochlear dimensions in specific age groups and its correlation to audiometric status are recommended to determine other significant physiologic correlations. figure 3. measurement of the cochlear turns through the 3d reconstructed cochlea. cochlea with a. 2 ¾ turns and b. 2 ½ turns. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 editorial 4 philippine journal of otolaryngology-head and neck surgery “research, no matter how ‘good’, is incomplete, until it has been published.”1 in my opinion, otolaryngology residents, fellows and consultants do not lack in research or scholarly capability. however, “the proof of the pudding is (indeed) in the eating,” and scholarly societies are recognized not so much for what goes on within their hallowed halls but for what is made public outside those walls. indeed, “publishing” means to make something public.2 and though we may not lack in research, we certainly still lag in publication. i would therefore not be amiss in addressing the need for psohns fellows, diplomates and trainees to publish, in electronic or hard-copy, in print or other media, including the social media. because of my background, much of my reflections will deal with writing – but by no means do i mean to limit publication to that of the written word. why write and publish? “start where you are: taking your place in the history of scholarship”2 “similar to others who write (historians and poets), scientists and those involved in research need to write … to leave behind a documented legacy of their accomplishments.”1 whatever we discover or unearth in the laboratory, clinic or in the field; whether from samples, specimens, subjects, patients or participants; utilizing theoretical or applied instruments, materials and methods; simply “did not happen” unless it is documented and disseminated. in filipino,“ kung hindi nakasulat, hindi nangyari.” how often do we hear comments like “naisip ko na iyan,” or “napresenta ko na iyan” or even “sinulat ko na iyan” at a scientific meeting where a speaker presents a study. the sad fact of the matter is that many of these colleagues may indeed have had similar thoughts, or delivered previous oral presentations, or even written reports. but because none of these had been properly published, they remain inaccessible to subsequent scholars, and are therefore neither cited nor acknowledged. “while ‘doing’ the research is important, ‘writing’ about why and how it was done, what was found, and what it means is far more important as it serves as a permanent record of scientific work that has been completed and accepted by peers.”1 and writing and publishing are an entirely different ball game from researching alone. publication, or “making ideas public,” allows “scholars (to) provide each other with the opportunity to build on each other’s contributions, create dialogue (sometimes heated) with one another and join the documented and ongoing history of their field.”2 it is by participating in this “documented and ongoing history” of whatever field we may be in, that we and our specialty society gain international recognition and become internationally competitive. correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone (632) 554 8467 telefax (632) 524 4455 email lapenajf@upm.edu.ph reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines publish, don’t perish: research and publication for otolaryngologists philipp j otolaryngol head neck surg 2014; 29 (2): 4-6 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 5 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 editorial taking your place in the history of scholarship starts where you are, as an author. publication involves communication between the author and his or her audience via the written article.3 unlike public speakers or performing artists, the author’s interaction with the audience is limited by the written and published work. hence, “a successful researcher is usually a good communicator who has the ability to maximize the transmission of research findings to his or her chosen audience.”1 setting the stage: advantages of writing and publication a few may write “ for the pleasure derived from the creative activity of writing and intellectual sharing, and the desire to advance knowledge and benefit mankind” and for these individuals, “writing may act as a channel for expressing the joy of scientific discovery, and may even be regarded as a leisurely pursuit.”1 an historical article on jose rizal4 that i researched for a year and a half before the occasion of his 150th anniversary and another on the evolution of indirect laryngoscopy5 that i researched for two years are personal examples of these. for most everyone else, there are career, professional, institutional and practical advantages that can be gained from writing and publication.6 as far as career benefits are concerned, “getting published in prestigious, scholarly journals may have the most direct bearing on your appointment, promotion, tenure and advancement within your institution, organization and discipline.”2 the “up or out” situation faced by many young to mid-career academics would have been easily avoided by publishing early. moreover, publications are the primary basis for promotion and advancement in academe. professional benefits are just as important. for junior consultants and younger faculty, “having published articles in reputable international journals are a great help when applying for positions in foreign institutions, and when applying for competitive overseas fellowships.”1 as editor of our specialty scholarly journal, i receive numerous urgent requests from postgraduate residents and young diplomates (unaware of the tedious editing and peer review process) to rush-publish research they undertook in training, in fulfillment of publication requirements for overseas positions or fellowships they are applying for. had they realized this earlier, they could have been much better-prepared. for more established consultants, “gaining recognition as experts in a particular field at regional and international levels leads to invitations to lecture at scientific meetings and refresher courses, and appointments as consultants to external agencies, expert panels and advisory boards, reviewer and editorial boards.”1 much of my local and international travels are direct offshoots of previous research, lectures and publications. these generate further research and publication opportunities in turn, as track records in research and publication are considered in “applications for, extension of, and further research funding.”1 closer to home, publication “increases (the) depth of knowledge in a particular subject that complements and hones clinical (practical) skills, and enables better teaching of students, clinical trainees and postgraduates.”1 indeed, a true professor must have something to profess, and a well-published professor can certainly profess what he or she does more authoritatively. of course, the practical benefits gained from engaging in the research and publication process cannot be overlooked. the “inherent training gained during the process of manuscript preparation,” the “discipline of performing a thorough literature search, collating and analyzing data and drafting and repeatedly revising the manuscript”1 during the editing and review process, provide undeniable practical benefits to the author. researchers who have published are much better positioned to evaluate scholarly publications, having themselves experienced the writing, editing and review process. in this era of “information overload” the published researcher can more effectively evaluate and utilize available evidence. because of institutional benefits, it is in the best interests of our scholarly society to encourage scholarly writing, as “publication in peerreviewed journals is arguably the most important means to achieve international recognition for an individual, department, hospital, and university.”1 various international survey and ranking systems place a premium on such publication, explaining why philippine academic institutions lag behind their counterparts in asia and the rest of the world. it is also in the best interests of the philippines that her clinicians, scientists, artists and scholars publish, as “the author’s country, and even the region, may also derive benefit from published work, particularly if it is on a topic of major importance.”1 at least in the medical field, filipino publications have made their mark, albeit sparsely. the up college of medicine and national health sciences journal acta medica philippina is the source of material indelibly inscribed in the world medical map, and we certainly look forward to the philippine journal of otolaryngology head and neck surgery achieving the same. the generous research allocation for fellows and full support for our journal by the psohns board of trustees are a step in the right direction, as are the annual awarding of the outstanding ent specialist in research and editors’ pick award for outstanding publication. in keeping with international practice, we should accord due public recognition to our philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 6 philippine journal of otolaryngology-head and neck surgery editorial references 1. peh wcg, ng kh. effective medical writing (pointers to getting your article published): why write? singapore med j 2008; 49(6):443. 2. publish, not perish: the art and craft of publishing in scholarly journals. university of colorado 2006. available from http://www.publishnotperish.org [cited may 25, 2013]. 3. clearihan l. writing for publication. monash uniiversity, melbourne. available from: http:// www.phcris.org.au/conference/2005/workshops/clearihan.pdf [cited may 25, 2013]. 4. lapeña jf. josé protacio rizal (1861-1896): physician and philippine national hero. medicine in stamps series. singapore med j. 2011 jun; 52(6):390-393. 5. lapeña jf. mirrors and reflections: the evolution of indirect laryngoscopy. ann saudi med 2013 mar-apr; 33(2): 177-181. doi: 10.5144/0256-4947.2013.177 6. peh wcg. scientific writing and publishing: its importance to radiologists. biomed imaging interv j 2007;3(3):e55 doi: 10.2349/biij.3.3.e55. excellent reviewers and editors at official psohns functions such as annual conventions, if but for the recognition they reciprocally bring to the society. the american academy of otolaryngology head and neck surgery has journal editors and star reviewers wear special ribbons at their annual meeting, and openly campaigns for participants to thank these reviewers for their contribution. on another note, i was elected president 2014-2016 of the asia pacific association of medical journal editors during the recent joint meeting of apame and the western pacific region index medicus and index medicus of the south east asia region of who in ulaanbaatar, mongolia last august 15 – 17, 2014. this is fortuitous as we prepare to host the apame convention 2015 and joint meeting with wprim and imsear at the who western pacific region office, sofitel hotel and philippine international convention center from august 24-26, 2015 in conjunction with forum 2015. the other officers are: executive vice president prof. jeong-wook seo (korea), vice president for internal affairs prof. kiichiro tsutani (japan), vice president for external affairs prof. dai tao (china) and secretary-general prof. wilfred peh (singapore). the philippine journal of otolaryngology head and neck surgery is now indexed in the hinari access to research in health programme of the world health organization www.who.int/hinari making us readily available to a multitude of users from developing countries and increasing our accessibility tremendously. our society and journal can be accessed via http://extranet.who.int/hinari/en/browse_publisher. php?pub=695 in addition, apamed central (on which the philippine journal of otolaryngology head and neck surgery is indexed) has been formally ratified for indexing in the worldwidescience.org database during the world wide science alliance annual meeting in tokyo last october 2014. henceforth, all articles from oct 19 2014, including this issue, will be searchable on this database. finally, i am especially thankful to our president and my friend, howard m. enriquez, md and the psohns board of trustees (especially the scientific committee chair and my friend elmo r. lago, jr., md) for the support given to me, and our journal on my ninth year as editor-inchief. philippine journal of otolaryngology-head and neck surgery 31 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 featured grand rounds good prognosis has been associated with early detection of squamous cell carcinoma of the larynx. the patient’s choice for any treatment modality depends highly on the cure rate, larynx preservation rate, post-treatment voice quality, morbidity, and treatment cost.1 regardless of which stage of disease, the choice of treatment centers mainly on the maintenance of quality of life and minimal adverse effects. case report a 56-year-old male presented with a 9-month history of intermittent hoarseness with occasional low-grade fever. a local private physician diagnosed pulmonary tuberculosis and treated him with anti-tuberculosis medications for six months. persistence of hoarseness after treatment prompted consult in our institution where laryngeal videostroboscopy revealed a fleshy, fungating mass occupying the anterior 1/3 of the right true vocal cord extending towards the midline with probable involvement of the contralateral anterior ¼ of the left true vocal cord and full, symmetric mobility of both arytenoids. (figure 1) direct laryngoscopy, tracheoscopy, esophagoscopy and biopsy yielded histopathologic findings consistent with well-differentiated squamous cell carcinoma. computed tomography revealed an isolated right glottic mass with no radiologic extension to the cricoid, contralateral vocal cord and ipsilateral arytenoid. american joint committee on cancer (ajcc) staging of the patient at this time was stage i (tibn0m0). options for radiotherapy or conservation laryngectomy (via frontolateral laryngectomy with imbrication laryngoplasty) were presented to the patient, as well as prognosis, and expected outcomes. having opted for conservation laryngectomy, the patient underwent frontolateral laryngectomy with imbrication laryngoplasty. at the beginning of the procedure, the larynx was exposed via a 5 cm horizontal skin incision and strap muscle retraction. a perichondrial flap was elevated over the right thyroid lamina. (figure 2) a midline laryngotomy allowed direct visualization of the tumor and its location. in this case, an extension of 3 mm beyond the midline afforded better exposure. cartilage and mucosal cuts were mapped and the superior cut was performed at the level of the ventricle. the inferior cut was 1 cm from the superior margin, providing an ample margin of resection. prior to making the cartilage cuts, a fine cutting burr was used to drill two pairs of holes on each cartilage strip of the involved side. the superior cut was made through the ventricle and paraglottic tissues, leaving behind the posterior 1/3 of the right true vocal cord together with the right arytenoid. the specimen included the anterior 2/3 of the right true vocal cord, inferior and superior surfaces, vocalis muscle, and ipsilateral thyroid cartilage strip. hemostasis was achieved using bipolar cautery. (figure 3) specimens from the posterior, anterior and inferior margins were sent for final histopathology. frontolateral laryngectomy with imbrication laryngoplasty for stage i glottic carcinoma anne margaux v. artates, md department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: dr. anne margaux v. artates department of otorhinolaryngology ward 10 philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 554 8400 local 2151 or 2152 email: a_artates@yahoo.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosure: the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. this paper was presented in the 4th interhospital grandrounds of the philippine society of otorhinolaryngology-head and neck surgery on september 16, 2011 at the university of the philippines – manila class ’72 theater philipp j otolaryngol head neck surg 2012; 27 (1): 31-34 c philippine society of otolaryngology – head and neck surgery, inc. 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 featured grand rounds figure 1. a. right true vocal cord mass on videolaryngoscopy with both vocal cords in abduction; and b. in adduction. reconstruction of the remaining hemilarynx comprised two steps: first, imbrication of the remaining thyroid cartilage for the cartilaginous framework; and second, development of the superiorly-based vocal fold mucosal flap. the vocal fold mucosal flap was developed by undermining the mucosa of the remaining false vocal fold from the inner aspect of the superior thyroid cartilage strip. the superior and inferior cartilage strips were then imbricated– whereby both strips were overlapped by placing the superior strip medial to the inferior strip– a technique also known as internal imbrication laryngoplasty. (figure 4) two prolene 2-0 sutures were placed through the predrilled holes to secure the cartilage strips together and the knots were placed externally. (figure 5) complete closure of the anterior and posterior commissure was accomplished using absorbable vicryl 5-0 sutures. a tracheotomy was performed in this patient and a nasogastric tube inserted. estimated blood loss was 100 cc, and the procedure lasted 4 hours and 20 minutes. the nasogastric tube was removed 10 days after the operation and decannulation was a b figure 2. exposure of the right thyroid lamina. figure 3. specimen showing the involved anterior 2/3 of the right glottis achieved three weeks after surgery with no complaints of aspiration. (figure 6) monthly follow-up for 10 months with indirect laryngoscopy and videostroboscopy has shown no evidence of recurrence in this patient. philippine journal of otolaryngology-head and neck surgery 33 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 featured grand rounds discussion laryngeal squamous cell carcinoma involving one subsite as defined by the tnm staging of the ajcc is managed with a single treatment modality – the choice of treatment is influenced by the associated morbidities.2 historically, gordon buck performed the first reported laryngofissure and local excision of laryngeal cancer in 1851. it was in 1878 that bilroth introduced transcervical vertical partial laryngectomy and achieved long-term cure for glottic carcinoma.1 publications by chawla et al., ferlito et al. and har-el et al. enumerate the treatment strategies for stage i and ii glottic carcinoma, namely radiation therapy, endoscopic surgery, transoral laser surgery, laryngofissure with cordectomy, and partial laryngectomy, including its modifications and reconstructive options.1,3,4 silver et al. have claimed that results of laser surgery are equivalent to those obtained with conservation surgery.6 the international federation of head and neck oncologic societies (ifhnos)’ dr. randall webber enumerated four factors promoting renewed interest in organ preservation surgery: cost, functional outcome, lack of demonstrated survival benefit for non-surgical therapy, and improvement of surgical precision and limited access approaches driven by technological advances.5 while complete eradicaton of disease has remained the principal goal in oncologic management, the said factors should be taken into consideration prior to initiation of treatment. depending on the availability of treatment choices, t1/ t2 glottic lesions can be managed effectively by a single treatment protocol – via transoral endoscopic surgery or radiotherapy or openapproach conservation laryngectomy. isolated cases have reported figure 6. videolaryngoscopy 6 months after the procedure figure 4. superior and inferior cartilage strips after tumor resection figure 5. internal imbrication laryngoplasty 34 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 featured grand rounds acknowledgement i would like to acknowledge my adviser, dr. melfred l. hernandez for his guidance in the approach to, and performance of the surgical procedure. references 1. chawla s, carney as. organ preservation surgery for laryngeal cancer. head and neck oncol. 2009 may 15; 1:12. 2. rubinstein m, armstrong wb. transoral laser surgery for laryngeal cancer: a primer and review of laser dosimetry. lasers med sci. 2011 jan; 26(1): 113-124. 3. har-el g, paniello rc, abemayor e, rice dh, rassekh c. partial laryngectomy with imbrication laryngoplasty for glottic carcinoma. arch otolaryngol head neck surg. 2003 jan; 129(1): 65-71. 4. ferlliot a, silver ce, howard dj, laccourreye o, rinaldo a, owen r. the role of partial laryngeal resection in current management of laryngeal cancer: a collective review. acta otolaryngol. 2000 jun; 120 (4):456-65. 5. weber, rs. laryngopharyngeal squamous cell carcinoma lecture. current concepts in head and neck surgery and oncology. the international federation of head and neck oncology societies world tour lecture series 2010. 6. silver ce, beitler jj, shaha ar, rinaldo a, ferlito a. current trends in initial management of laryngeal cancer: the declining use of open surgery. eur. arch otorhinolaryol. 2009 sept; 266(9): 1333-52. 7. dedivitis ra, guimaraes av, guirado cr. outcome after partial frontolateral laryngectomy. int surg. 2005apr-jun; 90(2): 113-8. failure of disease control in transoral endoscopic surgery when the anterior commissure is involved. it is in the same light that frontolateral laryngectomy was given as an option in the case presented. the phonatory and protective functions of the laryngeal complex are achieved by normal or otherwise acceptable apposition of the vocal cords. in the case of a neo-glottis, this is achieved by imbrication laryngoplasty. this technique, as described by gady and paniello,3 includes endolaryngeal mucosal reconstruction with a false vocal fold flap that is combined with the medialization of the thyroid cartilaginous framework. the result is an improved voice quality owing to the vocal fold flap that forms a smaller glottic gap. furthermore, paniello et al. 3 were able to measure outcomes in their retrospective study of patients who underwent partial frontolateral laryngectomy with imbrication laryngoplasty (plil) by means of monitoring local control rate of the disease, postoperative course, length of treatment, postoperative voice quality, swallowing function and patient satisfaction. their results revealed that the said technique compare favorably with those treated with radiation therapy and endoscopic surgery. local control rates reported by dedivitis et al.7 in 2005 involved a retrospective analysis of 30 patients with the ajcc staging of t1bn0m0 and t2n0m0 from 19952002. twenty five of the said patients showed no evidence of disease during follow-up while five experienced local recurrence and were subsequently treated with salvage surgery. individual discussions on indications and outcomes of each modality for t1/t2 glottic lesions are beyond the scope of this report. however, we encourage that partial frontolateral laryngectomy with imbrication laryngoplasty also be presented as a treatment option for selected early glottis carcinoma cases. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 case reports philippine journal of otolaryngology-head and neck surgery 23 philipp j otolaryngol head neck surg 2014; 29 (1): 23-25 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to describe a case of nasopharyngeal carcinoma coexistent with primary nasopharyngeal tuberculosis and review the literature. methods: design: case report setting: tertiary public university hospital patient: one results: aa 28-year-old man presented with recurrent sore throat and neck pain with clinically enlarged tonsils. he underwent a routine adenotonsilectomy. histopathologic examination revealed non-keratinizing squamous cell carcinoma with caseating granulomatous inflammation typical for tuberculosis in the same adenoid specimen. nasopharyngeal carcinoma was staged t2bn2m0. he was treated with concurrent chemoradiotherapy and a 9-month course of anti tuberculosis treatment. he recovered and remained symptom free one year after treatment. conclusion: nasopharyngeal carcinoma (npc) and tuberculosis (tb) are both very common diseases in sabah, east malaysia. however, it is very rare that both diseases present at the same time and same anatomical area in a patient. diagnosis can be very challenging and confusing. multidisciplinary consultations are warranted for appropriate treatment. combined antituberculosis treatment and concurrent chemoradiotherapy may be appropriate and effective. keywords: nasopharyngeal carcinoma, primary nasopharyngeal tuberculosis, adenotonsillectomy case report a 28-year-old malay man presented with the complaint of recurrent sore throat and fever over the past few years. he denied epitaxis, rhinorrhoea, tinnitus, cough, loss of appetite or weight. clinical examination showed enlarged tonsils. he underwent a routine adenotonsilectomy. histopathologic examination of the same slide of the adenoid specimen showed fragments of lymphoid tissue covered by respiratory epithelium. the underlying stroma showed infiltrations by clusters and sheets of malignant squamoid cells. there was also presence of caseating necrosis surrounded by epitheloid granulomas with occasional langhan’s giant cells seen. no acid-fast an incidental nasopharyngeal carcinoma coexistent with primary nasopharyngeal tuberculosis hon syn chong, mbbs,1 mohd razif mohammed yunus, ms (orl-hns),1 norafidaah ali, ms (anatomy pathology)2 1department of otorhinolaryngology, universiti kebangsaan malaysia medical centre, kuala lumpur, malaysia 2department of pathology, queen elizabeth hospital, sabah, malaysia correspondence: dr. mohd razif bin mohamad yunus, department of otorhinolaryngology, ukm medical centre jalan yaacob latif, bandar tun razak, 56000 cheras, kuala lumpur malaysia. phone: +601 9321 2198 telefax: +603 9145 6675 e-mail: razif72@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 24 philippine journal of otolaryngology-head and neck surgery case reports bacilli (afb) were detected. the diagnosis was a non-keratinizing differentiated squamous cell carcinoma with caseating granulomatous inflammation. he developed a tender left level ii cervical lymph node (3x2cm2) several weeks after the adenotonsillectomy. fine needle aspiration cytology revealed lymphoid cells with very occasional clusters of atypical cells suspicious for metastasis. no granuloma or afb was seen. tuberculosis work-up results showed three negative serial sputum afb zn stains, a normal chest x ray and negative mantoux test (0 mm after 3 days). hepatitis b and c and hiv screening were non-reactive. other basic blood investigations were normal. ct scan of the neck revealed a large heterogeneously-enhancing lesion in the nasopharynx causing obliteration of the parapharyngeal space more on left side and left level ii cervical lymphadenopathy less than 6 cm. ultrasound of the abdomen was normal. he was referred to the infectious disease and oncology teams and thereafter agreed to undergo concurrent chemoradiotherpy (35 fractions of radiotherapy + weekly iv cisplatin 50mg/m2 followed by three cycles of adjuvant chemotherapy iv 5fu 700mg/m2+iv cisplatin 100mg/m2 ) and anti tb (ehrz) treatment for nine months. upon completion of his concurrent chemoradiotherapy and anti tb treatment, the left cervical lymph nodes regressed and became unpalpable. he was clinically well on follow up at one year, with no local recurrence visualized on nasopharyngeal endoscopy. a c b d figure 1 a, b show caseating granuloma with concurrent malignant squamoid cells. (40x) figure 1 c (100x) and d (400x) show higher magnifications of malignant cells with high mitotic activities. (hematoxylin and eosin, 40x) (hematoxylin and eosin, 100x) (hematoxylin and eosin, 40x) (hematoxylin and eosin, 400x) philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 case reports philippine journal of otolaryngology-head and neck surgery 25 discussion both nasopharyngeal carcinoma (npc) and tuberculosis are common diseases in this region. however, the incidence of primary nasopharyngeal tuberculosis (nptb) is very low, comprising about 0.1% of all tuberculosis cases.1 it is even rarer to have a patient present with both pathologies at the same time and in the same anatomical area. it is a diagnostic dilemma to make a diagnosis as such (npc with nptb). it is even more challenging to treat a patient with afb zn staining negative in a tb endemic country like malaysia. in 2007, the state of sabah contributed slightly more than 3000 of 16,129 new and relapse cases reported in the country.2 the incidence of notification of smear-positive ptb is 47 per 100,000 population in malaysia.3 a literature search using ovid and medline was done to assess the prevalence of npc with nptb and the management experience of others. concomitant npc with nptb has previously been reported by zalesska-krecicka et al.4 (1 case), wang et al.5 (6 cases) and chan et al.6 (4 cases). however, all reported a difficult diagnosis and suggested detailed clinical examinations, careful and thorough specimen histopathological examination with necessary staining with more advanced investigations such as polymerase chain reactivity (pcr) and magnetic resonance imaging (mri). these meticulous steps may help in making a more definitive diagnosis and treatment. misdiagnosis may lead to npc diagnosed as nptb or vice-versa. as reported by wang et al.5 the clinical manifestations of nptb include being young; small, numerous, bilateral, soft and movable cervical lymph nodes; concomitant lung tuberculosis; unusual symptoms in the ear and nose; no cranial nerve complications; the nasopharyngeal roof plate as the common site of infection; and pharyngalgia and pain in the neck. on the other hand, clinical manifestations of nptb with npc include being old; large, hard and fixed cervical lymph nodes; hearing loss and tinnitus; blood-tinged discharge from the nasopharynx and involvement of the cranial nerves. in that study the diagnosis of npc was initially missed in 3 of the 6 cases (50%). therefore, it is suggested that misdiagnosis of nptb with npc could be avoided by improved awareness of npc and thorough analysis of clinical symptoms of nptb and nptb with npc on top of histopathological examination. histopathological examination could be confusing to the pathologist because nasopharyngeal carcinoma may harbor foci of granulomatous reactions.5 the granulomatous reactions reflect a favorable local host and cell-mediated immune response. chen et al.7 reported that 7 of 47 cases initially diagnosed as primary nptb were reexamined and found to have npc. in routine stains, residual malignant tumor cells could be identified in two cases while in the remaining five cases malignant cells could only be identified after careful examination. however, with the use of immunohistochemical staining for keratin, tumor cells acknowledgement we are grateful to professor prepageran narayanan (frcs) from the university malaya of kuala lumpur for reviewing this paper. references 1. rohwedder jj. upper respiratory tract tuberculosis. sixteen cases in a general hospital. ann intern med. 1974 jun 1; 80(6):708-713. 2. rundi c. understanding tuberculosis: perspectives and experiences of the people of sabah, east malaysia. j health popul nutr. 2010 apr; 28(2):114-123. 3. world health organization. global health atlas. global tuberculosis database. cited 3 may 2010. available from: http://apps.who.int/globalatlas/dataquery/default.asp 4. zalesska-krecicka m, krecicki t, morawska-kochman m. [nasopharyngeal carcinoma coexistent with lymph node tuberculosis, diagnostic difficulties – case report]. otolaryngol pol, 2005; 59(4):607-9. 5. wang h, zhong yq, qiu hg. [diagnosis of nasopharyngeal tuberculosis (nptb) and nptb with nasopharyngeal carcinoma.] china trop med, 2005,5(2):280-281. cited 3 may 2013. available from: http://en.cnki.com.cn/article_en/cjfdtotal-rdyx200502014.htm 6. chan ab, ma tk, yu bk, king ad, ho fn, tse gm. nasopharyngeal granulomatous inflammation and tuberculosis complicating undifferentiated carcinoma. otolaryngol head neck surg. 2004 jan; 130(1):125-130. 7. chen cl, su ij, hsu mm, hsu hc. granulomatous nasopharyngeal carcinoma: with emphasis on difficulty in diagnosis and favorable outcome. j formos med assoc. 1991 apr; 90(4):353-6. 8. su k, jiang f, miao d, he x, zhang y. [nasopharyngeal tuberculosis: an analytical study and report on 12 cases]. lin chuang er bi yan hou ke za zhi. 2002 aug,16(8):414-5. were easily demonstrated engulfing the granulomatous lesions in all seven cases. several studies from npc and tb epidemic countries also reported difficulties and confusion in making diagnosis both clinically and histologically.8 from the literature review, the previously published studies and case reports were not incidental. they were either suspected tb later diagnosed to have npc, vice-versa or both coexistent. however, in this case, the patient initially presented with symptoms of chronic tonsillitis with adenoid remnants and the coexistent pathologies were diagnosed incidentally by histopathological examination. this patient was a therapeutic dilemma initially. after combined discussion among ent, oncology, infectious disease and pathology teams, the combined treatment was recommended in view of the high prevalence of both diseases in this hospital and the supporting symptoms and investigation results. he recuperated well and currently remains symptom free on regular follow up. it is very important that in cases like this, the approach should be multidisciplinary with professional inputs from all related fields to achieve the best outcome of treatment for the patient. 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 featured grand rounds intracranial abscess is a serious, life-threatening condition with a dire prognosis. although the advent of the antibiotic era has drastically reduced the incidence of the disease, predisposing factors such as untreated ear infections, poor personal hygiene, significant trauma with violation of the sterile cranial environment as well as existing co-morbidities such as an immunocompromised state make intracranial abscess a horrifying reality. ear infections, in particular, are notorious for being the origin of roughly 50% of cerebellar abscesses.1 chronic suppurative otitis media (csom) is one of the leading causes of brain abscess. shaw and russell2 reviewed 47 cases of cerebellar abscess and showed that 93% were caused by csom; the most common mechanism of entry into the brain parenchyma being direct extension. chronic infection in the middle ear space could erode through the tegmen tympani and into the temporal lobe or through the tegmen mastoidei into the cerebellum. neurological symptoms may be delayed as the abscess ‘grows’ in areas around the cerebellum that are regarded as ‘silent’, until vital areas such as those responsible for coordination and balance are violated. we describe a case of cerebellar abscess secondary to csom and discuss the possibility of performing ear surgery with simultaneous drainage of a contiguous abscess through a transmastoid approach in cases of chronic suppurative otitis media with intracranial complications. case report a 21-year-old man consulted with a chief complaint of headache. the history started 13 years prior to consult, when at the age of 8, he developed ear pain with ear discharge. since then, ear discharge recurred around 4-5 times a year despite various medications prescribed by different physicians. each time, an ent specialty consultation was advised but not availed of. one month prior to admission, the patient consulted a physician for recurrent temporal headaches radiating to the periorbital area and described as sometimes crushing, sometimes throbbing, with vas pain scale 5/10 and associated with nausea. there was also pain in both ears and purulent, foul smelling discharge from the left ear associated with decreased hearing. unrecalled medications were again prescribed and he was sent home with an ent specialist referral which he did not comply with. two weeks prior to admission, the headache grew worse, 8-9/10 on the pain scale with persistent nausea and progressive hearing loss on the left ear despite the unrecalled medications. one week prior to admission, the intolerable condition prompted an ent specialist consult and diagnosis of chronic suppurative otitis media, as and chronic otitis media, ad. cefuroxime 500mg tab every 8 hours, celecoxib 200mg tab every 12 hours and ofloxacin otic drops every 8 hours were started and hospital admission was advised but initially refused. a temporal bone ct scan showed a large cholesteatoma with destruction of the posterior wall of the left mastoid and probable intracranial extension. (figure 1) the patient then consented to admission. surgical management of chronic suppurative otitis media with intracranial complicationsgerardo aniano c. dimaguila, md, mphnixon s. see, md francisco a. victoria, md department of otolaryngology head and neck surgery ospital ng maynila medical center correspondence: dr. gerardo aniano c. dimaguila department of otolaryngologyhead and neck surgery ospital ng maynila medical center quirino ave. corner roxas blvd., malate, manila 1004 philippines phone: (+63) 524 6061 local 220 fax: (+63) 524 6065 email: ommc_enthns@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2012; 27 (2): 32-34 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 33 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 featured grand rounds on the day of admission, he now had severe headache, dizziness and occasional vomiting. no neurologic symptoms such as facial asymmetry, lagopthalmos, or paresthesias were reported. a cerebellar abscess was entertained. on the second hospital day, the patient’s neurologic status started to deteriorate with moments of agitation and combative behavior interspersed with drowsiness and lucid behavior. his blood pressure also started to increase from 110/80 on admission to 160/110. magnetic resonance imaging (mri) revealed a rim-enhancing destructive lesion in the left mastoid and a left cerebellar abscess. (figure 2) on the third hospital day, he showed signs of neurologic deterioration despite aggressive medical management, but we opted to continue temporizing rather than risk worsening the situation by performing mastoidectomy alone without the availability of the neurosurgery service. on the fifth hospital day, emergency burr holes with left lateral occipital craniectomy and aspiration of abscess was performed with radical mastoidectomy and meatoplasty, as. he was discharged improved on the 9th hospital day (4th post-operative day). discussion a common dictum in our institution about the management of chronic suppurative otitis media (csom) with extraor intracranial complications is, ‘never let the sun set without performing ear surgery on the patient.’ our patient presented at the emergency room with warning signs of an intracranial extension of the ear infection. the frequent headaches and vomiting probably indicated an increase in intracranial pressure. the patient’s deteriorating neurologic status with moments of agitation and combative behavior interspersed with drowsiness and lucid behavior and increasing blood pressure by the second hospital day were further signs of increased intracranial pressure. a cerebellar abscess was confirmed on mri. deciding that the risks of herniation and further damage were far greater than potential benefits of performing mastoidectomy alone without aspiration of the cerebellar abscess, we opted to wait until simultaneous left lateral occipital craniectomy and aspiration of abscess could be performed with the mastoidectomy and meatoplasty. a review of the literature shows authors advocating neurosurgery figure 2. brain mri axial section at the level of the superior semicircular canals showing a large rim enhancing mass involving the periphery of the left cerebellar hemisphere measuring approximately 3.3cm x 4.1cm x 2.6cm in ap, transverse and craniocaudal dimensions. figure 1. temporal bone ct scan, axial section at the level of the superior semicircular canals showing a large cholesteatoma on the left with destruction of the posterior wall of the mastoid and extension into the posterior cranial fossa. 34 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 featured grand rounds references thomas le, goldstein jn. 2010. brain abscess in emergency medicine. 1. medscape reference [homepage on the internet] c1994-2012 [updated 2010 may 13; cited 2012 sept.12]. available from: http://emedicine.medscape.com/article/781021-overview#showall. shaw md, russel ja. cerebellar abscess. a review of 47 cases. 2. j neurol, neurosurg, psychiatry. 1975 may,38(5):429-435. richter gt, smith ja, dornhoffer jl. otogenic cerebellar abscess: a case report. 3. ear nose throat j. 2009 apr;88(4):e25-28. garayev a, talyshinskiy a, büntzel j. [otogenic cerebellar abscess: two case histories]. [article 4. in german]. laryngorhinootologie 2007 sep;86(9):660-663. epub 2007 jan 11. [abstract cited 2012 sept 2] available from: http://www.ncbi.nlm.nih.gov/pubmed/17219339. kurien m, job a, matthew j, chandy m. otogenic intracranial abscess: concurrent craniotomy 5. and mastoidectomychanging trends in a developing country. arch otolaryngol head neck surg. 1998 dec;124(12):1353-1356. penido nde o, borin a, iha lc, suguri vm, onishi e, fukuda y, cruz ol. intracranial complications 6. of otitis media: 15 years of experience in 33 patients. otolaryngol head neck surg. 2005 jan;132(1):37-42. alaani a, coulson c, mcdermott al, irving rm. transtemporal approach to otogenic brain 7. abscesses. acta otolaryngol. 2010 nov;130(11):1214-1219. first then performing ear surgery after the patient has been stabilized. this has been emphasized time and again by shaw and russel.2 through the years, the practice has slowly shifted to performing simultaneous neurosurgery and mastoidectomy. richter et al.3 reported a case of a 39-year-old male diagnosed with otogenic cerebellar abscess surgically managed by performing craniectomy and mastoidectomy together. other physicians also reported favorable outcomes for concomitant craniectomy and mastoidectomy, including garayev et al.4 and kurien et al.5 another shift in surgical practice advocates evacuation of the brain abscess via a transtemporal approach. penido nde et al.6 reported favorable results for 10 patients in whom the brain abscess was drained through open mastoidectomy out of 33 patients with otogenic brain abscess over 15 years. in 2010, alaani et al.7 reported a series of seven patients where a transtemporal approach to otogenic brain abscess was employed. in all cases, the abscess and ear pathology were successfully treated using a single-stage transmastoid approach. these experiences all show that mastoidectomy and drainage of brain abscess could be done safely together with little risk. in the overall management of patients it is also wise to consider the economic aspects of treating disease. if shorter hospital stays can be attained by alternative methods with the same favorable outcomes as gained by usual practices, it may be time to consider new management approaches. the benefits of waiting for a neurosurgeon versus the risks of evacuating the abscess through a transtemporal approach should be weighed in emergent situations. based on the current literature, a transtemporal approach to the evacuation of a brain abscess can be performed in the absence of a neurosurgeon but prudence would dictate that a neurosurgical evaluation should be undertaken if readily available. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 6 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: auricular perichondritis refers to inflammation involving the perichondrium of the external ear. it is a very serious disease which may lead to permanent deformity of the pinna. we describe the predisposing factors, pathogenic organisms, interventions and residual deformities in a prospective consecutive sample of patients. methods: design: prospective cohort study setting: tertiary rural government teaching hospital participants: all patients presenting with auricular perichondritis for a period of one year between march 2011 and february 2012 were consecutively enrolled and a clinical history and demographic details were obtained. routine hematologic, blood biochemical examinations and culture / sensitivity of discharge from the pinna were conducted, and empiric intravenous ciprofloxacin was administered and continued if confirmed by culture and sensitivity. those sensitive to co-amoxiclav, ceftazidime or amikacin were shifted to those medications. medications were shifted to oral forms when available and indicated by resolution of acute inflammation, wound healing and no growth on cultures. parenteral medications were maintained until the same parameters were achieved. surgical incision and drainage was also performed when indicated, followed by a standardized wound care regimen. follow up was for six months ending with assessment of pinna deformity. results: of the total study population of 50, 76% were male and 24% were female; 1575 years of age (range 60 years) displaying male predominance and clustering in the fourth decade of life. the most common predisposing factors were trauma from motor vehicle accidents (30%) followed by high ear piercing (22%). pseudomonas aeruginosa (48%) followed by staphylococcus aureus (20%) were the most common organisms isolated. all were managed with intravenous antibiotics but 76% also required surgical intervention. sixty-eight percent developed residual deformities of the pinna with 50% being total and 18% being partial. conclusion: auricular perichondritis is a frightening disease which requires early management. as pseudomonas aeruginosa is the most common organism, antipseudomonal antibiotics should be started as early as possible. despite medical and surgical intervention, residual deformities may ensue. keywords: auricular perichondritis, pinna, trauma, pseudomonas aeruginosa auricular perichondritis in a tertiary rural hospital gautam dhar, md1 bijan basak, ms (ent)2 ganesh chandra gayen, ms (ent)2 ritam ray, ms (ent)2 1department of community medicine, swasthya bhawan, salt lake city, west bengal, india 2department of ent, burdwan medical college, west bengal, india correspondence: dr. ritam ray department of ent, burdwan medical college and hospital 193, b.c.road, uttar fatak, p.o. – rajbati, dist. – burdwan west bengal pin – 713104 india e-mail: drritamray@gmail.com mobile: 09475854916 reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2013; 28 (1): 6-9 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 original articles philippine journal of otolaryngology-head and neck surgery 7 perichondritis refers to an inflammation of the perichondrium, a layer of connective tissue which surrounds cartilage. auricular perichondritis, the commonest form, involves the pinna due to infection of a traumatic or surgical wound or the deep spread of superficial inflammation. this type of disease often leads to residual deformity, and its incidence in our experience seems to be increasing.1 the present study was conducted to determine the predisposing factors, pathogenic organisms, interventions and residual deformities of the disease in a local rural setting in west bengal, india. materials and methods with institutional ethical review board approval, this prospective series was conducted in the department of ent, burdwan medical college and hospital, burdwan. all patients presenting with auricular perichondritis over a period of one year from march 2011 to february 2012 were consecutively enrolled after obtaining informed consent. no other inclusion or exclusion criteria were applied. a detailed clinical history including demographic details, medical history (diabetes mellitus, autoimmune diseases, recurrent otitis), recent medical history related to current illness (any surgical intervention on the infected ear within one month of the current hospitalization) possible predisposing events (trauma, acupuncture), clinical data (body temperature and physical signs such as local hyperemia, swelling, discharge and tenderness), were taken from each patient. they were all examined properly to exclude other pathologies. all patients subsequently underwent routine hematologic and blood biochemical examinations and discharge from the pinna was sent for culture and sensitivity. all patients were treated with empirical intravenous ciprofloxacin after admission, and continued on ciprofloxacin if clinical response and culture and sensitivity were confirmed. those sensitive to co-amoxiclav, ceftazidime or amikacin were shifted to these medications. step-down to oral medications (ciprofloxacin or co-amoxiclav) was done when signs of acute inflammation resolved, the wound appeared healthy and culture revealed no growth. those on ceftazidime or amikacin were maintained on parenteral medications until proper wound healing had been achieved. when associated with hyperemia, fluctuant swelling of the pinna and aspirated pus, surgical incision and drainage was also performed. regular wound dressing was done in every patient with hydrogen peroxide (20%) sprayed into the wound, rinsed with normal saline, washed with povidone iodine 10% (betadine), rinsed with normal saline, swabbed with tetrachlorodecaoxide 1:55 dilution (oxoferin) with a cotton applicator and finally coated after 20 minutes with mupirocin 2% (t-bact) ointment. as the wound appearance improved, hydrogen peroxide, followed by povidone iodine and normal saline were successively discontinued. tetrachlorodecaoxide was continued until crust formation, and mupirocin was used until epithelialisation. all the patients were followed up for six months after control of infection for assessment of pinna deformity as a sequelae of perichondritis. deformity of pinna following perichondritis was classified into three: no deformity, partial deformity (part of the pinna is deformed) and total deformity (whole pinna is deformed). the data was tabulated and analyzed manually using means and percentages. results a total of 50 patients were studied over a period of one year. of these, 38 (76%) were male and 12 (24%) were female. their ages ranged from 15-75 years, with a range of 60 years. most patients (38 patients, 76%) were within the age group between 30-50 years. among the predisposing factors, 15 cases (30%) were from trauma due to road traffic accidents, followed by ear piercing (11, 22 %). (table 1) pseudomonas aeruginosa was the most common pathogenic organism isolated from the diseased pinna (48%) followed by staphylococcus aureus (20%). polymicrobial infection was found in 8%. (table 2) table 1. predisposing factors for perichondritis of the auricle predisposing factors no of cases (n = 50) percentage (%) road traffic accident ear piercing burn post – surgical diabetes allergic reaction total 15 11 8 7 5 4 50 30 22 16 14 10 8 100 philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 original articles 8 philippine journal of otolaryngology-head and neck surgery table 2. pathogenic organisms isolated from perichondritis pathogenic isolates no of cases (n = 50) percentage (%) pseudomonas aeruginosa staphylococcus aureus enterococcus faecalis streptococcus group a polymicrobial infection klebsiella pneumonia candida spp total 24 10 5 3 4 2 2 50 48 20 10 6 8 4 4 100 table 4. deformity following perichondritis type of deformity no of cases (n = 50) percentage (%) no deformity partial deformity total deformity total 16 25 9 50 32 50 18 100 twelve patients (24%) responded to antibiotic therapy alone while 38 patients (76%) required additional surgical incision and drainage. thirty patients (60%) responded with empiric ciprofloxacin and their culture sensitivity reports confirmed sensitivity to ciprofloxacin in twenty nine (29) or 58%. eleven patients (22%) whose reports revealed sensitivity to coamoxiclav were shifted to it but only 10 or 20% were continued on a full course. one patient each on initial ciprofloxacin and co-amoxiclav subsequently had candida spp on culture, prompting us to cease the respective antibiotics and continue with topical wound care alone. six patients required amikacin and three (3) were shifted to ceftazidime. (table 3) all patients on table 3. pathogenic organisms and antibiotic sensitivities ciprofloxacin s s s si i i ir r r r co-amoxiclav amikacin ceftazidime antibiotic sensitivity**pathogenicorganisms pseudomonas aeuroginosa staph aureus enterococcus faecalis streptococcus group a klebsiella pneumoniae polymicrobial infection* total 22 3 3 0 0 1 29 0 7 0 0 3 10 1 0 2 3 0 0 6 1 0 0 2 0 3 2 7 2 3 2 3 19 24 3 5 3 2 1 38 23 10 3 0 2 4 42 23 10 5 3 0 4 45 *organisms in polymicrobial infection patient 1e.coli, enterobacter, shigella, proteus: sensitive to ciprofloxacin. patient 2h.influenzae, shigella, enterobacter: sensitive to co-amoxiclav. patient 3proteus, shigella, enterobacter: sensitive to co-amoxiclav patient 4salmonella, h.influenzae, e.coli: sensitive to co-amoxiclav **one patient each had ciprofloxacin and co-amoxiclav discontinued after candida spp was grown; totalling 50 patients (48 reflected in this table). ciprofloxacin and co-amoxiclav were eventually shifted to oral forms, and those on amikacin and ceftazidime were maintained on parenteral forms. all wounds healed sufficiently to cease oral or intravenous antibiotics within 20 to 46 days. after six months follow-up, 34 patients (68%) developed residual deformity. these were further subdivided into 25 (50%) with total deformity of the pinna and 9 (18%) with partial deformity. (table 4) philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 original articles philippine journal of otolaryngology-head and neck surgery 9 discussion perichondritis of the auricle is a frightening and perturbing complication of the traumatized ear that can lead to residual deformity.1 it usually results from trauma which may include injuries following road traffic accidents, post-surgery.2,3 and burns.2,3,4,5 contaminated wounds following road traffic accidents are more prone to perichondritis of the pinna. the popularity of high ear piercings has been increa sing among teenagers6 and when performed by untrained, unqualified persons without maintaining aseptic technique, may increase the incidence of aural perichondritis, as seen in our study. skin moisture fosters the proliferation of the most common causal agent.7 patients usually present with unbearable pain, erythema of pinna and rise of body temperature. if left untreated, the disease progresses as diffuse edema of the pinna and subsequent abscess formation leading to cartilage necrosis and cauliflower deformity. dowling et al.,8 apfelberg et al.9 and bassiouny3 found that pseudomonas aeruginosa is the most common pathogenic organism responsible for this disease followed by staphylococcus aureus10 which was consistent with our findings. these pathogens are usually sensitive to ciprofloxacin or co-amoxiclav, as seen in our study. other pathogens include enterococcus faecalis, streptococcus group a and klebsiella pneumonia which may be treated with ceftazidime and amikacin, again reflected in our study. four patients had polymicrobial infection with escherichia coli, enterobacter, shigella, proteus, h.influenzae and salmonella found on cluture. of the four patients, three were sensitive to co-amoxiclav and one was sensitive to ciprofloxacin. auricular perichondritis not only involves the perichondrium but also the chondral cartilage. the regeneration of damaged cartilage is difficult and necrotic chondrocytes will eventually be replaced by dense fibrosis and scar formation, which will cause consequent ear deformity.11 in our study, residual deformity of pinna was found in 68% of cases after six months follow-up. indeed, auricular perichondritis is a very frightening and frustrating disease. it requires prompt intervention and management, despite which permanent remodelling of the pinna may occur. perhaps the best way to prevent sequelae of this disease is still highlighting education on the risk factors and early intervention with administration of proper medications. future references davidi e, paz a, duchman h, luntz m, potasman i. perichondritis of the auricle: analysis 1. of 114 cases. isr med assoc j 2011 jan;13(1): 21–24. prasad hk, sreedharan s, prasad hs, meyyappan mh, harsha ks. perichondritis of the 2. auricle and its management. j laryngol otol 2007;121(6):530-4. bassiouny a. perichondritis of the auricle. 3. laryngoscope 1981;91(3):422-31 prasad kc, karthik s, prasad sc. a comprehensive study on lesions of the pinna, 4. am j otolaryngol 2005; 26(1): 1-6. templer j, renner gj. injuries of the external ear. 5. otolaryngol clin north am 1990; 23(5): 1003-18. more dr, seidel js, bryan pa. ear piercing techniques as a cause of auricular chondritis. 6. pediatr emerg care. 1999;15(3):189-92. das p. piercing the cartilage and not the lobules leads to ear infections. 7. lancet infect dis 2002;2(12):715 dowling ja, foley fd, moncrief ja. chondritis in the burned ear. 8. plast reconstr surg 1968; 42(2) :115–22. apfelberg db, waisbren ba, masters fw, robinson dw. treatment of chondritis in 9. the burned ear by the local instillation of antibiotics. plast reconstr surg 1974;53(2): 179–83. stirn a. body piercing: medical consequences and psychological motivations.10. lancet 2003; 361(9364):1205-15. stroud mh. a simple treatment for suppurative perichondritis. 11. laryngoscope 1963 ; 73(5):556-63 studies should investigate the role allergic reactions may have as important contributing factors to auricular perichondritis, as we were unable to do so in this study. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 case reports 28 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2014; 29 (2): 28-31 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to present a case of bilateral temporomandibular joint ankylosis that was managed successfully through gap arthroplasty. methods: design: case report setting: tertiary government hospital patient: one results: a 25-year-old man presented with inability to open his mouth for 18 years after direct trauma to his chin. ct scan showed bilateral bony fusion of condyles to glenoid fossae, hypertrophic sclerosis and fusion of the condylar heads to the temporal bones. he underwent bilateral gap arthroplasty via preauricular approach with creation of a 15 mm space on the mandibular fossa. as of latest follow up, the patient maintained an inter-alveolar distance of 30 mm for five months postoperatively through continuous aggressive mouth opening exercises. conclusion: gap arthroplasty may be an efficient procedure for temporomandibular joint ankylosis in achieving satisfactory post-operative inter-alveolar opening and articular function. early and meticulous rehabilitation is required to prevent relapse. long-term follow up is recommended to document possible recurrence. keywords: temporomandibular joint ankylosis, gap arthroplasty, tmj ankylosis, ankylosis temporomandibular joint (tmj) ankylosis is the union of articular surfaces (mandibular condyle to the cranial base) by means of osseous and/or fibrous tissue with partial or complete mandibular impediment.1 the most common etiologic factors include trauma (13-100%), infections (10-49%), rheumathoid arthritis (10%), congenital anomalies and neoplastic processes.2 it is a condition leading to problems in mastication, digestion, speech, facial and oral hygiene. when acquired at childhood, devastating effects are observed during growth and development of teeth and jaws. it can negatively influence the psychosocial behavior of the patient due to the consequent facial deformity magnified as the child grows.2 various methods have been used to manage tmj ankylosis including gap arthroplasty, interpositional arthroplasty and joint reconstruction by bone grafts or joint prosthesis.1,2,3 recent studies advocate distraction osteogenesis in management of tmj ankylosis as it provides excellent cosmetic results.4 a local report in 1984 by nolasco et al. involved a case of bilateral tmj ankylosis treated with interpositional arthroplasty wherein 5 mm length of the bone was removed from edge to edge then interposed with temporalis fascia and muscle.4 the patient gap arthroplasty of bilateral temporomandibular joint ankylosisferdinand z. guintu, mdalexander t. laoag, md joselito f. david, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. joselito f. david department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 743 6921; (632) 711 9491 local 320 email: entjrrmmc@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at: interesting case contest, philippine society of otolaryngology head and neck surgery, iloilo grand hotel, iloilo city, philippines, april 28, 2012. philippine journal of otolaryngology-head and neck surgery 29 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 case reports failed to follow up two weeks postoperatively and no further documentation of success or recurrence could be made.4 gap arthroplasty can be an additional armamentarium for practicing otolaryngologists in developing countries where a major reason for delayed management is the lack of adequate resources. our goal was to perform a simple yet effective procedure amenable to our filipino patients. we present a case of bilateral temporomandibular joint ankylosis that was managed successfully through gap arthroplasty. to the best of our knowledge, this is the first such case documented in the philippines. case report a 25-year-old man consulted due to inability to open his mouth. at the age of 7 years, he hit his chin on the handlebar of a jeepney during a vehicular accident. he was admitted with multiple contusions and discharged on the fifth hospital day. a week after discharge, he experienced gradual and progressive limitation of jaw movement. he consulted his attending physician and was advised that the limitation of jaw movement was due to infection. antibiotics did not improve his symptoms and he ceased to follow-up. he had progressive loss of jaw movement but was able to feed himself by inserting shredded pieces of noodles and meat through the small space between his teeth. physical examination revealed a classical ‘bird face appearance.” (figure 1a) there was excessive vertical overlap of the maxillary incisors (overbite), horizontal extension anteriorly of the maxillary incisors (overjet), dental caries and periodontal disease. mouth opening is measured via inter-incisal distance but for edentulous cases, inter-alveolar distance is used. our patient had zero inter-alveolar distance. (figure 1b) there were no gliding, protrusion and lateral movements of the mandible. mandibular bodies with inward displacement of the symphysis mentum. (figure 2) figures 1a. retrognathia “bird face” appearance; b. inter-alveolar distance of zero a b facial ct scans revealed bilateral bony fusion of the condyles to the glenoid fossae, hypertrophic sclerosis with fusion of the condylar heads to the temporal bones and shortening of the figure 2. hypertrophic sclerosis and fusion of the lateral aspect of condylar heads to the temporal bone. figures 3a & b. intraoperative finding of bilateral bony fusion of condyle and coronoid on the temporal bone b a after extensive literature review of the pros and con of the three commonly used treatment modalities for tmj ankylosis, we decided on gap arthroplasty. it is cheap, yet effective in achieving desired mouth opening, less invasive with no donor site morbidity. the operation was explained to the patient and he consented to the surgery. under general anesthesia via tracheostomy, both tmj were exposed through a preauricular approach taking care to preserve the branches of the facial philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 case reports 30 philippine journal of otolaryngology-head and neck surgery nerve. after exposure and identification of the sites of ankylosis (figure 3), the fibrous and bony masses were aggressively excised with round burs and chisels until adequate mandibular movements were achieved. bilateral coronoidectomies were also performed. a gap of 15 mm was created between the recontoured glenoid fossa and mandible. (figure 4) the cut sharp edges were smoothened with diamond burs. discussion ankylosis of the tmj is a challenging problem for both the patient and surgeon. over the years, fundamental principles of tmj surgery and “trial and error” have shaped the evolution of different techniques to correct the problem.6 in this case, trauma directed to the patient’s chin led to bilateral condylar fractures. neglected condylar fractures resulted in tmj ankylosis. tmj ankylosis is classified according to location (intra or extraarticular), type of tissue (osseous, fibrous, or fibro-osseous) and the degree of union (partial or complete) involved.1 it is further classified into true and false ankylosis. true ankylosis results in osseous or fibrous adhesion between the surfaces of the tmj, while false ankylosis results from diseases not directly related to the joint. sawhney in 1986 classified tmj ankylosis into four different types: type ipresence of fibroadhesions at the condyle; type ii – bone fusion with condyle remodeling and an intact medial pole; type iii – anquilotic mass, mandibular ramus union with the zygomatic arch and medial pole intact; and type iv – complete anquilotic mass, total union of the mandibular ramus with the zygomatic arch.7 our patient’s tmj ankylosis was classified as intra-articular, fibroosseus, partial union and type ii (only the lateral aspect has bony fusion). the diagnostic process consists of physical and radiographic examinations (ct with three-dimensional (3d) reconstruction). radiographic findings include condylar deformation, narrowing or irregularities at the inter-articular space. early diagnosis and treatment are pivotal to avoid sequelae.3 in our case, financial constraints wasted 18 years without treatment. the best results can be achieved after complete evaluation and establishment of long-term treatment planning. a variety of treatment techniques have been described in the literature. the three most commonly used are gap arthroplasty, interpositional arthroplasty and excision of ankylosed bone with articular reconstruction.1,2,3 vasconcelos et al. reported a b figures 4a & b. a 15mm space created on bilateral mandibular fossa one week postoperatively, the patient had an inter-alveolar distance of 30 mm. (figure 5) physiotherapy included stretching and electrical stimulation of muscles of mastication and the contract-hold-relax technique for masticatory muscles. at five months post-physiotherapy, he had gained weight and was well satisfied with the operation. inter-alveolar distance then remained at 30 mm. (figure 6) figure 5. one week postoperative inter-alveolar distance of 30 mm figure 6. a 30mm interalveolar distance 5 months post operatively philippine journal of otolaryngology-head and neck surgery 31 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 case reports references 1. de andrade lh, cavalcante ma, raymundo r jr, de souza ip. temporomandibular joint ankylosis in children. j dent. child. 2009 jan-apr; 76(1): 41-5. 2. vasconcelos bc, porto gg, bessa-noguiera rv, nascimento mm. surgical treatment of temporomandibular joint ankylosis: follow-up of 15 cases and literature review. med oral patol oral cir bucal. 2009 jan 1; 14(1): 34-8. 3. balaji sm. modified temporalis anchorage in craniomandibular reankylosis. int j oral maxillofac surg. 2003 oct; 32(5): 480-5. 4. mehrotra d, dhasmanaa s, kumar s. management of temporomandibular ankylosis with temporal fascia inter-positional arthroplasty and distraction osteogenesis: report of 30 cases. j long term eff med implants. 2009;19 (2):139-48. 5. nolasco f, cosalan e, dela cruz r. bilateral ankylosis of the temporomandibular joint. philipp j otolaryngol head neck surg. 1984: 309-11. 6. felstead am, revington pj. surgical management of temporomandibular joint ankylosis in ankylosing spondylitis. int j rheumatol. 2011 jan; 2011: 854167. 7. sawhney cp. bony ankylosis of the temporomandibular joint: follow-up of 70 patients treated with arthroplasty and acrylic spacer interposition. plast. reconstr. surg. 1986 jan; 77(10): 29-40. eight cases of tmj ankylosis managed by gap arthroplasty with no recurrence within a 24-month period.2 there is still no agreed standard treatment for tmj ankylosis. results of frequently reported operations like gap arthroplasty, interpositional arthroplasty and joint reconstruction with autogenous or alloplastic materials have been variable and often less than satisfactory because of documented recurrences. the interposition of autogenous or alloplastic materials at the osteotomy site may lead to morbidity at the donor site, unpredictable resorption and risk of a foreign body reaction.6 gap arthroplasty is a frequently used surgical option that is less invasive and requires less surgical time. the postoperative condition is more comfortable because no donor site is required, reducing the risk of lesions to other structures. the recurrence rate for gap arthroplasty is 13%. relapse usually occurred in sawhney type iv ankylosis. aggressive physiotherapy after surgery will reduce recurrence.2,6 meticulous preoperative planning, perioperative management and diligent postoperative care remain the keys to successful surgery. gap arthroplasty may be an efficient procedure for temporomandibular joint ankylosis in achieving satisfactory post-operative inter-alveolar opening and articular function. early and meticulous rehabilitation is required to prevent relapse. long-term follow up is recommended to document possible recurrence. philippine journal of otolaryngology-head and neck surgery 47 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports philipp j otolaryngol head neck surg 2015; 30 (1): 47-50 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to present an uncommon cause for a submandibular mass and review of the literature. methods: design: case report setting: tertiary government hospital patient: one results: a 25-year-old lady presented with a painless chronic submandibular swelling. ultrasound identified a solid mass following which an uncomplicated core biopsy was performed obtaining an accurate pre-operative histopathological diagnosis. pre-operative arterial embolization of this vascular mass led to a relatively bloodless wide local excision. radiological imaging for distant metastases was negative. conclusion: epitheloid hemangioendothelioma is an uncommon cause for a submandibular mass. a malignant vascular soft tissue tumor with morphologic characteristics similar to carcinomas, melanomas and epitheloid sarcomas, it has a high rate of metastasis and morbidity when it affects the soft tissues and viscera. immunohistochemistry provides clues to differentiation and recommended treatment consists of a surgical wide local excision with regional lymph node resection. as there are no established standard therapeutic protocols for this disease due to its rarity, an individual case-by-case approach and follow-up needs to be undertaken. keywords: epitheloid hemangioendothelioma, malignant vascular tumor, submandibular mass epitheloid hemangioendothelioma (ehe) is an uncommon vascular soft tissue tumor with intermediate malignancy risk and was first reported by weiss & enzinger in 1982.1 ehe is known to be the most aggressive of hemangioendotheliomas and carries a high rate of metastasis (20-30%) and mortality (10-20%). 2-5 we report an uncommon case of ehe in the submandibular region epitheloid hemangioendothelioma of the submandibular region peter ranjit, feborl-hns, ms (orl), dnb (orl), parekh nayan madhusudan, ms (orl), dnb (orl), frcs (orl) dayangku norsuhazenah pengiran suhaili, ms (orl-hns), mrcs (edin.) bickle ian christopher, mb, bch, bao, frcr correspondence: dr. ranjit peter department of orl, level 3, specialist building i ripas hospital bandar seri begawan, negara ba1710 brunei darussalam phone: +(673) 862 8007 fax: +(673) 222 1085 email: drranjitpeter@gmail.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. 48 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports case report a 25-year-old lady presented to the otorhinolaryngology clinic of ripas hospital, bandar seri begawan, negara brunei darussalam with a large painless right submandibular swelling which had grown very slowly over a 6-year period. the submandibular mass was non-inflammatory, non-pulsatile, non-tender, lobulated and soft in consistency measuring approximately 4x4 cm in dimension. it exhibited an element of mobility with respect to the adjacent mandible with no fixation to the overlying skin. there were no palpable neck nodes and minimal movement on tongue protrusion. there were no significant ear, nose or throat findings on clinical examination. (figure 1) revealed fibro-vascular tissue containing large numbers of prominent endothelial lined capillaries along with a moderate number of veins around the lesion. (figure 3) a proportion of the cells showed intracytoplasmic lumina with the pleomorphic nuclei. (figure 4) tumor cells stained for cd 34. however, s100 was negative. reticulin stain highlighted the vascular nature of the tumor. the appearance was consistent with ehe. figure1. lateral view of the right submandibular swelling hematological evaluation was normal. an ultrasound scan (uss) of the neck revealed a 3.3cm well defined, mildly heterogeneous mass in the right submandibular region, separate from the submandibular gland. minimal internal doppler flow was elicited. a uss guided 18g core biopsy was performed. (figure 2) histopathological examination figure 2. longitudinal ultrasound: well defined, solid heterogeneous submental mass, with needle core biopsy in situ figure 3. photomicrograph, scanner view, magnification 4x, h&e. fibrovascular tissue containing large numbers of prominent endothelial lined capillaries along with a moderate number of veins around the lesion. (hematoxylin and eosin, 4x) figure 4. photomicrograph, high power view, magnification 40x, h&e. cells showed intra-cytoplasmic lumina with the nuclei of the cells being pleomorphic. (hematoxylin and eosin, 40x) an arterial phase ct scan of the neck was performed which revealed a 4 x 2.9 cm well-defined avidly enhancing mass in the right submandibular space with the vascular supply from an engorged retromandibular vein and facial artery lying on the medial aspect of the mass. immediately adjacent to the mass on the anteromedial aspect 49 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports was an apparent separate identical 1.1cm lesion recruiting its vascular supply from the right lingual artery. in view of histopathological diagnosis, ct of the chest and abdomen was performed for staging purposes but was negative. pre-operative catheter angiography and embolization was performed 24 hours prior to surgery which revealed a vascular mass in the right submandibular region being supplied by a large feeder vessel from the lingual branch of the facial artery. (figure 5) this was embolized with surgicel. figure 5. longitudinal angiographic image: highly vascular submandibular mass, recruiting its arterial supply from branches of the facial artery wide local excision of the tumor was performed under general anesthesia via a horizontal curvilinear incision, 4 cm inferior to the horizontal lower border of mandible. sub-platysmal wide dissection around the tumor mass was undertaken. the arterial branch from the facial artery and a feeding vessel from the deeper surface of the gland were ligated and divided. the venous branches were electro-cauterized. the tumor mass was anatomically located in the right submandibular region with the mylohyoid muscle and the right anterior belly of digastric muscle forming the surgical floor of the resected mass. it was distinct from the submandibular salivary gland located posteriorly. the excised surgical specimen was 6 x 4 x 2.5 cm in dimension. (figure 6) the right marginal mandibular nerve function was intact postoperatively. a vacuum lantern drain was placed for 48 hours. histopathology of the resected specimen revealed a tumor consisting of thin walled capillaries arranged in a lobular pattern situated in a hyalinized stroma. it contained prominent endothelial cells with eosinophilic cytoplasm and hyperchromatic, pleomorphic nuclei with indistinct nucleoli. there were 2-3 mitotic figures per 10 high power field. the margins were free of the tumor. the findings were consistent with ehe. discussion ehe has been documented to occur at several anatomical sites such as the liver, lung, pleura, bone, lymph nodes, skin, brain, meninges and heart. ehe in the head and neck has been found to originate from the soft tissues with approximately 26% of cases exhibiting re-absorption and / or adjacent bone destruction. tongue and gingival ridges are the most common sites of origin in the oral cavity with the upper gingivae and oral mucosa being the most common sites of relapse. lesions in the nasal cavity, parotid gland, larynx and thyroid have also been reported.6 in our case, there was no evidence of adjacent soft tissue or bone involvement. ehe has no age or sex predisposition. it is rare in children. 6,7 these lesions are generally asymptomatic, painless and present as illdefined solitary masses in the superficial or deep soft tissues. enzinger and weiss considered the biological behavior of ehe to be between a hemangioma and angiosarcoma.1 the world health organization (who) has classified ehe as a malignant vascular soft tissue tumor.8 ehe has been reported to have a high rate of metastasis (20-30%) and mortality (10-20%) when it affects the soft tissues and viscera.6 deyrup et al. analyzed 49 cases of ehe in soft tissues and concluded that large tumors (diameter > 3cm) with high mitotic activity ( > 3 mitotic figures / 50 hpf) have an aggressive clinical course.9 ehe has several morphological characteristics that are similar to carcinomas, melanomas and epitheloid sarcomas.10 immunohistochemistry provides reliable clues regarding differentiation. some surgeons advocate pre-operative embolization in order to prevent excessive intra-operative hemorrhage.11 in our case, radiological evaluation with doppler ultrasonography and contrast-enhanced ct was helpful in assessing the vascularity and pre-operative angiography figure 6. excised tumor gross specimen measuring 6x4x2.5 cm with suture marking on its superiormedial aspect 50 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports acknowledgements we acknowledge dr. pemasiri upali telisinghe, frc (path) for histopathological reporting and photomicrographs and dr. zachariah varkki, ms (ent) for the intra-operative photographs. references 1. weiss sw, enzinger fm. epitheloid hemangioendothelioma: a vascular tumor often mistaken for a carcinoma. cancer 1982; 50:970-981 2. chi ac, weathers dr, folpe al, dunlap dt, rasenberger k, neville bw. epithelioid hemangioendothelioma of the oral cavity: report of two cases and review of the literature. oral surg oral med oral pathol oral radiol endod, v. 100, n. 6, p. 717-24, 2005. 3. goh sgn, calonje e. cutaneous vascular tumours: an update. histopathology, v. 52, p. 66173, 2008. 4. makhlouf hr, ishak kg, goodman zd. epithelioid hemangioendothelioma of the liver. a clinicopathologic study of 137 cases. cancer, v. 85, p. 562-82, 1999. 5. mentzel t, beham a, calonje e, katenkamp d, fletcher cd. epithelioid hemangioendothelioma of skin and soft tissues: clinicopathologic and immunohistochemical study of 30 cases. am j surg pathol, v. 21, p. 363-74, 1997. 6. ana karla ac, sérgio de or, ana lucia ae. epithelioid hemangioendothelioma: 15 years at the national cancer institute. literature review.” jornal brasileiro de patologia e medicina laboratorial 49.2 (2013): 119-125. url: http://www.scielo.br/pdf/jbpml/v49n2/07.pdf 7. tseng cc, tsay sh, tsai tl, shu ch. epitheloid hemangioendothelioma of the nasal cavity. j chin med assoc january 2005 vol 68 no.1: 45-48 8. fletcher cdm. the evolving classification of soft tissue tumours – an update based on the new 2013 who classification. histopathology 2014, 64, 2–11. doi: 10.1111/his.12267 9. deyrup, at, tighiouart m, montag ag, weiss sw. epithelioid hemangioendothelioma of soft tissue: a proposal for risk stratification based on 49 cases. am j surg pathol, v. 32, n.6, p. 924-7, 2008. 10. jabeen n, nelson go, mario al, michelle dw, randal sw, adel ke. epithelioid hemangioendothelioma of the head and neck: role of podoplanin in the differential diagnosis. head and neck pathol (2008) 2:25–30 . doi 10.1007/s12105-007-0035-0 11. phookan g, a. t. davis at, holmes b. hemangioendothelioma of the cavernous sinus: case report. neurosurgery, vol.42, no. 5, pp. 1153–1156, 1998. 12. enzinger fm, weiss sw. hemangioendothelioma: vascular tumors of intermediate malignancy. soft tissue tumors, 4th edition. st.louis: cv mosby, 1995:891-900 13. weiss sw, ishak kg, dail dh. epethelioid hemangioendothelioma and related lesions. seminars in diagnostic pathology, vol. 3, no. 4, pp. 259–287, 1986. 14. aksoy ea, atalar b, beylergil v, unal of. unresectable epitheloid hemangioendothelioma of the neck region cured by radiotherapy. j med cases 2011;2(4):147-150 doi : 10.4021/jmc216w. followed by embolization led to a relatively bloodless surgical excision. the recommended treatment for ehe consists of a wide local excision with regional lymph node resection due to the high risk of lymphatic metastases.12,13 however, there are no established standard therapeutic protocols for this disease due to its rarity. therefore an individual caseby-case approach and follow-up needs to be undertaken. unresectable invasive ehe may be subjected to radiotherapy.14 anti-angiogenic agents have been proposed as a possible future treatment option.10 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles 14 philippine journal of otolaryngology-head and neck surgery abstract objectives: this study aims to determine the sensitivity, specificity, positive predictive value and negative predictive value of computerized dynamic posturography (cdp) in properly labeling patients with peripheral vestibular disorders by videonystagmography (vng) as having vestibular dysfunction. methods: design: case control study setting: tertiary private hospital subjects: twenty-three (23) patients aged 18 and above with no history of hypertension or cardiovascular disease and no intake of anti-vertigo medications for at least 48 hours prior to testing and with complete vng and cdp results obtained on the same day or at least two days apart were included in the study. cases were defined as those diagnosed with a peripheral vestibular disorder by vng while controls were defined as those with normal vng results. sensitivity, specificity, positive predictive value and negative predictive value of cdp in labeling those with peripheral vestibular disorders as vestibular were determined using vng as gold standard. results: there were 11 cases (4 males, 7 females) and 12 controls (8 males, 4 females). using vng as the gold standard for diagnosing peripheral vestibular disorders, cdp had a sensitivity of 45.45% and specificity of 66.67% with positive predictive value(ppv) of 55.56% and negative predictive value(npv) of 57.14% in assessing peripheral vestibular disorders among the adults tested. interestingly, 33.33% of patients with normal vng may actually have had a vestibular dysfunction that could be detected by cdp. conclusion: prospective studies with larger sample sizes utilizing vng and cdp are recommended in order to verify our findings. keywords: dizziness, posturography, vertigo dizziness is one of the most common complaints of patients seeking medical attention. the estimated prevalence of dizziness in the general population is said to be around 20 to 30%1 with a reported prevalence rate of 2.5% for dizziness and vertigo at a tertiary hospital in the philippines.2 the term dizziness has been described as a spinning sensation, floating or lightheadedness and falling or loss of balance. when dizziness is described as a spinning sensation either of self, the environment or both, we call this type of dizziness vertigo. peripheral vestibular disorders which include benign paroxysmal positional vertigo (bppv) represent the most common group of the vertiginous diseases.1 diagnostic value of computerized dynamic posturography in the assessment of peripheral vestibular disorders ronaldo g. soriano, md reylan b. david, md norberto v. martinez, md department of otolaryngology head and neck surgery st. luke’s medical center correspondence: dr. ronaldo g. soriano department of otolaryngology head and neck surgery saint luke’s medical center 279 e. rodriguez ave., quezon city 1102 philippines phone: (632) 727 5543 fax: (632) 723 1199 (h) email: slmcearnosethroat@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at philippine society of otolaryngology head and neck surgery analytical research contest (4th place), october 24, 2013, cet auditorium, glaxosmithkline (gsk) bldg., chino roces ave., makati city philipp j otolaryngol head neck surg 2015; 30 (1): 14-16 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 15 a good history and physical examination have remained a very reliable tool in the diagnosis of most vestibular conditions.3 however, in conditions where the diagnosis of vertigo remains unclear even after a detailed medical examination, videonystagmography (vng), a test that evaluates the presence of pathologic nystagmus has been a helpful tool in assessing the presence of a vertiginous disorder.4 nevertheless, criticisms regarding its use abound as it (1) primarily evaluates the lateral semicircular canals, (2) provides less information regarding possible central pathology, (3) has limited insight into overall balance function (i.e. it does not evaluate visual inputs and balance adaptation), and (4) does not characterize deficits in terms of patient’s functional status (i.e ability to stand).5 videonystagmography (vng) was used in this study. it is an objective way to evaluate and screen for a variety of vestibular disorders and is available in our local setting. computerized dynamic posturography (cdp), a relatively newer test that assesses postural stability and tendency to fall has recently been introduced in our country. it has traditionally been used in the rehabilitation of patients suffering from dizziness. some studies6,7 have shown the capacity of cdp in the treatment rehabilitation and assessment of patients with bppv. other authors 8,9 have correlated cdp and eng in evaluating patients with dizziness. in a previous study10, patients with peripheral vertigo had 45% abnormal cdp using eng as the gold standard; on the other hand, another study11 suggested that 90% of those with peripheral vestibular disorder using vng had abnormal cdp. our purpose in undertaking this study was to determine the sensitivity, specificity, positive predictive value and negative predictive value of computerized dynamic posturography in properly labeling patients diagnosed with peripheral vestibular disorders by vng as having vestibular dysfunction in order to see if the above findings correlate well in the local setting. methods this was a retrospective study of records of patients with peripheral vestibular disorders and cdp and vng results seen at the institute of neurosciences hearing and balance center of st. luke’s medical center, global city from 2007 to 2013. data such as age, gender, type of dizziness, timing and duration of dizziness retrieved from previouslyaccomplished videonystagmography questionnaires in patient charts as well as vng and cdp results were culled using ms excel 2007 (v12.0) (microsoft, redmond, washington, usa). records of patients aged 18 and above with no history of hypertension or cardiovascular diseases and no intake of anti-vertigo medications for at least 48 hours prior to testing and complete vng and cdp results obtained on the same day or at least two days apart were included in the study. cases were defined as those diagnosed with a peripheral vestibular disorder by vng while controls were defined as those with normal vng results. our goal was to consider only those with purely peripheral vestibular disorders as cases and therefore, those with hypertension and cardiovascular diseases were excluded. only the sensory organization test part of the cdp was used in this study. chi-square test was used to determine the difference between patient demographics with numerical values > 5. fisher’s exact test was used for values < 5. epi info™ version 6 (centers for disease control and prevention, atlanta, georgia, usa) was utilized. the sensitivity, specificity, positive predictive value and negative predictive value of cdp in labeling those with peripheral vestibular disorders as vestibular were determined using vng as the gold standard. results records of 23 patients meeting inclusion and exclusion criteria were included. twelve (12) were male (52%) and 11 were female (48%). their ages ranged from 21 to 82-years-old. there were 11 cases (4 males, 7 females) and 12 controls (8 males, 4 females). using chi-square test, there was no significant difference between cases and controls with regards to age (p = 0.73; level of significance at 0.05), sex (p=0.24), pattern of dizziness (p=0.45) and duration of dizziness (p=0.18) using vng as the gold standard for diagnosing peripheral vestibular disorders, cdp had a sensitivity of 45.45% and specificity of 66.66% with ppv of 55.56% and npv of 57.14%. interestingly, 33.33% (4/12) of patients with normal vng had a vestibular dysfunction detected by cdp. (table i) table 1. patients with dizziness based on vng and cdp results control casespopulation cdp results vestibular visual somatosensory visual and vestibular visual, vestibular and somatosensory normal male 0 2 1 0 1 4 male 1 0 0 3 0 0 female 0 0 1 2 1 0 female 0 1 0 1 0 5 total 0 2 2 2 2 4 total 1 1 0 4 0 5 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles 16 philippine journal of otolaryngology-head and neck surgery discussion a study exploring the diagnostic value of cdp in assessing peripheral vestibular disorders using vng by zhang et al. found that 90% of those with peripheral vestibular disorders had abnormal cdp.11 this contrasts with the findings of voorhees10 that 45% of 112 peripheral cases of vertigo had abnormal results on cdp using electronystagmography (eng) as gold standard (assuming any abnormality detected by cdp to be a positive test). despite our small sample size, our findings seem to confirm those of voorhees11 that cdp has a low 45% sensitivity in detecting a vestibular disorder if vng is assumed to be the gold standard. however, a significant number of patients (33.33%) presenting with normal vng findings may actually have had a vestibular dysfunction perceived only by cdp. this finding may still suggest a role for cdp in diagnosing vestibular disorders. we recognize the limitations of this study such as small sample size and the limitation of vng as well disadvantages inherent in a retrospective approach. we recommend future prospective studies with larger sample sizes utilizing vng and cdp in order to verify our findings. acknowledgements we would like to thank charisse ballad, msc of the clinical information services for helping with the statistics and to the institute of neurosciences hearing and balance center of st. luke’s medical center for helping and providing us with access to the records of our patients. we also want to express our gratitude to our department chairs and training officers (st.luke’squezon city: dr. ray casile and dr. joel romualdez; st.luke’s-bonifacio global city: dr. william lim and dr. keith aguilera) for their continuing support and inspiring us to do our research. references hannaford pc, simpson ja, bisset af, davis a, mckerrow w, mills r. the prevalence of ear, nose 1. and throat problems in the community results from a national cross-sectional postal survey in scotland. fam pract. 2005 jun; 22(3):227-33. caro, rm, chiong cm, jose em: philippine society of otolaryngology-head and neck surgery, 2. inc. task force on clinical practice guidelines. proceeding of the consensus on vertigo, november 7, 2003 asian institute of management makati city. philipp j otolaryngol head neck surg supplement (december 2004), 19(4):1-22. strupp m, brandt t. diagnosis and treatment of vertigo and dizziness. 3. dtsch arztbel int. 2008 mar; 105 (10): 173-180. hathiram bt, khattar vs. videonystagmography. 4. int j otorhinolaryngol clin. 2012; 4(1) : 17-24 sataloff rt, hawkshaw mj, mandel h, zwislewski ab, armour j, mandel s. abnormal 5. computerized dynamic posturography findings in dizzy patients with normal eng results. ear nose throat j. 2005 apr; 84(4):212-4. zhang dg, fan zm, han yc, yu g, wang hb. clinical value of dynamic posturography in the 6. evaluation and rehabilitation of vestibular function of patients with bppv. zhonghua er bi yan houtou jing waikezazhi. 2010 sep;45(9):732-6 liu j, guo s, wang k, li z, du z, xie w, liu y. significance of eng and dpg in the vestibular 7. function examination in patients suffering bppv. lin chung er bi yan hou tou jing wai ke za zhi. 2012 apr; 26(7): 289-92 goebel ja, paige gd. dynamic posturography and caloric test results in patients with and 8. without vertigo. otolaryngol head neck sur. 1989 jun; 100(6):553-8. lipp m, longridge ns. computerised dynamic posturography: its place in the evaluation of 9. patients with dizziness and imbalance. j otolaryngol. 1994 jun;23(3):177-83. voorhees rl. the role of dynamic posturography in neurotologic diagnosis. 10. laryngoscope. 1989 oct; 99(10 pt 1):995-1001. zhang d, fan z, yu g, wang h. the clinical value of dynamic posturography in the 11. peripheral vertigo. lin chung er bi yan hou tou jing wai ke za zhi. 2009 aug;23(16):721-3, 727. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 24 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2012; 27 (2): 24-27 c philippine society of otolaryngology – head and neck surgery, inc. giant cell tumor of the maxilla somnath saha, ms1 sharmila sen, md2 v. padmini saha, mch3 sudipta pal, ms1 1department of ent & hns r.g. kar medical college & hospital kolkata, west bengal, india 2department of pathology calcutta national medical college kolkata, west bengal, india 3department of plastic & reconstructive surgery rg kar medical college & hospital kolkata, west bengal, india correspondence: dr sudipta pal 223, lane no.-3, jhilpark j.c.khan road, p.o.: mankundu dist: hooghly, west bengal india pin: 712139 phone: +919051757391/+919231535309 e-mail: drsudiptapal@gmail.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. abstract objective: to present a rare case of maxillary swelling; its investigation and management. methods: design: case report setting: tertiary government teaching hospital patient: one results: a 45-year-old female presented with a right maxillary swelling of six months duration. radiological investigation revealed a radiolucent lesion arising from the inferior aspect of the right maxilla with no areas of calcification. incisional biopsy report was consistent with giant cell tumor. the mass was excised via a weber ferguson incision under general anesthesia. conclusion: though rare, giant cell tumor should be considered as one of the differential diagnosis in cases of maxillary swelling. adequate surgical excision with long-term follow-up should be the treatment of choice for managing a giant cell lesion of the maxilla. keywords: maxillary swelling, giant cell tumor giant cell tumors make up 4-5% of all primary bone tumors.1 they are usually benign, but occasionally, they can be primarily malignant or can undergo malignant transformation. they can behave aggressively and metastasize. more than 75% are located in the epiphyseal region of long bones, and the most common locations in order of frequency are the lower end of femur, upper end of tibia and lower end of radius. true giant cell tumors (gct) of the head and neck are exceedingly rare and constitute approximately 2% of all gcts.2 most of the lesions diagnosed as giant cell tumors are in truth giant cell granulomas. in one large series of gct from south india, rockwell & small reported only one case of maxillary involvement over a period of 10 years.3 we present a case of gct involving the right maxilla from a rural medical college of bengal with its management. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 case reports philippine journal of otolaryngology-head and neck surgery 25 figure 3. microphotograph of the histopathological slide (hematoxylin & eosin stain, high power view, magnification – 40x) showing numerous multinucleated giant cells distributed in a highly cellular stroma composed of spindle-shaped and round cells. the patient did report using tobacco. examination revealed a diffuse hard swelling on the right side of the face of approximately 5 cm. diameter obliterating the ipsilateral nasolabial fold and pushing up the ala of nose. the swelling was nontender, hard, smooth-surfaced, firmly related to the underlying maxillary bone and had an eggshell-like crackling on palpation. the overlying skin was normal and there was no local rise of temperature. intraoral examination revealed a swelling in the gingivo-labial groove extending from the right upper lateral incisor to the first molar with no extension to the palate. there was no associated lymphadenopathy. routine hemogram was within normal limits. serum calcium was 9.3 mg/dl, phosphorus 4.1 mg/dl and alkaline phosphatase was 92 u l. ecg and chest x-ray were within normal limits. computed tomography scan showed a radiolucent lesion arising from the inferior aspect of the right maxilla with no areas of calcification, completely obliterating the left maxillary antrum with thinning and destruction of parts of the antral wall. (figure 2) it extended inferiorly into the body of the maxilla up to the alveolus, involving the adjoining teeth. infero-medially, it reached the midline. medially, it almost obliterated the posterior third of the left nasal cavity. posteriorly it reached the pterygoid plates. superiorly, it figure 2. axial ct scan of paranasal sinuses showing tumor in the right maxilla. note the homogenous opacity without any calcification along with destruction of adjoining bone. case report a 45-year-old woman presented to the department of otorhinolaryngology with a painless swelling on the right side of the face for six months. (figure 1) the swelling was of insidious onset and had progressed slowly. there was no history of any loosening of teeth. there was a history of trauma to the face five to six years ago. there were no facial paraesthesias, nasal discharge, epiphora or systemic symptoms. medical history and family history were non-contributory. (hematoxylin & eosin stain, high power view, magnification – 40x) figure 1. clinical photograph of the patient showing right maxillary swelling 26 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 case reports references som pm, brandwein m. sinonasal cavities: inflammatory diseases, tumors, fractures and post-1. operative findings. in: som pm, curtin hd editors. head and neck imaging vol. 1, 3rd ed. new york: cv mosby year book publishers; 1996. pp. 126-318. marioni g, marchese-ragona r, guarda-nardini l, stramare r, tognazza e, marino f, staffieri a. 2. giant cell tumour (central giant cell lesion) of the maxilla. acta otolaryngol. 2006 jul;126(7):77981. rockwell ma, small cs. giant-cell tumors of bone in south india.3. j bone joint surg am. 1961 oct; 43-a:1035-1040. stacy gs, peabody td, dixon lb. mimics on radiography of giant cell tumor of bone. 4. ajr am j roentgenol. 2003 dec;181(6):1583–1589. micheau c, schwaab g, vera sempere fj, llombart-bosch a. giant cell tumors of maxilla; 5. ann otolaryngol chir cervicofac.1987;104(4):251-7. mooney ww, bridger gp, baldwin m, donellan m. recurrent giant cell tumour of the maxilla 6. associated with both paget’s disease and primary hyperparathyroidism. anz j surg. 2003 oct;73(10):863-864. murphey md, nomikos gc, flemming dj, gannon fh, temple ht, kransdorf mj. from the 7. archives of afip. imaging of giant cell tumor and giant cell reparative granuloma of bone: radiologic-pathologic correlation. radiographics, 2001 sep-oct; 21(5):1283-309. stolovitzky jp, waldron ca, mcconnel fm. giant cell lesions of the maxilla and paranasal sinuses. 8. head neck. 1994 mar-apr;16(2):143 – 148. magu s, mathur sk, gulati sp, yadav a, kaushal v.giant cell reparative granuloma of the base of 9. the skull presenting as a parapharyngeal mass. neurol india. 2003 jun;51( 2):260-262. 10. mcdonald dj, sim fh, mcleod ra, dahlin dc. giant-cell tumor of bone. j bone joint surg am 1986 feb;68(2):235-242. extended up to the floor of the orbit. incisional biopsy through the involved gingivo-labial sulcus yielded a histopathological reading of numerous multinucleated giant cells, which were distributed in a highly cellular stroma composed of spindleshaped and round cells which were found mostly in the areas of hemorrhages. the giant cells were numerous and distributed randomly, their nuclei mainly confined to the center of the cells leaving a clear zone of cytoplasm at the periphery. ingested rbcs and scanty collagen were also seen. (figure 3) these findings were consistent with diagnosis of a giant cell tumor. under general anesthesia, the tumor was exposed by a weber ferguson incision and a 5cm x 5cm mass was enucleated. postoperative recovery was uneventful and the final histopathological report was consistent with giant cell tumor. discussion multinucleated giant cells are found in many fibro-osseous lesions of the jaw with many differential diagnoses. the giant cells in themselves are of little diagnostic importance and may be found in a number of pathologies affecting the jaw.4 giant cell tumors (gcts or osteoclastomas) are epiphyseal mesenchymal neoplasms of low malignant potential, comprising 4-5% of all primary bone tumors in adults.1 true gcts constitute 2% of all giant cell-rich tumors of the jaw.2 they usually occur after the second decade of life. growth of the tumor is intermittent and variable, and pain is the commonest presenting symptom.4 gct may sometimes be associated with other pathologies like von recklinghausen’s disease, francescatti syndrome, hyperthyroidism and paget’s disease.5,6 multiple gcts, although rare, do occur and may be associated with paget’s disease. malignant gct accounts for 5%-10% of all gcts and is usually secondary to previous irradiation of benign gct7 although a minor proportion of malignant gcts occur de novo. in gct, the multinucleated giant cells do not appear to be neoplastic and result from fusion of circulating monocytes recruited into the lesion. the mononuclear stromal cells form the neoplastic component as it is the only proliferating element in the lesion. their nature is controversial. they are clearly mesenchymal in origin rather than hematopoietic and share many features with normal mesenchymal stromal cells. giant-cell tumor of the jaw is a difficult clinical diagnosis as it may resemble other jaw lesions. the differentiation between these entities may be impossible even on biopsy without radiographic and clinical correlation.2 radiologically, gct is characterized by a lytic, expansile lesion in the epiphysis usually without peripheral bone sclerosis or periosteal reaction. the lesion is usually multilocular and may show multiple fluid levels or soft tissue density mass with expansion of the bone. cystic (secondary aneurysmal bone cyst) components are reported in 14% of gcts. the bony cortex is usually intact. the post contrast scan reveals homogenous enhancement of the mass. on mri, the solid components demonstrate low to intermediate signal intensity in a t2 weighted image, a feature that can be helpful in diagnosis.7 true gcts of the jaw should be clinically, radiologically and histologically differentiated from a giant cell reparative granuloma, brown tumor of hyperparathyroidism, aneurysmal bone cysts and cherubism. giant cell reparative granuloma (gcrg) of the jaw may be either peripheral-involving the gingiva and the alveolar mucosa or central occurring as an endosteal lesion within the jaw bones.4 these lesions are related to prior tooth extraction or an ill-fitting denture and are self limited, may regress, seldom recur & never metastasize. histopathologically, its hemorrhagic fibroblastic background with innumerable giant cells differentiates it from a gct.1 analyzing four cases of giant cell lesion of the maxilla, stolovitzky et al. hypothesize that giant cell granuloma of the maxilla and paranasal sinuses and true gcts of these bones represent a continuum of a single disease process, which may have an aggressive clinical behavior.8 in hyperparathyroidism, the mandible or maxilla may be the site for a giant cell lesion (brown tumor). hyperparathyroidism should always be considered if the patient is older, if the maxilla or facial bones or both are the sites if involvement and recurrences prevail.4 differential diagnosis of brown tumors of hyperparathyroidism from other jaw tumors is based mainly on clinical and laboratory data such as serum and urinary levels of calcium, phosphates, radioimmunoassay for parathyroid hormone, phosphate clearance, bone and serum alkaline phosphatase, etc.9 aneurysmal bone cysts rarely occur in the maxilla, orbit, ethmoid or frontal bones. these lesions are slow growing and predominantly affect patients below the age of 20 years. the lesions are multilocular and demonstrate multiple fluid levels. microscopically, they consist of numerous blood filled cavernous spaces lined by young connective tissue but devoid of endothelial lining, elastic or muscular elements. cherubism is an autosomal dominant disorder affecting the maxilla and mandible, where osteoclastic and osteoblastic activity of the bones cause them to be replaced by fibrous tissue along with cysts. cherubism is a rare differential for gct of jaw bones.10 a main microscopic difference between a true giant cell tumor and these close morphologic mimics is based on the spatial relationship between giant and stromal cells in the lesion. in gct, giant cells tend to be distributed regularly and uniformly whereas in lesions that simulate giant cell tumor, foci containing numerous clumped giant cells alternate with large areas devoid of giant cells. treatment of gct usually consists of surgical resection and the type of surgery depends on location of the tumor. the recommended surgical procedure in gcts is curettage with bone grafting or en bloc excision with replacement with allograft or biocompatible material. in one advanced central giant cell lesion of the maxilla, marrioni et al. described maxillectomy as the treatment of choice and they successfully reconstructed the maxillary defect with autologous calvaria and a temporalis muscle pedicled flap.2 in the present case, partial anterolateral maxillectomy was done and the defect was covered only by soft tissue from the cheek. recurrence is common and the type of initial surgical removal is the most significant factor in recurrence. recurrence usually occurs if curettage or any other treatment short of complete removal is employed. the recurrence rate is 34% following curettage and 7% following wide resection.10 though rare, giant cell tumor should be considered as one of the differential diagnosis in cases of maxillary swelling. the diagnosis is made on the basis of radiological and histological features. adequate surgical excision with long-term follow-up should be the treatment of choice for managing a giant cell lesion of the maxilla. philippine journal of otolaryngology-head and neck surgery 27 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 case reports references som pm, brandwein m. sinonasal cavities: inflammatory diseases, tumors, fractures and post-1. operative findings. in: som pm, curtin hd editors. head and neck imaging vol. 1, 3rd ed. new york: cv mosby year book publishers; 1996. pp. 126-318. marioni g, marchese-ragona r, guarda-nardini l, stramare r, tognazza e, marino f, staffieri a. 2. giant cell tumour (central giant cell lesion) of the maxilla. acta otolaryngol. 2006 jul;126(7):77981. rockwell ma, small cs. giant-cell tumors of bone in south india.3. j bone joint surg am. 1961 oct; 43-a:1035-1040. stacy gs, peabody td, dixon lb. mimics on radiography of giant cell tumor of bone. 4. ajr am j roentgenol. 2003 dec;181(6):1583–1589. micheau c, schwaab g, vera sempere fj, llombart-bosch a. giant cell tumors of maxilla; 5. ann otolaryngol chir cervicofac.1987;104(4):251-7. mooney ww, bridger gp, baldwin m, donellan m. recurrent giant cell tumour of the maxilla 6. associated with both paget’s disease and primary hyperparathyroidism. anz j surg. 2003 oct;73(10):863-864. murphey md, nomikos gc, flemming dj, gannon fh, temple ht, kransdorf mj. from the 7. archives of afip. imaging of giant cell tumor and giant cell reparative granuloma of bone: radiologic-pathologic correlation. radiographics, 2001 sep-oct; 21(5):1283-309. stolovitzky jp, waldron ca, mcconnel fm. giant cell lesions of the maxilla and paranasal sinuses. 8. head neck. 1994 mar-apr;16(2):143 – 148. magu s, mathur sk, gulati sp, yadav a, kaushal v.giant cell reparative granuloma of the base of 9. the skull presenting as a parapharyngeal mass. neurol india. 2003 jun;51( 2):260-262. 10. mcdonald dj, sim fh, mcleod ra, dahlin dc. giant-cell tumor of bone. j bone joint surg am 1986 feb;68(2):235-242. extended up to the floor of the orbit. incisional biopsy through the involved gingivo-labial sulcus yielded a histopathological reading of numerous multinucleated giant cells, which were distributed in a highly cellular stroma composed of spindleshaped and round cells which were found mostly in the areas of hemorrhages. the giant cells were numerous and distributed randomly, their nuclei mainly confined to the center of the cells leaving a clear zone of cytoplasm at the periphery. ingested rbcs and scanty collagen were also seen. (figure 3) these findings were consistent with diagnosis of a giant cell tumor. under general anesthesia, the tumor was exposed by a weber ferguson incision and a 5cm x 5cm mass was enucleated. postoperative recovery was uneventful and the final histopathological report was consistent with giant cell tumor. discussion multinucleated giant cells are found in many fibro-osseous lesions of the jaw with many differential diagnoses. the giant cells in themselves are of little diagnostic importance and may be found in a number of pathologies affecting the jaw.4 giant cell tumors (gcts or osteoclastomas) are epiphyseal mesenchymal neoplasms of low malignant potential, comprising 4-5% of all primary bone tumors in adults.1 true gcts constitute 2% of all giant cell-rich tumors of the jaw.2 they usually occur after the second decade of life. growth of the tumor is intermittent and variable, and pain is the commonest presenting symptom.4 gct may sometimes be associated with other pathologies like von recklinghausen’s disease, francescatti syndrome, hyperthyroidism and paget’s disease.5,6 multiple gcts, although rare, do occur and may be associated with paget’s disease. malignant gct accounts for 5%-10% of all gcts and is usually secondary to previous irradiation of benign gct7 although a minor proportion of malignant gcts occur de novo. in gct, the multinucleated giant cells do not appear to be neoplastic and result from fusion of circulating monocytes recruited into the lesion. the mononuclear stromal cells form the neoplastic component as it is the only proliferating element in the lesion. their nature is controversial. they are clearly mesenchymal in origin rather than hematopoietic and share many features with normal mesenchymal stromal cells. giant-cell tumor of the jaw is a difficult clinical diagnosis as it may resemble other jaw lesions. the differentiation between these entities may be impossible even on biopsy without radiographic and clinical correlation.2 radiologically, gct is characterized by a lytic, expansile lesion in the epiphysis usually without peripheral bone sclerosis or periosteal reaction. the lesion is usually multilocular and may show multiple fluid levels or soft tissue density mass with expansion of the bone. cystic (secondary aneurysmal bone cyst) components are reported in 14% of gcts. the bony cortex is usually intact. the post contrast scan reveals homogenous enhancement of the mass. on mri, the solid components demonstrate low to intermediate signal intensity in a t2 weighted image, a feature that can be helpful in diagnosis.7 true gcts of the jaw should be clinically, radiologically and histologically differentiated from a giant cell reparative granuloma, brown tumor of hyperparathyroidism, aneurysmal bone cysts and cherubism. giant cell reparative granuloma (gcrg) of the jaw may be either peripheral-involving the gingiva and the alveolar mucosa or central occurring as an endosteal lesion within the jaw bones.4 these lesions are related to prior tooth extraction or an ill-fitting denture and are self limited, may regress, seldom recur & never metastasize. histopathologically, its hemorrhagic fibroblastic background with innumerable giant cells differentiates it from a gct.1 analyzing four cases of giant cell lesion of the maxilla, stolovitzky et al. hypothesize that giant cell granuloma of the maxilla and paranasal sinuses and true gcts of these bones represent a continuum of a single disease process, which may have an aggressive clinical behavior.8 in hyperparathyroidism, the mandible or maxilla may be the site for a giant cell lesion (brown tumor). hyperparathyroidism should always be considered if the patient is older, if the maxilla or facial bones or both are the sites if involvement and recurrences prevail.4 differential diagnosis of brown tumors of hyperparathyroidism from other jaw tumors is based mainly on clinical and laboratory data such as serum and urinary levels of calcium, phosphates, radioimmunoassay for parathyroid hormone, phosphate clearance, bone and serum alkaline phosphatase, etc.9 aneurysmal bone cysts rarely occur in the maxilla, orbit, ethmoid or frontal bones. these lesions are slow growing and predominantly affect patients below the age of 20 years. the lesions are multilocular and demonstrate multiple fluid levels. microscopically, they consist of numerous blood filled cavernous spaces lined by young connective tissue but devoid of endothelial lining, elastic or muscular elements. cherubism is an autosomal dominant disorder affecting the maxilla and mandible, where osteoclastic and osteoblastic activity of the bones cause them to be replaced by fibrous tissue along with cysts. cherubism is a rare differential for gct of jaw bones.10 a main microscopic difference between a true giant cell tumor and these close morphologic mimics is based on the spatial relationship between giant and stromal cells in the lesion. in gct, giant cells tend to be distributed regularly and uniformly whereas in lesions that simulate giant cell tumor, foci containing numerous clumped giant cells alternate with large areas devoid of giant cells. treatment of gct usually consists of surgical resection and the type of surgery depends on location of the tumor. the recommended surgical procedure in gcts is curettage with bone grafting or en bloc excision with replacement with allograft or biocompatible material. in one advanced central giant cell lesion of the maxilla, marrioni et al. described maxillectomy as the treatment of choice and they successfully reconstructed the maxillary defect with autologous calvaria and a temporalis muscle pedicled flap.2 in the present case, partial anterolateral maxillectomy was done and the defect was covered only by soft tissue from the cheek. recurrence is common and the type of initial surgical removal is the most significant factor in recurrence. recurrence usually occurs if curettage or any other treatment short of complete removal is employed. the recurrence rate is 34% following curettage and 7% following wide resection.10 though rare, giant cell tumor should be considered as one of the differential diagnosis in cases of maxillary swelling. the diagnosis is made on the basis of radiological and histological features. adequate surgical excision with long-term follow-up should be the treatment of choice for managing a giant cell lesion of the maxilla. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports philippine journal of otolaryngology-head and neck surgery 19 philipp j otolaryngol head neck surg 2013; 28 (1): 19-23 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to report a case of extragnathic sinonasal ameloblastoma and discuss its clinical features, approach to diagnosis, pathology and management. methods: design: case report setting: tertiary government universityhospital patient: one results: a 40-year-old f emale consulted for a rapidly enlarging right intranasal mass of four months duration associated with recurrent profuse epistaxis and nasal obstruction. previous specimens of the mass were histopathologically interpreted as ameloblastoma versus craniopharyngioma. examination revealed a pink, fleshy, smooth right intranasal mass with associated nasomaxillary bulge and supero-lateral displacement of the right eye. computed tomography (ct) scan and magnetic resonance imaging (mri) of the nasal cavity and paranasal sinuses demonstrated a soft-tissue density occupying the entire nasal cavity with erosion but no invasion of the maxillary sinus and no intracranial extension despite erosion of the skull base. the mass was completely excised via lateral rhinotomy and the final histopathologic diagnosis was ameloblastoma. conclusion: extragnathic sinonasal ameloblastoma is a benign but locally aggressive variant of ameloblastoma involving the nasal cavity and/or paranasal sinuses often mimicking malignant tumors. diagnosis is primarily based on histopathology but radiologic and intraoperative findings help distinguish it from differentials. complete surgical excision remains the treatment of choice, and coupled with good follow up, may improve the prognosis of patients. keywords: sinonasal ameloblastoma, extragnathic, craniopharyngioma signs and symptoms of a recurrent rapidly enlarging intranasal mass, epistaxis, nasal obstruction and displacement of the ipsilateral globe lead one to suspect a possible malignancy. a physician who performs a biopsy may be surprised by a histopathologic diagnosis of extragnathic sinonasal ameloblastoma: a rare benign intranasal tumor with malignant features jonel donn leo s. gloria, md1 1department of otorhinolaryngology philippine general hospital university of the philippines manila philippines correspondence: dr. jonel donn leo s. gloria department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 554-8400 local 2151 e-mail: jonel.gloria@gmail.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the annual residents’ interesting case contest (1st place), philippine general hospital – department of otorhinolaryngology, manila, february 24, 2012. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports 20 philippine journal of otolaryngology-head and neck surgery ameloblastoma – not only because it is benign but also due to its unusual location in the nasal cavity (being odontogenic). although benign, ameloblastoma is a locally aggressive tumor predominantly involving tooth-bearing regions of the oral cavity including the mandible and the maxilla. it is relatively rare comprising only 1% of all head and neck tumors despite being the most common true odontogenic neoplasm with an incidence of 11%.1 extragnathic ameloblastoma is a variant of ameloblastoma that appears to elude its pathogenesis as it arises outside the boundaries of the odontogenic apparatus.2 extragnathic ameloblastoma primarily from the nasal cavity is extremely rare with only few documented reports in the literature.2-6 its unusual location and highly aggressive behavior make it a worthy consideration among the differential diagnosis of nasal masses that should be of interest not only to ent surgeons with special interest in rhinology, but to maxillofacial surgeons, oral surgeons and pathologists. here is one such case of extragnathic sinonasal ameloblastoma and a discussion of its clinical features, approach to diagnosis, pathology and management. case report a 40-year old female presented with a 4-month history of persistent mucoid, non-foul smelling, occasionally blood-tinged right rhinorrhea and recurrent nasal congestion. a previous intranasal mass punch biopsy by an otorhinolaryngologist revealed ameloblastoma; the final histopathologic diagnosis following undisclosed nasal surgery by another otorhinolaryngologist was craniopharyngioma. one month after surgery, the patient experienced recurrence of nasal obstruction and rhinorrhea, with bulging of the right nasal bridge, an enlarging right intranasal mass and spontaneous recurrent profuse epistaxis. this prompted emergency consult at our hospital. on examination a right nasomaxillary bulge and supero-lateral displacement of the right eye were evident. nasal endoscopy revealed a pink, fleshy, smooth mass with foul-smelling, mucoid discharge in the right nasal vestibule and contralateral septal deviation. the nasopharyngeal mass was appreciated on posterior rhinoscopy. the rest of the head and neck examination findings were unremarkable. plain and contrast-enhanced axial and coronal computed tomography images of the nasal cavity and paranasal sinuses showed a large, lobulated, heterogeneously enhancing intranasal mass measuring 4.15 x 4.95 x 8.01 cm (transverse, craniocaudal, anteroposterior) occupying the entire nasal cavity. (figures 1 and 2) the mass extended to the ethmoid sinuses with suspicious extension into the right orbit, sphenoid sinus, nasopharynx and partially to the right maxillary sinus with associated thinning of the medial maxillary wall. figure 1. contrast-enhanced ct scan of the nasal cavity and paranasal sinuses, coronal view showing a heterogeneously enhancing mass occupying the entire nasal cavity with thinning of the right medial maxillary wall and lamina papyracea. there is opacification of the right maxillary sinus. figure 2. contrast-enhanced ct scan of the nasal cavity and paranasal sinuses, axial view showing additional opacification of the right sphenoid sinus. due to the extensive involvement of adjacent structures, mri was requested to rule out intracranial extension or origin (excluding craniopharyngioma) and paranasal origin (excluding gnathic maxillary ameloblastoma) of the tumor. mri revealed fluid accumulation- possibly from obstruction without invasion of the maxillary sinus. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports philippine journal of otolaryngology-head and neck surgery 21 (figure 3) the sphenoid sinus was only partially occupied by the tumor alongside fluid accumulation. (figure 4) likewise, there was no evidence of intracranial extension or origin. a slide review of the specimen from the previous surgery was interpreted as consistent with ameloblastoma versus figure 3. mri of the nasal cavity and paranasal sinuses with gadolinium, coronal view showing a heterogeneously contrast-enhancing mass in the nasal cavities with fluid accumulation in the right maxillary sinus. figure 4. mri of the nasal cavity and paranasal sinuses with gadolinium, sagittal view showing a heterogeneously contrast-enhancing mass in the nasal cavities with extension to the right sphenoid sinus. figure 5. histopathologic slide, hematoxylin and eosin stain, scanning view (10x) shows blue-gray relatively less cellular areas (blue arrow) and dark blue cellular areas (yellow arrow). the blue-gray areas correspond to the loose, fibrous stroma while the dark blue cellular areas correspond to the interspersed cords and islands of epithelial cells. (hematoxylin and eosin, 10x) figure 6. histopathologic section, hematoxylin and eosin stain, higher magnification (40x) of the epithelial component shows two cell types. in the periphery, there are columnar cells that show palisading with a reversed polarity arrangement (dark arrow). medial to it, the cells are arranged more loosely, corresponding to the stellate reticulum. higher magnification of the stroma (light arrow) shows fibroblasts arranged in loose connective tissue. (hematoxylin and eosin, 40x) craniopharyngioma. excision of the mass via right lateral rhinotomy and partial medial maxillectomy yielded a grayish, friable, fungating mass occupying the right nasal cavity attached to the right posteromedial choana extending to the sphenoid sinus pushing against (but not involving) the septum with no involvement of the right maxillary sinus or attachment to the skull base. final histopathology was signed out as ameloblastoma. no recurrence was noted after 11 months of postoperative follow up. discussion ameloblastoma is a locally aggressive benign tumor of odontogenic tissues with a high rate of recurrence if not adequately excised. it represents 1% of all oral cavity tumors, generally appearing in the philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 22 philippine journal of otolaryngology-head and neck surgery case reports mandible in 80% of cases and 15-20% in the maxilla.2 differential diagnoses of an intranasal ameloblastoma include 1) gnathic ameloblastoma from the maxilla with the nasal cavity only secondarily involved; 2) extragnathic ameloblastoma, a variant of ameloblastoma that arises primarily in the sinonasal mucosa known as primary sinonasal ameloblastoma7; and 3) infrasellar craniopharyngioma extending down to the nasal cavity. the majority of intranasal ameloblastomas in the literature are actually of maxillary origin with extension into the nasal cavity.8 ameloblastoma exclusively arising in the sinonasal tract is extremely rare, with very few reported cases in the literature2-6 and its presence should be well established before making a definitive diagnosis. there are even fewer reports of infrasellar craniopharyngioma with intranasal extension in the literature.9,10 the difficulty in distinguishing these two entities (ameloblastoma and craniopharyngioma) as evidenced by the histopathologic reports in this case stems from the very similar histopathologic features reflective of their odontogenic origins. in addition, the possibility of malignant ameloblastic carcinoma (although rare) should never be discounted, especially in aggressive recurrent cases11 nor should malignant transformation of ameloblastoma be overlooked (diagnosed with specific staining like ck ae1/ae3).12 the histopathologic sections (figures 5 and 6) showing odontogenic epithelium arranged in long strands and cords that appear to surround central areas of supporting stroma with palisading columnar cells exhibiting reverse polarization surrounding loosely arranged stellate reticulum–like epithelium are compatible with a diagnosis of ameloblastoma, both for gnathic and extragnathic variants. although the same features are found in craniopharyngioma, the absence of cystic formation, degenerative changes, calcifications and cholesterol clefts6 characteristic of the latter favor a diagnosis of ameloblastoma. figure 7. gross specimen consisting of cream tan, irregular, soft to rubbery tissue fragments with an aggregate diameter of 8 cm. as evidenced by the histomorphologic, radiologic and intraoperative findings in the patient, a diagnosis of extragnathic sinonasal ameloblastoma was established. extragnathic ameloblastomas comprise only 2–10% of all ameloblastomas.10 extragnathic sinonasal ameloblastomas are even less common. schafer et al. reviewed nearly 20,000 sinonasal tumors over a 40-year period and reported only 24 cases of ameloblastoma exclusively arising in the sinonasal tract.8 to date, only five additional case reports have been published, based on a pubmed and google search using the keywords “ameloblastoma,” “sinonasal,” and “extragnathic.”2-,6 the overall mean age at presentation is 59.7 years and more males are affected than females with a ratio of 3.8:1.4 in contrast, this case involved a relatively young 40-year-old female. usual presenting signs and symptoms mimic those of malignant tumors which include intranasal mass, nasal obstruction, sinusitis, epistaxis, facial swelling, dizziness, and headache.8 in this case, the intranasal mass, epistaxis and nasal obstruction are consistent with the usual signs and symptoms. the additional supero-lateral displacement of the right globe can be attributed to tumor mass effect. sinonasal amelobastomas are described as polypoid, predominantly solid masses with glistening gray-white, pink or yellow-tan color, ranging from a few millimeters to 9.0 cm with consistency varying from rubbery to granular8 consistent with the cream to tan, fleshy, rubbery mass in this case. (figure 7) ct scans of the nasal cavity and pns were the primary imaging modality in previous reports. the appearance of sinonasal ameloblastoma depends on tumor extent, generally as a solid mass, soft tissue density or opacification occupying the nasal cavity and/or the paranasal sinuses with occasional bony erosion as seen in this case.3,8 the additional use of mri in this case was beneficial in delineating tumor extent. the reported sites of origin of primary sinonasal ameloblastoma confined to the nasal cavity include the nasal septum, lateral nasal wall and turbinates.4,8,10 among the paranasal sinuses, the maxillary sinus was most commonly affected, followed by the ethmoid, frontal and sphenoid sinuses (the latter with only one reported case).8 in this case, the mass was surgically confirmed to arise from the postero-medial choana with extension into the sphenoid sinus, an occurrence not previously reported. gnathic ameloblastoma arises most frequently from rests of primitive dental lamina in the gingiva, alveolar bone above the level of tooth apices, follicular walls of unerupted teeth, lining of odontogenic cysts, and even gingival surface epithelium.10 controversy surrounds the origin of extragnathic ameloblastoma particularly those arising in the nasal cavity. this entity is believed to arise from the pluripotential philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports philippine journal of otolaryngology-head and neck surgery 23 acknowledgements the author thanks dr. arsenio claro a. cabungcal and dr. jan warren a. holgado of the department of otorhinolaryngology, philippine general hospital, university of the philippines manila for their valuable contributions; the former, in managing the patient in this report and the latter, in helping draft the initial manuscript. references angadi pv. head and neck: odontogenic tumor: ameloblastoma [monograph on the internet]. 1. atlas genet cytogenet oncol haematol; may 2010 [cited 2012 feb 8]. available from: http:// atlasgeneticsoncology.org/tumors/ameloblastomid5945.html guilemany jm, ballesteros f, alós l, alobid i, prades e, menéndez lm, cardesa a. plexiform 2. ameloblastoma presenting as a sinonasal tumor. eur arch otorhinolaryngol [serial on the internet]. 2004 jul [cited 9 feb 2012];261(6):304-306. available from: http://www.deepdyve. com/lp/springer-journals/plexiform-ameloblastoma-presenting-as-a-sinonasal-tumore32ptq004d leong sc, karkos pd, krajacevic j, islam r, kent se. ameloblastoma of the sinonasal tract: a case 3. report. ear nose throat j [serial on the internet]. 2010 feb;89(2):70-71. available from: http:// www.mdlinx.com/otolaryngology/news-article.cfm/3353607/sinonasal ereño c, etxegarai l, corral m, basurko jm, bilbao fj, lópez ji. primary sinonasal ameloblastoma 4. [abstract]. apmis 2005 feb [cited 9 feb 2012];113(2):148-150. available from http://onlinelibrary. wiley.com/doi/10.1111/j.1600-0463.2005.apm1130210.x/abstract ang ma, vergel de dios a, carnate j. primary sinonasal ameloblastoma in a filipino female. 5. philipp j otolaryngol head neck surg [serial on the internet]. 2011 jul-dec [cited 8 feb 2012];26 (2):39-41. available from: http://www.pso-hns.org/psojournals/pjohns/2011b/08-under_ microscope.pdf sharma v, purohit jp. ameloblastoma: a rare nasal polyp. 6. indian j otolaryngol head neck surg [serial on the internet]. 2011 jul [cited 8 feb 2012]; 63(suppl 1):893-895. available from http:// www.ncbi.nlm.nih.gov/pmc/articles/pmc3146654/pdf/12070_2011_article_211.pdf michaels l, hellquist h. ear, nose and throat histopathology. 27. nd ed. london: springer; 2001. 254-255. schafer dr, thompson ldr, smith bc, wenig bm. primary ameloblastoma of the sinonasal 8. tract: a clinicopathologic study of 24 cases. cancer [serial on the internet]. 1998 feb [cited 9 feb 2012]; 82(4):667-674. available from http://www.lester-thompson.com/articles/cancer/cancer1998-02_primary ameloblastoma of the sinonasal tract.pdf deutsch h, kothbauer k, persky m, epstein fj, jallo gi. infrasellar craniopharyngiomas: case 9. report and review of the literature. skull base [serial on the internet]. 2001 may [cited 8 feb 2012];11(2):121-128. available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1656789/ pdf/skullbase00006-0037.pdf gnepp dr. diagnostic surgical pathology of the head and neck. 2nd ed. philadelphia, pa: 10. saunders; 2009. 168-170. kruze al, zwahlen ra, gratz kw. new classification of maxillary ameloblastic carcinoma 11. based on an evidenced-based literature review over the last 60 years. head neck oncol [serial on the internet]. 2009 aug 12 [cited 23 feb 2012];1(1):31. available from: http://www. headandneckoncology.org/content/pdf/1758-3284-1-31.pdf prashad kv, ramesh v, balamurali pd, premalatha b. ameloblastic carcinoma-a case report 12. highlighting its variations in histology. j. int oral health [serial on the internet]. 2011 december [cited 24 may 2013};3(6):37-42. available from: http://www.ispcd.org/~cmsdev/userfiles/ rishabh/jioh-03-06-037.pdf basal layer of the surface epithelium or from ectopic epithelial rests.8,10 management of extragnathic sinonasal ameloblastoma as with ameloblastoma is surgical with good prognosis following complete tumor excision. the approach depends on the extent of the tumor and experience of the surgeon. the goal is to completely remove the entire tumor to reduce the risk of recurrence with preservation of as much normal tissue as possible to reduce morbidity. in the current case, a lateral rhinotomy approach was employed due to the extensive involvement of adjacent structures by tumor. recurrences have been documented even after adequate surgery, and close follow up should be emphasized. extragnathic sinonasal ameloblastoma, an extremely rare variant of ameloblastoma, is benign but may present as a locally aggressive entity, mimicking malignant tumors involving the nasal cavity and/or the paranasal sinuses. diagnosis is primarily based on histopathology but radiologic and intraoperative findings aid in its distinction from the closest differentials. apart from ct scan as a primary imaging modality, mri plays a crucial role in extensive cases where involvement of vital structures needs to be assessed. complete surgical excision remains the treatment of choice, and coupled with good follow up should serve to improve the prognosis of patients. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 original articles philippine journal of otolaryngology-head and neck surgery 15 abstract background: thyroid nodules are a common disease entity occurring in 5-10% of the general population and increasing with age. their detection on ultrasonography ranges from 13% to 67%. calcifications on ultrasound may occur in both benign and malignant diseases but have been cited for increased risk of thyroid carcinoma. objective: to determine the association of calcifications found on thyroid ultrasonography and the different types of calcifications with thyroid carcinoma. methods: design: retrospective study setting: tertiary private hospital participants: 126 patients with pre-operative thyroid or neck ultrasonography who subsequently underwent thyroidectomy (total or subtotal, with or without frozen section) were selected from a database covering a one-year period from january to december 2012. the presence and type of calcification on ultrasonography was correlated with the final histopathologic report for a diagnosis of thyroid carcinoma. sensitivity, specificity, positive and negative predictive values were obtained. results: 51 out of 126 studies (40%) were observed to have calcifications of any description in both histologically benign (41%) and malignant (59%) nodules. calcifications seen in malignancy arose from papillary carcinoma (86%). follicular carcinoma and others (plasmacytoma and lymphoma) accounted for 7% each. the peripheral type of calcification was most prevalent accounting for 37% (11 out of 30). the sensitivity of detecting calcifications on ultrasonography is 58.82%, specificity 81.33%, positive predictive value 68.18% and negative predictive value 74.38%. chi square test computed was 21.54 (p <0.05). conclusion: there was an association between calcification found on ultrasonography and thyroid carcinoma and 86% of the calcifications were peripheral patterns mostly found in papillary thyroid carcinomas. ultrasonography alone is not sufficient in diagnosing thyroid carcinoma but may increase the suspicion of malignancy depending on the type of calcification. keywords: thyroid carcinoma, papillary carcinoma, calcifications, ultrasonography calcifications in thyroid ultrasonography and thyroid carcinoma maria christina d. sio, md jacqueline austine u. uy, md ronaldo g. soriano, md department of otolaryngology head and neck surgery st. luke’s medical center correspondence: dr. ronaldo g. soriano department of otolaryngology head and neck surgery st. luke’s medical center 279 e. rodriguez ave., quezon city 1102 philippines phone: (632) 727 5543 fax: (632) 723 1199 (h) email: slmcearnosethroat@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at philippine society of otolaryngologyhead and neck surgery, descriptive research contest (2nd place), september 19, 2013, natrapharm, the patriot bldg., km 18 slex, paranaque city. philipp j otolaryngol head neck surg 2014; 29 (2): 15-18 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 original articles 16 philippine journal of otolaryngology-head and neck surgery a b thyroid nodules are common and occur in 5-10% of the general population with increasing age.1 they have a relative frequency of 4-7% by palpation alone and 13-67% by sonography.4 the incidence of thyroid nodular disease is quite high spontaneously occurring at a rate of 0.08% per year starting in early life and extending into the eighth decade. although thyroid nodules represent a wide spectrum of disease, most are colloid nodules, adenomas, cysts and focal thyroiditis with only a few (5%) being carcinoma.2 the most recent ata guidelines for the evaluation of thyroid nodules and cancer emphasize the use of thyroid ultrasound to guide the clinician on which nodule requires biopsy to exclude malignancy. microcalcifications are frequently cited with increased risk of thyroid malignancy specifically papillary thyroid carcinomas.7 diagnosis of thyroid carcinoma includes a comprehensive history, physical examination and the aid of diagnostic tests. high-resolution ultrasonography is commonly used but frequently misperceived as unhelpful for identifying features that distinguish benign from malignant nodules. although individual ultrasonographic findings may be of limited value, multiple signs of thyroid malignancy that appear in combination can make a more accurate prediction. calcifications on ultrasound may occur in both benign and malignant diseases.5 according to the literature, microcalcifications are one of the most specific ultrasound findings suggestive of a thyroid malignancy.3 thyroid calcifications can be classified as microcalcification, coarse calcification or peripheral.3 because most thyroid nodules are benign, calcifications may seem to appear more in benign nodules, thus being neglected by clinicians. this study aims to determine the association of calcifications found in thyroid or neck ultrasonography and of their types with thyroid carcinoma. this study will also determine the predictive value for malignancy of calcifications determined by thyroid ultrasonography. methods subjects this is a retrospective study analyzing 126 thyroidectomy patients selected from a database covering a one-year period between january to december 2012 at our institution. all patients included in the study underwent pre-operative thyroid or neck ultrasound in the same institution. patients who underwent thyroidectomy where ultrasonography was done at a different institution were excluded. all data was retrieved from the healthcare database system, which included official results of the procedures including the final histopathological report after each operation. board-certified radiology and pathology consultants interpreted the ultrasonographic and histopathologic studies. calcifications on ultrasonography these studies were stored at the picture archiving and communication systems (pacs) system and were reviewed using the barco coronis fusion 6 megapixel dl (mdcc-6130) system (barco pte ltd, singapore). its technical specifications include the following: tft am color lcd dual domain ips-pro, native 6 megapixel 3280 x 2048 display, 654 x 409 mm active screen size and 800 cd/m2 maximum luminance (500 cd/m2 dicom calibrated). each ultrasound result had already been officially tandem-read by two radiology consultants (reader a) and then re-read by the co-author, a senior radiology resident (reader b) to ascertain the presence or absence of calcifications and to describe the types of calcifications with the reviewer blinded to the final histopathology. calcifications were defined as hyperechoic signals observed in the periphery or within a thyroid nodule or mass. calcifications were further subdivided into (1) probably benign (inspissated colloid calcifications with typical reverberation artifacts) and (2) probably malignant. subtypes of the latter include (2.a) microcalcifications (round laminar and punctate hyperechoic focus), (2.b) coarse (larger hyperechoic structures, either spicule or granular) and (2.c) peripheral (either rim or arc and further described as stippled, curvilinear smooth and irregular). statistical analysis a certified statistician at our institution then analyzed the data using statistical package for the social sciences spssv16.0 (ibm, new york, usa). sensitivity, specificity, positive predictive and negative predictive values were then calculated. results out of the 126 patients with thyroid mass who underwent ultrasonography, 17 were male, 109 female, with ages ranging from 10 to 73 years old (median age 45). there were 81 benign and 45 malignant final diagnoses by histopathology. table 1 summarizes the findings. benign number of patients multiple colloid adenomatous goiter (mcag) follicular adenoma nodular hyperplasia hashimoto’s thyroiditis tuberculosis hurthle cell adenoma unremarkable total 58 4 11 5 1 1 1 81 table 1. summary of the histopathologic findings philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 original articles philippine journal of otolaryngology-head and neck surgery 17 of the 126 patients included, 51 studies (40%) were observed to have calcifications of any description in both histologically benign and malignant nodules. out of the 51 studies with calcifications, 30 (59%) studies were seen in malignancies and 21 (41%) in benign conditions. (figure 1) the studies reviewed by the co-author revealed reader disagreement in 14 studies or only 11%. they differed in the types of calcification reported (ex. peripheral, coarse or microcalcification). the co-author based the description of the type of calcification reported from literature published by hoang and his colleagues.3 these discrepant readings are listed in table 2 with the final histopathology results. malignant number of patients papillary carcinoma papillary microcarcinoma follicular carcinoma hodgkin’s lymphoma plasmacytoma total 34 6 3 1 1 45 figure 1. breakdown of malignant and benign cases with and without calcifications figure 2. types of calcifications seen in malignant cases majority of the calcifications in malignant cases were seen in those diagnosed with papillary carcinoma (26 out of 30 malignancies, 86%). the rest were seen in follicular carcinoma (2 out of 30 malignancies, 7%) and other cancers-hodgkin’s lymphoma and plasmacytoma (2 out of 30 malignancies, 7%). calcifications secondary to inspissated colloid were described and all five examinations with this type of calcification were proven benign (multiple colloid adenomatous goiter). it should be noted that out of all the calcifications under the umbrella of malignant subtypes, there were more of the peripheral type of calcification seen in 37% followed by microcalcifications 33% and lastly the coarse types which accounted for 30%. (figure 2) reader a reader b (co-author) final histopathology presence or absence of calcification calcification calcification calcification peripheral calcification peripheral calcifications peripheral calcifications calcifications calcifications calcifications calcifications calcifications calcifications peripheral calcifications calcifications peripheral calcification coarse calcification peripheral calcification microcalcification coarse calcifications coarse calcifications microcalcifications coarse and microcalcifications coarse microcalcifications coarse and microcalcifications microcalcifications coarse calcifications coarse calcifications coarse calcifications papillary thyroid carcinoma multiple colloid adenomatous goiter papillary thyroid carcinoma multiple colloid adenomatous goiter multiple colloid adenomatous goiter multiple colloid adenomatous goiter papillary thyroid carcinoma multiple colloid adenomatous goiter multiple colloid adenomatous goiter with nodular hyperplasia multiple colloid adenomatous goiter multiple colloid adenomatous goiter papillary microcarcinoma multiple colloid adenomatous goiter multiple colloid adenomatous goiter present present present present present present present present present present present present present present table 2. reader discrepancy between reader a and co-author with final histopathology the sensitivity of the type of calcification in predicting malignancy on ultrasonography was calculated to be 58.82%, specificity was 81.33%. on the other hand, predicting thyroid malignancy based on philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 original articles 18 philippine journal of otolaryngology-head and neck surgery references wang n, xu y, ge c, guo r, guo k. association of sonographically detected calcification 1. with thyroid carcinoma. head neck. 2006 dec; 28(12):1077-83. kakkos sk, scopa cd, chalmoukis ak, karachalios da, spiliotis jd, harkoftakis jg, 2. et al. relative risk of cancer in sonographically detected thyroid nodules with calcifications. j clin ultrasound. 2000 sep; 28(7):347–52. hoang jk, lee wk, lee m, johnson d, farrell s. us features of thyroid malignancy: 3. pearls and pitfalls. radiographics. 2007 may-jun; 27(3):847-65. yunus, m, ahmed z. significance of ultrasound features in predicting solid malignant 4. thyroid nodules: need for fine needle aspiration. j pak medassoc.2010 oct; 60(10):84853. rahman ga, abdulkadir ay, braimoh kt. thyroid calcification: radiographic patterns 5. and histological significance. ama. 2008 nov 18; 37:99-105 yoon dy, lee jw, chang sk, choi cs, yun ej, seo yl, 6. et al. peripheral calcification in thyroid nodules, ultrasonographic features and prediction malignancy. j ultrasound med. 2007 oct; 26(10):1349-55. lu z, mu y, zhu h, luo y, kong q, duo j, 7. et al. clinical value of using ultrasound to assess calcification patterns in thyroid nodules. world j surg. 2011 mar; 23(3):14-5. khoo ml, asa sl, witterick ij, freeman jl. thyroid calcification and its association with 8. thyroid carcinoma. head neck. 2002 jul; 24(7):651–655. taki s, terahata s, yamashita r, kinuya k, nobata k, kakuda k, 9. et al. thyroid calcifications: sonographic patterns and incidence of cancer. clin imaging. 2004 sepoct; 28(5):368–371. the type of calcification had a positive predictive value of 68.18% and negative predictive value of 74.39%. (table 3) tells us that 81% of patients who do not have thyroid carcinoma will test negative for the test (calcification on ultrasonography). therefore a positive result from this means a high probability of the presence of the disease. sixty-eight (68) % of those with calcification detected on thyroid ultrasonography will actually have a thyroid carcinoma (whether papillary or follicular). lastly, the probability of not having thyroid carcinoma given a negative thyroid ultrasound test is 74%. this study can guide clinicians in diagnosing thyroid nodules particularly in pre-operative evaluation and counseling patients and relatives. ultrasound can help direct the biopsy toward areas of calcification with a high probability of disease. the limitation of this study is small sample size. in conclusion, there was an association between calcifications found on ultrasonography and thyroid carcinoma and 86% of the calcifications were peripheral patterns mostly found in papillary thyroid carcinomas. ultrasonography alone is not sufficient in diagnosing thyroid carcinoma but may increase the suspicion of malignancy depending on the type of calcification. parameter percentage sensitivity specificity ppv npv 58.82% 81.33% 68.18% 74.39% table 3. statistical analyses of calcification found on ultrasonography chi square test to determine the association of presence or absence of calcifications with benign and malignant disease was statistically significant at 21.54 (p < 0.05). discussion calcifications detected on thyroid ultrasonography may appear coarse or dense as microcalcifications or peripheral rim-like.6 among these, the microcalcification and coarse types are known to be associated with increased likelihood of malignancy.6 based on the study by hoang et al. in 2007, microcalcifications are found in 29% to 59% of all primary thyroid carcinomas, most commonly in papillary thyroid carcinoma. this subtype is one of the most specific features of thyroid malignancy with a specificity of 85.8%–95% and a positive predictive value of 41.8%–94.2%.3 in our study, there were more peripheral types of calcification at 33%. similar studies were published by yoon et al. in 2007 and park et al. in 2011 on peripheral calcification seen on ultrasonography, its pattern and association with thyroid malignancy. on histopathology, thyroid calcifications are divided into psammomatous and dystrophic types. psammomatous calcifications consist of laminated round calcium deposits in the epithelium which are formed in papillary thyroid carcinomas. these are detected as microcalcifications on ultrasonography. in contrast, dystrophic calcifications consist of non-laminated amorphous deposits in fibrous tissue septa. this type of calcification is thought to correspond to coarse calcifications on ultrasonography, which can occur in both benign and malignant conditions. peripheral calcifications on the other hand, are patterns of dystrophic calcification located around nodules. they were generally thought to be more frequently associated with benign conditions but cases of papillary thyroid carcinoma associated with this type of calcification have been reported.6 the results of the this study are congruent with these reports. based on statistical analysis, the presence of calcification on thyroid ultrasound will yield a positive result 59% of the time in patients with thyroid carcinoma. however, it will yield false positive results in 19% of patients without thyroid carcinoma. on the other hand, the study philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 29 abstract objective: to investigate the outcome and complications of augmentation rhinoplasty with rib cartilage grafts. methods: design: retrospective study setting: tertiary government hospital subjects: patients who underwent dorsal nasal augmentation with autologous rib cartilage grafts between june 2008 and october 2012. results: a total of 12 patients (3 male, 9 female) were included in the study. mean age was 29 years. seven were cases of primary simple rhinoplasty with four cases of revision (previously using alloplastic materials) and one case of trauma. indications for the procedure were all cosmetic. there was no incidence of infection, both in the donor and recipient sites, warping of the graft, graft extrusion, resorption, pneumothorax, chest wall deformity or prolonged edema. postoperative pain in the donor site was relieved by oral pain medications. no revision surgery was required. conclusion: costal cartilage is a good option for structural support of the nose. in our experience patients have become wary of the complication of allografts and have opted to use autografts. the surgeon’s knowledge of the nasal anatomy as well as his or her experience with autologous grafts plays a major role in avoiding post-operative morbidity. keywords: rhinoplasty, rib graft, costal cartilage graft, southeast asian nose the nose occupies a central position in the face. any deformity of the nose can lead to functional and psychological disability.1 rhinoplasty aims to achieve nasal balance and establish harmony with the face while preserving a functional nasal airway. graft and implant materials are used primarily to maintain or strengthen the structural framework to provide contour or camouflage defects and to restore the nose to an aesthetic ideal.2 there are three broad categories of graft and implant materials currently available for rhinoplasty: autografts from the patient’s own tissues; homografts from tissues obtained from a different donor of the same species; and alloplasts.2 autogenous cartilage has generally been augmentation rhinoplasty with rib cartilage graft elaine marie a. lagura, md eduardo c. yap, md anna victoria g. garcia, md department of otolaryngology head and neck surgery ospital ng makati correspondence: dr. eduardo c. yap department of otolaryngology head and neck surgery 5th floor, ospital ng makati sampaguita street, brgy. pembo, makati city 1208 philippines phone: (632) 882 6316 local 309 email: osmakenthns@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2015; 30 (1): 29-33 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 30 philippine journal of otolaryngology-head and neck surgery original articles considered the gold standard grafting material in reconstructive septorhinoplasty for volume filling and structural support. it can be harvested from the nasal septum, the auricle or the rib but costal cartilage is considered the best graft material in patients requiring major reconstruction.3 costal cartilage provides the advantages of a large volume of graft material with excellent structural support and low rate of complications such as resorption, infection and extrusion compared to homografts and alloplastic implants. the disadvantages observed include warping and potential donor site morbidities including pneumothorax, scar visibility and chest wall deformity.2-3 methods a retrospective analysis was done on patients who underwent augmentation rhinoplasty with rib cartilage graft in a tertiary government hospital from june 2008 to october 2012. the patients were admitted with detailed history, clinical examination, routine investigations and special investigations including photography. consent was obtained from each patient for surgical demonstration as well as the possible public viewing of videos and pictures taken during the procedure. (appendix a) additional consent was obtained for the publication of pictures for this study. all procedures were carried out under general anesthesia and were covered by prophylactic intravenous antibiotics. the open rhinoplasty was performed by the same senior surgeon on all patients. rib cartilage harvest in male patients, the incision was made over the seventh costal cartilage and in women under the breast crease to hide the scar. although either side may be utilized, all of our patients had their grafts harvested from the right side. after the skin incision, the overlying muscles were spread and retracted until the underlying costal cartilage figure 1. harvest of 7th intercostal rib figure 2. harvested 7thintercostals rib, with black arrow, part used for dorsal graft, white arrow used for other enhancement grafts. figure 3. shaping of the dorsal graft figure 4. exposure using open technique figure 5. positioning of rib graft philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 31 figure 7. pre-operative and 6 months post operative picture. photos printed in full with permission. figure 6. immediate pre operative and post operative was exposed. the perichondrium was cut and subperichondrial dissection was done using a periosteal elevator. the cartilaginous rib was separated from its medial attachment near the sternum and laterally from the bony rib. a partial-thickness incision was made perpendicular to the long axis of the rib. the cartilaginous incision was then completed with the sharp end of a freer elevator. (figure 1) once the cartilage segment was released both medially and laterally, the graft was easily removed from the wound and placed in sterile saline with gentamicin until the surgeon was ready for shaping. water leak test was performed to make sure there was no tear in the pleura. the longer end of the cartilage was used for dorsal augmentation while the shorter segment could be utilized for support or contour grafts. (figure 2) in shaping of the dorsal graft, cross-hatching of the cartilage was done to prevent warping. (figure 3) rhinoplasty an open approach was utilized. (figure 4) the columellar flap was freed with scissors dissecting up to expose the dome of the lower lateral cartilage. soft tissue dissection was continued in the superficial muscular aponeurotic system plane and in the subperiostal plane over the bony vault for adequate access to the nasal dorsum. (figure 5) septoplasty was done in cases where there was septal deviation leaving a 10 mm l-strut. the shorter limb of the harvested costal cartilage was fashioned into 2 mm sheets for use as septal extension graft, spreader graft and tip grafts. depending on the vector of the new tip, the septal extension graft was sutured to the caudal end of the septum using pds 5-0. the lower lateral cartilage was fixed to the caudal end of the septal extension graft. further enhancement of the tip was done using various tip grafts e.g. shield and onlay graft. (figure 6) alar lift procedure via sail excision and alar base plasty were done when needed. all of the patients were discharged one day post operatively with continuation of antibiotics for one week and adequate analgesics. follow-up was done 5-7 days post operatively for the removal of splint and sutures, then again at one month, 3 months, six months, 12 months and yearly thereafter with photo documentation. (figures 7, 8) philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 32 philippine journal of otolaryngology-head and neck surgery original articles results a total of 12 patients (3 male and 9 female) were included in the study. age ranged from 23 to 54 years old with a mean age of 29 years. there were four cases of revision rhinoplasty previously using alloplastic materials and one case of trauma. the rest of the cases were primary simple rhinoplasty. indications for the procedure were all cosmetic. there was no incidence of infection, both in the donor and recipient sites, warping of the graft, graft extrusion, resorption, pneumothorax, chest wall deformity or prolonged edema. patients complained of minimal post-operative pain in the donor site relieved by oral pain medication. patients usually noted the pain to be maximal at 3 to 5 days and tolerable at 7 to 10 days. no revision surgery was required. discussion the goal of septorhinoplasty is reconstruction of the nasal skeleton to provide adequate structural support allowing optimum functioning of the nasal airway while achieving an aesthetically pleasing result with the rest of the face. to obtain aesthetically pleasing results, ensure patient satisfaction and minimize complications, the rhinoplasty surgeon must possess a thorough knowledge of nasal anatomy and ideal facial aesthetic proportions. the surgeon must be familiar with all types of graft material and the current methods to correct nasal deformities.1,4 understanding the use of autologous, homologous and alloplastic materials for grafting and implantation purposes has become a necessity in the armamentarium of the rhinoplasty surgeon.2 graft and implant materials are used primarily to maintain or strengthen the structural framework to provide contour or camouflage defects and to restore the nose to an aesthetic ideal. the ideal graft or implant material is biocompatible and possesses physical properties and long-term stability devoid of complications. cartilage is nearly the ideal implantation material by its excellent biotolerance having low infection and extrusion rates. cartilage possesses excellent elasticity, resistance, is easy to shape, has good vitality even with poor blood supply and a minimal resorption rate.2 the rib offers an abundant supply of cartilage for use in virtually every aspect of rhinoplasty and is the preferred donor site when rigid support is necessary. the most significant advantage of rib cartilage is that grafts can be produced with considerable versatility with respect to shape, length and width. this facilitates reconstruction of the nasal framework in patients with virtually all types of functional and aesthetic requirements.5,6 uppal et al. did a retrospective study on 42 patients who underwent coastal cartilage harvest for ear reconstruction. they noted that donor site pain and clicking sound were the most common complaints. donor site scarring and deformity were acceptable for most patients but five figure 8. pre operative and 2 years post operative picture. photos printed in full with permission. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 33 references 1. tahir m, abir s, ullah f. rib graft rhinoplasty for the depressed dorsum of the nose. jpmi. 2006; 20(3):264-267. 2. lin g, lawson w. complications using grafts and implants in rhinoplasty, operative techniques in otolaryngology. 2007; 18: 315-323 3. morrieti a, scuito s. rib grafts in septorhinoplasty. acta otorhinolaryngol ital. 2013 jun;33(3):190195. 4. saeed m. costal cartilage graft in augmentation rhinoplasty. apmc.2012 jul-dec; 6(2): 166170. 5. gunter jp, cochran cs, marin vp. dorsal augmentation with autogenous rib cartilage. semin plast surg. 2008 may; 22( 2): 74-89. 6. marin vp, landecker a, gunter jp. harvesting rib cartilage grafts for secondary rhinoplasty. plastreconstrsurg. 2008 apr; 121(4): 1442-8. 7. baladiang dea, olveda mb, yap ec. the “sail” excision technique: a modified alar lift procedure for southeast asian noses. philipp j otolaryngol head neck surg. 2010 jan-jun; 25( 1): 31-37. 8. lee m, inman j, ducic y. central segment harvest of costal cartilage in rhinoplasty. laryngoscope. 2011 oct; 121(10):2155–2158. 9. al-aziz a, ahmadh, al-leithy i. autogenous cartilage grafts in primary rhinoplasty in the noncaucasian population , egypt. j plast reconstr surg. 2005 jan; 29(1): 67-72. 10. cakmak o, ergin t. the versatile autogenous costal cartilage graft in septorhinoplasty. arch facial plast surg. 2002 jul-sep;4(3):172-6. 11. uppal rs, sabbagh w, chana j, gault dt. donor-site morbidity after autologous costal cartilage harvest in ear reconstruction and approaches to reducing donor-site contour deformity. plast reconstr surg. 2008 jun; 121(6):1949-55. 12. park jh, jin hr. use of autologous costal cartilage in asian rhinoplasty. plast reconstr surg. 2012 dec; 130(6):1338-48. 13. yap ec. improving the hanging ala. facial plast surg. 2012; 28(02): 213-217. underwent reconstruction to correct the deformity. in a study by cakmak et al. 20 patients with severe nasal deformity, 19 of which were revision cases received autogenous costal cartilage grafts. they had one patient with early wound infection and three cases of minor warping. they did not observe graft extrusion or resorption. other than temporary pain, there were no donor site morbidities encountered. saeed likewise did a retrospective study of 60 patients who underwent augmentation rhinoplasty with rib cartilage harvest for patients with saddle nose deformity with no incidence of graft resorption, infection and extrusion as with our study. they had one patient with pneumothorax (2%), another with marginal show (2%) and five patients with keloid formation (8%). another study by park et al. noted a complication rate of 12%: of the 83 patients included in the study, five developed post-operative infection controlled by intravenous antibiotics and five had a warped graft. in our study, there were no incidence of post-operative infection in both donor and recipient sites, warping of the graft, graft resorption, graft extrusion, pneumothorax, chest wall deformity or prolonged edema. the only donor site morbidity we encountered was pain that was adequately managed with oral analgesics. we conclude that costal cartilage is a good option for structural support of the nose especially in patients with previous allografts. in our experience patients have become wary of the complications of allografts and have opted to use autografts. the surgeon’s knowledge of nasal anatomy as well as his or her experience with autologous grafts plays a major role in avoiding post-operative morbidity. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 original articles philippine journal of otolaryngology-head and neck surgery 21 abstract objective: to describe the audiological profile, clinical features and briefly summarize the speech and language development of a child with kabuki syndrome (ks). ks is a rare malformation syndrome that usually presents with mental retardation and multiple congenital anomalies including ear diseases and hearing loss. methods: design: case report setting: tertiary public university hospital subject: one patient results: a five-year-old female diagnosed with ks at age three presented with moderate to severe conductive hearing loss in the right ear with a drop at the high frequencies and moderate to severe conductive sloping hearing loss in the left ear. she also had fluctuating tympanometric findings. she was fit with binaural hearing aids. conclusion: ear diseases and hearing loss should immediately be considered in patients diagnosed with ks. a comprehensive audiological and otolaryngological evaluation should also be performed when presented with a ks case. keywords: kabuki syndrome, niikawa-kuroki syndrome, hearing loss, multiple anomalies ks is a rare disorder discovered by japanese doctors norio niikawa and yoshikazu kuroki in 1981. the syndrome received its name due to the resemblance of the characteristic facial features of patients to the make-up used in the traditional japanese kabuki play.1 niikawa and kuroki independently described the syndrome in a subset of ten japanese children that were reported to have distinctive facial features, skeletal abnormalities, dermatoglyphic abnormalities, short stature and mental retardation.2 audiological manifestations in kabuki (niikawa-kuroki) syndrome celina ann m. tobias, rn, mclinaud1*,2 teresa luisa gloria-cruz, md, mhped1, 2 charlotte m. chiong, md1, 2 1department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila 2 philippine national ear institute national institutes of health university of the philippines manila correspondence: celina ann m. tobias ear unit, 2/f philippine general hospital, taft avenue, ermita, manila 1000 philippines phone (632) 554 8400 e-mail address: celinatobias@yahoo.com *this case was previously presented as part of the requirements of the course caud 203: auditory and language pathology, in partial fulfillment of the requirements for the degree master of clinical audiology, department of otorhinolaryngology, college of medicine, university of the philippines manila. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (1): 21-26 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports 22 philippine journal of otolaryngology-head and neck surgery table 1. summary of tympanometric findings december 6, 2006 july 13, 2009 right ear right earleft ear left ear type ecv compliance pressure b 0.66 ml 0.16 ml -393dapa a 1.35 ml 0.86 ml -12 dapa b 0.54 0.08 -146 dapa c 1.20 ml 0.33 ml -129 dapa table 2. speech and language milestones age expected (years:months) receptive language expressive language skill age acquired (years:months) localizing to sound localizing to voice/calling by name recognizing names of familiar people and object following simple commands answering simple questions cooing babbling imitated adult sounds 1-word utterances 2-word utterances phrases/sentences 0 – 0:6 0:5 – 0:9 0:6 – 1:0 1:0 – 1:6 1:0 – 2:0 0:2 – 0:3 0:4 – 0:6 0:6 – 1:0 1:0 1:6 – 2:0 3:0 < 1:0 2:0 3:0 3:0 3:6 unrecalled unrecalled unrecalled unrecalled unrecalled still unable figure 1 (a). puretone audiometry results obtained last december 6, 2006 showing moderate to severe conductive hearing loss in the right ear with a drop at the high frequencies and moderate to severe conductive sloping hearing loss in the left ear. (b) puretone audiometry results obtained last july 13, 2009 showing similar results to (a) hearing loss is also a frequent finding in patients with ks, comprising 82% of the reported cases in the literature.3 most of the cases of hearing loss were due to otitis media. other cases were attributed to inner ear deformities or severe ossicular malformation.4 we present the case of a five-year-old female diagnosed with ks at age three. she presented with bilateral moderate to severe hearing loss determined by puretone audiometry and auditory brainstem testing. fluctuating tympanometric findings were reported in both ears. knowledge of the audiological and speech manifestations as well as the physical deformities of patients with ks could be useful to the clinician in the diagnosis of hearing loss in future cases. case report our patient was born full term via caesarean section to a 26-yearold gravida 1 para 0 mother. at birth, the patient was cyanotic and had difficulty breathing. she was confined in the neonatal intensive care unit for 12 days where an atrial septal defect (that spontaneously closed later) was diagnosed. she was re-admitted for persistent diarrhea at 24 days of age and for pneumonia at one month of age. she failed her newborn hearing screening at one month of age, and though she was already suspected to have hearing difficulties, no intervention was made for hearing loss at that time. an auditory brainstem response test at 18 months of age revealed mild to moderate hearing loss in the left ear and moderate to severe hearing loss in the right ear. at seven months of age, the patient was hospitalized for a urinary tract infection and enterocolitis, the latter condition resulting in six further admissions in twelve months. she also had benign febrile convulsions and premature thelarche. at 12 months of age, puretone audiometry revealed moderate to severe conductive hearing loss in the right ear with a drop at the high frequencies and moderate to severe conductive sloping hearing loss in the left ear. a summary of unaided audiometry results can be found on figures 1a and 1b. the patient was also fit binaurally with behind-theear digital hearing aids (powermaxx 411, ad and powermaxx211, as; phonak; manila hearing aid center). she reportedly wore both hearing aids for an average of eight hours per day. at 12 months of age tympanometry revealed type b tympanograms bilaterally. otorhinolaryngologic consultation was recommended but was not completed at this time. three years later, tympanometry revealed a type a tympanogram on the right and a type c tympanogram on the left. a summary of tympanometric findings can be found on table 1. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports philippine journal of otolaryngology-head and neck surgery 23 at three years of age she was diagnosed with ks by a developmental and behavioral pediatrician. an assessment using the denver developmental screening test (denver developmental materials, inc.; denver, colorado, usa) resulted in a diagnosis of mental retardation. at four years of age, three years post-amplification, the patient’s speech and language was assessed by a speech pathologist. it was noted that there was a delay in receptive and expressive language (table 2). a general observation of the patient’s latest speech and language skills included localizing to environmental sounds, responding to her name, following simple commands, using 1-2 words to express her needs i.e. “mama kain” (mama, eat), “akin yan” (that’s mine) and answering simple questions. she is currently undergoing speech and language habilitation. based on the latest aided puretone audiometry results (figure 2), her thresholds for both ears fall within the average speech spectrum from 250-4000 hz. this suggests that she should have access to low, mid and high frequency speech sounds. before amplification, the patient was reported to solely use signs and gestures to communicate. currently, she uses signs at school and at home and is now able to use speech as well. however, most of her speech was noted to be unintelligible to unfamiliar and familiar people under unknown contexts. according to her mother, she becomes frustrated and throws tantrums when she is not understood. figure 2. aided puretone audiometry results figure 3 (a). ). facial features of kabuki syndrome i.e. arched eyebrows, large palpebral fissures, large protruding ears, depressed nasal tip, and (b) widely spaced teeth. photos printed in full with permission. figure 4. pre-auricular pits on both the right and left ear of the patient. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports 24 philippine journal of otolaryngology-head and neck surgery figure 5. ct scan of the temporal bone showing bilateral superior semicircular canal dehiscence figure 6. ct of the temporal bone showing patent cochlear aqueduct, as currently, the patient manifests with arched eyebrows with the lateral one third dispersed or sparse, eversion of the lower lateral eyelid, depressed nasal tip, prominent ears (figure 3a), and widely spaced teeth (figure 3b)—all of which are physical features typical of a patient with ks.5 she was also found to have pre-auricular pits bilaterally (figure 4). otoscopy could not be performed because the patient was uncooperative but computed tomography (ct) findings of the temporal bone showed bilateral superior semicircular canal dehiscence (figure 5), patent cochlear aqueduct, as (figure 6) and enlarged vestibular aqueduct, ad (figure 7). discussion based on a review of 62 cases, niikawa reported five cardinal manifestations of ks. these include; (1) abnormal facial features: long palpebral fissures, large protruding ears, arched eyebrows and a depressed nasal tip; (2) skeletal anomalies like scoliosis; (3) dermatoglyphic abnormalities, which have been cited in around 90% of the cases including increased digital ulnar loops and persistence of fetal fingertip pads; (4) mild to moderate mental retardation with average iqs of 50–62; and (5) postnatal growth deficiency.5 although the etiology of ks is still unclear, recent studies suggest that it could be inherited as an autosomal dominant trait with variable expressivity.6, 7although it is claimed to be genetic in nature, there are currently no genetic tests available for ks, nor are there any uniform diagnostic criteria for the syndrome. a diagnosis of ks is usually based on the physical manifestations of the disease. studies have shown that ks is not partial to a particular race or ethnic background. 8 the syndrome affects all races as well as males and females equally.9 because the phenotype takes time to develop, a diagnosis of ks is difficult to make in neonates.10 according to the literature, a diagnosis is usually made by two years of age.11 in terms of findings related to otolaryngology and audiology, the most commonly reported problems are dysmorphic pinnae, otitis media, and hearing loss.12 prominent, cup-shaped ears are a usual finding in ks patients. preauricular pits have also been reported in close to 20% of the cases and were present bilaterally in this case. one-third of the reported cases have also been found to have cleft palate. this, coupled with the fact that a majority of the patients have increased susceptibility to infections could also contribute to complications due to otitis media in a majority of cases.1,13 cases of conductive, sensorineural and mixed hearing loss have all been reported. conductive hearing loss is the most prevalent type in philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports philippine journal of otolaryngology-head and neck surgery 25 the literature. sensorineural hearing loss is rare in patients with ks, and when present were mostly caused by anomalies of the inner ear such as bilateral absence of the cochlea with dilated dysplastic vestibules or unilateral enlarged vestibules. a study done at a multidisciplinary craniofacial clinic reported hearing loss in 82% of cases however, other studies have cited true prevalence to be somewhere between 20-30%. 1, 13, 14 aside from audiologic and otolaryngologic findings, studies have also reported vestibular findings in a small number of patients with ks. a study by barozzi et al. found that in a group of patients with ks that underwent vestibular assessment, 8% were found to have abnormal results.3 the first report of a large vestibular aqueduct in a patient with ks was presented by hempel et al. in 2005.15 in this patient, the presence of bilateral superior semicircular canal dehiscence, enlarged vestibular aqueduct in the right and a patent cochlear aqueduct in the left may explain the presence of bilateral conductive hearing loss. as ks presents with multiple anomalies, other organ systems are usually affected. aside from the aforementioned findings, patients with ks may also present neurologically with hypotonia, dysarthria and dyspraxia.9 opthalmologic problems including ptosis, strabismus, and blue sclerae have also been reported in approximately one-third to one-half of cases.16 cardiovascular problems have also been reported in 40-50% of cases. renal problems including malposition of the kidneys and renal hypoplasia have been reported in about 25% of cases. cranial and vertebral abnormalities are commonly described along with other figure 7. ct of the temporal bone showing enlarged vestibular aqueduct, ad skeletal anomalies. in the literature, respiratory and gastrointestinal findings have been rare. studies have reported that the prognosis for survival into adulthood of patients with ks is good as long as congenital anomalies and other reported problems are properly managed.3 a rare case of ks has been presented and the clinical features, audiological manifestations, as well as a summary of the patient’s speech and language development were discussed. knowledge of these audiologic manifestations as well as the other findings in patients with ks may aid in the diagnosis of future cases. it is recommended that when confronted with a diagnosed case of ks, the patient should undergo comprehensive audiological and otolaryngological evaluation. patients should be examined for the following: hearing loss that is conductive, sensorineural, or mixed; otitis media, protruding ears, dysmorphic pinnae, preauricular pits, inner ear abnormalities, and cleft palate. vestibular assessment should also be considered in select patients with vestibular symptoms, sensorineural hearing loss, or inner ear abnormalities.3 in patients that need vestibular assessment, caloric tests or vestibular evoked myogenic potentials testing can be done if the patient is cooperative. pure tone audiometry, immitance audiometry, auditory brainstem response testing and auditory steady state response testing should be included in the audiologic diagnostic test battery given to patients with ks. patients should also undergo ct of the temporal bone to rule out inner ear abnormalities. management of the audiologic and otolaryngologic problems of patients with ks may include fitting hearing aids for the hearing loss, prescribing antibiotics for cases of otitis media, or surgery to repair dysmorphic pinnae. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 26 philippine journal of otolaryngology-head and neck surgery case reports references 1. schrander-stumpel c, meinecke p, wilson g, gillessen-kaesbach g, tinschert s, könig r, et al. the kabuki (niikawa-kuroki) syndrome: further delineation of the phenotype in 29 nonjapanese patients. eur j pediatr. 1994; 153 (6): 438-45. 2. adam mp, hudgins l. kabuki syndrome: a review. clin genet. 2004; 67: 209–19. 3. barozzi s, di berardino f, atzeri f, filipponi e, cerutti m, selicorni a, cesarani a audiological and vestibular findings in the kabuki syndrome. am j med genet a. 2009; 149a(2):171-6 . 4. toutain a, plée y, ployet mj, benoit s, perrot a, sembely c, et al. deafness and mondini dysplasia in kabuki (niikawa-kuroki) syndrome: report of a case and review of the literature. genet couns. 1997; 8(2):99-105. 5. niikawa n, kuroki y, kajii t, matsuura n, ishikiriyama s, tonoki h, et al. kabuki make-up (niikawa– kuroki) syndrome: a study of 62 patients. am j med genet. 1988; 31: 565–89. 6. courtens w, rassart a, stene jj, vamos e. further evidence for autosomal dominant inheritance and ectodermal abnormalities in kabuki syndrome. am j med genet a. 2000; 93(3): 244-49. 7. halal f, gledhill r, dudkiewicz a. autosomal dominant inheritance of the kabuki make-up (niikawa–kuroki) syndrome. am j med genet. 1989; 33: 376–81. 8. philip n, meinecke p, david a, dean j, ayme s, clark r, et al. kabuki make-up (niikawa–kuroki) syndrome: a study of 16 non-japanese cases. clin dysmorphol. 1992; 1: 63–77. 9. burke lw, jones mc. kabuki syndrome: underdiagnosed recognizable pattern in cleft palate patients. cleft palate craniofac j. 1995; 32: 77–84. 10. lung zhs, rennie a. kabuki syndrome: a case report. orthodontics j. 2006; 33: 242-45. 11. vaux kk, hudgins l, bird lm, roeder e, curry cj, jones m, et al. neonatal phenotype in kabuki syndrome. am j med genet a. 2005; 132(3): 244–47. 12. matsumoto n, niikawa n. kabuki make-up syndrome: a review. am j med genet. 2003; 117c: 57–65. 13. kawame h, hannibal mc, hudgins l, pagon ra. phenotypic spectrum and management issues in kabuki syndrome. j pediatr. 1999; 134: 480–85. 14. peterson-falzone sj, golabi m, lalwani ak. otolaryngologic manifestations of kabuki syndrome. int j pediatr otorhinolaryngol. 1997; 38: 227–36. 15. hempel jm, jäger l, naumann a, schorn k. niikawa-kuroki syndrome. which characteristics must the hno doctor consider in its diagnosis. hno. 2005; 53(3): 253-6. 16. kluijt i, van dorp db, kwee ml, toutain a, keppler-noreuil k, warburg m, et al. kabuki syndrome –report of six cases and review of the literature with emphasis on ocular features. ophthalmic genet. 2000; 21:51–61. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 editorial 4 philippine journal of otolaryngology-head and neck surgery the “kuala lumpur declaration on promotion of scholarly writing skills and standards in the asia pacific region” was launched at the 2012 convention of the asia pacific association of medical journal editors (apame) held in kuala lumpur, malaysia from 31 august to 3 september 2012.2 considering the importance of “scholarly, scientific and technical health information” as an “invaluable resource” for “universal health promotion and policy development;” the necessity that this health information be “reliable, comprehensible and available” to the region and the world; the reality that the asia pacific region represents over half of the world population that both “generate(s) and need(s) an enormous amount of health information;” and that the asia pacific association of medical journal editors (apame) “is an important catalyst for the promotion of scholarly writing skills and standards” that will “increase the reliability, comprehensibility and availability” of such vital health information; participants confirmed their commitment to “promoting scholarly writing skills and standards;” to the “continuing education of researchers, authors, reviewers and editors;” and to “collaboration with academic societies, universities, government and non-government organizations” in order to “ensure greater access to publication;” “empower them to write, review and edit;” and “promote research and publication” thereby “elevating loco-regional research and publishing to the global arena;” “promoting health and well-being in the region and the world;” and the “betterment of health and societal development in the region and globally.”2 the promotion of scholarly writing skills and standards presupposes giving them preference, precedence or priority (1: the quality or state of being prior; 2: precedence 3: superiority in rank, position, or privilege; 4: a preferential rating; especially: one that allocates rights to goods and services usually in limited supply; 5: something given or meriting attention before competing alternatives).3 without prioritization, promotion is mere lip service. promotion (the act of furthering the growth or development of something; especially: the furtherance of the acceptance and sale of merchandise through advertising, publicity, or discounting)4 in publishing entails concrete and sustained measures to ensure the growth and development of individual and collective researchers, authors, reviewers and editors, as well as librarians and ultimately, our readers. correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft ave., ermita, manila 1000 philippines phone (632) 526 4360 telefax (632) 524 4455 email lapenajf@upm.edu.ph reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author has no relevant financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila department of otorhinolaryngology head and neck surgery east avenue medical center, diliman, quezon city supporting scholarly writing skills and standards: promotion and priority philipp j otolaryngol head neck surg 2012; 27 (2): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. “i’m deep inside a funny mood again, like to brood again, if i could again i feel like walking on a cloud again, think aloud again, write and then...”1 philippine journal of otolaryngology-head and neck surgery 5 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 editorial the introductory medical writing skills workshop co-hosted by the philippine society of otolaryngology head and neck surgery on november 17, 2012 embodies “our commitment to the continuing education of researchers, authors, reviewers and editors, to empower them to write, review and edit scholarly manuscripts for publication and dissemination, thereby promoting health and well-being in the region and the world.”2 this workshop begins the formal introduction of fellows, diplomates and resident physicians to “scholarly writing skills and standards, in order to set the example for our peers, authors, reviewers, editors and librarians.”2 we are conducting or have conducted similar workshops in manila, davao, cebu, baguio and iloilo as well as in singapore, malaysia, brunei darussalam, india, vietnam and cambodia. ultimately, this workshop will help the philippine journal of otolaryngology head and neck surgery attain “increasing scholarly quality worthy of continued production and dissemination.”2 references lapeña jf. “i’d rather write a song” [unpublished song] manila: 1979. 1. asia pacific association of medical journal editors (apame) “kuala lumpur declaration on 2. promotion of scholarly writing skills and standards in the asia pacific region” 2012. available at http://www2.wpro.who.int/nr/rdonlyres/18b2d878-aa4b-4933-b008-86a48dcf7b8a/0/ apame2012kldeclaration.pdf cited on 31 october 2012; co-published as a special announcement in the philipp j otolaryngol head neck surg 2012 jul-dec;27(2):5. priority. (2012) in 3. merriam-webster online dictionary. retrieved october 31, 2012, from http:// www.merriam-webster.com/dictionary/priority publication. (2012) in 4. merriam-webster online dictionary. retrieved october 31, 2012, from http://www.merriam-webster.com/dictionary/promotion i was especially gratified to recently learn from a colleague that a 2009 article published in our journal had generated an inquiry from a potential patient in australia, who was in search of a therapeutic solution for his problem. it is this same visibility that generates submissions from various countries, which to date includes malaysia, india, brunei darussalam, japan, new zealand, turkey and the united states of america. as we continue to grow and nurture our international pool of authors, reviewers and editors, may we likewise harvest more and more local talent for the various roles that make up our journal. i am very happy to announce that the philippine journal of otolaryngology head and neck surgery is now also indexed on the asia pacific medical journal articles central archives (apamed central) available at http://apamedcentral.org/ a digital archive and reference linking platform of journals published in member states of the who western pacific region and southeast asian region, supported by the world health organization and powered by koreamed synapse. this additional archive ensures our increasing presence to the rest of the world, promoting greater visibility of our published research. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports 18 philippine journal of otolaryngology-head and neck surgery abstract objective: to describe a rare case of kimura’s disease initially misdiagnosed as malignancy then tuberculosis. methods: design: case report setting: tertiary private hospital patient: one results: a 30-year-old male with a 6-year history of gradually-enlarging right infra-auricular mass revealed an enlarged mass in the right infraauricular area and multiple cervical lymphadenopathies on physical examination. initial fine-needle aspiration biopsy was interpreted as pleomorphic adenocarcinoma but succeeding work-ups and imaging studies led to treatment for tuberculosis. subsequent biopsies finally led to the proper histopathologic diagnosis of kimura’s disease and the patient was shifted to appropriate treatment with oral prednisone. conclusion: kimura’s disease is rare and may be confused with other diseases such as malignancy or tuberculosis. histopathologic diagnosis is necessary as its treatment differs from tuberculosis and other diseases. keywords: kimura’s disease, parotid gland tumor, angiolymphoid hyperplasia with eosinophilia neck masses are among the most common clinical findings to confront any physician, more so an otolaryngologist. although most masses are benign, malignant processes must still be considered. infectious causes of neck masses such as tuberculosis are constantly included in the differential diagnosis especially in the asia-pacific where it is still prevalent. however, in rare instances, knowledge of uncommon diseases should also be kept in mind. this case illustrates the rare occasion when a common disease entity is considered but turns out to be an unusual diagnosis. case report a 30-year-old micronesian male presented with a gradually-enlarging, painless right infraauricular mass that he noted to measure about the size of a marble six years prior to consult, without any other associated symptoms. a fine-needle aspiration biopsy of the mass revealed pleomorphic adenocarcinoma and he was advised surgical excision but was lost to follow-up. one year prior to consult, the patient experienced progressive enlargement of the right infraauricular mass with numbness over the area and weight loss but did not consult until one month prior to admission when the size of the mass had increased to approximately 8 x 8 x 5cm kimura’s disease initially diagnosed as malignancy then extra-pulmonary tuberculosisnikki lorraine y. king-chao, m.d.1 samantha s. castaneda, m.d.1, 2, 3 michael a. sarte, m.d.1, 2, 4 1department of otorhinolaryngology head and neck surgery the medical city 2department of otorhinolaryngology head and neck surgery rizal medical center 3department of otorhinolaryngology head and neck surgery jose reyes memorial medical center 4department of otorhinolaryngology head and neck surgery st. luke’s medical center correspondence: dr. nikki lorraine y. king-chao department of otorhinolaryngology head and neck surgery the medical city ortigas avenue, pasig city 1600 philippines phone (632) 635 6789 local 6250 fax (632) 687 3349 email address: nikkilorrainekingmd@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the clinical case report contest (3rd place), philippine society of otolaryngology – head and neck surgery, taal vista hotel, tagaytay city, philippines april 24, 2010. philipp j otolaryngol head neck surg 2012; 27 (1): 18-22 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports philippine journal of otolaryngology-head and neck surgery 19 with pain and numbness in the area, limitation of neck motion and easy fatigability. he denied any dyspnea, dysphagia, sore throat, hoarseness or fever. review of systems was unremarkable except for weight loss and anorexia. his past medical, family and surgical history were noncontributory. he was previously a construction worker with a smoking history of 2 pack-years, occasional intake of alcoholic beverages and no history of illicit drug use. physical examination revealed a soft, fluctuant, non-tender, nonhyperemic right infra-auricular mass measuring approximately 11 x 8 x 5 cm with no induration or fixation to underlying structures. (figure 1a and 1b) multiple 1 x 1 cm non-tender cervical lymphadenopathies were also noted in the right side of the neck at level ii. he had a hyperemic posterior pharyngeal wall without tonsillar enlargement but anterior rhinoscopy and otoscopy were unremarkable and there were no lesions on the external ear and face. the initial assessment was parotid mass, rule out malignancy. complete blood count, urinalysis, fasting blood sugar, lipid profile and creatinine were unremarkable except for neutrophilia at 20.6 x 10^9/l (reference range 4.5-10) and eosinophilia at 0.5 (reference range 0.01-0.04). chest x-ray and computed tomography (ct) scans of the chest and abdomen were unremarkable. contrast-ct of the neck showed a diffusely-enlarged heterogenous right parotid gland with multiple varied sized nodules while the left parotid gland was normal in size with multiple nodules. (figure 2) multiple cervical lymphadenopathies were noted. (figure 3) nodular fullness of the nasopharynx and right side of the oropharynx and tonsillar region was also reported. (figure 4) the differentials at this point were lymphoma, tuberculosis and metastatic lymphadenopathy either from a primary malignancy in the parotid gland or nasopharynx. flexible nasal endoscopy confirmed the ct scan findings of nasopharyngeal mass seen more on the right side. a nasopharyngeal biopsy yielded chronic inflammation and a tissue acid-fast bacilli (afb) smear of the nasopharyngeal mass was negative. however, tuberculosis (tb) polymerase chain reaction (pcr) of the same specimen was positive, hence, tuberculosis chemotherapy was started. fine needle aspiration biopsy of the right parotid was inconclusive, and incisional biopsy under general anesthesia revealed a 10 cm mass with caseous material and a soft, well-encapsulated 3 cm deep cervical lymph node. pathologic gross description of the lymph node was a reddish-pink, ovoid, flat, doughy tissue measuring 2.5 x 2.4 x 1 cm with a yellowish-pink mucoid glistening cut surface. the right parotid mass was grossly described as an irregularly ovoid yellowbrown granular doughy tissue measuring 3.0 x 2.0 x 1.3 cm with a pink to brown smooth homogenous cut surface. purified protein derivative (ppd) skin tests showed negative results at 3 mm with no induration. histopathologic examination of both specimens demonstrated reactive germinal follicles with dense eosinophilic cell infiltrates (figure 5, 6, 7) diagnosed as angiolymphoid hyperplasia with eosinophilia, otherwise known as kimura’s disease. a follow-up blood examination of total ige revealed >5,000 ku/l (reference range 25-100 ku/l). surgical excision was recommended but the patient opted for more conservative management and he was started on oral prednisone at 40mg/day in two divided doses over a 4-week tapering dose. there was an interval decrease in the size of the mass after three days of treatment and the patient was subsequently discharged but lost to follow-up. a b figure 1. a. anterior view of the patient showing the mass at the right infraauricular area. b. lateral view figure 2. contrast axial ct scan of the neck showing a diffusely-enlarged heterogenous right parotid gland with multiple varied sized nodules and a normal-sized left parotid gland. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports 20 philippine journal of otolaryngology-head and neck surgery discussion the differential diagnosis for neck masses is extremely broad, making it necessary to categorize patients according to age group and location of the mass to narrow down other considerations. categorizing patients according to age group and location of the mass is helpful in narrowing the differential diagnosis.1 the differential diagnosis of patients presenting with neck masses in the lateral neck area, in the age group of 16-40 years old include inflammatory conditions such as viral or bacterial adenitis, sialadenitis and granulomas; neoplasms such as lymphomas, sarcomas, parotid carcinomas and metastasis and other infectious processes such as tuberculosis.1,2 in this case, the patient was a 30-year-old micronesian male presenting with the triad of painless slowly growing enlarging soft tissue mass, associated lymphadenopathy and peripheral eosinophilia. the presentation in this case could be easily mistaken for a primary parotid gland tumor, lymphoma, metastasis or tuberculosis. although a high index of suspicion is required and malignancy should be considered if presented with a head and neck mass,3 parotid malignancy and lymphoma were ruled out based on the absence of symptoms such as facial nerve paralysis, rapid growth of mass, fever and loss of appetite. in a study by henry and burnett in 1978, the incidence of alhe within racial groups was categorized into 115 orientals, 46 whites, 7 blacks and 3 middle eastern patients. to our knowledge, there have been only four published reports of alhe occurring in filipinos as of 2009. one case report occurred in a 26-year-old filipino male presenting with multiple reddish-brown papules and nodules over the left external ear.4 another report involved a 15-year-old filipino male with a 9-year history of a corn-sized mass on his left earlobe.5 the third report entailed a 32-yearold man with a slowly growing right upper neck mass accompanied by multiple subcutaneous nodules for two years.6 the fourth report was mentioned by soeria-atmadja et al. from karolinska university hospital in sweden7 but was not included in this report. routine blood tests help rule out inflammatory causes while imaging studies aid in the location and size of tumors. laboratory findings for this patient included peripheral eosinophilia, which gives a clue to the diagnosis of kimura’s disease.2 this finding can be further confirmed by an elevated serum ige level. imaging studies can also support the diagnosis of kd but may not always do so as the case of a 21-year-old caucasian male with an initial clinical assessment of lymphangioma or hemangioma. intra-operatively, the mass was so described: a characteristic appearance was the adherence of the skin to the parotid mass, with no clear plane of dissection between the lesion and the parotid tissue. the mass was not cystic but solid opposing the preoperative palpation findings.3 the diagnostic challenge of kd can be solved with histologic study, preferably from a lymph node biopsy. fine needle aspiration cytology is helpful but often inconclusive. histologic examination of the excised tissue remains the more diagnostic approach.3,8 in this patient, definitive diagnosis was only confirmed after histopathologic study of the right infraauricular mass. malignancies such as pleomorphic adenocarcinoma or hodgkin’s lymphoma were ruled out as histopathologic findings did not reveal any atypical cells, lymphocyte predominance or malignant change. kimura’s disease is a rare entity that usually occurs sporadically in figure 3. multiple cervical lymphadenopathies seen in axial contrast ct scan of the neck at the level of the hyoid. figure 4. nodular fullness of the nasopharynx and right side of the oropharynx and tonsillar region seen in contrast axial ct scan of the neck. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 case reports philippine journal of otolaryngology-head and neck surgery 21 western countries but is endemic in asia. it was first described in 1937 in the chinese literature but the definitive histological description was published by kimura, et al. in 1948.8 clinical presentation is varied and may fluctuate for several years. kimura’s disease usually presents with solitary or several subcutaneous nodules located in the head and neck which sometimes can be painful and pruritic that slowly increase in volume accompanied by satellite adenopathies and/or increase volume of the salivary glands.9 although the masses enlarge slowly, the patients remain otherwise asymptomatic. it can also present with symptoms of cough, massive hemoptysis and lymph nodes similar to tuberculosis.10 histopathologic examination findings are the same regardless of the site of involvement, and are characterized by lymphoid follicle formation with prominent germinal centres, infiltration of eosinophils, sometimes forming microabscesses, fibrosis, increased post-capillary venules and vascular proliferation.8, 9 constant features of kd are preserved lymph node architecture, florid germinal centers, eosinophilic infiltration and increased amount of post-capillary venules. the single rare feature is progressive transformation of the germinal center. 6, 11 several authors have used the terms alhe and kd interchangeably due to similarities in their clinical and pathologic presentations. even in this study, the final histopathologic result released stated that the diagnosis is angiolymphoid hyperplasia with eosinophilia, otherwise known as kimura’s disease. however, in a review of seven cases, salal aljittawa et al. attempted to distinguish these two entities. as described, kimura’s disease usually presents with subcutaneous nodules located in the head and neck more commonly seen in men in the second to third decade.9,12 prominent manifestations are blood eosinophilia and regional lymphadenopathy with long-standing history averaging 9.6 years. histologic features primarily show lymphoid follicle formation with prominent germinal centres, infiltration of eosinophils, lymphocytes, plasma cells and mast cells with variable degree of vascular proliferation. on the other hand, alhe can be either dermal or subcutaneous located in the head and neck mostly seen in women from the second to the fifth decade. blood eosinophilia and regional lymphadenopathy appear less frequently. histologically, vascular proliferation is more prominent with infiltrates similar to kd but with less fibrosis and lymphoid follicle formation owing to its shorter duration of 2 to 3 years. 8, 9, 12 based on this differentiation, the demographic features of this case in a 30-year-old male with a 6-year history of lymphadenopathy in the head and neck and blood eosinophilia point more towards the diagnosis of kd. optimal treatment of kd is not well established but is aimed to preserve cosmesis and prevent recurrences and long-term sequelae. the range of treatment options includes conservative management, figure 5. cervical lymph node, (h&e stain) lower magnification (4x) shows reactive germinal follicles with dense eosinophilic cell infiltrates. (inset) higher magnification (40x). (higher magnification, 40x) (hematoxylin-eosin, lower magnification 4x) (higher magnification, 40x) (hematoxylin-eosin, lower magnification 4x) (higher magnification, 40x) (hematoxylin-eosin, lower magnification 4x) figure 6. cervical lymph node, (h&estain) lower magnification (4x) shows reactive germinal follicles with dense eosinophilic cell infiltrates. (inset) higher magnification (40 x). figure 7. parotid mass, right. (h&e stain). lower magnification (4x) shows reactive germinal follicles with dense eosinophilic cell infiltrates. (inset) higher magnification (40x). philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 22 philippine journal of otolaryngology-head and neck surgery case reports oral corticosteroids, radiotherapy, cryotherapy, laser fulguration and surgical excision. other therapeutic options include cytotoxic agents, cyclosporine and pentoxifyline but with variable results.13, 14 the diagnosis of kimura’s disease is highly difficult and misleading. it is indeed a diagnostic and therapeutic challenge. this report emphasizes the importance of having a high index of suspicion in an asian patient presenting with a head and neck mass and reiterates the need of becoming acquainted with this disease to prevent subsequent complications due to delays in diagnosis and treatment. acknowledgements we would like to thank agustina abelardo, m.d., our pathologist and scientific advisor; and mr. mark james g. cayabyab who helped in the review of literature. references cummings cw, haughey bh, thomas jr, harker la, flint pw. cummings otolaryngology head 1. & neck surgery. 4th ed. pennsylvania: mosby; 2005. roufosse fe, goldman m, cogan e. hypereosinophilic syndromes. 2007 september 11 [accessed 2. 2010 march 1] available from http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2045078/ pdf/1750-1172-2-37.pdf can i̇h, guduz v, pulat h, samim e. kimura’s disease in the parotid gland. 3. internet j head neck surg. 2009 february 13 [accessed 2010 march 1] available from http://www.ispub.com/ostia/ index.php?xmlfilepath=journals/ijhns/vol1n2/kimura.xml roxas-rosete c, tianco e, king-ismael d. angiolymphoid hyperplasia with eosinophilia in a 4. filipino man. int j dermatol. 1995 apr; 34(4): 267-70. rossi h, dy w. cancer and keloid or kimura and steroid.5. philipp j otolaryngol head neck surg 1990; 5: 34-38. jani a, coulson m. kimura’s disease: a typical case of a rare disorder. 6. west j med 1997 feb; 166(2):142-144. soeria-atmadja s, oskarsson t, celci g, sander b, berg u, gustafsson b. maintenance of 7. remission with cyclosporine in paediatric patients with kimura′s disease – two case reports. acta paediatrica, 2011 100: e186–e189. doi: 10.1111/j.1651-2227.2011.02259.x viswanatha b. kimura disease: an unusual cause of head and neck masses. report of 2 cases. 8. ear, nose throat j. 2010 feb; 89(2): 87-89. kuo tt, shih ly, chan hl. kimura’s disease. involvement of regional lymph nodes and distinction 9. from angiolymphoid hyperplasia with eosinophilia. am j surg pathol 1988 nov; 12(11):843-54. rajaver s, acharya v, rau a, sivaramakrishnan c, sahoo rc, lobo f. a rare case of kimura’s 10. disease presenting with cough, hemoptysis and axillary lymph node involvement. internet j pulm med 2009; 11:1. googe pb, harris nl, mihm mc jr. kimura’s disease and angiolymphoid hyperplasia with 11. eosinophilia: two distinct histopathological entities. j cutan pathol 1987 oct; 14(5): 263-71 al-jittawi s, oumeish o. angiolymphoid hyperplasia with eosinophilia. 12. intl dermatol 1989: 28: 114-118. hui pk, chan jk, ng cs, kung it, gwi e. lymphadenopathy of kimura’s disease. 13. am j surg pathol 1989 mar; 13(3):177-186. yuen hw, goh yh, low wk, lim-tan sk. kimura’s disease: diagnostic and therapeutic challenge.14. singapore med j 2005 apr; 46(4): 179-183. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles philippine journal of otolaryngology-head and neck surgery 13 philipp j otolaryngol head neck surg 2011; 26 (2): 13-17 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to describe the anatomic relationship of the recurrent laryngeal nerve and the inferior thyroid artery in adult cadavers in the philippines and to compare the proportions of these anatomic relationships with those reported in the foreign literature. methods: design: descriptive, cross-sectional setting: university of the philippines college of medicine anatomy laboratory subjects: fifty-four (54) preserved cadavers (108 sides) dissected within a period from june 2008 to aug 2010. the anatomy and position of both the right and the left recurrent laryngeal nerves (rln) and inferior thyroid arteries (ita) were noted. the rln was further classified into two variations: non-branching or branching prior to insertion at the cricothyroid joint under the inferior constrictor muscle. the ita was also classified into non-branching and branching. the results were compared to two foreign studies using a z-test for two proportions. results: fifty four (54) cadavers (108 sides) were dissected. among the cadavers, both the recurrent laryngeal nerves and inferior thyroid arteries had a maximum of two branches although both the rlns and itas for both the right and left sides were mostly non-branching. the right side of one cadaver was noted to have both a branching rln and a branching ita. there were no non-recurrent laryngeal nerves seen among the 54 cadavers. for both left and right sides, the rln was mostly dorsal to the ita. branching rlns was mostly dorsal to a non-branching itas. most of the non-branching rlns were dorsal to the itas. nonbranching rlns were usually dorsal to the ita. the local patterns of the course of the rln in relation to the ita approximates those of chinese where there is predominance of the rln dorsal to the ita but differs from those of brazilians where the rln is usually between ita branches. conclusion: there are multiple anatomical variations regarding the relationship of the rln and the ita. the anatomic variation among asians may be different from brazilians. the surgeon’s knowledge of the possible various configurations of the rln and ita should be able to help in identification and preservation of the rln and prevention of complications in thyroid surgery. keywords: recurrent laryngeal nerve, inferior thyroid artery, thyroid surgery, filipino cadavers, anatomical variations the recurrent laryngeal nerve in relation to the inferior thyroid artery in adult filipino cadavers jacob s. matubis, md1,2 karen june p. dumlao, md2 ryner jose c. carrillo, md, msc1,2 1department of anatomy college of medicine university of the philippines manila 2department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: dr. jacob s. matubis department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 e-mail: jacobmatubis@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the descriptive research contest (1st place) philippine society of otolaryngology-head and neck surgery, glaxosmithkline (gsk) bldg., chino roces ave., makati city, philippines, october 11, 2010. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles 14 philippine journal of otolaryngology-head and neck surgery a surgeon’s knowledge of surgical anatomy and its variations is essential to prevent complications in any thyroid surgery. modern technology has tried to minimize these problems but many patients still suffer recurrent laryngeal nerve complications which may include dysphonia, aspiration and even difficulty in breathing. a study of 624 thyroidectomy patients with 1076 nerves at risk by steurer et al. showed 2.4% had temporary rln palsy and 0.3% had permanent rln paralysis.1 there are several surgical landmarks used to locate the recurrent laryngeal nerve such as the rln triangle described by lore et al. which is bounded by the trachea / esophagus, the carotid artery / internal jugular vein and the inferior thyroid pole.2 a study by uen et al. found the rln to be within 3mm of berry’s ligament with no nerve penetrating the ligament.3 the inferior cornu of the thyroid cartilage is also a landmark which indicates the point of entry of the nerve into the larynx.4 identification of zuckerkandl’s tubercle is also important because it shows relations with the branches of the inferior thyroid artery and recurrent laryngeal nerve.5,6 a number of studies have established the relationship of the recurrent laryngeal nerve and the inferior thyroid artery. however, we do not know of any local study regarding the topic. this study aims to describe the anatomic relationship of the recurrent laryngeal nerve and the inferior thyroid artery in cadavers in the philippines and to compare the proportions of these anatomic relationships with those reported in the foreign literature. methods fifty-four preserved cadavers (108 sides) in the university of the philippines college of medicine anatomy laboratory were dissected from the period of june 2008 to august 2010. two anatomists figure 1. rln ventral to ita figure 2. rln dorsal to ita. figure 3. rln between branches of ita figure 4. branching rln dorsal to ita philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles philippine journal of otolaryngology-head and neck surgery 15 rln – recurrent laryngeal nerve ; ita – inferior thyroid artery; n – number of subjects table 2. course of the recurrent laryngeal nerve in relation to the inferior thyroid artery: pattern right n(%) left n(%) rln ventral to the ita rln dorsal to ita rln between branches of ita total 12 (22.2) 39 (72.2) 3 (5.6) 54 (100) 20 (37.0) 25 (46.3) 9 (16.7) 54 (100) rln – recurrent laryngeal nerve ; ita – inferior thyroid artery; n – number of subjects pattern non-branching ita right n(%) left n(%) branching rln ventral to the ita branching rln dorsal to ita branching rln between branches of ita non branching rln total 2 (3.7) 2 (3.7) 0 (0) 50 (92.6) 54 (100) 1(1.9) 5 (9.3) 0 (0) 48 (88.8) 54 (100) table 3. relationship of branching rln and nonbranching ita performed the dissection. medical histories and causes of death were unknown to the investigators. the anatomy and relationship of both the right and the left recurrent laryngeal nerves (rln) and inferior thyroid arteries (ita) were noted. the rln was classified into two variations: non-branching or branching prior to insertion at the cricothyroid joint under the inferior constrictor muscle. the ita was also classified into non-branching and branching. the anatomical relationship of the rln and ita were classified into three types: the rln was ventral to the ita (figure 1), rln dorsal to the ita (figure 2) or rln between branches of the ita (figure 3). the results obtained were compared to the studies by campos et al. of brazil 7 and uen et al. of china 3 using the z test for two proportions with the confidence level set at 95% and level of significance at <0.05. results among the 54 cadavers, both the recurrent laryngeal nerves and inferior thyroid arteries had a maximum of two branches although both the rlns and itas for both the right and left sides were mostly non-branching. the right side of one cadaver was noted to have both a branching rln and a branching ita. table 1 shows the proportion of branching laryngeal nerves and inferior thyroid arteries. there were no non-recurrent laryngeal nerves seen among the 54 cadavers. table 2 shows the course of the rln in relation to the ita. for both left and right sides, the rln was mostly dorsal to the ita. table 3 shows the relationship of the branching rlns and nonbranching itas. a branching rln was mostly dorsal to a non-branching ita. (figure 4) table 4 shows the relationship of non-branching rlns and nonbranching itas. most of the non-branching rln were dorsal to the non branching ita. (figure 2) table 5 shows the relationship of non-branching rlns and a branching ita. most of the non-branching rlns were dorsal to the branching ita. it is important to note that in 10.19% the rln coursed between the branches of the ita. tables 6 and 7 compare the results of the present study with those of uen and campos. campos et al. 7 dissected 76 cadavers and yielded results shown in table 6. all p values from the z test for two proportions were more than the level of significance of 0.05. uen et al. 3dissected 60 cadavers with results shown in table 7. the p values of the rln between branches of the ita on the right and rln dorsal to ita on the left were below the level of significance of 0.05. the rest of the p values were more than the level of significance of 0.05. table 1. proportion of branching of recurrent laryngeal nerve and inferior thyroid artery. right side left side recurrent laryngeal nerve inferior thyroid artery nonbranching n(%) 45 (83) 29 (54) nonbranching n(%) 47 (87) 31 (57) branching in 2 n(%) 9 (17) 25 (46) branching in 2 n(%) 7 (13) 23 (43) total n(%) 54 (100) 54 (100) total n(%) 54 (100) 54 (100) rln – recurrent laryngeal nerve ; ita – inferior thyroid artery; n – number of subjects rln – recurrent laryngeal nerve ; ita – inferior thyroid artery; n – number of subjects pattern non-branching ita right n(%) left n(%) non branching rln ventral to the ita non branching rln dorsal to ita non branching rln between branches of ita branching rln total 3 (5.6) 21(38.9) 0 (0) 30 (55.6) 54 (100) 9 (16.7) 11 (20.4) 1 (1.9) 33 (61.1) 54 (100) table 4. relationship of non-branching rln and non-branching ita philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles 16 philippine journal of otolaryngology-head and neck surgery rln – recurrent laryngeal nerve ; ita – inferior thyroid artery; n – number of subjects pattern branching ita right n(%) left n(%) non branching rln ventral to the ita non branching rln dorsal to ita non branching rln between branches of ita branching rln total 4 (7.4) 13 (24.1) 3 (5.6) 20 (37.0) 54 (100) 8 (14.8) 6 (11.1) 8 (14.8) 32 (59.3) 54 (100) table 5. relationship of non-branching rln and a branching ita discussion in the present study, 14.8% of the rlns on either side were noted to branch in two prior to insertion in the cricothyroid junction. this study also found that 44.4% of the ita branched in two. (table 1) this situation could be very difficult and crucial for the surgeon and this may have a higher likelihood of nerve injury if the surgeon is not aware of the branching variations of the ita and the rln. in this study, the rln was frequently found dorsal to the ita whereas the study of campos et al.7 found the rln more frequently between branches of the ita. this difference was true for both right and left sides, and was statistically significant. uen et al.3 noted the rln more frequently passed between the ita branches on the left side, but not the right. again, the difference in proportions between their findings and those of this study was statistically significant. recurrent laryngeal nerve injury is a very disturbing complication of any thyroid surgery. it has psychosocial and functional impact and greatly affects quality of life especially among those who are highly dependent on the use of voice. 8 the incidence may vary among countries, surgeons and specific types of thyroid surgery done and the type of thyroid disease. 5 a meta-analysis by schulte et al. 5 noted permanent recurrent laryngeal nerve palsy in 999 out of 28,957 post thyroid surgery patients (3.5%). however, studies they reviewed from the year 1997 onwards showed a marked decrease in permanent recurrent laryngeal nerve palsy to 114 out of 14,687 (0.7%). this may reflect improvement in the technique of recurrent laryngeal nerve preservation or better awareness of the variable anatomy. numerous techniques have been described for preservation of the recurrent laryngeal nerve during thyroid surgery. nerve-monitoring techniques include the use of intramuscular electromyography (emg) and palpation of the cricothyroid after stimulation of the nerve with a disposable stimulator. 9 dralle et al. 10 compared the outcomes of intra-operative nerve monitoring (ionm) versus visual nerve identification and concluded that the difference was not statistically significant. they also compared the outcomes of intra-operative nerve monitoring on top of visual nerve identification versus visual nerve identification alone. again, they concluded that ionm on top of visual nerve identification did not lower the incidence of recurrent laryngeal nerve palsy. thomusch et al. 11 analysed the postoperative rln palsy rate in thyroid surgeries using ionm versus visual identification of the rln. table 6. comparison of proportions of the values from this study compared to the studies of campos et al. 7 *level of significance p<0.05 rln – recurrent laryngeal nerve ; ita – inferior thyroid artery; n – number of subjects pattern p valuecampos7 n = 76 present study n = 54 rln ventral to the ita rln dorsal to ita rln between branches of ita rln ventral to the ita rln dorsal to ita rln between branches of ita 0.1 4.3 3.6 0.3 3.8 4.6 38.0% 11.3% 49.3% 18.1% 37.1% 44.5% 37.0% 46.3% 16.7% 22.2% 72.2% 5.6%p at te rn pa tt er n *level of significance p<0.05 rln – recurrent laryngeal nerve ; ita – inferior thyroid artery; n – number of subjects p valueuen5 n = 60 present study n = 54 rln ventral to the ita rln dorsal to ita rln between branches of ita rln ventral to the ita rln dorsal to ita rln between branches of ita 1.8 1.5 -0.1 1.8 0.0 2.2 20% 61.6% 18.4% 8.3% 70% 21.7% 37.0% 46.3% 16.7% 22.2% 72.2% 5.6% table 7. comparison of proportions of the values from this study compared to the studies of uen et al.5 pa tt er n pa tt er n the local patterns of the course of the rln in relation to the ita approximated those of chinese where there is a predominance of the rln dorsal to the ita, but differs from brazilians where the rln is usually between ita branches. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 original articles philippine journal of otolaryngology-head and neck surgery 17 references 1. steurer m, passler c, denk dm, schneider b, mancusi g, schickinger b et al. functional laryngeal results after thyroidectomy and extensive recurrent laryngeal nerve dissection without neuromonitoring – an analysis of more than 1000 nerves at risk. eur surg. 2003 oct; 35(5): 262267. 2. lore jm, medina je. an atlas of head and neck surgery. fourth edition. pennsylvania: elsevier; 2005. 3. uen yh, chen th, shyu jf, shyr tm, su ch, chen jy, et al. surgical anatomy of the recurrent laryngeal nerves and its clinical applications in chinese adults. surgery today. 2006; 36(4):312–315. 4. wang c. the use of the inferior cornu of the thyroid cartilage in identifying the recurrent laryngeal nerve. surg gynecol obstet. 1975 jan;140(1):91-4. 5. schulte km, roher hd. complications in the surgery of benign thyroid. acta chir, austriaca 2001; 33(4):164-172. 6. yalçin b, poyrazoĝlu y, ozan h. relationship between zuckerkandl’s tubercle and the inferior laryngeal nerve including the laryngeal branches. surgery today. 2007 jan;37(2)109–113. 7. campos ba, henriques prf. relationship between the recurrent laryngeal nerve and the inferior thyroid artery: a study in corpses. rev. hosp. clín. fac. med. s. paulo 2000 nov; 55(6):195-200. 8. sturniolo g, d’alia c, tonante a, gagliano e, taranto f, lo schiavo mg. the recurrent laryngeal nerve related to thyroid surgery. am j surg. 1999 june;177(6):485–8. 9. shindo m, chheda nn. incidence of vocal cord paralysis with and without recurrent laryngeal nerve monitoring during thyroidectomy. arch otolaryngol head neck surg. 2007 may;133(5):481-485. 10. dralle h, sekulla c, lorenz k, brauckhoff m, machens a. intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. world j surg 2008 jul; 32(7):1358–1366. 11. thomusch o, sekulla c, timmermann w, neumann hj, kruse e, muhlig hp, et al. intraoperative neuromonitoring in thyroid surgery – results of the german prospective multicentre study. eur. surg. 2003; 35(5):240–245. the use of ionm significantly decreased the early rln palsy rate (3.3%) versus visual identification (4.9%). however, ionm showed only a slight advantage over visual identification on the permanent rln palsy rate (0.7% versus 0.9%) which was not statistically significant. the gold standard for preservation of the recurrent laryngeal nerve during thyroid surgery is still visual anatomical identification. proper dissection and anatomical identification of the rln and all its branches is very important prior to the clamping of the ita and all its branches. other techniques which aim to preserve the rln may be used only as an adjunct to the gold standard. in a setting where advances in technology are not readily available, the surgeon must be knowledgeable about the variations in the neurovascular anatomy of the thyroid gland to prevent complications of surgery. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles philippine journal of otolaryngology-head and neck surgery 11 abstract objective: to evaluate the necessity of placing a drain in post-thyroidectomy patients, we aimed to determine whether insertion of a passive drain as compared to no drain in post-thyroidectomy patients would significantly affect hematoma formation, wound infection, wound dehiscence and length of hospital stay. methods: design: prospective randomized controlled trial setting: tertiary government training hospital subjects: patients who underwent thyroidectomy for various thyroid pathologies were divided into two postoperative treatment arms: one group with insertion of a passive drain, and another group without a drain. hematoma, wound infection, wound dehiscence and length of hospital stay were the outcomes measured per treatment arm. results: a total of 66 patients were evaluated. there were 54 females (81.81%) and 12 males (18.18%). the mean age for the drain group was 44.88 years and 43.67 years for the no drain group. four patients developed complications in the drain group and two developed complications in the no drain group. the rate of complications between both groups was not statistically significant. the mean hospital stay of the drain group was 3.15 days which in the no drain group was 2.51 days. the difference in length of hospital stay was statistically significant. conclusion: there was no difference in the development of complications among the drain and no drain group. thyroidectomy without surgical drains was associated with a significant reduction in hospital stay compared to thyroidectomy with routine placement of drains. keywords: surgical drainage / methods, hematoma / prevention and control, postoperative complications / prevention and control, thyroid disease / surgery, thyroidectomy / methods many surgeons practice the tradition of leaving a drain after thyroid surgery with the hope that this will obliterate dead space and prevent hematoma and seroma formation in the thyroid bed by passive evacuation.1,2,3,4 this belief is further reinforced by the fact that postoperative drains usually yield fluid. however, blood and serum that they are supposed to drain may block drains. drains also add to discomfort, give extra scar and may increase hospital stay.1 khanna et al. pointed out that placement of drains after routine thyroid surgery may induce rather than prevent drain versus no drain after thyroidectomy: a preliminary prospective randomized controlled trial jefferson a. alamani, md elias t. reala, md samantha s. castaneda, md antonio h. chua, md department of otolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. jefferson a. alamani department of otolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 743 6921 (632) 711 9491 local 320 email: dyeph.kk10@gmail.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or in electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2014; 29 (1): 11-15 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles 12 philippine journal of otolaryngology-head and neck surgery fluid collection, is not related to the type of surgery or size of nodule, has no influence on complications, leads to an extra scar and may increase the hospital stay.2 they added that meticulous hemostasis and attention to finer details during surgery are more important. routine use of drains after thyroid surgery may therefore not be necessary. colak added that postoperative complications cannot be prevented by using drains after total thyroidectomy or lobectomy for benign thyroid disorders.1 moreover, the use of drains may increase postoperative pain and the analgesic requirement and prolong the hospital stay.1 tabaqchali observed 606 thyroid procedures and concluded that there was a significant increase in the rate of postoperative bleeding/ hematoma in patients with a drain.3 wound infection occurred only in the patients with a drain. there was no difference in the incidence of postoperative bleeding and airway obstruction between the drain and selective groups.3 and yet, the widespread use of drains persists, prompting us to undertake this study. objective: to evaluate the necessity of placing a drain in postthyroidectomy patients, we aimed to determine whether insertion of a passive drain as compared to no drain in post-thyroidectomy patients, would significantly affect hematoma formation, wound infection, wound dehiscence and length of hospital stay. methods this was a prospective randomized controlled trial conducted in a tertiary government training hospital in the philippines from april 2012 to june 2013. participants: all patients seen at the outpatient department and diagnosed with a thyroid neoplasm were considered for inclusion. diagnoses included nodular and multinodular non-toxic goiter with normal thyroid function tests and fine needle biopsy suggesting benign disease (nodular goiter, colloid goiter, hyperplastic / adenomatous nodule, hashimoto’s thyroiditis), as well as well-differentiated tumors (papillary thyroid carcinoma, follicular neoplasm). surgical plans included total thyroidectomy, total thyroid lobectomy or completion thyroidectomy approved by a subspecialty consultant or with a consensus from a pre-operative conference. no patient was excluded on the basis of size of the gland, laterality or bi-laterality, difficulty of surgery, or re-operation in the neck. following patients were excluded: extensive malignancy such as skin metastasis1. mediastinal extension2. cervical lymph node metastases requiring neck dissection3. clinical or laboratory indicators of coagulation disorders4. no consent 5. the sample size was computed as follows: sample size description: n = required sample size t = confidence level at 95% (standard value of 1.96) p = estimated prevalence of complications of thyroid cases – 2% m = margin of error at 5% (standard value of 0.05) *in general, serious complications occur in fewer than 2% of all thyroid cases5 n = 1.962 x 0.02 (1-0.02) / 0.052 = 3.8416 x 0.0196 / .0025 = 0.0752954 / .0025 n = 30.11816 n = 30 per group, total number of patients for the study 60 pre-operative preparation with approval from the hospital review board and ethics committee, all patients seen at the ear nose throat outpatient department and emergency room fulfilling the inclusion and exclusion criteria for this study were given a short lecture on thyroid nodules and surgery and regarding the use of drains. all prospective participants underwent pre-operative evaluation that included thyroid function tests, thyroid ultrasound and fine needle biopsy. written informed consent was obtained and each participant was admitted and prepared for the thyroid surgery. all participants also underwent routine preoperative and postoperative video laryngoscopy to verify the pre-operative vocal fold status and movement, documenting that paralysis was not present. the patients were randomly allocated to drain and non-drain group on the basis of computer-generated random numbers (microsoft excel). the randomization was performed by an independent staff. intra-operative procedure six surgeons with equal thyroid surgery competency were rotated to perform the surgeries using the standard techniques for total thyroidectomy, thyroid lobectomy and completion thyroidectomy with the use of monopolar electrocautery and silk suture ligatures. each surgeon was only informed of the randomized intervention (drain or no drain) just before the closure of the skin incision. in the drain group, a well-ventilated half-inch rubber drain was used. n = t² x p(1-p) m² philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles philippine journal of otolaryngology-head and neck surgery 13 post-operative evaluation a single researcher monitored the progress of each patient noting any complications that occurred. the rubber drains were removed after 48 hours. outcomes measured were the following: 1. bleeding: complications included post-operative minor bleeding described as bruises or hematoma that did not require re-operation and major bleeding which required reopening of the surgical field. 2. wound infection: wound or surgical site infection (ssi) was determined in accordance with centers for disease control and prevention (cdc) guidelines by horan et al.6 a. infection occurs within 30 days of procedure b. involves only skin or subcutaneous tissue around the incision. c. and at least one of the following: i. purulent drainage from superficial incision ii. organism isolated from aseptically obtained culture of fluid or tissue from superficial incision iii. at least one of the following signs and symptoms of infection: pain or tenderness, localized swelling, redness or heat and superficial incision is deliberately opened by surgeon, unless culture of incision is negative. iv. diagnosis of superficial incisional ssi by the surgeon or attending physician. 3. wound dehiscence: persistent open surgical wound observed at one week postoperatively 4. length of hospital stay: days recorded from the day of surgery to the day of discharge all specimens were subjected to histopathological examination for final confirmation of diagnosis. data were encoded and tallied in microsoft excel. descriptive statistics were generated for all the variables. nominal data, frequencies and percentages were computed. for numerical data, means with standard deviation (sd) were computed. analysis of the different variables was done using t-test and fisher exact test. results a total of 66 patients [12 males (18.18%), 54 females (81.81%), mean age 44.25 years, range 20-80] fulfilled the inclusion and exclusion criteria. the drain group served as the control group and the no drain group served as the treatment group. thirty-two patients (6 males, 26 females) were in the drain group with 34 patients (6 males, 28 females) in the no drain group. there was no statistically significant difference in demographic characteristics of age and gender between the two groups (p value < 0.05). (table 1) the patients were older in the drain group (mean age 44.73 years, range of 2180) than the no drain group (mean age 43.79 years, range 20-66) but the mean age difference between groups was not statistically significant. (table 1) of the 32 patients in the drain group, 20 underwent total thyroidectomy and 12 underwent lobectomy. in the no drain group, 9 underwent total thyroidectomy and 25 underwent lobectomy. this comparison of operations performed in both groups was statistically significant (p value = 0.006). most of the specimens (62/66 or 93.94%) were forwarded to the pathology department of the hospital, submerged in formalin solution (potentially resulting in smaller measurements) and were measured by an independent pathology resident. in the drain group, the mean specimen volume was 132.61cm3 (range 15.36-554.5 cm3) while the no drain group specimen volume was 73.06 cm3 (range of 12.0-357.5 cm3). the difference in specimen volume between groups was not statistically significant (p value = 0.06). (table 1) the final histopathologic reports in the drain group were 12 welldifferentiated thyroid carcinoma and 20 benign compared to 8 welldifferentiated thyroid carcinoma and 26 benign in the no drain group. this distribution was not statistically significant (p value = 0.29). (table 1) the mean operative time for the procedure from skin incision to closure was 243.19 minutes (sd 66.57) in the drain group and 209.24 minutes (sd 79.68) in the no drain group. the difference in operative time between the two groups was statistically significant at p value of 0.02 (table i). this difference could be due to the number of total thyroidectomies done in the drain group compared to the no drain group translating into longer operative time. the amount of blood loss in milliliters was also recorded, an estimation of the blood suctioned and operating sponges consumed which the anesthesiologist noted. the drain group had a mean of 318.79 ml (sd 252.91) versus 262.42ml (sd 158.69) in the no drain group. the difference of blood loss was not statistically significant at p value of 0.13 (table 1). the two groups were relatively equal in terms of age, gender distribution, blood loss and final histopathological report. there were significant differences in operation performed and operative time. (table 1) the increase number in the lobectomy operation compared to total thyroidectomy translated to the increased duration of operation. there were a total of six complications out of 66 patients recorded during the study, a rate of 9.09%. of the 32 patients in the drain group, four developed complications, while two complications were observed out of 34 patients in the no drain group. (table 2) the four complications of the drain group included two bleeding which were both expanding hematomas that needed re-opening for ligation of bleeders and evacuation and two wound dehiscences. both complications from the no drain group were wound dehiscences. no patient developed wound infection. the comparison of occurrence of complications between the two groups was not statistically significant (p value = 0.10) philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles 14 philippine journal of otolaryngology-head and neck surgery figure 1. length of hospital stay of patients. the line corresponded with the hospital stay in days of each patient. the vertical axis is the frequency in days and the horizontal axis is the order of each patient randomly allocated on each group. the drain group was plotted with rhombus while the no drain was plotted with squares. table 1. comparison of demographic characteristics between the two groups drain (n=32) no drain (n=34) p value age in years mean ± sd gender female male volume of thyroid in cubic centimeters mean ± sd operation performed total thyroidectomy lobectomy blood loss in millimeter mean ± sd operative time in minutes mean ± sd histopathological report benign wdtc 44.73 ± 14.30 26 (81.25%) 6 (18.75%) 132.61±176.85 20 12 318.79 ± 252.91 243.19 ± 66.57 20 12 43.79±12.96 28 (82.53%) 6 (17.64%) 73.06 ± 75.28 9 25 262.42 ± 158.69 209.24 ± 79.68 26 8 0.36 (ns) † 1.0 (ns) * 0.06 (ns) † 0.006 (s)* 0.13 (ns) † 0.02 (s) † 0.29 (ns) * † t-test *fisher exact test legend: sd = standard deviation, ns = not significant table 2. rate of post-operative complications complications drain (n=32) no drain (n=34) bleeding wound infection wound dehiscence total 2 (6.25%) 0 2 (6.25%) 4 (12.5%) 0 0 2 (5.88%) 2 (5.88%) 0 0 0 p value 0.10 (ns) legend: sd = standard deviation, ns = not significant the comparison of length of hospital stay (surgery to discharge) between the two groups showed a significant difference at p value of < 0.05. the distribution of length of stay is shown in figure 1. the mean length of hospital stay in the drain group was 3.15 days (range 2 to 6 days, sd 0.99). the mean length of hospital stay in the no drain group was 2.51 days (range 2 to 6 days, sd 0.89). the mean difference in length of hospital stay between the two groups was statistically significant (p value = 0.003). philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 original articles philippine journal of otolaryngology-head and neck surgery 15 references colak t, akca t, turkmenoglu o, canbaz h, ustunsoy b, kanik a, 1. et al. drainage after total thyroidectomy or lobectomy for benign thyroidal disorders; univ sci b 2008; 9(4):319-323. khanna j, chintamani rsm, bhatnagar d, mittal mk, sahoo m, mehrota m. is the routine 2. drainage after surgery for thyroid necessary? – a prospective randomized clinical study, bmc surgery 2005;5:11 tabaqchali ma, hanson jm, proud g. drains for thyroidectomy/parathyroidectomy: fact or 3. fiction?; ann r coll surg engl 1999; 81(5): 302-305. chalya pi, gilyoma jm, mchembe m. drain versus no drain after thyroidectomy: a prospective 4. randomized clinical study. east cent afr j surg. 2011; 16(2): 55-61. lai sy, mandel sj, weber rs, management of thyroid neoplasm in flint pw, haughey bh, lund 5. vj, niparko jk, richardson ma, robbins kt, thomas jr. cummings otolaryngology head and neck surgery, 5th edition. 124:1750-72. mosby elsevier 2010. horan tc, gaynes rp, martone wj, jarvis wr, emori tg. cdc definitions of nosocomial surgical 6. site infections. a modification of cdc definitions of surgical wound infections. infect control hosp epidemiol 1992; 13 (10): 606-08. shan ck, zhang w, jiang xm, liu s, qui m. prevalence, risk factors, and management of seroma 7. formation after breast approach endoscopic thyroidectomy, world j surg 2010 aug; 34(8): 181722. discussion are surgical wound drains used by head and neck surgeons after thyroidectomy really needed? we evaluated the necessity of placing a drain post-thyroidectomy and compared the difference in complication rates and hospital stay between the drain and no drain groups. the difference in complication rates between the two groups was not statistically significant. complications occurred in both groups. all complications that occurred in the two groups (4 in the drain group and 2 in the no drain group) were in-patients with a final histopathologic result of well-differentiated thyroid carcinoma (papillary thyroid or follicular carcinoma). could the complications of bleeding and wound dehiscence be related to angiogenesis promoted by malignancy and a higher probability of bleeding during thyroidectomy? nevertheless, our findings suggest that postoperative complications cannot be prevented by drains after thyroid surgery, in consonance with the literature.1-4 the use of drains may not be necessary in most cases of thyroidectomy. meticulous dissection and hemostasis remain the key to minimizing drastic complications in thyroid surgeries. the occurrence of wound dehiscence in both groups may be attributed to seroma formation. seroma is caused by division of lymphatic and adipose tissues during neck dissection. seroma is defined as the collection of serous fluid in the potential space between cervical skin flaps and underlying structures. seromas present as enlarging masses under the skin with or without overlying induration or erythema.5 a study by shan et al. explained that the presence of seroma can lead to flap detachment, incision dehiscence and wound infection.7 the seroma that developed in four patients could have been due to increased subcutaneous dissection during elevation of skin flaps. the difference in length of hospital stay between the two groups was statistically significant. the duration of stay was longer in the drain group compared to the no drain group. the placement of drain translated to longer days in the hospital as observed in the literature.1-4 in conclusion there was no difference in the development of complications among the drain and no drain group. thyroidectomy without drains led to a significant reduction of hospital stay compared to the routine placement of drains. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 38 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2015; 30 (2): 38-42 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to report a case of acute tonsillitis that subsequently developed descending necrotizing mediastinitis and to discuss the signs and symptoms, differential diagnosis, pathophysiology, diagnostic criteria, ancillary procedures and management. methods: design: case report setting: tertiary private and government hospital patient: one results: a 36-year-old woman was admitted with a 2-day history of sore throat and a diagnosis of acute exudative tonsillitis. she complained of sore throat accompanied by dyspnea, neck and chest pain which rapidly progressed to mediastinitis. she was transferred to a tertiary government hospital where video assisted thoracoscopic surgery with bilateral deloculation, mediastinoscopy and bronchoscopy revealed purulent discharge from the right main stem bronchus with multiloculated effusion in the left lung and posterolateral loculated effusion in the right lung. her condition improved and she was discharged after a month of antibiotic therapy. conclusion: acute tonsillitis seldom leads to a life-threatening complication such as mediastinitis. descending necrotizing mediastinitis develops when acute tonsillar infection progresses and descends to the mediastinum. it is a surgical emergency which requires mediastinal drainage, thoracotomy and long-term antimicrobials. clinicians who manage oropharyngeal infections should be aware of this rare but lethal complication which may occur even in nonimmunocompromised individuals. keywords: acute tonsillophraryngitis, tonsillitis, mediastinitis, descending necrotizing mediastinitis. acute tonsillitis is a common problem encountered in the outpatient clinic mostly due to viruses that affect the pharynx with 30 to 60% being self-limiting.1 bacterial origin involves 5-10% in adults and 30-40% in children.1 group a beta hemolytic streptococcus (gabhs) is predominantly responsible but anaerobes have also been implicated.1 most cases resolve with antimicrobials and only a few develop life threatening complications such as mediastinitis. since this complication is rarely encountered nowadays, clinicians may not be aware of the dire consequences and serious implications of mediastinitis that can develop from simple acute tonsillar infection. descending necrotizing mediastinitis, a dreaded complication of acute tonsillitis ma. stephanie c. go, md1 emmanuel tadeus s. cruz, md1, 2 1department of otorhinolaryngology head & neck surgery quezon city general hospital and medical center 2department of otorhinolaryngology head & neck surgery manila central university-filemon d. tanchoco medical foundation correspondence: dr. emmanuel tadeus s. cruz department of otorhinolaryngology-head & neck surgery quezon city general hospital and medical center seminary road, munoz, quezon city 1106 philippines phone: (632) 426 1314 local 232 fax: (632) 920 7081; 920 6270 email: orl_hns_qcgh@yahoo.com.ph reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports philippine journal of otolaryngology-head and neck surgery 39 the objective of this paper is to share the clinical experience gained in managing a case of acute tonsillitis that later developed mediastinitis and to discuss the signs and symptoms, differential diagnosis, pathophysiology, diagnostic criteria, ancillary procedures and management of such conditions. case report a 36-year-old woman with a 2-day history of sore throat, odynophagia, fever and body malaise was admitted for difficulty of breathing and chest pain that developed a few hours prior to admission. the patient had no history of hypertension, diabetes or prior hospitalizations. she was conscious and coherent with normal vital signs. oral cavity examination showed a hyperemic pharynx and grade 1-2 tonsils with exudates. there was slight tenderness of the neck on palpation but no swelling or palpable neck nodes. she had symmetrical chest expansion with no retractions and clear breath sounds. the rest of the physical examination was normal. the admitting impression was acute exudative tonsillitis. laboratory examinations revealed leucocytosis of 29 x 109/l (4-11 x109/l) and increased fasting blood sugar (fbs) of 177mg/dl (65101mg/dl). clindamycin 600mg iv every 6 hours was started based on the elevated wbc and tramadol 50mg iv was administered when necessary, for pain. chest x-ray (figure 1) and soft tissue lateral and antero-posterior x-rays of the neck (figure 2a, b) were unremarkable. a few hours after admission, her chest pain worsened and she complained of back pain (8/10 on pain scale) with low grade fever of 37.7 ºc. her dyspnea also worsened but her 12-lead ecg was normal. oxygen, tramadol and hydrocortisone were given to relieve her symptoms. late at night, dyspnea became severe even with high back rest. she was afebrile with blood pressure (bp) of 110/60 mm hg, cardiac rate of 105/min, respiratory rate of 24/min with decreased breath sounds and occasional fine crackles on the right lung field. a second 12-lead ecg showed abnormal ecg with sinus tachycardia and rate-related non-specific st-t wave changes. follow-up chest x-ray showed suspicious blunting of both costophrenic sulci and possible pleural effusion. (figure 3) a pulmonologist requested laboratory examinations, additional analgesics and shifted clindamycin to piperacillin-tazobactam and clarithromycin. on the 2nd hospital day, the patient’s sore throat and tonsillar figure 1. normal chest x-ray upon admission figure 2. normal a. soft tissue lateral, and b. antero-posterior, x-rays of the neck. a b philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports 40 philippine journal of otolaryngology-head and neck surgery exudates decreased but she continued to have the same symptoms. ultrasonography of the chest showed bilateral minimal pleural effusion of 45ml on the right and 145ml on the left. on the 3rd hospital day, her oxygen saturation decreased to 91% with crackles over both lung fields. she became febrile (38.1°c) and had low urine output. at this juncture, septicemia with possible mediastinitis was contemplated and the patient was referred to an infectious disease specialist. piperacillin-tazobactam and clarithromycin were shifted to meropenem and azithromycin. blood cultures taken from 2 sites had no growth after 7 days. on the 4th hospital day, chest x-ray showed significant interval progression of pleural fluid in both lungs. (figure 4) white blood cells decreased on the 5th hospital day while pleural effusion further increased on ultrasonography of the chest: 200ml in the right and 520ml in the left lung. she was eventually transferred to a government hospital where thoracentesis of the left lung yielded 200 ml of serous pleural fluid. chest computed tomography (ct) scan demonstrated paratracheal and paraesophageal edema, pneumonia and loculated pleural effusion in both lungs with bi-apical fibrosis. (figure 5 ) the patient underwent video assisted thoracoscopy (vats) with bilateral deloculation and mediastinoscopy. intraoperative findings revealed purulent discharge from the right main stem bronchus and posterolateral loculated sanguinous effusion in the right lung amounting to 250cc while approximately 350cc multiloculated serous effusion in the left lung was extracted. cytology of the left hemithorax indicated acute on chronic inflammation with no malignant cells. pleural fluid culture had no growth after 7 days. figure 3. repeat chest x-ray 2 days after the initial study. suspicious blunting of both costophrenic sulci and pleural effusion is seen. figure 4. chest x-ray showing progression of pleural fluid in both lungs after 4 days. figure 5. chest ct scan with contrast showing bilateral hypodense areas of loculated pleural effusion (e) and pneumonia (p) on the left lung. e p e figure 6. ct scan after video assisted thoracoscopy showing hypodensity surrounding the heart (arrow) showing moderate pericardial effusion, presence of pneumomediastinum (pm) and minimal bilateral pleural effusion (e). two separate right chest tubes (rt1,rt2) and one left chest tube (lt1) are seen. pm e e lti rt2 rt1 philippine journal of otolaryngology-head and neck surgery 41 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports another chest ct scan after a week confirmed marked diminution of mediastinal fluid collection with pneumomediastinum. there was moderate pericardial effusion and minimal bilateral pleural effusion. (figure 6) bibasal subsegmental atelectasis was also observed. fiberoptic bronchospcopy showed seromucoid secretions in all bronchi. bronchial aspirate cultured burkholderia cepaciae while sputum culture revealed candida albicans. after a month of antibiotic and antifungal therapy, the patient improved and was discharged with a final diagnosis of descending necrotizing mediastinitis. discussion complications of tonsillitis can be non suppurative which include scarlet fever, acute rheumatic fever, and poststreptococcal glomerulonephritis or suppurative, results from abscess formation including peritonsillar and parapharyngeal abscess. most often, the use of antimicrobials minimizes the possibility of these complications and only a few develop mediastinitis.1 quinsy or peritonsillar abscess may progress to deep neck infection and/or mediastinitis in 1.8% of cases2 while deep neck infections may develop into mediastinitis in 10% of cases.3,4 patients who developed mediastinitis were reported to have a 30-40% mortality rate.1 albeit rare, the clinician should be aware of the signs and symptoms of mediastinitis to facilitate early intervention. a patient with acute tonsillitis often complains of sore throat, fever, dysphagia and odynophagia. examination of the oral cavity may show enlarged inflamed tonsils with or without exudates and tender cervical lymph nodes.1 when shortness of breath, chest pain, muffled heart sounds or pericardial rub are present, mediastinitis should be entertained.2 foroulis and sileli5 included substernal and pleuritic pain, dysphagia, dyspnea and signs of pleural and/or pericardial effusion plus septic shock as part of the signs and symptoms. these were clearly manifested in the clinical course of our patient. therefore, clinicians should be vigilant when pulmonary distress, severe neck and chest discomfort develop in the course of managing oropharyngeal infection because these are tell-tale signs of mediastinitis. signs and symptoms of tonsillitis may be present in epiglottitis or pharyngitis.6 neck swelling, erythema, tenderness and crepitation are signs of deep cervical infections which can rapidly progress to mediastinitis.5 when shortness of breath and chest pain pertaining to mediastinal involvement develop, pneumonia, pericarditis and bronchitis should be ruled out.6 islam and oko7 reported a case where aside from tonsillitis and descending necrotizing mediastinitis, cervical necrotising fasciitis (cnf) also ensued from the oropharyngeal infection. mediastinitis may be secondary to odontogenic infection, esophageal disruption, open intracardiac procedures and iatrogenic causes.2,5,6 respiratory tract and oropharyngeal infections rarely progress to mediastinitis but involvement of the fascial planes makes this possible. as for pathophysiology, when tonsillopharyngeal infection begins to affect the superior constrictor muscle, cellulitis of neck tissues develops and may spread and encroach on the parapharyngeal space. rapid infection through the fascial planes towards the mediastinum makes mediastinitis possible in 2-10% of cases.2 foroulis and sileli5 stipulated that descending necrotizing mediastinitis (dnm) occurs when cervical infection descends to the mediastinum through the deep and superficial cervical fascial planes in communication with the mediastinum. the pretracheal, paraesophageal, prevertebral and retropharyngeal spaces as well as the carotid sheaths become channels for the spread of infection. the retropharyngeal space otherwise known as “danger space,” extending from the skull base to the mediastinum, could be responsible to the spread of odontogenic infections within the posterior mediastinum and pleural space. pierce et al.6 similarly suggested that this “danger space,” also called the retrovisceral space is accountable for the passage of infection from the previsceral space to the mediastinum when the alar fascia is obliterated. the lateral pharyngeal space serves as a transfer point for infections particularly from the mandible, parotid gland, tonsils and cellulitis of the sublingual and submaxillary spaces. infections can move through the lateral pharyngeal space to the connecting previsceral space. furthermore, they explained that respiratory dynamics contribute by creating a fluctuating negative intrathroracic pressure in these spaces that pulls the contents of the fascial spaces into the mediastinum. saliva, air and microorganisms are drawn into the mediastinum adding to the spread of infection leading to dnm.6 as for etiologic agents of mediastinitis, culture and sensitivity usually reveal β haemolytic streptococci, anaerobic gram-positive cocci and staphylococcus haemolyticus.2,6 several studies gathered by foroulis and sileli5 include fusobacterium, bacteroides species, haemophilus species, clostridium perfringens, esherichia coli and pseudomonas aeruginosa as part of the flora that could be present in dnm. culture and sensitivity is indispensable to help guide the physician in selecting the appropriate therapeutic regimen. in this case, no growth was observed in the pleural fluid but candida albicans was isolated from the bronchial aspirate and sputum of the patient and was treated with antifungal medication. mediastinitis is regarded as a surgical emergency. the diagnostic criteria for descending necrotizing mediastinitis defined by estrera et al. and wheatley et al.8 include the following: 1) clinical evidence of severe cervical infection, 2) characteristic radiographic features of mediastinitis, 3) documentation of necrotizing mediastinal infection at operation or at post-mortem; 4) establishment of the relationship between the philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 case reports 42 philippine journal of otolaryngology-head and neck surgery descending necrotizing mediastinitis and the oropharyngeal infection. these criteria were satisfactorily met by our patient based on her clinical course and history documented by radiographs, computed tomography and intraoperative findings. deep neck space infection and mediastinitis are frequently encountered in patients with co-morbid conditions such as diabetes, hepatitis, collagen vascular diseases, hematologic malignancy, previous radiation exposure, chemotherapy and immunodeficiency virus.1,7,9 even steroid use increases the risk of atypical pathogens and hastens the progression of these diseases.1,9 however, mediastinitis may also develop in non-immunocompromised individuals. there have been reported cases of patients with unremarkable past medical histories who had dnm after oropharyngeal infections;2,6,7 one was even caused by an opportunistic bacteria.2,9 in our case, the patient was young in her 30’s with no previous hospitalization. she rarely experienced sore throat in the past, was a non-smoker and was not asthmatic. her initially elevated fbs may be attributed to hydrocortisone administered the night before the blood was extracted. chest radiographs are a valuable tool that may reveal the following in mediastinitis: widening of the mediastinum and mediastinal emphysema, air-fluid levels within the mediastinal shadow, anterior displacement of the tracheal air column by a prevertebral soft tissue opacity, enlargement of the cardiac silhouette and loss of the normal cervical spine lordosis and unilateral or bilateral pleural effusion.2,5 soft tissue x-ray of the neck may reveal air or gas in the soft tissues.7 although the patient’s soft tissue lateral xray was interpreted as normal, closer scrutiny shows widening of the prevertebral soft tissue which may be interpreted as a sign of deep neck space involvement. the patient’s chest x-ray showed widening of the mediastinum which later progressed to pleural effusion. the presence and interval accumulation of pleural fluid was monitored and confirmed by a series of chest xrays, ultrasonography and ct scans. chest ct scans may reveal soft tissue infiltration and loss of the normal appearance of mediastinal fat (increased density), mediastinal emphysema and mediastinal fluid collections with or without air bubbles. pleural and pericardial effusions may also be seen.5 the patient’s ct scan showed paratracheal and paraesophageal edema with loculated pleural effusion in both lungs. (figure 5) management of mediastinitis is primarily surgical and the cornerstone of management include: aggressive cervical and mediastinal debridement and drainage, effective pleural and pericardial drainage, intravenous administration of broad spectrum antibiotics and confinement in intensive care unit to render support to the vital organs of the patient.5 endo et al.10 suggested a management plan based on ct scan findings divided into 3 types. type 1 is defined as a localized dnm acknowledgements we would like to thank drs. daphne bate, jessica catalan and guia elena ladrera for their insights and invaluable contributions. our gratitude also goes to drs. anna agabao and juan vergara who helped in the interpretation and selection of the xray and ct scan plates. references 1. nussenbaum b, bradford cr. pharyngitis in adults. in: flint pw, haughey bh, lund vj, niparko jk, richardson ma, robbins kt et al. eds. cummings otolaryngology head and neck surgery. 5th edition. philadelphia: mosby; 2010. p.192. 2. collin j, beasley n. tonsillitis to mediastinitis. j laryngol otol. 2006 nov; 120(11):963-966. 3. wang lf, kuo wr, lin cs, lee kw, huang kj. space infection of the head and neck. kaohsiung j med sci, 2002 aug; 18(8): 386-92. 4. wang lf, kuo wr, tsai sm, huang kj. characteristics of life threatening deep cervical space infections: review of 196 cases. am j otolaryngol, 2003 mar-apr; 24(2): 111-17. 5. foroulis, c, sileli, m. descending necrotizing mediastinitis: review of the literature and controversies in management. open surg j, 2011mar; 5(5): 12-18. 6. pierce tb, razzuk ma, razzuk lm, luterman dl, sutker wl. acute mediastinitis. bumc proceedings. 2000 jan;13(1):31-33. 7. islam a, oko m. cervical necrotising fasciitis and descending mediastinitis secondary to unilateral tonsillitis: a case report. j med case reports. 2008 dec; 2(2): 368-12. 8. wheatley mj, stirling mc, kirsh mm, gago o, orringer mb. descending necrotizing mediastinitis: transcervical drainage is not enough. ann thorac surg. 1990 may;49(5):780-4. 9. lee mk, choi sh, ryu dw. descending necrotizing mediastinitis caused by kocuria rosea: a case report. bmc infect dis. 2013oct;13(1):475-11. 10. endo s, murayama f, hasegawa t, yamamoto s, yamaguchi t, fuse k et al. guideline of surgical management based on diffusion of descending necrotizing mediastinitis. jpn j thorac cardiovasc surg. 1999jan;47(1):14–19. on the upper mediastinal space above the carina which can be managed with parenteral antibiotics with or without drainage. type iia is diffuse dnm reaching the lower anterior mediastinum which may require subxiphoidal mediastinal drainage and type iib is characterized by dnm down to the lower anterior and posterior mediastinum which should be completely drained and for which thoracotomy is warranted.10 the patient may be classified under type iib which eventually resolved after mediastinal drainage and thoracoscopy. (figure 6) acute tonsillitis seldom develops into a life-threatening complication such as mediastinitis. descending necrotizing mediastinitis develops when acute tonsillar infection progresses and descends via the retropharyngeal space reaching the mediastinum. it is a surgical emergency which requires mediastinal drainage, thoracotomy and long term antimicrobials. clinicians who often manage oropharyngeal infection should be aware of this rare but lethal complication which may occur even in nonimmunocompromised individuals. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 original articles 12 philippine journal of otolaryngology-head and neck surgery abstract objective: topical cepae extract-heparin sodium-allantoin gel is one of the many non-invasive scar treatments available to improve the appearance and physical attributes of scars. this paper aims to compare the effectiveness of topical cepae extract-heparin sodium-allantoin gel versus placebo based on appearance and physical attributes of hypertrophic thyroidectomy scars. methods: design: randomized, double-blinded, split-scar controlled trial setting: out-patient department of a tertiary government hospital patient: 20 patients with hypertrophic thyroidectomy scars had each side of the scar randomly assigned treatment with topical extract cepae-heparin sodium-allantoin gel or placebo (glycerine gel). each product was applied two times daily for six weeks, and scars were evaluated prior to initiation of treatment and after six weeks by patients and one observer. preand posttreatment photo documentation and scar evaluation using a local language translation of the patient and observer scar assessment scale (posas) were completed for each side of the scar. results: there was no significant difference in effectiveness of topical cepae extract-heparin sodium-allantoin gel versus placebo for both the patient scale (p = 0.91) and observer scale (p = 0.87) in appearance and physical attributes of a thyroidectomy scar. conclusion: topical cepae extract-heparin sodium-allantoin gel was not proven to be superior to the placebo as scar therapy in all parameters assessed by the filipino translation of posas. the small sample size, duration of hypertrophic scar, duration of treatment, and validity and reliability of the filipino translation of posas may have affected our results; and periodic subjective and objective assessments with multi-observer evaluation of scars and preand posttreatment photographs may be considered for further studies. keywords: topical cepae extract-heparin sodium-allantoin gel, glycerine, patient and observer scar assessment scale, thyroidectomy scar, scar head and neck surgical scars may be difficult to conceal, and thyroid surgery is a common head and neck procedure whose scar may create stigma for the patient. the first two months of scar maturation are especially associated with a tendency for hypertrophic scar development.1 the disfiguring appearance of the linear hypertrophic scar in the neck can produce low selftopical cepae extract-heparin sodiumallantoin gel versus placebo on hypertrophic thyroidectomy scars: a randomized, doubleblinded, split-scar controlled trial michael paolo m. tapangco, md1 waynn neilsen destriza, md1 bernardo d. dimacali, md1, 2 mildred b. olveda, md1 1department of otolaryngology head and neck surgery ospital ng makati 2department of otolaryngology head and neck surgery far eastern university nicanor reyes memorial medical foundation correspondence: dr. michael paolo m. tapangco 5th floor, department of ent-hns, ospital ng makati sampaguita st. pembo makati city 1208 philippines phone: (632) 882 6316 local 309 fax: (632) 882 6316 local 309 e-mail: tpx_04@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2012; 27 (2): 12-16 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 original articles philippine journal of otolaryngology-head and neck surgery 13 esteem and social isolation which can significantly interfere with the psychological well being of the person afflicted. there are numerous invasive and non-invasive treatment options to improve scar appearance, including intra-lesional corticosteroids (triamcinolone), topical silicone gel, compression or pressure therapy and surgical scar excision or revision, radiotherapy and cryotherapy.1,2,3 treatment with topical cepae extract-heparin sodium-allantoin gel has been claimed to have special value in hypertrophic scars due to its anti inflammatory activity, fibroblast anti-proliferative activity, inhibition of proteoglycan and collagen formation, loosening of collagen structure and improvement of scar elasticity.4 however, there is conflicting evidence on the effectiveness of this preparation in improving scar appearance. some reported improvement in the color of scar alone1,2,3,4 while others claim no improvement in scar appearance.2,3 this study aims to assess the effectiveness of cepae extract-heparin sodium-allantoin gel versus placebo in the treatment of thyroidectomy scars using a filipino translation of the patient and observer scar assessment scale (posas).5 methods study design and setting a randomized, double-blinded, split scar controlled trial was conducted between january and june 2010 at the out-patient department of the ospital ng makati, a tertiary government hospital in the philippines. participants with institutional ethics committee approval, 56 patients with hypertrophic scars were recruited from the thyroidectomy patients of the primary investigator. inclusion criteria were: age between 18-60 years old, total or subtotal thyroidectomy or thyroid lobectomy through a transcervical incision performed by a single surgeon, benign thyroid pathology, hypertrophic scar, and at least four weeks healing after surgery. excluded were patients under treatment with topical antibiotics or topical corticosteroids, thyroid malignancy, uncontrolled diabetes, autoimmune disorders, plans of pregnancy or current pregnancy or breastfeeding, and patients with known sensitivities to any ingredients of the test products. with informed consent, 20 patients who were eligible for the study were randomly assigned patient identification numbers and frontal-view photographs of the scars were taken. procedures prior to the start of the study, an independent nurse prepared 10 grams each of cepae extract-heparin sodium-allantoin gel (contractubex®, merz pharmaceuticals, frankfurt, germany) and placebo (glycerine gel) in paired identical containers. the paired containers had color-coded red (right) and blue (left) labels. the topical cepae extractheparin sodium-allantoin gel was randomly assigned to either right (red) or left (blue) container. the test drug and placebo shared the same physical attributes, both being colorless and gel-like. the samples were kept in identical envelopes and were sealed. envelopes and sample containers were also number-coded and were given randomly to the participants by the independent nurse to ensure that both the patient and the observer were blinded . at the start of the study, pre-treatment assesments were separately performed by each patient and one observer using the patient and observer scar assessment scale version 1.0 whose validity and reliability had been previously established (posas v1.0, draaijers et al., 2004).5 (appendix a) the patients used a filipino translation of the scale which was pre-tested prior to the study and approved by the ethics commitee. (appendix b) pre-treatment photographs were likewise taken for documentation and comparison. after completing the scales and photographs, instructions and follow-up schedules with colorcoded containers containing the test drug and placebo in numbercoded envelopes were given each patient by the assistant. patients were instructed to divide the scar in the midline by an imaginary line from the mentum to the sternal notch. gel was applied in a layer of 1 mm by simple spreading on the skin towards the periphery and application to each half of the scar was performed twice a day, guided by the color-labeled containers and instructions in each envelope. to prevent diffusion of test drug and placebo, patients were instructed to start the application approximately 1 cm or 1 finger breath away from the center or the imaginary line drawn from the mentum to the sternal notch towards left or right side scar. 1mm of gel was rubbed continuously into each half-scar until it dried up, from the first day after initial assessment for six weeks. patients were advised follow-up every two weeks, to contact the primary investigator in case of untoward side effects, and to stop treatment immediately if signs of allergy or adverse drug reactions occured. at the end of the 6-week treatment period, each patient and the same observer separately accomplished the filipino translation of the posas for the second time. post-treatment photographs were also taken. outcome measures the primary outcome measures were the subjective observations of patients and the lone observer with regards to the appearance and physical attributes of the scar at baseline and after six weeks of treatment. the normalization or the change in the scar in terms of pain, pruritus, color, stiffness, thickness, and irregularity were the specific parameters assessed in the patient scale while the vascularity, philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 original articles 14 philippine journal of otolaryngology-head and neck surgery pigmentation, thickness, relief, and pliability were considered in the observer scale. pre and post-tratment photographs were also used to compare scar appearance. data analysis after completion of data collection, decoding of the collected data was performed. data were recorded and analysed using statistical package for social sciences (spss) version 17.0 for windows (ibm, armonk, ny, usa). the t-test (p= 0.05) was used to test for any significant differences of the total posas scores preand post-treatment. results of the 56 subjects initially considered, 20 were finally included in the study, making a total of 40 split-scars. there were 18 women and 2 men, with a mean age of 43.5 years old (range 29 to 60 years old). all of the patients claimed good compliance with the treatment protocol and reported no adverse reactions. initial visit patient scales yielded a mean score of 5.98 on both sides while observer scales had mean scores of 5.65 on both sides. at the end of the 6-week treatment period, the means score for the patient scales was 3.08 for the placebo and 3.28 for the test drug while on the observer scale, the mean score for the placebo was 3.71 and for the test drug was 3.84. using the t-test, there was no significant difference pretreatment and post treatment between test drug and placebo (p= 0.91) in either the patient scales or observer scale (p=0.87). discussion hypertrophic scars are among the major concerns of thyroidectomy patients. the incidence of hypertropic scars following surgery is about 40 to 70%.6,7 in contrast to keloids, which extend beyond the borders of the original injury, hypertrophic scars remain confined to the borders of the original wound and most of the time retain their shape.7,8 the collagen fibers in this type of scar are oriented somewhat parallel to the long axis of the scar.8 based on a classification by mustoe, a linear hypertrophic (e.g., surgical/traumatic) scar is described as a red, raised, sometimes itchy scar confined to the border of the original surgical incision that occurs within weeks after surgery.3 numerous non-invasive techniques to address scars have been described. silicone gel using polyethylene or polyurethane is a safe and effective management option for hypertrophic scars and keloids.1,6,7 compression or pressure therapy recommends that pressure be maintained between 24 and 30 mmhg for 6 to 12 months to be effective.1 intralesional corticosteroids using triamcinolone are the first-line therapy for treatment of keloids and second-line therapy for treatment of hypertrophic scars if other non-invasive treatment options have failed.1 topical cepae extract-heparin sodium-allantoin gel has been claimed to have special value in hypertrophic scars due to its anti inflammatory activity, fibroblast anti-proliferative activity, inhibition of proteoglycan and collagen formation, loosening of collagen structure and improvement of scar elasticity.4,8 at least three months of continous use is recommended by the product literature, but one study only used it for 1 month11 while other studies had application periods ranging from 3 to 12 months.13 conflicting results have been reported and no true consensus has been established. a study by beuth concluded that extract cepae gel application proved to be significantly superior to corticosteroid application in terms of safety and efficacy.4 in another study, the clinical course of scar development was rated as “very good” or “good” in more than 90% of treated thoracic surgery patients.8 extract cepae was found to be more effective in improving scar color but statistically ineffective in improving scar height and itching.9, 10 another study comparing topical cepae extract, heparin, and allantoin gel preparation with no treatment in thoracic scars concluded that the rating was “good” and “very good” in 84% of treated cases, compared to 59% of untreated cases.11 other studies have contrary findings, concluding for instance that extract cepae gel did not improve scar cosmesis or symptomatology when compared with a petrolatumbased ointment among surgical scars,10 or that topical cepae extract gel was ineffective in improving scar erythema and pruritus in patients who underwent moh’s surgery.11 our study showed no significant difference between test drug and placebo in the comparison of changes in mean scores. this suggests that topical cepae extract-heparin sodium-allantoin gel was no better than placebo in improving the appearance of hypertrophic thyroidectomy scars in our study. the significant improvement noted in the placebo group may be attributed to the hydrating effects of glycerine. glycerine gel is often used as a lubricant for nasogastric or endotracheal tube insertion. like mineral oil, hydrating lotions and petrolatum-based ointments, glycerine may promote moist healing and rapid epithelialization, thereby decreasing hypertrophic scar formation.12 having said that, the midlines between right and left sides of the scars may have been affected by various degrees of diffusion from either side, or not at all, and yet appeared unremarkable. perhaps neither test drug nor placebo really made a difference after all? that this study did not prove cepae extract-heparin sodium-allantoin gel to be more effective than placebo in improving scar appearance may also be attributable to the small sample size. the duration of the philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 original articles philippine journal of otolaryngology-head and neck surgery 15 hypertrophic scar at the time of initiation of the study as well as duration of treatment could also affect results, and a longer period of application of the test drug in accordance with product recommendations may be implemented in future studies. the validity and reliability of the filipino translation of the posas, although pretested, are also limitations to this study. periodic subjective and objective assessments aside from baseline and post-treatment subjective assessments, and multiobserver evaluation of scars and preand posttreatment photographs can also be included among the parameters to consider for further studies. appendix a patient code no: week number 0 2 4 6 observer scar assessment scale right 1 2 3 4 5 6 7 8 9 10 vascularization pigmentation thickness relief pliability total observer scale patient code no: week number 0 2 4 6 observer scar assessment scale left 1 2 3 4 5 6 7 8 9 10 vascularization pigmentation thickness relief pliability total observer scale appendix b patient code no:_____ week number 2 4 6 8 patient scar assessment scale please answer this scale according to your scar characteristics on the right side. maaari po bang sagutan ninyo ang mga tanong ukol sa inyong peklat sa bahaging kanan no, no complaints yes, worst imaginable walang reklamo meron, pinakamatindi 1 2 3 4 5 6 7 8 9 10 is the scar painful? masakit ba ang peklat? is the scar itching? kumakati ba ang peklat? no, as to normal skin yes, very different wala kung ikukumpara oo, malaki pagkakaiba sa normal na balat is the color of the scar different? nagkaiba ba ang kulay ng peklat? is the scar more stiff? mas matigas ba ang peklat? is the thickness of the scar different? nagkaiba ba ang kapal ng peklat? is the scar irregular? pantay-pantay ba ang peklat? total patient scale philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 original articles 16 philippine journal of otolaryngology-head and neck surgery acknowledgements the authors would like to thank the following: dr. alberto f. calderon and dr. howard enriquez, who critically reviewed the study proposal; ms. may legaspi, for acting as the independent nurse for blinding of both subjects and investigators; drs. angel cruz-daylo, carina glorioso, ardie dizon, lorelyn dino, and elaine lagura, for providing and caring for the study participants, and the patients who actively participated as subjects for this trial. references al-attar a, mess s, thomassen jm, kauffman cl, davison sp. keloid pathogenesis and treatment. 1. plast reconstr surg. 2006 jan;117(1):286-300. reish rg, eriksson e. scars: a review of emerging and currently available therapies. 2. plast reconstr surg. 2008 oct;122(4):1068-78. mustoe ta, cooter rd, gold mh, hobbs fd, ramelet aa, shakespeare pg, 3. et al.; international advisory panel on scar management. international clinical recommendations on scar management. plast reconstr surg. 2002 aug;110(2):560-71 beuth j, hunzelmann n, van leendert r, basten r, noehle m, schneider b. safety and efficacy 4. of local administration of contractubex to hypertrophic scars in comparison to corticosteroid treatment. results of a multicenter, comparative epidemiological cohort study in germany. in vivo. 2006 mar-apr;20(2):277-283. draaijers lj, tempelman fr, botman ya, tuinebreijer we, middelkoop e, kreis rw, 5. et al. the patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. plast reconstr surg. 2004 jun;113(7):1960-1965. edriss as, mesták j. management of keloid and hypertrophic scars.6. ann burns fire disasters. 2005 dec;18(4):202-10. chan ky, lau cl, adeeb sm, somasundaram s, nasir-zahari m. a randomized, placebo-7. controlled, double-blind, prospective clinical trial of silicone gel in prevention of hypertrophic scar development in median sternotomy wound. plast reconstr surg. 2005 sep;116(4):1013-20. willittal gh, heine h. efficacy of contractubex gel in the treatment of fresh scars after thoracic 8. surgery in children and adolescents. int j clin pharmacol res. 1994; 14(5-6):193-202. hosnuter m, payasli c, isikdemir a, tekerekoglu b. the effects of onion extract on hypertrophic 9. and keloid scars. j wound care. 2007 jun;16(6):251-4. chung vq, kelly l, marra d, jiang sb. onion extract gel versus petrolatum emollient on new 10. surgical scars: prospective double-blinded study. dermatol surg. 2006 feb;32(2):193-7. jackson ba, shelton aj. pilot study evaluating topical onion extract as treatment for postsurgical 11. scars. dermatol surg. 1999 apr;25(4):267-9. maragakis m, willital gh, michel g, görtelmeyer r. possibilities of scar treatment after thoracic 12. surgery. drugs exp clin res.1995;21(5):199-206. dyakov r., petrova m., tzolova n., argirova m., treatment of superficial burns, post-burn scars, 13. and keloids with contractubex® gel. annals of burns and fire disasters 2002jun(40) n. 2 patient code no:_____ week number 2 4 6 8 patient scar assessment scale please answer this scale according to your scar characteristics on the left side. maaari po bang sagutan ninyo ang mga tanong ukol sa inyong peklat sa bahaging kaliwa no, no complaints yes, worst imaginable walang reklamo meron, pinakamatindi 1 2 3 4 5 6 7 8 9 10 is the scar painful? masakit ba ang peklat? is the scar itching? kumakati ba ang peklat? no, as to normal skin yes, very different wala kung ikukumpara oo, malaki pagkakaiba sa normal na balat is the color of the scar different? nagkaiba ba ang kulay ng peklat? is the scar more stiff? mas matigas ba ang peklat? is the thickness of the scar different? nagkaiba ba ang kapal ng peklat? is the scar irregular? pantay-pantay ba ang peklat? total patient scale philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 original articles 14 philippine journal of otolaryngology-head and neck surgery abstract objective: vocal cord paralysis or immobility is a debilitating condition that may result from neural injury or mechanical fixation of the vocal cord (vc). when permanent, therapy is aimed at improving closure by modifying the position of the vocal cord. whatever surgical intervention is chosen, pre and post operative voice evaluation is important. this study aimed to investigate the usefulness of the glottal function index (gfi) and grade, roughness, breathiness, asthenia, strain (grbas) scale in the evaluation of treatment outcomes in patients with unilateral vocal cord paralysis (uvcp) who underwent medialization thyroplasty type 1 with a modified lock-in soft silicone implant. methods: design: descriptive case series setting: tertiary government hospital patient: five results: five patients (3 females, 2 males) consulted due to hoarseness underwent rigid endoscopy. four (2 right, 2 left) had unilateral paramedian vc paralysis while one had bilateral paresis with bowing of the left vocal cord. one of those with left vc paralysis was diagnosed as idiopathic; the four were iatrogenic (3 from thyroid surgery, 1 from multiple surgical procedures). all patients underwent medialization thyroplasty type 1 using locked-in soft silicone implant. the gfi and grbas scale were utilized for pre-operative and post-operative perceptual evaluation of voice. the gfi showed severe glottic insufficiency among all five patients prior to surgery with improvement of subjective symptoms one day and one week post-surgery in four patients. likewise, the hirano grbas scale showed improvement of voice quality and correlated well with the improvement of the patient’s subjective symptoms from the gfi scores. however, case 5 with bilateral vocal cord paresis, showed no improvement of voice quality despite recovery from subjective symptoms. conclusion: for glottal insufficiency, perceptual voice evaluation using self-administered gfi and grbas scale assessment are important parameters in determining quality of life among patients with glottal insufficiency undergoing medialization laryngoplasty. keywords: hoarseness, unilateral vocal cord paralysis, medialization thyroplasty, glottal function index, hirano grbas score glottal function index and grbas scale of patients undergoing vocal cord medialization: a series of five patients enrique c. papa ii, md emmanuel s. samson, md francisco a. victoria, md department of otolaryngology-head and neck surgery ospital ng maynila medical center correspondence: dr. enrique c. papa ii department of otolaryngology-head and neck surgery ospital ng maynila medical center quirino ave. cor roxas blvd., malate, manila 1004 philippines phone: (632) 524 6061 local 220 email: enriq9tales@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the descriptive research contest philippine society of otolaryngology head and neck surgery, natrapharm, the patriot building september 14, 2011 philipp j otolaryngol head neck surg 2013; 28 (2): 14-17 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 original articles philippine journal of otolaryngology-head and neck surgery 15 vocal cord paralysis or immobility is a debilitating condition that causes great impact on an individual. it may result from neural injury or mechanical fixation of the vocal cord (vc). the most common causes are previous surgery to the head, neck or chest, and neoplasms of the head, neck or thorax while a minority of causes include trauma, central nervous system diseases, inflammatory diseases or idiopathic origins.1,2 when vocal cord paralysis is permanent, therapy is aimed at improving closure by modifying the position of the vocal fold. whatever surgical intervention is chosen (injection thyroplasty, medialization thyroplasty, arytenoid adduction or laryngeal reinnervation), preoperative and postoperative voice evaluation is important. this study aims to investigate the usefulness of the glottal function index (gfi) and grade, roughness, breathiness, asthenia, strain (grbas) scale in the evaluation of treatment outcomes in patients with unilateral vocal cord paralysis (uvcp) who underwent medialization thyroplasty type 1 with a modified lock-in soft silicone implant. materials and methods study design: descriptive case series setting: tertiary government hospital patients: five patients patient selection with institutional review board approval, all patients diagnosed with unilateral vocal cord paralysis between january 1, 2008 and december 31, 2010 from whom informed consent was obtained were included in the study with no further inclusion or exclusion criteria. methods of voice examination the glottal function index (gfi) a validated 4-item self-administered survey was used to evaluate glottal insufficiency using the cut-off for an abnormal gfi at 4 (mean +2sd).2 (table 1) the hirano grbas scale3 for perceptual analysis of voice was also used. in a quiet audiometry room, the patients were instructed to read at a comfortable loudness level at a comfortable rate. recordings were performed using a sony handicam dcr-sr45 (sony corp., usa). preoperative and post-operative voice recordings of the patients were taken one day before, one day and one week after surgery and graded by a single observer (the surgeon). voice was scored using the parameters of the grbas system: grade=overall degree of deviance of voice, roughness= irregular fluctuation of the fundamental frequency, breathiness= turbulent noise produced by air leakage, aesthenia= overall weakness of the voice, and strain= impression of tenseness or excess effort. each parameter was scored on a scale of 0 to 3 (0 was considered normal, 1 with slight disturbance, 2 with moderate disturbance, and 3 with severe disturbance).6 surgical technique medialization thyroplasty was done in all five cases by a single surgeon, employing the surgical technique of ishiki.4 a horizontal incision was made a few millimeters from the midline anterior neck area approximating the location of the middle of the thyroid cartilage. flaps were developed and carried down to expose the entire height of the thyroid cartilage. the first case utilized a 9x4mm window below an imaginary line midway between the superior and inferior border of the right thyroid ala while the latter four cases had a smaller window width of 4x4mm. the dimensions of the soft-silicone implant were modified to fit the subperichondrial window. intraoperative voice assessment was done while adjusting the implant. excess silicon was then shaved. the operative site was closed in layers using chromic 3-0 and the skin approximated using silk 4-0. results from 2008-2010, five patients (2 males, 3 females, aged 34-56, mean 40) consulting for hoarseness were diagnosed with unilateral vocal cord paralysis by rigid endoscopy. (table 2) four (2 right, 2 left) had unilateral paramedian vc paralysis while one had bilateral paresis with bowing of the left vocal cord. one of those with left vc paralysis was diagnosed as idiopathic; the four were iatrogenic (3 from thyroid surgery, 1 from multiple surgical procedures). the duration of paralysis ranged from 8 months to 18 years, all presented with hoarseness, with one each experiencing aspiration and stridor as well. (table 2) all patients underwent medialization thyroplasty type 1 using locked-in soft silicone implant. the self-administered glottal function index (gfi) and observeradministered hirano grbas scale were utilized for pre-operative table 1. the glottal function index a score >4 may indicate a significant voice disorder within the last month, how did the following problems affect you? 1. speaking took extra effort 2. throat discomfort of pain after using your voice 3. vocal fatigue 4. voice cracked or sound different 0 = no problem 5 = severe problem 0 0 0 0 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 reproduced with permission from back kk, befalsky pc, wayslil k, postma gn, koufman ja. validity and reliability of the glottal function index. arch otolaryngol head neck surg, 2005 nov; 131(11):961-4. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 case reports 16 philippine journal of otolaryngology-head and neck surgery and post-operative perceptual evaluation of voice. the gfi showed severe glottic insufficiency among all five patients prior to surgery with improvement of subjective symptoms one day and one week post-surgery in four patients. (figure 1) likewise, the hirano grbas scale showed improvement of voice quality and correlated well with the improvement of the patient’s subjective symptoms from the gfi scores,except in the case of patient number 5 where no improvement of voice was noted despite minimal improvement in subjective symptoms. (figure 2) only one patient had wound infection 1 week post-operatively and following oral antibiotics, granulation tissue that developed at the operative site was treated with excision and primary closure. discussion glottic insufficiency is one of the common contributing factors in patients complaining of dysphonia. this condition may be brought about by unilateral vocal cord paralysis or paresis, presbylaryngis and other causes. glottic insufficiency yields a major impact on quality of life with the potential for significant morbidity and mortality.2 our patient demographics although small reflected the common causes of vocal cord paralysis with iatrogenic causes being most common with thyroid surgery accounting for the majority of uvcp.1 however, other non-thyroid surgical procedures when combined still far outnumber thyroid surgery related vocal cord paralysis. idiopathic vocal cord paralysis affects the left vocal cord more than the right due to anatomic reasons, and this holds true in our patients.1 the use of various surveys for assessment of voice rehabilitation outcome provides an objective insight to a patient’s initial disability and perceived benefit following surgery. the voice handicap index (vhi) developed by jacobson5 delivers a multifaceted assessment as it gives information on the functional, emotional and physical attributes table 2. patient profiles age sex symptoms vc laterality vc position etiologyduration case 1 case 2 case 3 case 4 case 5 50 56 42 37 34 female male male female female hoarseness hoarseness and aspiration to liquids hoarseness hoarseness hoarseness and stridor (s/p keel insertion) 3 years 8 months 10 months 2 years 18 years right left left right left paramedian paramedian paramedian paramedian bilateral paresis with bowing of left vc iatrogenic iatrogenic idiopathic iatrogenic iatrogenic figure 1. glottal function index showing severe glottic insufficiency among all five patients prior to surgery with improvement of subjective symptoms one day and one week post-surgery. figure 2. hirano grbas scale showing improvement of voice quality that correlated well with the improvement of the patient’s subjective symptoms from the gfi scores, except in the case of patient number 5 where no improvement of voice was noted despite minimal improvement in subjective symptoms. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 case reports philippine journal of otolaryngology-head and neck surgery 17 references 1. pavithran j, menon jr. unilateral vocal cord palsy: an etiopathological study. int j phonosurg laryngol, 2011 jan-jun; 1(1):5-10. 2. bach kk, belafsky pc, wasylik k, postma gn, koufman ja. validity and reliability of the glottal function index. arch otolaryngol head neck surg. 2005 nov; 131(11):961-4. 3. hirano m. psycho-acoustic evaluation of voice. in: arnold, winckel, wyke, eds. disorders of human communication, 5, clinical examination of voice. new york and wien: springer-verlag; 1981:81–84. 4. lore jm, medina j. an atlas of head and neck surgery. 4th edition. philadelphia: saunders; 2005. 5. bhuta t, patrick l, garnett jd. perceptual evaluation of voice quality and its correlation with acoustic measurements. j voice. 2004 sep;18(3):299-304. 6. gorham mm, avidano ma, crary ma, cotter cs, cassisi nj. laryngeal recovery following type i thyroplasty. arch otolaryngol head neck surg. 1998 jul; 124(7);739-42. 7. chrobok v, pellant a, sram f, fric m, praisler j, prymula r, svec jg. medialization thyroplasty with a customized silicone implant: clinical experience. folia phoniatr logop. 2008;60(2):91-6. 8. van ardenne n, vanderwegen j, van nuffelen g, de bodt m, van de heyning p. . medialization thyroplasty: vocal outcome of silicone and titanium implant. eur arch otorhinolaryngol. 2011 jan; 268(1):101–7. 9. kartha s, young k, mohan s. complications of medialization laryngoplasty (thyroplasty type-i). int j phonosurg laryngol. 2011 jan-jun; 1(1):1-3. of a patient with voice disorder although it has been observed that “this 30-item self-administered test often deters patients from finishing the task and requires a relative amount of patience and comprehension.”2 the glottal function index (gfi) was alternately used as it is a reliable, reproducible, 4-item, self-administered symptom index used effectively to evaluate patients and “its results are comparable to those of the vhi and provide a significant advantage for being brief, symptom focused and easily completed.”2 it also provides quick and easy administration and correlates well as an adjunct instrument with other perceptual tests. our study found that reduction in symptoms as related by the patients gave positive reinforcement on treatment success whether or not significant improvement of voice was achieved. the hirano grbas scale which is examiner-based is the gold standard in perceptual analysis of voice.5 it has a significant correlation with the voice parameters quantified by the multi-dimensional voice program (mdvp).4 the results we obtained using grbas strengthened our findings with gfi. both tests showed improvement of symptoms and voice quality post-operatively. however, it must be acknowledged that the lack of an independent blinded observer other than the surgeon is a major limitation of this study and blinded evaluation by a speech pathologist is recommended for future studies. another limitation is the early post-operative evaluation at one day and one week respectively. a change in voice quality one week postoperatively compared to one day post-operatively may be explained by formation of granulation tissue or decreased edema of laryngeal tissue which causes an increased glottic gap.6 even though postoperative recovery may occur rapidly from the first week to three months, optimal voice quality may not be obtained for at least three months following surgery since further reduction in laryngeal edema or hematoma may increase the glottic gap and may need further adjustment of the implant.6 our case 5 did not show any improvement on either the first day or one week post-operatively. lack of improved vocal quality immediately following surgery may indicate a prolonged period of healing, rather than surgical failure, for a particular patient. thus a longer period for evaluation of these patients is recommended to measure outcome success.6 medialization thyroplasty using soft silicone implants has been shown to be safe and effective.7 although the use of titanium implants have been shown to provide superior voice quality outcomes, the difference compared to soft silicone implants was insignificant.8 complications ranging from implant extrusion to airway compromise are low as shown in our patients, reflecting other studies.9 wound infection in one of our patients may have been caused by poor postoperative self-care. implant extrusion is commonly caused by migration of the implant due to forceful cough9 but this possibility was minimized by the implant design used in the study. the implant was designed to have an anterior extension from the thyroid cartilage that holds and locks it in place. in addition, further modification of the implant allowed rotational adjustment without having to remove it from its insertion inside the thyroid cartilage, thus decreasing patient discomfort during surgery. the approach to unilateral vocal cord paralysis is multidisciplinary, entailing a good clinical and voice history. for institutions without stateof-the-art equipment to assess voice quality, perceptual analysis of voice through the use of standardized surveys may provide substantial data to prognosticate treatment outcomes. for glottal insufficiency, perceptual voice evaluation using selfadministered gfi and speech pathologist grbas assessment are important parameters in determining quality of life among patients with glottal insufficiency undergoing medialization laryngoplasty. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 from the viewbox philippine journal of otolaryngology-head and neck surgery 37 this 63-year-old chinese female with both diabetes and hypertension underwent ct imaging of the brain after presenting with a progressive left sided hemiplegia. nasopharyngeal carcinoma presenting as a dual territory stroke: the hyperdense artery sign correspondence: dr. ian c. bickle department of radiology ripas hospital bandar seri begawan ba1710 brunei darrusalam phone: (673) 8 612182 fax: (673) 224 2690 email: ian@bickle.co.uk reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (2): 37-38 c philippine society of otolaryngology – head and neck surgery, inc. figure 1a. axial unenhanced ct of the brain: thrombosis in the right internal carotid artery (black circle) with surrounding tumour in the nasopharyngeal recess (white arrow). ian c. bickle, mb bch bao, frcr department of radiology ripas hospital, bandar seri begawan brunei philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 38 philippine journal of otolaryngology-head and neck surgery from the viewbox references 1. gács g, fox aj, barnett hj, vinuela f. ct visualization of intracranial arterial thromboembolism stroke. 1983; 14(5): 756-62. 2. ozdemir o, leung a, bussiére m,hachinski v, pelz d. hyperdense internal carotid artery sign: a ct sign of acute ischemia. stroke res treatment. 2008; 39: 2011-16. 3. morita s, ueno e, masukawa a, suzuki k, machida h, fujimura m. hyperattenuating signs at unenhanced ct indicating acute vascular disease. radiographics. 2010; 30: 111-125. figures 2a & b. axial unenhanced ct of the brain: anterior cerebral artery territory (white arrow) and middle cerebral artery (black arrow) infarctions. the ‘hyperdense artery sign’ is a generic description that can be evident in any artery of the body on unenhanced ct occurring due to the presence of intraluminal thrombosis (figure 1). it is a well-established sign most commonly described in ct imaging of the brain where it is visualised in the vast majority of cases in the middle cerebral artery in the context of an acute cerebral infarction.1 it occurs uncommonly elsewhere with the internal carotid artery (ica) and basilar artery being other clinically significant sites. the ‘hyperdense ica’ sign has been reported to be a reliable and highly specific marker of thromboembolic occlusion of the internal carotid artery.2 the ‘hyperdense artery sign’ is related to the attenuation value of intraluminal thrombus. the ct attenuation value (hounsfield unit or hu) of normal blood is dependent on the haematocrit ranging from 20 to 30 hu. as the process of thrombus retraction occurs, its water content decreases increasing the concentration of haemoglobin within the clot. as a result, this raises the attenuation value of the thrombus to 50–80 h. so the term ‘hyperdense’ is given.3 in this case, it proved to be the presenting symptom for an undiagnosed nasopharyngeal tumour, the thrombus likely developing as a complication of the surrounding tumour within the nasopharyngeal recess. the resultant outcome was a dual territory cerebral infarction of the anterior and middle cerebral artery territories both supplied by branches of the internal carotid artery (figures 2a & 2b). philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 under the microscope 36 philippine journal of otolaryngology-head and neck surgery the world health organization (2005) defines an epithelial-myoepithelial carcinoma (emc) as a malignancy composed of two cell types that typically form duct-like structures.1 we present herein an archival case from the parotid gland. emc occurs primarily in the major salivary glands particularly in the parotid where it presents as a painless, slow-growing mass.1 microscopic examination shows bi-layered tubular duct-like structures with pale to clear areas (figure 1). the inner luminal layer is composed of cuboidal cells that are of epithelial derivation while the outer layer is composed of polygonal cells that are of myoepithelial derivation (figures 2 and 3). the latter typically have abundant clear cytoplasm.1,2 the epithelial-myoepithelial dualism is confirmed using immunohistochemical stains; the epithelial cells being immunoreactive for low molecular weight keratin and the myoepithelial cells for s-100 protein, muscle specific actin, vimentin and p63.1, 3 emc is primarily a tumor of adulthood with peak incidence in the sixth and seventh decades. first described by donath et al. in 1972,3 they are rare salivary gland neoplasms with an incidence of less than 1% arising mainly in the parotid gland4 although they have been documented in the lungs.5 perineural and vascular invasion are frequent and recurrence occurs in around 40% of cases and metastasis in 14%.1 although thought to be of low-grade malignancy, fatal courses have been described4 and “analysis of the various series have demonstrated that tumors with a solid growing pattern, nuclear atypia, dna aneuploidy and high proliferative activity, generally have a more aggressive behavior and a higher frequency of local recurrences and metastases.”3 epithelial-myoepithelial carcinoma of the salivary gland correspondence: dr. jose m. carnate jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st., ermita, manila 1000 philippines phone (632) 526 4450 fax (632) 400 3638 email: jmcjpath@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2013; 28 (1): 36-37 c philippine society of otolaryngology – head and neck surgery, inc. jose m. carnate, jr., md1, jose florencio f. lapeña, jr., ma, md2 1department of pathology college of medicine university of the philippines manila philippines 2department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila philippines figure 1. tubular structures (single arrow) interspersed with pale to clear areas (double arrows) (hematoxylin and eosin, 100x) (hematoxylin and eosin, 100x) philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 philippine journal of otolaryngology-head and neck surgery 37 under the microscope references barnes l, eveson jw, reichart p, sidransky d. pathology and genetics of head and neck tumors. 1. in who classification of tumors. international agency for research on cancer (iarc) press, lyon 2005. gnepp dr, ed. diagnostic surgical pathology of the head and neck. wb saunders company, 2. 2009. tralongo v, daniele e. epithelial-myoepithelial carcinoma of the salivary glands: a review of 3. literature. anticancer res. 1998 jan-feb;18(1b):603-8. kasper hu, mellin w, kriegsmann j, cheremet e, lippert h, roessner a. epithelial-myoepithelial 4. carcinoma of the salivary gland—a low grade malignant neoplasm? report of two cases and review of the literature. pathol res pract. 1999;195(3):189-92. nguyen cv, suster s, moran ca. pulmonary epithelial-myoepithelial carcinoma: a 5. clinicopathologic and immunohistochemical study of 5 cases. hum pathol. 2009 mar;40(3):36673. doi: 10.1016/j.humpath.2008.08.009. epub 2008 oct 29. (hematoxylin and eosin, 400x) figures 2 and figure 3. tubular structures lined by a luminal layer of ductal epithelial cells (single arrow) with an abluminal layer of myoepithelial cells with clear cytoplasm (double arrows) (hematoxylin and eosin, 400x) (hematoxylin and eosin, 400x) philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 passages 44 philippine journal of otolaryngology-head and neck surgery manuel carlos tan jr., m.d. (1947-2012) “ a tribute to manny” gil m. vicente, m.d. la bamba…. oh carol….. volare…. the songs are still there but the singer is gone. yes, during entertainment time in the local as well as in the asean ent congresses, these songs reverberated as the leader of the band started rolling up the stage. there was so much energy, so much fun when manny’s voice delivered the songs. these signature songs will remain in our memory as manny finally sings the swan song. i have known manny ever since i joined our fraternity in the up college of medicine. during the rites, he was fond of using a stick to hit the palmar soles…. and when hit hard … omg…… it was very painful. that was one of the most dreaded stations of the ceremonial rites. when my turn came, he asked me if i had gone through his famous stick trick, i answered “not yet po.” for being honest i was just given a slight pat…. nakalusot ako in short. just after residency in 1988, manny and i were both representing the philippine delegation in jakarta. during one of our free nights, we were joined by our great beloved mentor, dr. mariano caparas. all night long till the wee hours of the morning, we stayed in dr. caparas’ hotel room. the discussion revolved around just one interesting topic and that was all about the nose. it was at that time that the term “the crazy nose” was coined. at 4 am, dr. caparas went to sleep happy. i went home crazy and manny just couldn’t help but become nosy. encounters like these became more often when i became more involved in the society. he was an upcoming president and i was an upcoming officer. every time he visited manila from davao, he would usually call me and we would go out to have dinner and then drink a bottle or two. we would talk on different topics starting with our dreams for the society, our activities in the future, about politics and about our research works. he was fond of telling me stories on innovative things he did in davao most specially when confronted with difficult situations. his was a creative mind that aimed for basic rationality and utmost practicality. we were both involved deeply in the society when he was both president of the society and upcoming president of the asean ent congress in 1998. i was the president of the upcoming international symposium of infection and allergy of the nose (isian) in 1999. for both of us it was an uphill challenging battle, an experience where we would gain friends as well as lose some. we carried crosses that were as big as you could imagine. we were able to survive the true test of mental and physical stress…. and that was because we both believed in perseverance….perseverance and perseverance. our bullheadedness was transformed to superior workmanship and leadership par excellence. years passed by and history tells us that money matters at the asean congress in davao got a little bit mystifying. the controversy turned a bit uncontrolled. one president after another tried their best to settle the issue once and for all but in vain. and finally when my time came as president of the society in 2008, i was able to convince manny to finally turn over the controversial pot of the decade. that became one of the top stories of the history of the society. the drama took place and the memory lingers on. manny indeed made a mark in our history. the songs he sang, the words he spoke, the dreams he foretold and the drama he created….. these are some of many things manny managed to make while on earth. may he rest in peace. philippine journal of otolaryngology-head and neck surgery 67 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 under the microscope a 27-year-old man presented with an 8 cm diameter left maxillary mass and an enlarged cervical lymph node at levels ii to iii. there was a reported history of a previous unspecified operation on the maxillary mass which had yielded a diagnosis of ameloblastoma. total maxillectomy with modified radical neck dissection was subsequently performed. microscopic examination of the maxillary mass shows epithelial islands and cords in a fibrocollagenous stroma. (figure 1) the islands and cords are lined in the periphery by palisaded columnar cells with regular ovoid nuclei exhibiting reverse polarization. the nuclei are uniform with dispersed chromatin and no significant atypia. towards the center of these islands are loosely arranged spindly to stellate cells (“stellate reticulum”). (figure 2) microscopic examination of the largest submitted lymph node shows an epithelial neoplasm with identical histologic features as the maxillary mass and a residual rim of lymphoid tissue at the periphery enclosed by the nodal capsule. (figure 3) similarly, there is neither atypia nor pleomorphism and only a few typical mitotic figures are seen in the nodal tumor. (figure 4) these features support the diagnosis of a metastasizing ameloblastoma (ma). metastasizing ameloblastoma is rare with only about 70 reported cases.1-5 both the gnathic primary tumor and the metastatic foci have typical morphologies of a benign ameloblastoma with bland nuclei and absent to rare mitosis.6,7 there are no morphologic criteria that can predict this metastatic behavior. thus, this diagnosis can only be made in retrospect upon the appearance of metastasis in a gnathic tumor that would otherwise have been diagnosed as a usual benign metastasizing ameloblastoma correspondence: dr. jose m. carnate, jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st. ermita, manila 1000 philippines phone (632) 526 4450 telefax (632) 400 3638 email: jmcjpath@gmail.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2015; 30 (2): 67-68 c philippine society of otolaryngology – head and neck surgery, inc. jenny maureen l. atun, md1 jose m. carnate, jr., md2 1department of laboratories philippine general hospital university of the philippines manila 2department of pathology college of medicine university of the philippines manila figure 1. section from the maxillary mass showing islands and cords of epithelial cells set in a fibro-collagenous stroma (hematoxylin and eosin, 40x magnification) (hematoxylin and eosin, 40x) philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 under the microscope 68 philippine journal of otolaryngology-head and neck surgery references lin y, he jf, li zy, liu jh. ameloblastoma with varied sites of metastasis: report 1. of two cases and literature review. j craniomaxillofac surg 2014 jul; 42(5): e301e304. gilijamse m, leemans cr, winters hah, schulten eajm, van der waal i. 2. metastasizing ameloblastoma. int j oral maxillofac surg. 2007 may; 36 (5): 462464. kim y, choi sw, lee jh, ahn km. a single cervical lymph node metastasis of 3. malignant ameloblastoma. j craniomaxillofac surg 2014 dec; 42 (8): 2035-2040. jayaraj g, sherlin hj, ramani p, premkumar p, natesan a, ramasubramanian a, 4. jagannathan n. metastasizing ameloblastoma – a perennial pathology enigma? report of a case and review of literature. j craniomaxillofacial surg 2014 sep; 42 (6): 772-779. dissanayake rkg, jayasooriya pr, siriwardena djl, tilakarante wm. review of 5. metastasizing (malignant) ameloblastoma (metam): pattern of metastasis and treatment. oral surg oral med oral pathol oral radiol endod 2011 jun; 111 (6):734741. neville bw, damm dd, allen cm. chapter 10: odontogenic cysts and tumors. 6. in: gnepp, dr. (editor) diagnostic surgical pathology of the head and neck. 2nd edition. 2009; philadelphia: saunders elsevier. pp. 802-810. sciubba jj, eversole lr, slootweg pj. odontogenic/ameloblastic carcinomas. in: 7. barnes, l., eveson, jw., reichart, p. and sidransky, d. world health organization classification of tumours. pathology and genetics of head and neck tumors. 2005; lyon: iarc press. p. 287. ahlem b, wided a, amani l, nadia l, amira a, faten f. study of ki67 and cd10 8. expression as predictive factors of recurrence of ameloblastoma. eur ann otorhinolaryngol head neck dis 2015 sep 16. pii: s1879-7296(15)00115-5. doi: 10.1016/j.anorl.2015.08.016. [epub ahead of print]. abdil-aziz a, amin mm. egfr, cd10 and proliferation marker ki67 expression in 9. ameloblastoma: possible role in local recurrence. diagn pathol 2012 feb; 7:14 doi: 10.1186/1746-1596-7-14. ameloblastoma.1-7 suggested risk factors include rapid tumor growth, large primary tumor, delay in treatment, mandibular site, prior radiotherapy and chemotherapy.4,5 however, what is most consistent in the literature is the history of multiple recurrences and multiple surgical interventions.1,4,5 the differential diagnosis is an ameloblastic carcinoma (ac). both ma and ac are considered as the malignant counterparts of ameloblastoma.7 however ac is characterized by the presence of the usual cytologic features of a malignant neoplasm such as nuclear pleomorphism, hyperchromasia and brisk mitotic activilty – features that are lacking in ma.6,7 the literature on metastasizing ameloblastoma lists the lungs (70 to 88% of cases) and the cervical lymph nodes (1537.8% of cases) as the most common sites of metastasis.1-5 increased ki-67 labeling and cd10 immunoreactivity have been reported to have significant correlation with recurrence.8,9 whether these observations also apply to the risk of metastasis is not known due to the rarity of cases and hence the small subject populations of these studies. as the risk of metastasis cannot be predicted by morphology, long-term follow-up appears prudent in all cases of ameloblastoma especially if characterized by recurrences and prior surgical interventions. figure 2. peripheral palisaded columnar cells with reversed nuclear polarization (arrow) and central stellate reticulum (circle). the nuclei do not exhibit pleomorphism. (hematoxylin and eosin, 400x magnification) (hematoxylin and eosin, 400x) figure 3. section from the cervical lymph node containing metastatic tumor. there is residual nodal lymphoid tissue (arrow). the lymph node capsule is also shown (circle). (hematoxylin and eosin, 100x magnification) (hematoxylin and eosin, 100x) figure 4. the tumor islands in the lymph node show a similar bland cytology. (hematoxylin and eosin, 400x magnification) (hematoxylin and eosin, 400x) 28 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports abstract objective: to report the first case of primary bilateral antro-choanal polyps in the elderly age group. methods: design: case report setting: tertiary government hospital patient: one result: a 60-year-old, non-allergic female with progressive bilateral nasal obstruction was subsequently diagnosed with bilateral antro-choanal polyps. endoscopic sinus surgery was performed and the patient remained asymptomatic on one year follow-up. conclusion: antro-choanal polyps can occur bilaterally in the elderly age group. to the best of our knowledge, this is the first reported case of primary bilateral antro-choanal polyps in an elderly female. keywords: antro-choanal polyp, bilateral, elderly, female antro-choanal polyps [acp] are benign, solitary lesions which arise from the mucosa of the maxillary sinus. the mucosa usually prolapses through the maxillary ostium and may protrude through the accessory ostium, if present. antro-choanal polyps usually involve the middle meatus. they increase in size and gradually progress towards the choana and nasopharynx and typically appear as a smooth, pale or bluish solitary mass on anterior or posterior rhinoscopy. antro-choanal polyps are generally recognized to represent approximately 4-6% of all nasal polyps and are more prevalent in the pediatric population.1 killian was the first to describe this entity in 1906.2 it is nearly always unilateral and bilateral acp is an extremely rare entity and seldom found in the literature. 3.4, 5, a pubmed search of medline, using the search terms ‘bilateral,’ ‘antrochoanal polyp’and ‘elderly’ did not yield any report of primary bilateral acp in an elderly person. the oldest report of primary bilateral acp was in a 24-year-old female6 while post-operative bilateral acp was documented emerging from previously-performed inferior meatus antrostomies in a 45-year-old female.7 we report what may be the first such case of primary bilateral acp in an elderly female. bilateral antro-choanal polyps in an elderly female indranil sen mbbs, ms ankur mukherjee mbbs, ms jayanta saha mbbs, ms satadal mandal mbbs, ms ramanuj sinha ms, dnb department of otorhinolaryngology r. g. kar medical college and hospital kolkata, west bengal, india correspondence: dr. ankur mukherjee room no-7, k b hostel r. g. kar medical college & hospital 1, khudiram bose sarani, kolkata -700004 india phone: (+91) 9434381027 fax: (+91) 33 2828 1551 email: ankurdoc007@gmail.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (2): 28-30 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 29 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports case report a 60-year-old female presented with gradually progressive rightsided nasal obstruction over the last six years. she did not seek any medical advice until similar symptoms developed in the left nasal cavity over the last 2-3 months. there was no history of pain, itching, sneezing, nasal bleeding or any other type of discharge. there was no history of associated asthma or allergy. on anterior rhinoscopy, smooth, pale, polypoidal masses were found in both nasal cavities. the choanae and nasopharynx were free from the polyps on posterior rhinoscopy. nasal endoscopy showed the polypoidal masses arising from both maxillary sinuses and protruding from their natural ostia. coronal non-contrast computed tomography (ct) scans revealed both maxillary sinuses filled with hypo-dense soft tissue shadows extending into the corresponding nasal cavities, typical of antro-choanal polyps. on both sides, the maxillary ostia were considerably widened. there were small amounts of retained secretions in the ethmoid sinuses but the frontal sinuses were clear. (figure 1) differential blood counts and serum immunoglobulins were within normal limits. the polyps were removed from both sides via endoscopic sinus surgery under general anaesthesia. on visualising the sinus with a 4.0 mm 70 degree nasal endoscope, the polyps were found to originate from the anterior and the lateral walls of the sinus cavities. the gross appearance of both specimens was bluish, smooth and boggy with constrictions corresponding to the maxillary ostium. (figure 2) the histopathologic report confirmed the diagnosis of benign allergic (antrochoanal) polyps. the patient remained symptom-free over a one year follow-up period. figure 1. coronal non-contrast ct scan showing both maxillary sinuses filled with hypo-dense soft tissue shadows extending into the corresponding nasal cavities, typical of antro-choanal polyps. note considerable widening of both maxillary ostia and small amounts of retained secretions in the ethmoid sinuses. figure 2. photograph of both surgical specimens showing bluish, smooth and boggy character with constrictions corresponding to the maxillary ostia. discussion antrochoanal polyps are thought to represent hypertrophic maxillary sinus mucosa prolapsing into the nasal cavity through the natural or accessory ostium. although the natural history and site of origin of acp was first reported by killian in 1906,2 the first description of acp was made by palfyn in 1753. 2 antro-choanal polyps are almost always unilateral and bilateral antrochoanal polyps are extremely rare. we found only three case reports in the literature3, 6, 8 with only one reported primary case in an adult.6 the largest series on acp by frosini et al. reported only three cases of bilateral acp, but no age was given for those cases.2 the common clinical presentation of acp is nasal obstruction, and acp usually presents as a hypo-attenuating mass occupying the maxillary sinus on ct scans, which distinctly reveals its extension.9 no definite etiological factor for acp has been found but chronic sinusitis, cystic fibrosis and allergy may have roles in its development. 1, 8 look et al. postulated that 24% of acp had the ‘aspirin-sensitive asthma triad’.8.10 the treatment of acp is surgical. the aim of surgery is to remove both the nasal and antral parts of the polyp as it tends to recur after 30 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 2 july – december 2011 case reports references 1. chen jm, schloss md, azouz me. antrochoanal polyp: a 10 year retrospective study in the paediatric population with a review of the literature. j otolaryngol. 1989 june;18(4):168-72. 2. fosini p, picarella g, de campora e. antrochoanal polyp: analysis of 200 cases. acta otolaryngologica italica. 2009 feb; 29(1):21-26. 3. basu sk, bandyopadhyay sn, bora h. bilateral antrochoanal polyps. j laryngol otol. 2001jul; 115 (7): 561-2. 4. markov d, drajina z, pole g. nasal polyps in children. acta med croatica. 1999; 53(2):97-99. 5. chung sk, chang bc, dhong hj. surgical, radiologic and histologic findings of antrochoanal polyp. am j rhinol. 2002 mar-apr;16(2):71-76. 6. yilmaz yf, titiz a, ozcan m, tezer ms, ozlugedik s, unal a. bilateral antrochoanal polyps in an adult: a case report. b-ent. 2007 ;3(2):97-9 7. konstantinidis i, tsakiropoulou e, vital i, vital v, constantinidis j. bilateral antrochoanal polyps originated from inferior meatal antrostomies. laryngorhinootologie. 2008 jun;87(6):417-9. epub 2008 jan 24. 8. myatt hm, cabrera m. bilateral antrochoanal polyps in a child; a case report. j laryngol otol. 1996 march;110(3):272-4. 9. weissman jl, tabor ek, curtin hd. sphenochoanal polyps. evaluation with ct and mri imaging. radiology. 1991 jan; 178(1): 145-8. 10. cook pr, davis we, mcdonald r, mckinsey jp. antrochoanal polposisa review of 33 cases. ent j 1993 jun; 72(6): 401-402, 404-410. 11. el guindy a, mansour mh. the role of transcanine surgery in antrochoanal polyps. j laryngol otol 1994 dec; 108 (12): 1055-1057. 12. ophir d, marshack g. removal of antral polyp through an extended nasoantral window. laryngoscope 1987 nov; 97 (11):1356-1357. 13. woolley al, clary ra, lusk rp. antrochoanal polyp in children. am j oto laryngol. 1996 nov-dec; 17(6): 368-373. 14. vleming m, de vries n. endoscopic sinus surgery for antrochoanal pol-yps. rhinology 1991; mar. 29 (1) 77-8. 15. ta-jen lee, shiang-fu huang. endoscopic sinus surgery for antrochoanal polyps in children. otolaryngol head neck surg 2006;135:688-92. 16. hong sk, min yg, kin ct, byun sw. endoscopic removal of the antral portion of antro-choanal polyp by powered instrumentation. laryngoscope 2001 october; 111 (10): 1774-8. simple avulsion. the maxillary antrum should always be carefully inspected. different approaches are recommended for this purpose, from the classical caldwell-luc approach11 to the modified caldwellluc approach (intranasal antrostomy with resection of anterior part of inferior turbinate)12 and functional endoscopic sinus surgery (fess). the caldwell-luc procedure may have possible side-effects including both anaesthesia and swelling of the cheek and also carries risks to the developing teeth in children.13 at present fess is a very popular technique14.15 and if properly performed there is no recurrence and very few complications.10 antro-choanal polyps originating from the anterolateral wall can be removed by a combined endoscopic and transcanine approach.16 antro-choanal polyps can occur bilaterally in the elderly age group. to the best of our knowledge, this is the first reported case of primary bilateral antro-choanal polyps in an elderly female. philippine journal of otolaryngology-head and neck surgery 35 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 from the viewbox this 43-year-old man with a known history of schizophrenia presented with a one-week history of left ear pain accompanied by a purulent discharge from the external auditory canal over the last three days. shortly afterwards he became confused. on direct examination, the left ear canal was oedematous containing granulation tissue. cerebral abscess with rupture into the ventricles due to chronic otitis media correspondence: dr. ian c. bickle department of radiology ripas hospital bandar seri begawan ba1710 brunei darrusalam phone: (673) 8 612182 fax: (673) 224 2690 email: ian@bickle.co.uk reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2012; 27 (1): 35-37 c philippine society of otolaryngology – head and neck surgery, inc. figure 1. high resolution ct of temporal bone: sclerosis of the temporal bone (thin black arrow) with pus in the mastoid air cells (wide black arrow). soft tissue in the middle ear surrounding the ossicular chain (white arrow). ian c. bickle , mb bch bao, frcr1 diyana mohamed, mbchb2 1department of radiology ripas hospital, bandar seri begawan brunei 2wellington school of medicine, university of otago new zealand philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 36 philippine journal of otolaryngology-head and neck surgery from the viewbox figure 3. pus contaminated csf in the extra-ventricular drain figure 2. a. contrast enhanced axial ct of the brain: a large left temporal lobe abscess containing pus (p) and gas (g), with similar content in the temporal horn of the left lateral ventricle (arrow). b. left temporal lobe abscess (asterisk) with tract formation (arrow) communicating with the ventricle. pus in the third ventricle and the right lateral ventricle (circles). high resolution ct of the temporal bones supplemented by contrast enhanced ct of the brain was performed in this patient. this identified sclerosis of the left temporal bone with opacified mastoid air cells along with soft tissue within the middle ear. (figure 1) contrast enhanced ct of the brain established the presence of a large left temporal lobe abscess, with a tract communicating with the left lateral ventricle, which contained pus resulting in a tri-ventricular obstructive hydrocephalus. (figures 2a & b) severe intracranial complications of otitis media are uncommon but are associated with significant morbidity and mortality. the incidence of intracranial and intra-temporal complications of otitis media is reported at 3.2 per million, of which only 18% are intracranial in nature.1 of the intracranial complications cerebral abscess is the commonest occurring in nearly half of all cases. typically, the bacteria causing the abscess are anaerobes. the annual risk in adults of developing a a b philippine journal of otolaryngology-head and neck surgery vol. 27 no. 1 january – june 2012 from the viewbox philippine journal of otolaryngology-head and neck surgery 37 references 1. leskinen k, jero j. acute complications of otitis media in adults. clin otolaryngol. 2005 dec; 30(6):511-516. 2. nunez da, browning gg. risks of developing an otogenic intracranial abscess. j laryngol otol.1990 jun;104(6):468-472. 3. dähnert w. radiology review manual. 5th ed. baltimore md and philadelphia pa: lippincott williams & wilkins; 2003. p257. 4. young rf, frazee j. gas within intracranial abscess cavities: an indication for surgical excision. ann neurol. 1984 jul;16(1):35-39. cerebral abscess secondary to otitis media is in the region of 1 in 10,000.2 other intracranial complications include; venous sinus thrombosis, meningitis, extra-axial collections and hydrocephalus. a known, albeit rare, complication of cerebral abscess is rupture into the ventricular system.3 obstructive hydrocephalus may then result. a left temporal craniotomy and abscess excision was performed with insertion of an extra-ventricular drain which contained pus. (figure 3) a modified radical mastoidectomy was then performed. the presence of gas within the intracranial abscess cavity is an indication for total surgical excision of the abscess as it allows removal of the mass lesion, prevention of possible persistent extra-corporal communication and provides debridement of devitalised tissue that might prevent resolution of infection.4 in this case, the diagnosis of brain abscess was delayed as his psychiatric history distracted from the history of confusion. this serves as a learning point for us all in our clinical endeavours. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery from the viewbox post-operative temporal lobe encephalocele this 24-year-old woman presented to ent outpatients with an enlarging swelling in the right external auditory canal. a radical mastoidectomy for chronic suppurative otitis media with cholesteatoma had previously been undertaken at another institution. on clinical examination there was an otologic mass that was tender on probing. high resolution imaging of the temporal bones and a subsequent mri brain confirmed the mass was a temporal lobe encephalocele. correspondence: dr. ian c bickle consultant radiologist department of radiology ripas hospital bandar seri begawan ba1710 negara brunei darussalam phone: + 673 224 2424 fax: + 673 224 2690 email: firbeckkona@gmail.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by both authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2018; 33 (1): 59-60 c philippine society of otolaryngology – head and neck surgery, inc. ian c. bickle, mb bch bao, frcr1 fakrudin salim, mb bch, feb orl-hns2 1department of radiology 2department of ent ripas hospital bandar seri begawan brunei creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. a. (axial) and b. (coronal) high resolution ct of the temporal bones showing a. soft tissue (black arrows) within the mastoid cavity; and b. large contiguous defect in the tegmen tympani (black arrow). b a philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery from the viewbox figure 2. a. (t1 coronal), b. (t2 fat sat coronal and c. (t2 axial fat sat) mri of the brain and iams show a large focus of the right inferior temporal lobe (white arrows) protrudes through the defect in the tegmen tympani into the post-surgical mastoid cavity. references mcmurphy ab, oghalai js. repair of iatrogenic temporal lobe encephalocele after canal 1. wall down mastoidectomy in the presence of active cholesteatoma. otol neurotol. 2005 jul;26(4):587-94. pmid:16015151. neely jg, kuhn jr. diagnosis amd treatment of iatrogenic cerebrospinal fluid leak and brain 2. herniation during or following mastoidectomy. laryngoscope 1985 nov;95(11):1299-300. pmid:4058205. glasscock me 3rd, dickins jr, jackson cg, wiet rj, feenstra l. surgical management of brain 3. tissue herniation into the middle ear and mastoid. laryngoscope. 1979 nov;89(11):1743-54. doi: 10.1288/00005537-197911000-00005 pmid:502695. jackson cg, pappas dg jr, manolidis s, glasscock me 3rd, von doersten pg, hampf cr, williams 4. jb, storper is. brain herniation into the middle ear and mastoid: concepts in diagnosis and surgical management. am j otol. 1997 mar;18(2):198-205. pmid:9093677. a b c a temporal lobe encephalocele is where a segment of the temporal lobe invaginates through a defect in the tegmen tympani. the brain is separated from the middle ear and mastoid process by an exceptionally thin layer of bone – the tegmen tympani. damage to the tegmen compromises the barrier with the brain and may occur for a number of reasons. this includes congenital, traumatic, post-infectious, malignant invasion, post-radiation therapy and post-surgical causes.1 when this occurs the brain may extrude through the defect resulting in a temporal lobe encephalocele. a bony defect alone, whatever the cause, is insufficient to always result in an encephalocele. even with dehiscence of the tegmen the dura is capable of supporting the brain issue without herniation. only when the integrity of the dura is compromised does an encephalocele occur.2 this may be due to the underlying disease process (such as cholesteatoma causing an intracranial abscess) or both purposeful (opening dura to drain an adjacent intracranial abscess) /non-purposeful surgical intervention. mainstream microsurgical techniques however have lowered the incidence of dural violation.3 historically, infection was a major cause but with the ready availability of antibiotics and prompt management, the key contemporary cause is iatrogenic following mastoid surgery. however, the overall incidence is uncommon following otologic surgery. in a review of 25 years of middle ear/mastoid encephalocele cases, 77% were identified to be iatrogenic in origin.4 this patient presented with the finding of a mass observed in the external auditory canal. less common findings at attendance include tympanic perforation, cholesteatoma, otorrhoea and meningitis.4 the key to diagnosis hinges on cross-sectional imaging: combined imaging with ct to assess the osseous structures and mri for soft tissue review. the high-resolution ct (hrct) of the temporal bones illustrates a large defect in the right tegmen tympani with a large soft tissue lesion occupying the post-surgical mastoid cavity abutting the tympanic membrane. (figures 1a, b) the defect of 15mm in the tegmen was more than double the average of 7.2mm reported elsewhere.4 the mri confirms the defect in the tegmen with the protrusion of a knuckle of the right temporal lobe and its overlying meninges through the defect into the mastoid cavity. the dumb-bell appearance is typical with the narrower neck at the site of the tegmental dehiscence. the extruded brain occupies the post-operative middle ear cavity. (figures 2 a, b and c) the defect size and volume of herniated brain can be accurately assessed, both of which may be key determinates of the type of surgical procedure. revision mastoidectomy with repair of the tegmen defect and dural integrity using a combined intracranial-mastoid approach is planned as a joint case with neurosurgical colleagues. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 surgical innovations and instrumentation 32 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2014; 29 (2): 32-33 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to create visual animated demonstrations of certain otorhinolaryngologic concepts and surgeries that can aid learning of students and orl residents. methods: several otorhinolaryngologic surgical procedures and pathophysiologic concepts were represented through two dimensional images. for every concept or procedure, a series of images was drawn and manipulated using the software adobe photoshop cs4. the series of images were then put into animation using the software morpheus photo animation suite v3.15. result: the end results were demonstrations of otorhinolaryngologic concepts and surgical procedures in movie (.avi) format. conclusion: concepts and surgeries in the field of otorhinolaryngology are usually explained or documented using texts or simple images. the generated animated demonstration of these ideas can aid in the learning of the orl specialist. keywords: animation, surgical procedure demonstration, pathophysiology animated presentation it is difficult to contest that learning a task from scratch, that is if one has no prior knowledge regarding the matter is a very overwhelming mission. however, it is believed that humans rarely try to learn from nothing. they obtain initial ideas as well as strategies on how to approach a learning problem from instructions and/or demonstrations of other humans.1 upon being introduced to a concept, the process of ‘learning-by-doing’ follows. this step is currently considered as the most effective way to learn.2 after this process, the learning is further reinforced through different methods such as repetition.3 this is probably the reason behind why most training institutions would have a minimum requirement of completed tasks before considering one individual as competent in doing such job. schaal1 investigated how learning from demonstration can be applied in the context of reinforcement learning and concluded that reinforcement learning can theoretically profit from demonstrations. using this concept, we aimed to create visual animated demonstrations of certain otorhinolaryngologic concepts and surgeries that can serve as a possible aid in the learning of students and orl residents. most concepts and procedures are explained in writing through textbooks and visual representations may potentially have a great impact on the absorption of knowledge by the learner. this innovation did not test the actual degree of assistance that the animated representations would provide to a learner. it was solely based on the assumption that if one saw a visual representation of something explained in texts, it would be easier to comprehend. animated demonstration of selected orlhns concepts and surgeries: a potential adjunct to learning edgar jake a. agullo, md emmanuel s. samson, md francisco a. victoria, md department of otorhinolaryngology head and neck surgery ospital ng maynila medical center correspondence: dr. francisco a. victoria department of otorhinolaryngology-head and neck surgery ospital ng maynila medical center quirino cor. harrison blvd. malate manila 1004 philippines phone: (632) 524 6061 local 220 email: ommc_enthns@yahoo.com reprints will not be available from the author the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the poster session contest on surgical innovation & instrumentation (1st place), philippine society of otolaryngology-head and neck surgery, sofitel philippine plaza hotel, ccp complex, manila, december 3, 2013. philippine journal of otolaryngology-head and neck surgery 33 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 surgical innovations and instrumentation references 1. schaal s. “learning from demonstration”. in: mozer mc, jordan m, petsche t, editors. advances in neural information processing systems 9, cambridge, ma: mit press. 1997. pp.1040-1046. 2. lombardi mm. authentic learning for the 21st century: an overview. oblinger dg, editor. eli report no. 1. boulder, co: educause learning initiative. 2007 [cited 2013 aug 23]. available from: http://www.educause.edu/ir/library/pdf/eli3009.pdf 3. cunningham t, gannon j, kavanagh m, greene j, reddy l, whitson l. theories of learning and curriculum design-key positionalities and their relationships. articles. 2007:1. results animated demonstrations of surgical procedures and concepts were produced. these were in the form of a movie (.avi) file. these could be viewed using a regular media player through computers, tablets or modern television sets. a sample video clip in .mp4 format is available at: http://youtu.be/5hwkpv6w9dy discussion not every scientific idea or step in a surgical procedure is available as a visual presentation in textbooks. much is explained in textual form and interpretation is left to the intellectual capacity of the reader. this may be one of the reasons why learning some concepts is challenging. through rendering animated demonstrations, grasping the essence of scientific concepts and surgical procedures and thereby learning can be assisted. our results need to be tested and the learning outcomes compared in order to establish their value and this may be the subject of a future study. figure 3. screenshot showing rendition of animation using morpheus photo animation suite figure 2. screenshot showing image of cleft lip done on adobe photoshop cs4 figure 1. sample series of images for the rhomboid flap methods several orl surgical procedures and concepts were selected. procedures included z-plasty technique, rhomboid advancement flap, abbe-estlander flap, bilobe flap and cheiloplasty. esophageal voice production for post laryngectomy patients and nystagmus were selected to represent the orl concepts. two-dimensional images were rendered. these included multiple frames that would represent the succeeding steps in such processes. (figure 1) these images were carefully adjusted and manipulated using the software adobe photoshop cs4 version 11.0 (san jose, ca, usa: adobe systems inc.). (figure 2) once all the steps were appropriately rendered, traditional animation was done. the images were allowed to animate using the software morpheus photo animation suite v3.15 full (ada, mi, usa: morpheus software, llc). (figure 3) philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 philippine journal of otolaryngology-head and neck surgery 41 practice pearls what makes the majority of noses beautiful? it is the tip.1,2,3 south east asian noses are usually small and short with bulbous tip and thick skin and soft tissue envelope (sste).2 the tip is determined by the shape and strength of the lower cartilages.2,3,4 the lower cartilages are usually soft and weak so there is a need for a strong support system for the attachment of the lower cartilages. thus, the surgical term is called “structural rhinoplasty.”2,3 the concept of the surgery involves re-structuring the tip to a new position for elongation and projection. since the septum is the most stable structure, a central part of the septum is harvested and is used as extended septal support graft for fixation of the lower cartilage for a whole new tip position.2,3 the open approach is often used. the sste dissection is wide up to the pyriform aperture laterally, nasal spine inferiorly and glabella superiorly. make certain that the dissection plane is below the superficial muscular aponeurotic system (smas) in the upper cartilage (uc) and lower cartilage (lc) and below the periosteum in the nasal bone. septoplasty “two points determine a line: a guide to anterior approach of the septum” once the transcolumellar incision is done and all external nasal anatomy is exposed, the septum can be easily approached via the concept “2 points determine a line.” one point is at the area of the footplate which is separated from each other via blunt dissection down to the nasal spine. the other point is the anterior septal angle which is easily palpated. an imaginary line between the two points is the membranous septum which can be safely cut and opened via sharp dissection till one reaches the caudal margin of the septum. (figure 1) principles of structural rhinoplasty in south east asian noses correspondence: dr. eduardo c. yap unit 3, 28 times st., west triangle, quezon city 1104 philippines phone: (632) 254 7881 email: edcyap88@gmail.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest philipp j otolaryngol head neck surg 2014; 29 (2): 41-44 c philippine society of otolaryngology – head and neck surgery, inc. eduardo c. yap, md1,2 1belo medical group 2department of ent metropolitan medical center figure 1. two points determine a line: anterior approach to the septum by identifying the 2 points landmarks: footplate and anterior angle of septum anterior angle of septum footplate after the caudal edge of the septum is identified, dissection of septum can be facilitated using converse or tenotomy scissors for sharp dissection on either side for 2-3mm until a submucoperichondrial plane is reached. once the plane is identified, further dissection is done using a sharp freer elevator. dissection may reach up to vomer and the entire bony septum. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 practice pearls 42 philippine journal of otolaryngology-head and neck surgery the dissection can be unilateral or bilateral depending on the septal deviation. after the mucoperichondrium is freed unilaterally, the central part of the septum can be harvested by initially scoring dorsally and caudally, leaving enough cartilage for support of the tip and dorsum. using a cottle elevator, the scored cartilage is entered making sure that the contralateral mucoperichondrium is not perforated. the contralateral side is then dissected in the submucoperichondrial plane. the cartilage is further mobilized using a side sharp periosteal elevator to dislocate the cartilage from the perpendicular plate of the ethmoid and the vomer. the most adherent part is at the palatine crest. the central cartilage can be removed and any bony spurs and deviation can be trimmed using a rongeur. generally a 10mm dorsal and caudal strut should be left behind for support. if the mucoperichondrium is dissected bilaterally, harvesting the central cartilage will be easier. (figure 2) tip suture technique: for llc that do not have a defined dome, a domal suture can be done to achieve a sharper tip. suturing is a simple mattress pds 5-0 suture at the tip to bring closer the lateral and medial component of the dome. if further narrowing of the tip is required, both domes can be sutured at the cephalic side. tip suturing does not project the tip; it just narrows the width of the tip.1 subcutaneous fat can be trimmed if the final appearance of the tip is still bulbous. (figure 3) figure 2. dorsal and caudal struts at this stage, any septal deviation and the internal valve can be corrected by several methods. deviated dorsal struts can be corrected with a spreader graft. a deviated caudal strut can be corrected by scoring the concave side and fixing a support graft e.g. septal extension graft (seg).3,4 a tight internal valve can be widened by a spreader graft. (figure 5) quilt closure of the septal mucosa using vicryl 5-0 can be done at this stage or at a later stage of surgery when the tip is repositioned to the desired projection. structural septorhinoplasty: achieving functionality with good form analysis of the tip southeast asian noses are usually bulbous which may be due to thick fatty skin and/or convex lower lateral cartilages (llc). a bulbous tip can be corrected by cephalic trim for convex llc. using fine hooks or brown adson forceps, the llc is retracted caudally and the cephalic border identified. a slim strip of llc cartilage is incised using a blade 15 leaving at least 5-8mm of caudal llc intact. the cephalic cartilage is then carefully raised from the mucosa. avoid excessive cephalic trim because it may lead to depressed llc consequently causing external valve collapse and rotation of the tip.2 figure 3. domal and interdomal suturing narrows the tip. it does not project the tip figure 4. two most common support grafts: spreader and septal extension graft tip directions: projection vs. de-projection and rotation vs. counter-rotation: most asian nasal tips need projection and elongation (counter rotation).3 if minimal correction is needed then a columellar strut and a tip shield graft can be used. if major tip repositioning is required, then a septal extension graft (seg) or extended spreader graft is needed. the central harvested cartilage is sutured at the caudal strut of the septum using pds 5-0. fixation of the seg needs 3-4 sutures. (figure 4) once the seg is fixed to the desired position, the dome and medial crura can be sutured to the caudal end of the seg using pds 5-0. once the lc is fixed to the seg, contoured tip grafts either from concha or septum can be used to further define the tip. once the tip is already at the desired position, a dorsal graft can be fashioned to blend the new tip with the radix. dorsal grafts may philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 philippine journal of otolaryngology-head and neck surgery 43 practice pearls figure 5. common grafts in structural septorhinoplasty: dorsal, spreader, seg, onlay tip, columellar strut figure 6. final tip defining grafts and an e-ptfe dorsal implant. figure 7. summar y of sail excision for correction of hanging ala. a. marking of sail. b. excision of skin and subcutaneous tissue, right alar. note the finished trimming in the left ala. c. nylon 6-0 is used for closure of the defect. it starts initially at both ends to avoid dog-ear deformity. d. immediate postop be cartilage, silicon or expanded polytetrafluoroethylene (e-ptfe, popularly known as gore-tex®). (figure 5) expanded polytetrafluoroethylene (e-ptfe) or gore-tex® has gained popularity because of its better aesthetic outcome. it was initially introduced in the market as sheets however recently many companies produced preformed e-ptfe of various shapes and sizes. this implant is now preferred because it is more natural looking and heals with tissue adhesion.5 despite it being less visible as an implant, there are times that it may show under thin skin. in order to make the e-ptfe implant better looking, the sides of the implant should be cut and carved well to avoid cornering appearance. make certain implant placement is midline and in full contact with undersurface. since e-ptfe is soft, it is not used in tip support surgery. one dreadful complication of e-ptfe is infection. infection can be avoided by diligently observing sterility, e.g. soaking the implant in gentamycin solution when not in use and avoidance of prolonged air exposure. the implant package should be opened only when it is time for insertion. the caudal edges of the implant should be clear of and away from the incision line since the incision wound can be the site of entry of microorganisms. trial closure is made and the tip is palpated. additional tip grafts may be used for refinement. (figure 6) the membranous and cartilaginous septal mucosa is then sutured using vicryl 5-0 running quilt closure. adjunctive procedures for the ala majority of southeast asian noses have a certain degree of hanging ala. the alar rim can be lifted by excision of a triangular piece of tissue in the inner lateral vestibular skin. the irregular triangular piece of skin tissue is shaped like a sail of a sailboat.6,7 the two sides are marked as the inner alar rim margin and a skin groove in the lateral vestibule area marked by transition of thin vibrissae to thick vibrissae. the defect is closed using nylon 6-0 simple interrupted. the alar rim skin is made to roll cephalically as a flap thus lifting the whole alar rim. (figure 7) the sail excision is usually done as the first procedure in rhinoplasty in order to allow maximum flexibility of maneuvering the ala from marking, incision, excision and suturing. closure of the transcolumellar incision starts first with subcutaneous fixation using vicryl 6-0 and skin closure using nylon 6-0. the marginal incision is closed using vicryl 6-0 simple interrupted a c b d a common feature also in southeast asian noses is the wide alar base and flared ala.3 the correction is a 3-dimensional approach wherein the sill can be excised via a wedge incision to narrow the base and if the wedge is extended laterally, the flaring can be corrected. (figure 8) figure 8. correction of wide alar base and alar flare philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 practice pearls 44 philippine journal of otolaryngology-head and neck surgery references 1. berhbohm h, tardy me. essentials of septorhinoplasty. stuttgart, germany; thieme. 2004. p. 49 2. toriumi dm. structure concept in nasal tip surgery. operative techniques in plastic and reconstructive surgery. 2000 jan; 7 (4): 175-186. doi: 10.1053/otpr.2000.26065 3. jang yj. rhinoplasty and septoplasty. 1st ed. koonja publishing. 2014. 371-392. 4. choi jy, kang ig, javidinia h, sykes jm. complications of septal extension grafts in asian patients. jama facial plast surg. 2014 may-jun; 16 (3); 169-175. 5. yap ec, abubakar ss, olveda mb. expanded polytetrafluoroethylene as dorsal augmentation material in rhinoplasty on southeast asian noses: three year experience. arch facial plast surg. 2011 jul-aug; 13(4): 234-238. 6. baladiang de, olveda mb, yap ec. the “sail” excision technique: a modified alar lift procedure for southeast asian noses. philipp j otolaryngol head neck surg. 2010 jan-jun; 25(1): 31-37 7. yap ec. improving the hanging ala. facial plast surg. 2012 apr; 28(2): 213-217. figure 9. pre op and immediate post op in the operating room the newly re-structured nose should look better before final closure. palpation is important to detect minor defects. everyone in the operating room including the surgeon should be satisfied with the outcome. (figure 9) the new nose has to be taped with 3m™ steri-strip™ (st. paul mn, usa) adhesive skin closures and covered with a thermal splint in order to control edema and fix the dorsal implant. sutures and splint are removed after 5-7 days. (figure 10) figure 10. a typical se asian nose before and after open structural rhinoplasty. note the improved nasal bridge, narrower ala, good columellar show, better ala-columella relationship, better tip projection and fuller premaxilla 36 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports abstract objectives: recurrence of a typical laryngeal carcinoid is extremely rare after surgery with tumor-free margins on histopathology. we present a rare case of typical laryngeal carcinoid that recurred after eight years and was managed by conservative surgery. methods: design: case report setting: tertiary government hospital patient: one results: a known case of typical laryngeal carcinoid treated eight years back reported again with the same symptoms he previously had. on evaluation local tumor recurrence was identified with a negative metastatic workup. the patient was subjected to microlaryngeal excision which was adequate histopathologically. he has had no evidence of disease on follow up of two years. conclusion: a typical laryngeal carcinoid tumor may present differently and recur locally but conservative surgery is still an option if local nodal and distant metastatic spread is ruled out. key words: neuroendocrine tumor,typical laryngeal carcinoid, microlaryngeal excision. hemoptysis laryngeal neuroendocrine tumors represent a heterogeneous group of neoplasms that have been classified into carcinoids (typical and atypical), small cell carcinomas & paragangliomas.1 these are the most common non-squamous tumors of the larynx and account for about 0.5 – 1% of all laryngeal tumors.2,3 the clinical features and gross endoscopic picture are very similar to a typical laryngeal carcinoma for which it can be mistaken. however histopathological and immunohistochemical studies are prerequisites for recognition of the tumor and its subclass that has a direct bearing on the treatment and prognosis. a typical carcinoid is rarest, accounting for about 3% of all neuroendocrine tumors, and has the most favorable prognosis because local invasion, nodal and distant metastases are very rare. local excision with tumor-free margins is recommended with regular follow up to detect any recurrence. case report a 55-year-old male was referred by a primary care physician to our department with three months history of recurrent episodes of hemoptysis and foreign body sensation in the throat. he typical laryngeal carcinoid recurrence and its management by conservative surgery syed majid hussain, mbbs, ms (ent-hns)1 rauf ahmad, mbbs, ms (ent-hns)1 1department of ear nose throat head and neck surgery sri maharaja hari singh hospital karan nagar srinagar, jammu & kashmir, india correspondence: syed majid hussain, mbbs, ms (ent-hns) registrar, department of ent hns sri maharaja hari singh hospital karan nagar srinagar, jammu & kashmir 190001 india phone: 09596478093 e-mail: majidhussain73@gmail.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2010; 25 (2): 36-38 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 37 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports was unremarkable. a contrast-enhanced ct scan of the neck showed an enhancing mass over the right arytenoid and adjoining posterior aryepiglottic fold which was well localized. there was no vocal cord or paraglottic space involvement and no significant cervical lymphadenopathy was detected. a direct laryngoscopic excision of the mass was carried out uneventfully. histopathology revealed a welldifferentiated neuroendocrine tumor with negative margins while immunohistochemical staining was positive for cytokeratin, serotonin, chromogranin and synaptophysin thereby confirming the carcinoid morphology. a complete metastatic workup had negative results. the patient did not follow up as advised. eight years later he again complained of similar symptoms which were increasing in severity. on examination tumor recurrence was noted in the same area. the patient was again subjected to direct laryngoscopic excision which was reported as well-differentiated carcinoid with tumor-free margins. a fresh metastatic workup was again negative. the patient has been following up regularly for the last two years and has had no evidence of disease until submission of this report. discussion since the first description of carcinoid by oberndorfer in 19074 as a distinct form of carcinoma, more than 500 cases of neuroendocrine tumors of the larynx have been reported. these tumors originate from the amine precursor uptake and decarboxylase (apud) cells or the diffuse neuroendocrine cell system.5 typical laryngeal carcinoid represents a rarest entity with no more than 14 cases reported so far with an overwhelming male preponderance and an average age of affliction of 58 years.6,7 in contrast to usual clinical features of dysphonia, dysphagia and otalgia the patient presented with foreign body sensation in the throat and recurrent hemoptysis, the latter being an unknown presentation of this disease. laryngoscopic examination usually reveals a sessile or polypoidal smooth surfaced pinkish-red mass with well-defined borders most frequently seen in the supraglottis, either on the aryepiglottic folds or arytenoids.7 a contrast-enhanced ct is essential for evaluating local tumor invasion and lymph nodal status. uniform cells with granular cytoplasm and centrally-placed oval or round nuclei and a pericellular hyalinized stroma characterize this tumor microscopically. mitosis, nuclear atypia and necrosis are conspicuously lacking. positive staining for cytokeratin, chromogranin and synaptophysin indicates an apud cell lineage.8 while surgery is the treatment of choice, the amount of excision varies with the size of tumor ranging from local excision to partial figure 1. smooth surfaced tumor (arrowhead) on right arytenoid. endotracheal tube (arrow) endolaryngeal appearance. figure 2. high power magnification showing sheets of cells with well defined round/oval nuclei and pericellular hyalinized stroma. (hematoxylin eosin, 100x) had no significant past medical or surgical history. he denied any voice or swallowing problems and there were no complaints referable to nose, nasopharynx and ear. the general physical and systemic examination was unremarkable. indirect laryngoscopy revealed a reddish smooth surfaced mass over the right arytenoid and adjacent aryepiglottic fold with normal vocal cord and mobility. the rest of the ent examination 38 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports acknowledgment we would like to thank dr. a r khan, consultant pathologist for his contribution to the histopathological aspect of the tumor. references 1. shanmugaratnam k, sobin lh. the world health organization histological classification of tumors of the upper respiratory tract and ear: a commentary on the second edition. cancer. 1993 apr 15;71(8): 2689 97 2. ferlito a, silver ce, bradford cr, rinaldo a. neuroendocrine neoplasms of the larynx: an overview. head neck. 2009 dec; 31 (12): 1634 – 46. 3. capelli m, bertino g, morbini p, villa c, zorzi s, benazzo m. neuroendocrine carcinomas of the upper airways: a small case series with histopathological considerations. tumori. 2007 sep-oct; 93(5):499-503. 4. oberndorfer s. karzinoide tumoren des dunndarms. frankf z pathol 1907; 1: 425-32. 5. overholt sm, donovan dt, schwartz mr, laucirica r, green lk, alford br. neuroendocrine neoplasms of the larynx. laryngoscope 1995 aug; 105 (8 pt1): 789-94. 6. cuzzort jc, pezold jc, dunn cw. typical carcinoid tumor of the larynx occurring with otalgia: a case report. ear nose throat j 2002 jan; 81(1): 40 – 3. 7. el-naggar ak, batsakis jg. carcinoid tumor of the larynx. a critical review of the literature. orl j otorhinolaryngol relat spec. 1991; 53(4): 188-93. 8. izadi f, ghanbari h, nouri hr, pousti b, sadeghipour ar. typical laryngeal carcinoid tumor: a case report. iranian red crescent med j 2010; 12(3): 322 – 324. 9. jouhadi h, mharrech a, benchakroun n, tawfiq n, acharki a, sahraoui s, benider a. typical carcinoid tumor of the larynx. fr orl 2006; 91: 270 -273. 10. mani r, belcadhi m, chahed h, ben abdelkader a, bouzouita k. carcinoid tumor of the larynx. ann otolaryngol chir cervicofac. 2009 apr; 126(2):71-4. 11. bapat u, mackinnon na, spencer mg. carcinoid tumors of the larynx. eur arch otorhinolaryngol 2005 mar; 262(3): 194 7. laryngectomy. neck dissection is indicated in patients with positive nodal disease clinically or radiologically, and the role of elective neck dissection is limited with only 4 of 13 patients showing node metastasis and only one death due to tumor itself.7 radiotherapy and chemotherapy are reserved for advanced tumors.9 although tumor recurrence has been reported after many symptomfree years as in our case,10 it is still possible to manage recurrence by local excision with minimal disturbance of laryngeal functions, subject to the absence of local and distant tumor spread, but regular followup is advised. the overall prognosis in such cases is excellent.11 hence, a typical laryngeal carcinoid tumor may present differently and recur locally but conservative surgery is still an option if local nodal and distant metastatic spread is ruled out. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 philippine journal of otolaryngology-head and neck surgery 55 practice pearls botolinum is a toxic polypeptide produced by the gram-positive anaerobic bacterium clostridium botulinum that inhibits acetylcholine release from nerve endings, resulting in reduced neuromuscular transmission and local muscle activity, as well as cholinergic mediated parasympathetic activities.1 its name is derived from the latin word botulus, meaning sausage, as its toxicity was initially attributed to the oil of spoiled sausages. of late, botolinum, packaged in various commercial forms such as onabotulinumtoxina (botox® type a, allergan, irvine, ca), is popularly used in several medical applications such as blepharospasm, hyperhidrosis and strabismus, and most famously in cosmetic surgery, where botox® injections are used to eliminate and/or smoothen wrinkles. in otolaryngology, common indications for botox® injections include management of rhytids, cervical dystonia and spasmodic dysphonia. another interesting application is pterygoid muscle injection. the lateral pterygoid muscles (lpm) pull the condylar head of the jaw forward, resulting in the opening of the jaw or displacement of the mandible anteriorly or towards the contralateral side, whereas the medial pterygoid muscles (mpm) pull the angle of the jaw upward and anteriorly to close or protrude the jaw, respectively. increased or unequal activity of these muscles relative to other muscles of mastication and temporomandibular joint ligaments may result in asymmetry, malocclusion, temporo-mandibular joint (tmj) dysfunction or dislocation.2 indications for pterygoid muscle botox injection include neurogenic tmj dislocation, recurrent tmj dislocation, oromandibular dystonia (omd) particularly lpm dystonia, lpm spasm in condylar fractures, tmj clicking, bruxism with myofascial pain and stroke-induced trismus.3-20 several patients with indications for botox® injection of the pterygoid muscle have been seen by this author, including post cerebro-vascular disease (cvd) dystonia with recurrent tmj dislocation, bruxism, condylar fracture and oromandibular dystonia, but only the latter had the opportunity to acquire botox® and the electrode needle (ambu® neuroline inoject 50mm/2” length x 0.50mm/25 gauge calibre, ambu a/s, denmark) due to cost constraints. we used a caldwell sierra wave® v electromyography (emg) machine with v. 10.0.125 software (caldwell laboratories, inc., kennewick, wa). the most exciting parts of performing the procedure are the anatomy and process of identifying the muscle with emg guidance and the immediate results after injection. electromyography (emg) – guided botolinum injection can measure muscle activity by recording muscle depolarization or electrical activity. using cannula needle electrodes with an open lumen, the muscles are identified by their activity during muscle contraction and then injected with botox® to decrease muscle activity. anatomically, the lpm is accessible through the mandibular notch which is directly anterior to the condylar head of the mandible. the latter is easily palpable and is anterior to the external auditory canal (figure 1). using a needle electrode, the lpm can be identified by opening the jaw or moving the jaw to the contralateral side.2,21 the pterygoid botolinum toxin injection correspondence: a/prof. dr. ryner jose c. carrillo department of anatomy, college of medicine university of the philippines manila pedro gil st., ermita, manila 1000 philippines phone number: (632) 526 4194 e-mail add: ryner_c@yahoo.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (1): 55-56 c philippine society of otolaryngology – head and neck surgery, inc. ryner jose c. carrillo, md, msc departments of anatomy and otorhinolaryngology college of medicine philippine general hospital university of the philippines manila philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 practice pearls 56 philippine journal of otolaryngology-head and neck surgery mpm is less easily targeted because it generally closes the jaw. however, to further decrease anterior displacement of the jaw, both the lpm and the mpm activity can be decreased. the mpm can be targeted transorally by inserting the emg electrode medial to the jaw and lateral to the pterygomandiular raphe, piercing through the buccinator muscle. identifying mpm contraction can be done by biting to occlude the upper and lower jaw. with the cheeks retracted and needle inserted, botox® injection can be done to lower mpm activity. clinical outcome can be assessed by measuring inter-incisor distance, mandibular deviation and protrusion, decrease in pain, restoration of masticatory function and proper occlusion. the dosage of botolinum injection in the pterygoid muscles will vary between indications and the specific toxin product used, but is usually in the range of 20 – 30 u/ml. injection dose is 10 u to 50 u per muscle every three months,20 with a total limit of 200 u for muscles of mastication. in the author’s experience, the 20 units of botox® wear off at two months after injection in a patient with oromandibular dystonia. pterygoid botox® injection can be an important ancillary to rehabilitation disorders of mastication and the tmj. however, it is not without risk. various complications have been reported such as changes in salivary consistency, swallowing and speech and facial muscle weakness.20 these complications may be attributed to the toxin diffusing to untargeted adjacent structures such as the parotid gland, facial muscles and superior constrictors. proper technique, sufficient knowledge of pterygoid anatomy and emg guidance are important in preventing complications. clinical outcomes for both shortand long-term goals still need to be standardized and defined to allow for figure 1. infratemporal fossa with zygomatic arch and coronoid process removed. lpm – lateral pterygoid muscle, mpm – medial pterygoid muscle comparison across different case series and trials. a multidisciplinary approach cannot be overemphasized. pearls: 1. short-term and long-term goals should be set. 2. zygomatic arch and condylar head are good landmarks for lateral pterygoid injection via extra-oral approach. 3. coronoid process and ramus can be palpated intra-orally when doing medial pterygoid muscle injection. the needle is guided medial to the bone, piercing the retromolar trigone. 4. emg guidance when using cannula electrodes to inject botox will facilitate muscle identification. 5. proper dosing and frequency of botox injection is individualized. references 1. ramachandran ts, molloy fm. botulinum toxin (botox (r)), dystonia treatment [monograph on the internet]. . medscape, llc; 2010 [cited 2011 may 6]. available from: http://emedicine. medscape.com/article/1818592-overview. 2. moore k. clinically oriented anatomy. 3rd ed. baltimore: william and wilkins; 1992. 3. schwartz m, freund b. treatment of temporomandibular disorders with botulinum toxin. clin j pain. 2002 nov-dec;18(6 suppl):s198-203. 4. karacalar a, yilmaz n, bilgici a, baş b, akan h. botulinum toxin for the treatment of temporomandibular joint disk disfigurement: clinical experience. j craniofac surg. 2005 may;16(3):476-81. 5. michelotti a, silva r, paduano s, cimino r, farella m. oromandibular dystonia and hormonal factors: twelve years follow-up of a case report. j oral rehabil. 2009 dec;36(12):916-21. epub 2009 oct 14. 6. mendes ra, upton lg. management of dystonia of the lateral pterygoid muscle with botulinum toxin a. br j oral maxillofac surg. 2009 sep;47(6):481-3. epub 2008 oct 1. 7. vazquez-delgado e, okeson jp. treatment of inferior lateral pterygoid muscle dystonia with zolpidem tartrate, botulinum toxin injections, and physical self-regulation procedures: a case report.cranio. 2004 oct;22(4):325-9. 8. vázquez bouso o, forteza gonzález g, mommsen j, grau vg, rodríguez fernández j, mateos micas m. neurogenic temporomandibular joint dislocation treated with botulinum toxin: report of 4 cases . oral surg oral med oral pathol oral radiol endod. 2010 mar; 109(3):e33-7. 9. fu ky, chen hm, sun zp, zhang zk, ma xc. long-term efficacy of botulinum toxin type a for the treatment of habitual dislocation of the temporomandibular joint. br j oral maxillofac surg. 2010 jun;48(4):281-4. epub 2009 aug 7. 10. møller e, bakke m, dalager t, werdelin lm. oromandibular dystonia involving the lateral pterygoid muscles: four cases with different complexity. mov disord. 2007 apr 30;22(6):78590. 11. yoshida k, iizuka t. botulinum toxin treatment for upper airway collapse resulting from temporomandibular joint dislocation due to jaw-opening dystonia. cranio. 2006 jul;24(3):21722.. 12. gilles r, magistris mr, hugentobler m, jaquinet a, richter m. treatment of recurrent luxation of the temporomandibular joint with botulinum toxin.rev stomatol chir maxillofac. 2000 oct;101(4):189-91. 13. ziegler cm, haag c, mühling j. treatment of recurrent temporomandibular joint dislocation with intramuscular botulinum toxin injection.clin oral investig. 2003 mar;7(1):52-5. epub 2003 jan 25. 14. daelen b, thorwirth v, koch a. treatment of recurrent dislocation of the temporomandibular joint with type a botulinum toxin. int j oral maxillofac surg. 1997 dec;26(6):458-60. 15. bakke m, møller e, werdelin lm, dalager t, kitai n, kreiborg s. treatment of severe temporomandibular joint clicking with botulinum toxin in the lateral pterygoid muscle in two cases of anterior disc displacement. oral surg oral med oral pathol oral radiol endod. 2005 dec;100(6):693-700. 16. canter hi, kayikcioglu a, aksu m, mavili me. botulinum toxin in closed treatment of mandibular condylar fracture. ann plast surg. 2007 may;58(5):474-8. 17. spillane ks, shelton je, hasty mf. stroke-induced trismus in a pediatric patient: long-term resolution with botulinum toxin a. am j phys med rehabil. 2003 jun;82(6):485-8. 18. guarda-nardini l, manfredini d, salamone m, salmaso l, tonello s, ferronato g. efficacy of botulinum toxin in treating myofascial pain in bruxers: a controlled placebo pilot study. cranio. 2008 apr;26(2):126-35. 19. arinci a, güven e, yazar m, başaran k, keklik b. effect of injection of botulinum toxin on lateral pterygoid muscle used together with the arthroscopy in patients with anterior disk displacement of the temporomandibular joint. kulak burun bogaz ihtis derg. 2009 may-jun;19(3):122-9. 20. clark gt. the management of oromandibular motor disorders and facial spasms with injections of botulinum toxin.phys med rehabil clin n am. 2003 nov;14(4):727-48. 21. cardona-garcia od, higgins dsjr,molho es. botulinum toxin in the management of dystonia. current treatment options in neurology 2 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 philippine journal of otolaryngology-head and neck surgery 59 featured grand rounds laryngeal web is a rare entity, constituting 5% of all congenital laryngeal lesions, with a reported incidence of 1 in 10,000.1 it usually presents with stridor in childhood, but can be discovered in asymptomatic adults under anesthesia and is associated with failed intubations.2 we present the case of a newborn with stridor and respiratory distress due to laryngeal web. case report a 47-day-old boy was referred to our institution for stridor. he was spontaneously born term at 40 3/7 weeks gestational age to a 26-year-old g2p2 (2002). birth weight was 3104 grams and maturity testing at 39 weeks was appropriate for gestational age. prenatal and perinatal history was unremarkable. upon delivery with an initial apgar score of 5 becoming 6, inspiratory stridor and impending respiratory failure prompted intubation. post-intubation chest x-ray revealed minimal lung disease and the baby was extubated after 24 hours. six hours after extubation, stridor was noted again and the baby was reintubated. a chest x-ray showed atelectasis and the baby was managed as a case of pulmonary hypertension. he was weaned from ventilatory support and continuous positive airway pressure (cpap) was commenced on day 15. lavage feeding was started on day 18 and 7-day empiric antibiotics were completed. however, stridor and respiratory distress persisted, and the baby was reintubated and recommitted to a mechanical ventilator. laryngomalacia was suspected, a tracheostomy was recommended and the baby was referred to our institution for further work-up and management. our admitting impression was a term baby boy with pneumonia, and laryngomalacia versus tracheomalacia. upon arrival at our institution, chest x-ray showed hazy and reticular opacities at the posterobasal segment of both lower lung lobes, more on the right, and interpreted as bilateral pneumonia. ampicillin and cefotaxime were started, and gram stain, culture and sensitivity of endotracheal secretions resulted in moderate growth of s. marscescens and light growth of k. pneumonia, both resistant to ampicillin. antibiotics were shifted to gentamycin and ceftazidime, given for 10 days. during this time, the baby was also exhibiting myoclonic upper extremity movements but was subsequently cleared for seizures or other structural brain pathology by neurology. our plan for airway evaluation was initial flexible endoscopy followed by bronchoscopy if extubation was tolerated. the possibility of a tracheostomy was considered if extubation would not be tolerated. flexible endoscopy revealed patent nasal airways with no demonstrable nasal obstruction or structural abnormalities. the endotracheal and orogastric tubes were visualized entering the trachea and esophagus respectively. (figure 1) there was pooling of secretions in the hypopharyngeal area, but no visible masses or lesions. stridor at birth: congenital laryngeal web correspondence: dr. ma. victoria p. pascual department of otorhinolaryngology head and neck surgery the medical city ortigas avenue, pasig city 1600 philippines phone: (632) 635 6789 local 6250 fax: (632) 687 3349 email: avic_pascual07@yahoo.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. ma. victoria p. pascual, md, mba department of otorhinolaryngology head and neck surgery the medical city philipp j otolaryngol head neck surg 2015; 30 (2): 59-61 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 featured grand rounds 60 philippine journal of otolaryngology-head and neck surgery figure 1. flexible nasal endoscopy showing the endotracheal tube (clear tube with white stripe) inserted into the airway and the orogastric tube (opaque) inserted into the esophagus. the rest of the surrounding structures were unremarkable. figure 2. flexible laryngoscopy after extubation. top photo shows vocal folds in abduction and bottom photo in adduction. note the soft tissue band (interarytenoid web) traversing the posterior portion of the vocal folds. arrow points to space where endotracheal tube previously passed. after extubation, a soft tissue band was visualized traversing the right and left true vocal cords posteriorly, consistent with an interarytenoid web. (figure 2) a space between this band and the interarytenoid area corresponded to the site where the et tube had passed. the arytenoid mucosa also appeared swollen and edematous. the epiglottis was normal. there was vocal fold motion with incomplete glottic closure, but the full extent of glottic opening and closing could not be assessed due to the band. because of decreasing oxygenation and episodes of desaturation, the baby was reintubated and a tracheostomy was performed. the baby was weaned off the ventilator a week later, and transferred out of intensive care to a regular room where he tolerated room air. clotrimazole that had been given for light growth of s. maltophilia obtained intraoperatively was shifted to levofloxacin and the last dose was given after 7 days. his postoperative course was unremarkable, and he was discharged with a tracheostomy and nasogastric tube, with suck and swallow therapy for eventual oral feeding. regular monitoring and routine tracheotomy care with periodic tube changes and endoscopic surveillance of the web and signs of reflux are scheduled. discussion the most likely conditions for stridor presenting at birth are congenital structural anomalies like laryngomalacia (60%), vocal cord paralysis (15-20%), congenital subglottic stenosis (15%), laryngeal web (5%), or subglottic hematoma (1.5%).1,2,3 the larynx develops from the endodermal lining and the adjacent mesenchyme of the foregut between the fourth and sixth branchial arches. the arytenoid swelling is formed at the cranial end of the laryngotracheal tube by the proliferation of the mesenchymal tissue (derived from neural crest cells). it grows towards the tongue and forms the primordial glottis. as it grows further, it changes the primordial glottis into a t-shaped laryngeal inlet.4 congenital laryngeal webs are uncommon, constituting 5% of all congenital laryngeal lesions; their incidence has been estimated at approximately 1 in 10,000 births.4 they are due to incomplete recanalization of the laryngotracheal tube during the third month of gestation, leading to different degrees of laryngeal webs. the most common site of development is at the level of the vocal folds anteriorly, although they may occur in the posterior interarytenoid or in the subglottic or supraglottic area.5 diagnosis may be made via flexible or rigid laryngoscopy, or airway films if subglottic or cricoid pathology is present.4 most congenital webs present at birth or in the first few months of life. symptoms range from mild dysphonia to significant airway obstruction, depending on the size of the web. hoarseness, croup, and dysphagia are some other symptoms. a third of children with laryngeal webs have anomalies of the respiratory tract, most commonly subglottic stenosis. when congenital in origin, this may be associated with various syndromes like di-george syndrome, velocardiofacial (shprintzen) philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 philippine journal of otolaryngology-head and neck surgery 61 featured grand rounds syndrome, conotruncal anomaly face syndrome.6,7 laryngeal webs may be classified according to airway obstruction. a t1 web is uniform in thickness with no subglottic extension, has true vocal cords clearly visible in the web, usually has no airway obstruction, and hoarseness as the only usual presenting sign. a t2 web is slightly thicker, with a significantly thicker anterior component, and may have minimal subglottic involvement, and a usually husky voice. a t3 web is thick with a solid anterior portion that extends into the subglottis, the true vocal cords are not well delineated, and there is marked vocal dysfunction, with a weak and whispery voice. a t4 web is uniformly thick and extends into the subglottic area with resulting subglottic stenosis. respiratory obstruction is severe, and the patient is almost always aphonic.4,7 webs may also be classified according to location, whether anterior, posterior (interarytenoid), subglottic, or supraglottc.4 our patient had a type 1, interarytenoid laryngeal web. about 75-90% of laryngeal webs are located anteriorly and extend toward the arytenoids. occasionally, a minor web will not be diagnosed until the child is older and undergoes evaluation for chronic hoarseness.1 it may vary in thickness, and the boundary is the vocal process.5 posterior webs may present with apparent bilateral vocal cord paralysis, especially if an interarytenoid web in the posterior larynx limits vocal fold abduction. this type of congenital web is rare and often necessitates a tracheotomy in the early years of life. stridor is the major presenting clinical feature (as in our case), but patients can also present with obstructive cyanosis at birth or episodes of apnea.2 asymptomatic patients do not require treatment. treatment depends on the severity of airway obstruction, and may be single or multi-staged. if a patient presents with difficulty breathing, the airway must first be secured. this can be done through endotracheal intubation, which can be converted into a tracheostomy if prolonged intubation is expected.6 long-term tracheotomy with observation for eventual decannulation after 3 to 5 years may be practiced. surgical division can be achieved using laryngeal knives, microscissors, galvanocautery or radiofrequency. however, these are frequently unsuccessful as vocal cords re-adhere in the area where the web was separated.4,8 surgical correction results in two opposing surfaces with denuded epithelium that tend to heal together and reform a web. to prevent re-adhesion, a keel, stent or probe may be positioned between the two raw edges. steroid injections or mitomycin may also diminish re-adhesion.2 extensive webs often require arytenoidectomy or even open laryngeal reconstruction to correct subglottic stenosis. this can be done with a costal graft, a posterior cricoid split, or a t-tube.9 given that our patient has a type 1 laryngeal web with a thin band, some may suggest that we observe the patient for 3-5 years in the hope that it might be outgrown.3 others would divide or excise the web.3,4 however, the course of healing in our pediatric patient may be different compared to adults. if we perform outright division, there could be a higher risk of re-adhesion. moreover, the presence of reflux (swollen arytenoids) may hasten the recurrence of the web or contribute to development of another laryngeal pathology like laryngomalacia.3 we are not aware of any definite treatment protocol that applies to our patient. as such, our current plan is serial monitoring to determine when he will be a good candidate for surgery. at the very least, we want to see a resolution of signs of reflux that may increase the risk of recurrence post surgery. we have yet to determine our final plan for surgical intervention and the optimal timing for it, and are open to receiving your comments. references 1. torre m, carlucci m, jasonni v. laryngeal anomalies. in: lima, m (ed). pediatric thoracic surgery. rome: springer; 2013. p. 194-203. 2. singh s, pancholi m, negi a, chaurishi v, vyas t. subglottic web: a rare cause of respiratory distress in neonate. j indian assoc pediatr surg. 2009 jul; 14 (3): 108-109. 3. adamczuk d, krzemień gg, szmigielska a, pierzchlewicz a, roszkowska-blaim m, biejat a, dębska m, jabłońska-jesionowska m. congenital laryngeal stridoran interdisciplinary problem. dev period med. 2013 apr-jun;17(2):174-178. 4. messner a. congenital disorders of the larynx. in: flint pw, haughey bh, lund vj, niparko jk, richardson ma, robbins kt, et al., editors. cummings otolaryngology head and neck surgery. 5th edition. philadelphia: mosby; 2010. p. 2866-2875. 5. nabi n, chaudhary s, ahuja s, goel a. a rare case of laryngeal web excision by co2 laser in a child: an anaesthetic challenge. j anaesthesiol clin pharmacol. 2011 jan; 27(1): 119–120. 6. singh pm, khanna p. incidental laryngeal web simulating intra-operative refractory bronchospasm. indian j anaesth. 2013 jan; 57 (1): 82-83. 7. rodriguez h, cuestas g, zanetta a, garrahan j. dysphonia child for congenital laryngeal web: case series. arch argent pediatr. 2013 jul-aug; 111 (4):82-85. 8. xiao y, wang j, han d, ma l, ye j, xu w. vocal cord mucosal flap for the treatment of acquired anterior laryngeal web. chin med j. 2014 november; 127 (7), 12941297. 9. mcclay je. subglottic stenosis in children. (article on the web) 2002. [cited aug 25, 2015]. available from: : http://www.tracheostomy.com/resources/articles/subglottic_stenosis/ philippine journal of otolaryngology-head and neck surgery 29 philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 featured grand rounds tracheal stenosis is a difficult complication to treat. it begins as a complication and eventually becomes serious enough to compromise the airway leading to surgery. the treatment of complete tracheal stenosis is resection with tracheal end-to-end anastomosis.1 the incidence of tracheal re-stenosis following anastomosis is relatively high at about 10.5% for caucasians.2 we are not aware of any studies on the incidence of this condition in the philippines. in airway management, endotracheal intubation is the initial choice to secure the patient’s airway followed by tracheostomy tube insertion. both modalities require proper weaning for eventual decannulation. if decannulation has failed, the possibility of tracheal stenosis as a complication must be considered and investigated. in cases of re-stenosis after tracheal resection and anastomosis, what to do next is a challenge. should another surgery for resection be planned? will there be any changes in the technique of the surgery or additional medical treatment? answering these questions may guide the surgeon’s next move and prevent re-stenosis and ultimately lead to decannulating the patient. we present a case of tracheal re-stenosis following two separate tracheal resections and endto-end anastomosis procedures. case report a 33-year-old man was admitted twice at our institution; initially four years ago for a cerebro vascular accident (cva) when he was confined in the intensive care unit (icu) and an endotracheal tube was inserted. the patient was medically managed for three weeks and was subjected to repeated re-intubation three times due to inadvertent extubation and mucus plugs. on the 21st hospital day, he was referred to our service for tracheostomy due to prolonged intubation, and a 1 x 1 cm tracheal window was created over the anterior portion of the third tracheal ring. the patient’s general condition improved and on the 21st post-tracheostomy day, decannulation was scheduled. however, upon occlusion of the tracheostomy tube, no escape of air from the upper airway passages was noted. imaging and visualization confirmed a tracheal stenosis above the cannula at the level of the second tracheal ring. the thickness was noted to be approximately 8mm to 12mm. (figures 13) the complete tracheal stenosis was excised with end-to-end anastomosis. the second, third tracheal rings were removed along with the granulation tissue and stenosis. the patient was discharged after 18 days. at home, he complained of difficulty breathing when using the fenestrated tube until he was eventually unable to tolerate the fenestrated tube and became aphonic. he did not consult during this period. tracheal re-stenosis after resection and anastomosis of complete tracheal stenosis correspondence: dr. walfrido c. adan, jr. department of otorhinolaryngology head and neck surgery quezon city general hospital & medical center seminary road, brgy. bahay toro project 8, quezon city 1106 philippines phone: +63093 2880 8749 email: zandromd@gmail.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represent honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to conflict of interest. walfrido c. adan, jr., md department of otorhinolaryngology head and neck surgery quezon city general hospital philipp j otolaryngol head neck surg 2013; 28 (2): 29-32 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 featured grand rounds 30 philippine journal of otolaryngology-head and neck surgery figure 1. plain ct scan, a. sagittal and b. coronal views showing 8-12 mm suprastomal stenosis prior to resection. a b four years later on follow-up, a recurrence of the complete tracheal stenosis was noted. (figure 4) he was re-admitted for a second tracheal resection with end-to-end anastomosis. the second tracheal ring and stenotic portion were removed. this second tracheal ring now corresponded with the patient’s actual fourth tracheal ring. a total of three tracheal rings had been excised, approximately 3-4 cm in length, since the first resection. the post-operative course was uneventful and the patient could use the fenestrated tube with good voice. he was discharged after 15 days with out-patient decannulation planned. figure 2. trans-oral endoscopic view using a rigid 70 degree 4.0 mm berci-ward laryngoscope, showing granulation tissue over the fenestration of the tracheostomy tube. figure 3. trans-oral endoscopic view, rigid 90˚ 4 mm berci-ward laryngoscope, after suctioning secretions, showing a funnel shaped, smooth pinkish mass completely occluding the tracheal lumen below the 1st tracheal ring. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 philippine journal of otolaryngology-head and neck surgery 31 featured grand rounds however, on follow-up two weeks later, there was note of grade iii restenosis on flexible laryngoscopy. (figure 5) at present, the patient can still use a fenestrated tube and has a breathy voice with no stridor. our present assessment is tracheal restenosis, membranous type, grade iii, status post tracheal resection with end-to-end anastomosis (2009 & 2013). discussion tracheal stenosis is an insidious process of inflammation, necrosis, granulation, fibrosis and contraction, bought about by pressure necrosis on the tracheal mucosa from an overly inflated tracheostomy or endotracheal tube balloon cuff.3 prolonged intubation is also implicated in the disease process.2 under the myer-cotton i-iv grading system,1,4 our patient had complete grade iv stenosis prior to the two resection procedures with grade iii (75-99% occlusion) stenosis now. the incidence of tracheal stenosis ranges from 10% 31%.1,2 the treatment for grade iv tracheal stenosis is resection with end-to-end anastomosis which is relatively successful in correcting the stenosis.1 however, the above procedure carries a 10.5% recurrence or failure rate.2 our patient had two failed resections and the potential for a third. in a study by azizolah et al., 494 patients underwent reconstruction of post-intubation airway stenosis. of the patients who had re-stenosis, length of resection > 4mm, tension, anastomotic infection and subglottic involvement were identified as the etiologic and pathophysiologic factors contributing to restenosis and failure of decannulation.2 in spite of the standard surgical technique used on our patient and uneventful post-operative course, re-stenosis still developed. it appears that fibrosis still developed on the background of inflammation causing the stenosis. thus, we posit that using an ankylating agent will supress inflammation and fibrosis and arrest the process of stenosis. in our case, because the underlying tracheal rings are still intact, the mucosal inflammation should be the target of treatment and another resection may not be indicated. endoscopic assisted bronchoscopy with sharp excision of the granulation and 4-quadrant/cloverleaf incisions of the stenotic mucosa could sufficiently enlarge the lumen. however, without an ankylating agent to supress the regrowth of the mucosa, re-stenosis will occur. mitomycin-c is such an agent that can be used topically to supress the growth of mucosal tissue in cases of tracheal stenosis.5 it is a novel approach and has yet to be standardized in the treatment of tracheal stenosis.6 mitomycin-c is an antimitotic drug that inhibits in vitro fibroblast proliferation and can prevent the formation of scars and fibrosis in both rabbits and humans. the effects of this drug have been tested in surgical treatment for pterygium, upper urinary tract, urothelial tumors, endoscopic sinus procedures, maxillary antrostomy and dacryocystorhinostomy.6,7 a recent retrospective study showed that topical mitomycin-c is an effective adjuvant in the treatment of tracheal stenosis. at a dosage of 0.04mg/ml, it has been found to be a potent inhibitor of the vigorous granulation response seen after airway injury in animal models figure 4. trans-nasal endoscopic view, using a 4.2 mm flexible rhino-pharyngo-laryngo fiberoptic scope, showing a blind pouch approximately 1cm below the vocal cords (arrow) prior to second resection with end-to-end anastomosis. figure 5. trans-nasal endoscopic view using a 4.2 mm flexible rhino-pharyngo-laryngo fiberoptic scope, showing re-stenosis (arrow) approximately 1cm below the vocal cords after second resection. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 2 july – december 2013 featured grand rounds 32 philippine journal of otolaryngology-head and neck surgery acknowledgement the author wishes to thank dr. rey vencio for the patience and technical expertise he shared in the making of this featured grand rounds. the department of orl-hns, qcgh, headed by its new chairman antonio g. talapian, md, fpsohns, and training officer emmanuel tadeus cruz, md, fpsohns for direction and logistic support in the writing and presenting this case. references khalid an, goldberg d. surgical management of upper airway stenosis. in:flint pw, haughey bh, 1. lund vj, niparko jk, richardson ma, robbins kt, thomas jr, editors. cummings otolaryngology head & neck surgery. 5th ed. philadelphia: mosby elsevier; 2010. p.943-52. azizollah ad, mohammad bs, mojtaba j, saviz p, abolghasem dk, reza s, et al. surgical 2. treatment of post-intubation tracheal stenosis. tanaffos. 2010 aug; 9(4): 9-21 macchiarini p, verhoye jp, chapelier a, fadel e, dartevelle p. partial cricoidectomy with primary 3. thyrotracheal anastomosis for postintubation subglottic stenosis. j thorac cardiovasc surg 2001 jan;121(1): 68-76 myer cm 3rd, o’connor dm, cotton rt. proposed grading system for subglottic stenosis based 4. on endotracheal tube sizes. ann otol rhinol laryngol. 1994 apr;103(4 pt 1):319-23 rahbar r, shapshay sm, healey gb. mitomycin: effects on laryngeal and tracheal stenosis, 5. benefits, and complications. ann otol rhinol laryngol. 2000 may;110(1):1-6. wong jl, tie st, samril b, lum cl, abdul rahman mr, abdul rahman ja. successful treatment 6. of tracheal stenosis by rigid bronchoscopy and topical mitomycin c: a case report. cases journal [serial on the internet]. 2010 sep [cited 2013 sep 22]; 3(2): [about 3 p.]. available from: http:// www.casesjournal.com/content/3/1/2. iñiguez-cuadra r, san martin prieto j, iñiguez-cuadra m, zuñiga erranz s, jofre pavez d, 7. gonzalez bombardiere s, et al. effect of mitomycin in the surgical treatment of tracheal stenosis. arch otolaryngol head neck surg. 2008 jul;134(7):709-14. regone rm, lambert e, roy s. management of acquired distal tracheal stenosis with 8. transtracheoscopic microdebrider assisted excision and balloon dilation. the university of texas health science center at houston. [cited 2013 sep 28]. available from: http://webcache. googleusercontent.com/search?q=cache:_odkfe6aan4j:www.triomeetingposters.org/wpcontent/uploads/2013/04/2-244.pdf+&cd=5&hl=en&ct=clnk&gl=ph zozzaro m, harirchian s, cohen e. flexible fiber co2 laser ablation of subglottic and tracheal 9. stenosis. laryngoscope. 2012 jan; 122(1):128-30. and pediatric patients.6 in another study, high dose mitomycin-c at 0.5mg/ml had a better success rate (> 52%) than low dose 0.2mg/ ml.7 success rates of adjuvant topical mitomycin-c application after laser, cauterization and microdebridement vary. microdebrider in combination with dilatation cases showed promising results.8 the same is seen with stenting.1 laser resection with dilatation had 60-70% success rates.9 no studies could be found comparing microdebrider, laser and stenting or their combinations. given the many options to treat tracheal stenosis, should a repeat resection-anastomosis be done? or should a less radical approach be undertaken to treat this patient? with all these in mind and upon the recommendation of the expert panel, we propose that the plan for this patient is 4-quadrant laser resection, application of mitomycin-c and insertion of a stent. 42 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports abstract objective: to report a rare form of metastasis from a primary nasopharyngeal carcinoma, a creeping form of dermal metastasis. methods: design: case report setting: tertiary public university hospital patient: one results: a 47-year-old male referred for radiotherapy after having undergone a selective neck dissection for multiple cervical lymphadenopathy with histopathologic diagnosis of undifferentiated carcinoma and no known primary underwent a four-quadrant nasopharyngeal biopsy which confirmed the presence of nasopharyngeal carcinoma. subsequent radiotherapy resolved the primary mass , and a new posterior cervical lymph node that appeared five months after completion of radiotherapy also resolved with additional radiotherapy. he was asymptomatic for two years until he noted thickening of the skin in his left supraclavicular area. a computed tomography (ct) scan showed deep cervical adenopathy and skin thickening, and biopsy confirmed dermal metastatic carcinoma. two courses of radiotherapy to the affected skin and left axilla where a lymph node had developed resulted in resolution and he was referred for chemotherapy. conclusion: dermal metastasis from nasopharyngeal carcinoma is rare and does not present with pathognomonic symptomatology. it may therefore be confused for a benign side effect (dermatitis), not the malignant manifestation that forebodes a bad prognosis. patients with dermal metastasis should receive treatment, and radiotherapy may play a significant part. chemotherapy may also play a role in its management. keywords: nasopharyngeal carcinoma, dermal metastasis nasopharyngeal carcinoma is fairly common in asia. it is said to be endemic among the southern chinese population.1,2 standard texts list the most common site of distant metastasis as bone followed closely by lung and liver metastasis1,2,3 with hardly any mention of skin metastasis. skin and dermal metastasis is commonly mentioned in association with breast cancer but not with nasopharyngeal carcinoma. this case presents an unusual occurrence of dermal metastasis in nasopharyngeal carcinoma. dermal metastasis from nasopharyngeal carcinoma: a rare form of metastasis johanna patricia a. cañal, md, mha department of radiology college of medicine philippine general hospital university of the philippines manila correspondence: a/prof. dr. johanna patricia a. cañal department of radiology philippine general hospital taft ave., ermita manila 1000 philippines phone: 02 – 5548471 fax: 02 5226597 e-mail: joie_canal@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (1): 42-45 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 43 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports case report a 47-year-old married male was first referred to the philippine general hospital for radiotherapy and further management in october 2002 following a selective neck dissection for multiple cervical lymphadenopathy in september 2002 with a histopathologic diagnosis of undifferentiated carcinoma. no primary site was identified at the time. a ct scan of the neck and nasopharynx revealed only cervical lymphadenopathy in the left anterior (4.2 x 2.3 cm) and posterior (4 x 2.7 cm) triangles. a chest x-ray was normal. no demonstrable nasopharyngeal mass was seen. because of a high index of suspicion, a four-quadrant nasopharyngeal biopsy was done confirming the presence of undifferentiated carcinoma. the diagnosis was nasopharyngeal carcinoma t1 n1 mx, stage iib. he underwent radiotherapy to the nasopharynx and neck from december 2002 to february 2003 receiving 76 gy to the primary site via opposing lateral fields and 50.4 gy to the neck via a single anterior low-neck field with a midline block. he remained asymptomatic for five months before noting new posterior cervical lymph nodes in the nape area. a biopsy again revealed metastatic undifferentiated carcinoma. the previously-untreated posterior neck was subjected to small field radiotherapy delivering 50 gy over 25 days in june and july 2003. a repeat ct scan of the nasopharynx and neck in september 2003 revealed no nasopharyngeal mass. the previously-noted cervical lymph nodes in levels ii and v decreased in size. the patient reported eventual disappearance of these lymph nodes and he was apparently well for the rest of 2003 and throughout 2004. a follow-up ct scan in june 2004 showed no nasopharyngeal mass but did show enlarged level iii deep cervical and posterior cervical lymph nodes on the right. the patient did not present himself for treatment at the time. over a year later, in august 2005, he consulted his attending physician for perceived thickening of the skin in his left supraclavicular area. the working impression was radiation dermatitis but another ct scan was requested which still showed no nasopharyngeal recurrence but revealed deep cervical lymphadenopathy in the left (figure 1). on examination, the skin over the left supraclavicular area was erythematous, swollen and had verrucous, plaque-like texture. the lesion involved the left upper chest and neck and crossed the midline (figure 2). there was some limitation of shoulder movement because of the swelling over the shoulder. a clavicle and shoulder x-ray showed intact osseous structures and skin thickening of the supraclavicular tissues with faint internal lucencies. he was referred to a dermapathologist who did an incisional skin biopsy which revealed metastatic carcinoma (figure 3). another ct scan of the neck in november 2005 revealed enlarged figure 1. ct scan showing a clear nasopharynx and enlarged left deep cervical nodes. figure 2. photograph showing erythematous,verrucous skin over left shoulder & clavicle 44 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports confluent nodes in levels 4 and 7 of the cervical chain and fat stranding (lymphedema) of the left supraclavicular region (figure 4). the patient then underwent repeat radiotherapy to the left supraclavicular, midupper chest and mid-upper back areas, via anteroposterior fields receiving 54 gy over six weeks. midway through the radiotherapy course, there was obvious regression of the skin lesion no longer crossing the midline. at the end of the radiotherapy course, there was even greater decrease in the skin lesion in the left supraclavicular area. however, there was edema of the left axillary area. when he followed up after one month, there was marked improvement in the left supraclavicular area but with note of an enlarged, partially fixed left axillary lymph node. he was advised chemotherapy but opted for radiotherapy to the affected area of the axilla instead. he received 300 cgy per day for 12 days with a bioequivalent dose of 3900 cgy. at the end of the 12 days, there was a decrease in size and improvement in mobility of the axillary node. he was referred once more for chemotherapy. discussion it is fairly common for a nasopharyngeal carcinoma to metastasize to the cervical lymph nodes. often, it is the cervical lymphadenopathy that will cause patients to seek medical management. likewise, it is common for a nasopharyngeal carcinoma to metastasize to bone. however, it is not common for nasopharyngeal cancers to metastasize to the skin. dermal metastasis is so termed because of the presence of metastatic tumor cells in the dermis. the epidermis is usually spared. this is most often seen in cases of breast carcinoma and is also known figure 4. ct scan showing cervical lymphadenopathy and lymphedema in november, 2005 as inflammatory carcinoma. the most frequent internal primaries that metastasize to the skin are breast, lung and gastrointestinal tract malignancies.4 a pubmed medline and google search using the terms “nasopharynx metastasis,” “dermal metastasis” and “skin metastasis”revealed only five other cases of dermal metastasis from nasopharyngeal carcinoma. most of the articles found were for other primary cancers. two other case reports by dasmajundar5 and walvekar6 cite tonsillar primaries that presented with nodular skin metastasis while osborne reported a case of dermal metastasis from tongue carcinoma.7 leong8 cited three cases of recurrent nasopharyngeal carcinoma with dermal metastasis, however, all presented with facial swelling and a nodular skin lesion. guberman9 reported a case that was similar in presentation to leong’s. caloglu10likewise presented a case of nasopharyngeal primary with extensive nodular metastasis. none presented like our patient—with a creeping, spreading form of dermal metastasis. our patient presented much like a breast cancer patient would have—with skin thickening and erythema. these occurred in an area that was previously irradiated. in both guberman’s9 case and this one, there was a quandary about whether the patient had radiodermatitis or skin metastasis. in such situations, a biopsy is unavoidable and indeed, mandatory. our patient’s dermal metastasis was treated with radiotherapy and it resolved, albeit partially. he was still referred for chemotherapy to better control his metastasis. at the end of treatment, it was fully expected that the skin metastasis would progress because of the behavior that it had figure 3. histopathologic section, hematoxylin and eosin, low –power magnification (40x) showing a few nodular collections of cells, most hyperplastic and in mitosis, surrounded by moderately dense perivascular infiltrates of lymphocytes in the upper and deep dermis. the report stated that the epidermis was normal. (hematoxylin-eosin, 40x) philippine journal of otolaryngology-head and neck surgery 45 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports references 1. lee awm, perez ca, law sck, chua dtt, wei wi, chong v. nasopharynx. in: halperin ec, perez ca, brady lw, editors. principles and practice of radiation oncology. 5th ed. philadelphia: lippincott williams & wilkins; 2008. p.820 – 857. 2 . batsakis jg, editor. tumors of the head and neck: clinical and pathological considerations, 2nd ed. baltimore: williams & wilkins; 1979. 3. chao ksc, perez ca, brady lw, editors. radiation oncology management decisions. 2nd ed. philadelphia: lippincott, william & wilkins; 2002. 4. wollina u, graefe t, konrad h, schönlebe j, koch a, hansel g, et al. cutaneous metastasis of internal cancer. acta dermatoven apa 2004; 13(3): 79. 5 . dasmajumdar sk, gairola m, sharma dn, mohanti bk. cutaneous metastasis from carcinoma of tonsil. j postgrad med [serial online] 2002 [cited 2006 oct 17];48:32-3. available from:http:// www.jpgmonline.com/article.asp?issn=0022-3859;year=2002; volume=48;issue=1;spage=32;e page=3;aulast=dasmajumdar. 6. walvekar rr, chaukar da, mahajan a, d’cruz ak. skin metastasis in an oropharyngeal cancer report of a case and review of literature. bombay hospital journal 2006 january; 48( 1): 175178. 7. osborne rf. case report: dermal metastasis from visceral primary. ear, nose throat j 2004 july; 83(7):432. 8. leong ss, tan eh, khoo-tan hs, yang tl, wee j, tan sh, et al. recurrent nasopharyngeal carcinoma presenting as diffuse dermal lymphatic infiltration in the neck: three case reports. head neck 2001; 23( 2):160-165. 9. guberman d, reinus c. carcinoma ersyipelatoides—cutaneous lymphatic vessel spread of a poorly differentiated nasopharyngeal carcinoma. dermatology online journal 200; 7 (2): 7. 10. caloglu m, uygun k, altaner s, uzal c, kocak z, piskin s. nasopharyngeal carcinoma with extensive nodular skin metastases: a case report. tumori 2006 mar-apr; 92 (2): 181-4. exhibited previously. similar to all forms of metastasis, the prognosis is most likely poor. as of three months after the radiotherapy, the patient had not presented himself for chemotherapy. standard texts do not discuss dermal metastasis and thus no standard treatment options are available. to the best of our knowledge, this is to date the only reported case of dermal metastasis that was treated with radiotherapy as a single modality. as such, optimal radiotherapy technique and dosing are unknown. although exceedingly rare, dermal metastasis from nasopharyngeal carcinoma does happen. it does not present with pathognomonic symptomatology and therefore may be confused for a benign side effect (dermatitis), not the malignant manifestation that forebodes a bad prognosis. patients with dermal metastasis should receive treatment, of which radiotherapy may play a significant part. chemotherapy, though not administered in this patient, may play a role in the management of this kind of metastasis. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 under the microscope philippine journal of otolaryngology-head and neck surgery 43 this is the case of a 72-year-old male who presented with a three year history of hoarseness. two years prior to admission, he developed dyspnea, dysphagia and odynophagia. three months prior to admission, the patient visited a private physician who noted a 3 cm diameter ill-defined laryngeal thickening and advised biopsy, hence the present consult. a biopsy and subsequent hemilaryngectomy were performed. histologic sections from the mass show an abundant subepithelial deposition of an acellular, extracellular, eosinophilic and non-fibrillar matrix that surrounds atrophic mucous acini (figuress. 1, 2, 3). scattered lymphocytes and foreign-body-type giant cells are noted. congo-red histochemical stains show a characteristic salmon-pink reaction (figure 4) which on polarizing microscopy showed a characteristic apple-green birefringence. no evidence of malignancy is seen. the diagnosis was localized laryngeal amyloidosis. laryngeal amyloidosis is rare, accounting for less than 1% of benign laryngeal tumors. most are localized not associated with deposits elsewhere in the body and are primary – not associated with any known systemic or neoplastic diseases such as disseminated tuberculosis or certain lymphomas and multiple myeloma. adults are usually affected although rarely, children can develop the condition. almost all patients present with hoarseness, in addition to symptoms related to the size, extent and location of the deposits. the false vocal cord is often affected although multifocality within the larynx occurs in 15% of cases.1, 3 careful histologic evaluation should exclude the presence of a coexistent laryngeal condition, particularly the malignant neoplasms stated above, as these would require more extensive management. other differential diagnoses include vocal cord polyps and papillomas.2, 3 the prognosis for isolated laryngeal amyloidosis is excellent although occasional repeat surgeries may be necessary for recurrent disease. on the other hand, the prognosis of laryngeal amyloidosis associated with systemic or neoplastic conditions is dictated largely by the course of the coexisting disease processes.1 although rare, laryngeal amyloidosis should not be overlooked in the differential diagnosis of hoarseness particularly in adults. an attempt to exclude a co-existing systemic or neoplastic disease should always be made. a rare case of hoarseness: laryngeal amyloidosis jose m. carnate jr., md department of pathology college of medicine – philippine general hospital university of the philippines manila correspondence: jose m. carnate, jr. md university of the philippines manila college of medicine department of pathology 547 pedro gil st., ermita, manila 1000 philippines phone (632) 526 4550 fax (632) 400 3638 email: jmcjpath@yahoo.com reprints will not be available from the author. philipp j otolaryngol head neck surg 2010; 25 (1): 43-44 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 44 philippine journal of otolaryngology-head and neck surgery under the microscope references 1. thompson ld. head and neck pathology. in foundations in diagnostic pathology series. goldblum jr ed. churchill livingstone elsevier, inc. 2006. 2. wenig b. atlas of head and neck pathology, 2nd ed. elsevier, inc. 2008. 3. gnepp dr, ed. diagnostic surgical pathology of the head and neck. wb saunders company, 2010. figure 1. extensive eosinophilic extracellular amorphous matrix (hematoxylin and eosin, 40x) figure 2. acellular matrix is found in a subepithelial location (hematoxylin and eosin, 100x) figure 4. characteristic salmon-pink reaction (congo-red, 400x) figure 3. matrix may have scattered lymphocytes and surround acini that undergo compressive atrophy (hematoxylin and eosin, 400x) (hematoxylin and eosin, 40x) (hematoxylin and eosin, 100x) (hematoxylin and eosin, 400x) (congo-red, 400x) 26 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 case reports philipp j otolaryngol head neck surg 2014; 29 (1): 26-29 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to present our application of a double anterolateral thigh (alt) free flap in reconstruction of a large full thickness defect of the oral cavity, cheek and cervical area. methods: design: case report setting: tertiary government hospital patient: one results: a 77-year-old male with a 20 x 25 cm full thickness soft tissue defect on the facial and cervical area contiguous with a 6 x 6 cm buccal defect resulting from wide tumor ablation of a stage iva (t4an2bm0) squamous cell carcinoma of the buccal mucosa underwent reconstruction using two alt free flaps. an alt flap was designed to cover the intraoral and cheek defect while another alt flap was used for external coverage of the cervical defect. the first alt flap measured approximately 8 x 22 cm while the second alt flap measured 6 x 21 cm harvested from the left and right thigh respectively. temporary venous congestion was observed on the inferiorly placed alt flap due to neck edema that spontaneously resolved on the second post-operative day. minimal donor site complications observed were linear scars and a 1 x 4 cm dehiscence on the right thigh that healed spontaneously by secondary intention. conclusion: the utilization of a double anterolateral thigh free flap allowed single-stage reconstruction of the large soft tissue head and neck defect with little donor site morbidity, shorter operating time and shorter hospital stay. keywords: anterolateral thigh free flap (alt flap), double alt flap, full-thickness buccal defect tumor ablation may be hampered when a reconstructive team is not available since head and neck surgeons performing tumor ablation may compromise the resection margins in consideration of subsequent closure of the defect especially in large and advanced-stage tumors. microvascular surgery has broadened the options for available tissue to close large and complex head and neck defects. in response to such a challenge, we present our experience in reconstructing a large through-and-through defect of the buccal mucosa and cervical skin using a double anterolateral thigh free flap. case report a 77-year-old man with a stage iv-a (t4an2bm0) moderately-differentiated squamous cell carcinoma of the left buccal mucosa that involved the lip and cheek underwent tumor ablation along with a left modified radical neck dissection and tracheostomy. (figure 1) the exophytic buccal mass measured 6 x 6 x 3 cm from the superior and inferior gingiva-buccal sulcus extending posteriorly to the retromolar trigone along with induration of the oral commissure and cutaneous reconstruction of a large through and through defect of the oral cavity using a double anterolateral thigh free flap jefferson a. alamani,1 samantha s. castaneda,1 adrian f. fernando1 1department of otorhinolaryngologyhead and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue, sta. cruz, manila correspondence: dr. jefferson a. alamani department of otolaryngology head and neck surgery, jose r. reyes memorial medical center san lazaro, compound, rizal avenue, sta. cruz, manila 1003 philippines phone: (632) 711 9491 local 320 telefax: (632) 743 6921 email: dyeph.kk10@gmail.com reprints will not be available from the author the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at: interesting case contest (1st place), philippine society of otolaryngology head and neck surgery, best western hotel, a venue, makati city, may 27, 2013. proferred paper session 6, third congress of the asian society of head and neck oncology (ashno), radisson blu hotel, cebu city, march 22, 2013. philippine journal of otolaryngology-head and neck surgery 27 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 case reports involvement of the cheek. included with the tumor ablation was a partial parotidectomy and marginal mandibulectomy resulting in a large complex full thickness defect. (figure 1) simultaneous with the neck dissection, two alt flaps measuring 8 x 22 cm on the left and 6 x 21 cm on the right were harvested by two reconstructive surgeons. (figures 2, 3) the larger left alt flap was folded and designed to cover both the intraoral and facial / cheek defect with its pedicle anastomosed to the left facial artery and vein. a lip sling was constructed using a strong non-absorbable 2.0 suture from the orbicularis oris muscle of the lower and upper lip through the folded portion of the flap to preserve oral competence. the smaller right alt flap was utilized to cover the upper cervical soft tissue loss and its vascular pedicle was anastomosed to the ipsilateral superior thyroid artery and facial vein. vacuum drains and nasogastric tube were later inserted, and the donor-sites were closed primarily without needing skin grafting. (figure 4) the entire procedure lasted 14 hours. the immediate postoperative period was fairly unremarkable. neck swelling and minimal flap venous congestion was noted on the second postoperative day that resolved spontaneously on the succeeding day. ambulation was allowed on the first postoperative day and the patient was decannulated on the fourth postoperative day. good function and aesthetic satisfaction were reported by the patient in the first postoperative week and oral diet was resumed progressively. (figure 5) the donor sites had a 1 x 4 cm dehiscence that was managed conservatively with wound debridement and healed spontaneously by secondary intention resulting in a linear scar. the patient was discharged on the ninth postoperative day and advised adjuvant chemotherapy figure 1. topographic tumor extent, surgical margins and resultant defect. a. stage iva (t4an2cm0) squamous cell carcinoma of the buccal cavity with cutaneous invasion. skin markings of tumor induration and planned neck incisions. b. markings of the 2 cm tumor margins incorporating the lower border of resection with the horizontal and upper vertical cervical incisions to prevent cervical flap necrosis. c. resultant complex defect of the oral cavity, cheek and neck regions following tumor ablation, marginal mandibulectomy, upper alveolar resection, partial parotidectomy, and mrnd. intraoperatively, tumor invasion extended caudally from the left lateral lip commissure, superiorly to the uppermost alveolar and buccal junction, posteriorly to the retromolar region inferiorly to the mandibular alveolus, and anteriorly invading the masseter muscles, parotid and cutaneous area of the cheek and submandibular area. figure 2. two alt flap design a. alt flap harvested from the left thigh measuring 8 x 22 cm for closure of the upper extent of the defect(*) the thin and most distal portion of the flap was used for intraoral defect closure, and was folded (broken lines) as the distal portion of the flap (open arrow) was used for closure of the external cheek defect. b. right alt flap showing distal(**) and proximal(bold arrow) portions, measuring 6 x 21 cm was used to close the lower cervical defect. and radiation therapy following multi-disciplinary consultation with the oncology services. the upper alt flap was over-corrected in size as atrophy was anticipated following adjuvant radiation while a secondstage lip reconstruction is planned following full oncologic treatment. (figure 6) 28 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 case reports discussion the anterolateral thigh (alt) free flap has gained popularity since its introduction by song et al. in 1984.1 its blood supply is from the perforators of the descending branch of the lateral circumflex femoral artery. in 2008, ramos et al. reported alt reconstruction of a throughand-through defect of the buccal mucosa and cheek that healed uneventfully.2 since then, the use of alt for reconstruction of head and neck defects in the philippines has increased because of its inherent versatility. the shortened operation time of 14 hours in our case was due to a simultaneous surgical team management comprised of as the head and neck ablative team and the reconstruction team. with a combined defect of 20 x 25 cm on the cheek and cervical area of our patient, various flaps were considered. (table 1) the pectoralis major myocutaneous flap (pmmf) which is considered for decades as the work-horse pedicled flap for head and neck reconstruction was excluded mainly because it lacks soft tissue coverage. other disadvantages that limits its use were unaesthetic supraclavicular bulge, chest wall deformity, short act of rotation for more cephalad defects and resulting restriction in neck motion.3figure 3. harvested alt flaps. a. right alt flap which measured 8 x 22cm, b. left alt flap which measured 6 x 21 figure 4. defect closure using the 2 alt flaps. a. the intraoral defect closure with the thin distal portion of the 1st alt flap (*), folded (broken lines) at the lip commissure and internally suturing the upper and lower orbicularis oris to preserve oral continence. b. closure of the external facial defect with the remaining portion of the 1st alt flap (open arrow). also illustrated is the course of the pedicle anastomosis to the facial artery and vein (broken line). c. the 2nd alt flap harvested from the right thigh used for the rest of the cervical defect. also illustrated is the course of the vascular pedicle anastomosed to the superior thyroid artery and facial vein (broken line). d. the resultant 2-flap closure of the large complex defect showing the right (bold arrow) and the left (open arrow) alt flaps. philippine journal of otolaryngology-head and neck surgery 29 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 case reports references song yg, chen gz, song yl, the free thigh flap: a new free flap concept based on the 1. septocutaneous artery, br j plast surg 1984, 37(2) 149–59. ramos rm, castañeda ss, alonzo dm,; anterolateral thigh flap reconstruction of full thickness 2. buccal defect; philipp j otolaryngol head neck surg 2008 jan-jun;23(1):28-30. yang jy, rosen mr, keane wm, flaps and grafts in the head and neck edited by snow jb jr, 3. ballenger jj, ballenger’s otorhinolaryngology head and neck surgery 16th edition 2003 spain; bc decker inc, , 972-94. camaioni a, loreti a, damini v, bellion m, passali fm, viti c; anterolateral thigh cutaneous flap 4. vs. radial forearm free flap in oral and oropharyngeal reconstruction: an analysis of 48 flaps acta otorhinolaryngol ital 2008;28: 7-12. farace f, fois ve, manconi a, puddu a, stomeo f, tullio a, meloni f, et al. free anterolateral thigh 5. flap versus free forearm flap: functional results in oral reconstruction. j plast reconstr aesthet surg. 2007;60(6):583 –7. di candia m, lie k, kumiponjera d, simcock j, cormack gc, malata cm; versatility of the 6. anterolateral thigh flap: the four seasons flap; eplasty 2012; 12: e21. kimata y, uchiyama k, ebihara s, sakuraba m, iida h, nakatsuka t, harii k, anterolateral thigh 7. flap donor-site complications and morbidity. plast reconstr surg 2000 sep;106(3):584-9. other flaps considered were the trapezius flap, latissimus dorsi free flap and the radial forearm free flap. all have been known of their vast applications for head and neck reconstruction but as with the pmmf, are mainly limited by deficient tissue coverage in relation to resultant defect in our patient, utilizing double alt flaps then established our goals of reconstructing the large complex full thickness defect; preserving oral cavity functions and providing an option with the least donor site morbidity and a fairly acceptable aesthetic outcome. figure 5. post-operative profile of the patient. a. the patient on mouth opening showing the bulky folded portion of the 1st alt flap, 1 month post-operatively. the flap was over-corrected in size anticipating atrophy after radiation treatment. b. side profile of patient showing good color aesthetic match coinciding the aesthetic zone of the cheek, with overlap of the preauricular and buccomandibular zones. figure 6. post-operative anterior thigh. a. the left (top) and b. right (bottom) anterior thighs of the patient one month post-operatively. even with dehiscence, both thighs had minimal morbidity and healing with secondary intention. a b the alt flap is a reliable and versatile option for head and neck reconstruction with reported size ranging from 12-35 cm in length and 4-11 cm in width.6 in our experience, the resultant complex defect that measured 20 x 25 cm may not be adequately reconstructed with a single alt flap nor other type of soft-tissue flaps. moreover, harvesting larger soft tissue flaps may already necessitate additional skin grafting and add up to possible donor-site complications. 7 the utilization of two alt flaps enabled the primary reconstruction of the complex defect minimal morbidity, shorter operating time and shorter hospital stay. table 1. alternative flaps for closing a large head and neck defect descriptionflap disadvantage pectoralis major myocutaneous flap (pmmf) latissimus dorsi free flap radial forearm free flap (rf) “work-horse” pedicled flap for head and neck reconstruction. vascular supply: thoracoacromial arety skin paddle surface area 26 x 16cm large surface area of 20 x 35cm vascular supply: thoracodorsal artery from volar surface of forearm thin and pliable with a dimension of 13 x 12cm vascular supply: radial artery, cephalic vein or venae commitantes bulky flap, postoperative stenosis unaesthetic supraclavicular bulge and chest wall deformity; fistula problems short arc of rotation restricted neck motion intraoperative repositioning and donor site morbidity, shoulder dysfunction donor site morbidity: tendon exposure, sacrificial of blood supply, unsightly scar. hand stiffness, pain and anesthesia / paresthesia philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 46 philippine journal of otolaryngology-head and neck surgery passages jesus t. co, md (1935-2009) “my tribute to my dad” johanna co-dy lim, md in behalf of our family, allow me to start by thanking each and everyone’s offering of support and prayers. indeed, we are having a most difficult time facing this loss. we desperately try and search for answers hoping to appease the hurt. i remember during his last days, papa turned to his bible and one of his favorite chapters was from psalms: “be still and know that i am god” (psalms 46:10), a passage that i have come across to dwell on. most of you probably received dr. jesus co’s passing in shock. unbeknownst to you, we have been dealing with his illness for about six months. and we know there are unending questions about the how, when and even why, but kindly indulge me in giving you a glimpse into his journey. jess, as his friends endearingly called him has been most passionate about his work. he cared deeply for his patients. he was so articulate and well-versed and could talk about anything under the sun. papa had a voracious appetite in reading and learning not limited to his field. he challenged us into healthy debates in all of our specialtiesgastroenterology, pediatrics and especially ent, but unfortunately he was no match for my mom’s showbiz knowledge. he was an avid sportsman as wellin golf and lately, one of his other loves, fishing. my dad’s happiest moments would be spending time with his grandchildren teaching them how to fish. i could go on endlessly with this tribute for he excelled in various endeavors. but let me just share with you that he was first and foremost a family man. he was the eldest of 10 children hailing from binalonan, pangasinan. his brothers and sisters addressed him as “manong” for he was almost like the head of their family since “angkong” died. i remember my aunts and uncles visiting often and heeding his advice. as my mom’s better half, he doted on her. their lives were so much intertwined and the best way to describe it is through their favorite love song“i can’t stop loving you.” surely, there are precious moments that only the two of them will treasure. it must have been a pleasant surprise to him that the stork delivered four girls. he instilled in us to strive for excellence and accept defeat as a stepping stone. one of my fondest recollections of when i was younger was losing a dogback then it seemed like such a tragedy. i was inconsolable and amidst my cries he tenderly imparted a pearl of his many wisdoms about life’s reality: there will be challenges and battles to bear and sometimes our best recourse is to be silent. for god is strong when we are at our weakest. it was heartbreaking to see him physically deteriorate but despite this, he pursued his dedication for his work and kept his dignity in times of suffering. we earnestly pray that beyond our words we were able to provide him with comfort and ease his pain. certainly, we would want to focus only on the joys of his life as it is painful to recall how tirelessly he fought and tried to overcome his sickness. his strength, character and unwavering faith carried him through until he eventually succumbed to the lord’s calling. friends and family, let us celebrate how dr. jesus co has inspired us to persevere and trust wholeheartedly in the lord. we can be still and be at peace in the knowledge that god’s grace will suffice and take care of all our needs. thank you. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 case reports philippine journal of otolaryngology-head and neck surgery 19 philipp j otolaryngol head neck surg 2014; 29 (2): 19-21 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to report a case of foreign body lodged within the sphenoid sinus and its extraction. methods: design: case report setting: tertiary government hospital patient: one results: an 11-year-old girl was hit in the eye by an unknown object from an improvised slingshot. she had loss of vision of the left eye and headache without loss of consciousness. a plain craniofacial computed tomography (ct) scan showed a round opaque foreign body abutting the left sphenoid sinus, left posterior ethmoid cells and medial aspect of the left orbital region with adjacent soft tissue densities extending into the apparently ruptured, irregular left globe. the left posterior part of the lamina papyracea was not visualized probably fractured or ruptured. transorbital enucleation of the left eye and endoscopy-assisted removal of the foreign body (a glass marble) were performed with no intra – operative and post – operative complications. conclusion: foreign body of the sphenoid sinus is a rare condition. adequate imaging is important for localization and planning the optimal surgical approach. endoscopic guidance may aid in extraction. keywords: sphenoid sinus foreign body, computed tomography (ct ), endoscopic-guided, transorbital approach the sphenoid sinuses lie deep within the skull and behind the ethmoid air cells. the orbit, frontal and maxillary sinuses are the most commonly involved structures with penetrating foreign bodies.1 foreign body of the sphenoid sinus is a rare condition and most of the documented cases are shrapnel wounds. we describe a non-shrapnel foreign body lodged within the sphenoid sinus. case report an 11-year-old girl was hit in the left eye by an unknown projectile from an improvised slingshot leading to loss of vision and accompanying left-sided headache without loss of consciousness. physical examination after one month revealed a ruptured left globe. there was no light perception in the left eye while the right had 20/20 vision. (figure 1) no visible entry wound or scar was seen. the neurologic examination was otherwise normal. a plain craniofacial ct scan revealed a round opaque foreign body abutting the left sphenoid sinus, left posterior ethmoid cells and medial aspect of the left orbital region with adjacent soft transorbital removal of foreign body in the sphenoid sinusdaniel jose c. mendoza, mdantonio h. chua, md samantha s. castañeda, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. samantha s. castañeda department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 7436921; (632) 711 9491 local 320 email: entjrrmmc@yahoo.com reprints will not be available from the author the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 20 philippine journal of otolaryngology-head and neck surgery case reports tissue densities extending into the apparently ruptured, irregular left globe. the posterior part of the left lamina papyracea was not visualized probably fractured or ruptured. (figure 2) following enucleation of the left eye, a 1.5 cm diameter glass marble was removed via endoscopy-assisted transorbital approach. (figure 3) there were no intra – operative and post – operative complications. figure 1. ruptured globe of the left eye of the patient figure 3. glass marble removed within the sphenoid sinus figure 2a. axial and b. coronal plain craniofacial ct scan views of the patient showing the opaque foreign body a b philippine journal of otolaryngology-head and neck surgery vol. 29 no. 2 july – december 2014 case reports philippine journal of otolaryngology-head and neck surgery 21 discussion paranasal sinus foreign body injuries have a lower incidence compared with facial injuries.2 one study documented four sphenoid sinus foreign bodies out of 26,000 war wounds.3 thus, foreign body lodged in the sphenoid sinus is a rare condition. most were due to shrapnel wounds and air gun pellets.1-8 in this case, a glass marble was the projectile from an improvised slingshot. it entered the medial aspect of the left orbital area, lodging within the left sphenoid sinus while fracturing both the left lamina papyracea and posterior ethmoid air cells. the exact point of entry and trajectory of the foreign body were not identified primarily due to the one-month delayed consult. the main and most important diagnostic procedure available is ct scan of the head which can localize the foreign body as well as demonstrate bone fragments and other lesions. coronal ct sections provide good views of the sphenoid and adjacent paranasal sinuses and possible intracranial penetration. magnetic resonance imaging (mri) is a usually less informative diagnostic procedure for adequate imaging of bones.8 lastly, ct scans can guide the surgical approach for extraction. craniofacial ct scan in our patient revealed the opaque foreign body within the sphenoid sinus. the left lamina papyracea was not visualized which indicated prior rupture or fracture. the left frontal and maxillary sinuses had mucosal thickening suggesting sinusitis. the ct scan was helpful in localizing the foreign body and revealing involvement of other structures such as bones and sinuses. it also showed that the foreign body could not be removed trans-nasally, favoring transorbital approach. with the relatively low rate of these injuries, there are no standard methods of diagnosis and management.9 a multidisciplinary ophthalmic, neurosurgical and otorhinolaryngological treatment approach is recommended.1 enucleation of the left eye was performed because the globe was already ruptured and the left eye was blind. of the different approaches used for removal of foreign bodies within the sphenoid sinus, endoscopic guidance was employed in most reported cases of air gun pellets.5-6, 9 a metallic foreign body was removed via a transmaxillary sublabial approach.2 in this case, endoscopic-guided removal of foreign body was done using a transorbital approach. the patient did not develop any intraoperative and post-operative complications. in summary, adequate imaging is important for localization and planning the optimal surgical approach for sphenoid sinus foreign bodies. endoscopic guidance may aid in their extraction. references 1. dimitriou c, karavelis a, triaridis k, antoniadis c. foreign body in the sphenoid sinus. j craniomaxillofac surg. 1992 jul; 20(5):228-9. 2. akhaddar a, abouchadi a, jidal m, gazzaz m, elmostarchid b, naama o, et al. metallic foreign body in the sphenoid sinus after ballistic injury: a case report. j neuroradiol. 2008 may; 35(2): 125-8. 3. harris wd. large sphenoid sinus foreign body. arch otolaryngol. 1968 oct; 88(4): 436-8. 4. kobek m, chowaniec c, rygol k, jabłoński c. an unusual case of gunshot wounds caused with an air gun. arch med sadowej kryminol. 2011 jan-mar; 61(1): 58-61. 5. liu sy, cheng wy, lee ht, shen cc. endonasal transphenoidal endoscopy-assisted removal of a shotgun pellet in the sphenoid sinus: a case report. surg neurol. 2008 dec; 70 suppl 1:s1 56-9. doi: 10.1016/j.surneu.2008.04.035. epub 2008 sep 11. 6. strek p, zagólski o, składzień j. endoscopic removal of air gun pellet in the sphenoid sinus. b-ent. 2005; 1(4): 205-7. 7. o’connell je, turner no, pahor al. air gun pellets in the sinuses. j laryngol otol. 1995 nov; 109(11): 1097-100. 8. wani na, khan aq. foreign body within sphenoid sinus: multidetector-row computed tomography (mdct) demonstration. turk neurosurg. 2010 oct; 20(4): 547-9. doi: 10.5137/10195149.jtn.2475-09.2. 9. kamat a, tabaee a. chronic foreign body of the nasal cavity and sphenoid sinus: surgical implications. cleft palate craniofac j. 2012 jan; 49(1): 114-7. doi: 10.1597/10-253. epub 2011 may 2. philippine journal of otolaryngology-head and neck surgery 51 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports philipp j otolaryngol head neck surg 2015; 30 (1): 51-53 c philippine society of otolaryngology – head and neck surgery, inc. abstract objectives: to report a benign tonsillar lesion presenting as a pedunculated polyp and discuss its diagnosis and management. methods: design: case report setting: tertiary government hospital patient: one results: a 14-year-old lad presented with a seven-year history of an elongated right tonsillar mass without associated bleeding, pain, dysphagia or obstructive sleep apnea. physical examination revealed a pedunculated mass about 2 x 1 x 0.5cm in size located in the superior pole. after unilateral tonsillectomy, histopathological examination revealed lymphangectatic lipomatous fibrotic polyp. conclusion: lymphangiomatous polyp of the palatine tonsils is an unusual benign lesion of the head and neck. these are commonly present as unilateral, polypoidal mass that cannot be clinically differentiated from other benign tonsillar lesions. tonsillectomy is the recommended surgical approach for both diagnostic and therapeutic purposes. histopathological study must be done to confirm diagnosis. keywords: palatine tonsil, pedunculated polyp, hamartoma, lymphangioma, tonsillectomy tumors of the tonsils are relatively rare and benign tumors of the palatine tonsils are less common than malignancies. squamous papillomas account for the majority of benign lesions, whereas vascular tumors are rarely reported.1lymphangiomatous polypoid lesions of the head and neck are likewise rare and such tumors arising from the palatine tonsils are sparse.2 we present the case of an adolescent male with a lymphangiomatous polyp of the palatine tonsil. unilateral pedunculated polyp of the palatine tonsil daniel jose c. mendoza, md antonio h. chua, md samantha s. castañeda, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. samantha s. castaneda department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 7436921; (632) 711 9491 local 320 email: docsamcastaneda@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at philippine society of otolaryngology – head and neck surgery free paper presentation, sofitel philippine plaza hotel, ccp complex, manila, december 4, 2012. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 case reports 52 philippine journal of otolaryngology-head and neck surgery case report a 14-year-old healthy lad consulted at the outpatient department for an oropharyngeal foreign body sensation. on review, he had a sevenyear history of an elongated right tonsillar mass without associated bleeding, pain, dysphagia or obstructive sleep apnea. physical examination revealed a solitary, smooth, pedunculated, elongated, pinkish, non-tender, soft mass within the right tonsillar pillar. (figure 1) unilateral tonsillectomy was performed under general anesthesia. the 2 x 1 x 0.5 cm mass was attached to the superior pole of the right tonsil by a distinct stalk. it was pinkish to whitish in color with soft consistency. (figure 2) on histopathologic evaluation, the specimen showed a non-keratinizing, stratified, squamous epithelial lining and a dense lymphoid tissue at the base. (figure 3) the central portion of the specimen contained numerous dilated lymphatic channels with thin epithelial lining and some blood vessels. (figure 4) there was no atypia or evidence of malignancy. the final histopathological report was lymphangectatic lipomatous fibrotic polyp (a term for lymphangiomatous polyp). figure 1. oropharyngeal examination of the patient revealing a pedunculated tonsillar mass on the right. figure 3. histopathologic specimen showing non-keratinizing, stratified squamous epithelial lining with lymphoid tissue at the base (h&e, 40x) figure 4. histopathologic specimen showing dilated lymphatic channels in the central portion. (h&e, 100x) figure 2. right tonsil and 2 x 1 x 0.5 cm pedunculated tonsillar mass with a distinct stalk after unilateral tonsillectomy. (hematoxylin and eosin, 40x) (hematoxylin and eosin, 100x) philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 philippine journal of otolaryngology-head and neck surgery 53 case reports references 1. roth m. lymphangiomatous polyp of the palatine tonsil. otolaryngol head neck surg 1996; 115(1): 172-3. 2. park e, pransky sm, malicki dm, hong p. unilateral lymphangiomatous polyp of the palatine tonsil in a very young child: a clinicopathologic case report. case rep pedriatr. 2011; 2011: 451524. doi 10.1155/2011/451542. epub 2012 jan 4. 3. kardon d, wenig bm, heffner dk, thompson ld. tonsillar lymphangiomatous polyps: a clinic pathologic series of 26 cases. mod pathol 2000 oct; 13(10):1128-33. 4. ohtsuki y, kurita n, iguchi m, kurabayashi a, matsumoto m, takeuchi t, et al. a pedunculated hamartomatous polyp of the palatine tonsil. biomedical research 2006; 17 (3): 155-8. 5. hyams vj. differential diagnosis of neoplasia of the palatine tonsil. clin otolaryngol allied sci. 1978 may; 3(2): 117-26. 6. balastouras dg, fassolis a, koukoutsis g, ganelis p, kaberos a. primary lymphangioma of the tonsil: a case report. case report med. 2011; 2011:183182. doi: 10.1155/2011/183182. epub 2011 may 31. 7. chen hh, lovell ma, chan kh. bilateral lymphangiomatous polyps of the palatine tonsils. int j pediatr otorhinolaryngol. 2010 jan; 74(1): 87-8. 8. kasznica j, kasznica a. tonsillar polypoid lymphangioma in a small child. n j med. 1991 oct; 88(10): 729-31. 9. al samarrae sm, amr ss, hyams vj. polypoid lymphangioma of the tonsil: report of two cases and review of the literature. j laryngol otol. 1985 aug; 99(8): 819-23. discussion lymphangiomatous polyps are uncommon benign lesions. the head and neck regions are the most common sites of these lesions. the tonsil is a less common site for the development of lymphangiomatous tumors and their classification in this location is confusing.3 different terms in the english literature have been used for classification such as lymphangectatic fibrous polyp, polypoid lymphangioma, angiofibroma, pedunculated squamous papilloma, hamartomatous tonsillar polyp, pedunculated tonsil, lipoma, lymphangectatic fibrolipomatous polyp, lymphangiomatous polyp and others.4 the true incidence of these lesions is difficult to accurately assess from the literature. this may be due to confusing histologic nomenclature used to describe benign lymphatic lesions. lymphangiomatous polyps account for 1.9% of all tonsillar tumors seen. another study done suggested a higher incidence for these tumors at 8% of all benign tonsillar tumors as compared to hemangiomas and fibromas representing 2 % and 3%, respectively.5 however, incidence may be higher and is only underreported and unrecognized due to its benign nature. to our knowledge, less than 50 documented cases of tonsillar lympangiomatous polyps have been reported to date.2-4,6-9 of these, 26 cases were identified in a single retrospective case series from the otolaryngologic-head and neck tumor registry of the armed forces institute of pathology.3 most authors recommend that tonsillectomy is the curative procedure of choice.3-4,6 however, a case report recommended excision as adequate instead of tonsillectomy.2 no recurrence was reported for both tonsillectomy and excision of mass. adequate excision should be performed for benign tonsillar lesions. unilateral tonsillectomy was the surgical option for this case. one of the diffential diagnoses considered was extra-pharyngeal juvenile angiofibroma which requires more aggressive resection to prevent recurrence. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 philippine journal of otolaryngology-head and neck surgery 49 under the microscope olfactory neuroblastomas (esthesioneuroblastomas, onb) are rare malignant neoplasms that arise from sensory neuroepithelial (neuroectodermal) olfactory cells found in the superior nasal concha and the cribriform plate of the ethmoid sinus. onbs comprise approximately 5% of sinonasal tract malignancies, affect both genders equally and primarily involve the middle aged adult group (range 3 – 79 years). the most common presenting symptoms are unilateral nasal obstruction, epistaxis and a fairly slow-growing mass high in the nasal cavity or ethmoid region. anosmia is also characteristic. a classic, though advanced, radiologic presentation is that of a “dumbbell-shaped” mass on either side of the cribriform plate, with an expansion into the nasal vault and an opposite expansion into the intracranial cavity. 1, 2, 3 we present here two illustrative cases. the first is a 67-year-old male who has had three recurrences of a left nasal mass over a span of 24 years. the initial occurrence was treated with excision and radiotherapy while subsequent recurrences were treated with excision alone. the material shown herein is from the latest recurrence. all previous slides were not available for review. the second case is a 52-year-old male who presented with a six-month history of a right nasal cavity mass that on initial consult already extended into the maxillary, ethmoid, sphenoid and bilateral frontal sinuses, penetrated the cribriform sinus and involved the right frontal lobe of the brain. a craniofacial resection was performed. the typical case is best described as a “malignant small round cell tumor” arranged in rounded lobules in a vascularized stroma (figure1). this general architecture is found irrespective of the grade of the tumor. the cells are neuroendocrine in appearance with uniform small round nuclei that have “salt-and-pepper” nuclear chromatin (figure 2) and scanty cytoplasm. tumors are graded according to the hyams’ grading system. grades 1 – 2 tumors have nil to few mitoses, minimal nuclear pleomorphism, absent necrosis and presence of homer-wright pseudorosettes (figure 3), while grades 3 – 4 tumors have brisk mitoses, prominent nuclear pleomorphism, frequent necrosis and predominance of flexner-wintersteiner true rosettes (figures 4, 5). the first case is an example of a grade 2 onb while the second shows a grade 4 morphology. immunohistochemistry typically shows diffuse positivity for the neuroendocrine markers neuron-specific enolase, chromogranin and synaptophysin (figure 6), and negative reactions for cytokeratins, desmin and cd99. the latter three stains are significant in that the differential diagnoses include sinonasal undifferentiated carcinomas (snuc), rhabdomyosarcomas and primitive neuroectodermal tumors/ewing sarcomas (pnet/es) in which these stains are expected to be positive, respectively.1, 3, 4 other differential diagnosis include a non-hodgkin lymphoma and a mucosal malignant melanoma for which a leukocyte common antigen (lca) and melanoma markers (e.g. hmb-45 or melan-a) may be performed. the two cases were however sufficiently distinct as to rule out these two entities on morphologic grounds. olfactory neuroblastoma correspondence: jose m. carnate, jr.,md department of pathology college of medicine university of the philippines manila 547 pedro gil st., ermita, manila 1000 philippines phone: (632) 526 4550 fax: (632) 400 3638 email: jmcjpath@yahoo.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2010; 25 (2): 49-51 c philippine society of otolaryngology – head and neck surgery, inc. jose m. carnate, jr.,md department of pathology college of medicine university of the philippines manila philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 under the microscope 50 philippine journal of otolaryngology-head and neck surgery prognosis is stage (90% 5-year survival rate for early-stage versus 40% for advanced-stage cases) and grade-dependent (80% for low-grade versus 40% for high-grade cases). recurrence occurs in approximately 30% of cases usually within two years. the long-term recurrences seen in the first case is compatible with its low-grade morphology. in contrast, the shorter history and high stage (kadish stage c)4 at presentation of the second case are both compatible with its high-grade morphology. metastases develop in about 20% of cases and usually involve the lymph nodes, lungs and bone. complete surgical excision with postoperative radiotherapy is the mainstay of treatment. 1,2 figure 1. case 2 rounded lobules of cohesive tumor cells separated by a vascularized stroma (hematoxylin-eosin, 40x). (hematoxylin-eosin, 40x). figure 2. case 1 uniform round nuclei with finely granular “salt-and-pepper” chromatin (hematoxylineosin, 400x) (hematoxylin-eosin, 400x) figure 3. case 1 homer-wright pseudorosette: tumor cells surround a pseudolumen that contains neurofibrillary material (hematoxylin-eosin, 400x) (hematoxylin-eosin, 400x) figure 4. case 2 flexner-wintersteiner true rosette: tumor cells surround a true central lumen simulating a gland; note the nuclear pleomorphism (hematoxylin-eosin, 400x) (hematoxylin-eosin, 400x) philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 philippine journal of otolaryngology-head and neck surgery 51 under the microscope acknowledgment the author would like to acknowledge drs. ramon antonio b. lopa and arsenio claro a. cabuncal for the two cases and drs. treah may d. suacillo and david brian u. olveda for the assistance in the pathologic sign-out and preparation of the microscopic images. references 1. thompson ld. malignant neoplasms of the nasal cavity, paranasal sinuses, and nasopharynx. in: thompson ld, ed. head and neck pathology foundations in diagnostic pathology series. goldblum jr series ed. churchill livingstone elsevier, inc. 2006, p. 179 – 189. 2. wenig bm, dulguerov p, kapadia sb, prasad ml, fanburg-smith jc, thompson ldr. tumours of the nasal cavity and paranasal sinuses: neuroectodermal tumours. in: barnes el, eveson jw, reichart p, sidransky d, eds. pathology and genetics of head and neck tumours, kleihues p, sobin lh, series eds. world health organization classification of tumors. lyon, france: iarc press; 2005: 65 – 75. 3. wenig b. atlas of head and neck pathology, 2nd ed. philadelphia: elsevier saunders, inc. 2008, p. 109 – 114. 4. prasad ml, perez-ordonez b. nonsquamous lesions of the nasal cavity, paranasal sinuses, and nasopharynx. in gnepp dr, ed. diagnostic surgical pathology of the head and neck. philadelphia: saunders-elsevier, 2009, p. 148 – 154. figure 5. case 2 nuclei that have more atypia and mitoses (hemtaoxylin-eosin, 400x) (hemtaoxylin-eosin, 400x) figure 6. archive case positive cytoplasmic reaction (neuron-specific enolase, 100x) (neuron-specific enolase, 100x) 38 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 featured grand rounds inflammatory pseudotumor (ipt) is a rarely occurring lesion with no identifiable local or systemic cause. first described in 1905 by birch-hirschfield,1 it remains somewhat of an enigmatic disease entity despite multiple otolaryngologic, radiologic and pathologic reports. the term “pseudotumor” was used because these lesions mimic invasive malignant tumors both clinically and radiologically. ipt most commonly involves the lung and orbit but has also been reported to occur at sites that make biopsy or excision difficult or potentially disfiguring.2 its diagnosis and prompt recognition may help avoid radical surgery for this benign lesion. case a 27-year-old male was seen at our outpatient department due to a progressively enlarging left infraorbital mass. two years prior, the patient noted a swelling over his left infraorbital area. the swelling was somewhat painful and rapidly grew in size so that it measured almost 2.5x2.5cm after a week. still tender, it became firm and violaceous in color. he sought medical attention at a local hospital after one more week of persistent swelling and increasing cheek pain but denied excessive lacrimation, blurring of vision, orbital pain, eye discharge or numbness. incision and drainage of the left infraorbital mass yielded purulent material with resolution of the swelling and associated symptoms but a pea-sized mass was still palpable over the post operative site. over the months that followed, the mass gradually increased in size with occasional serosanguinous discharge from the incision site. there was no pain, numbness or blurring of vision. he self-medicated with cefalexin, taken irregularly for 8 months without any improvement before finally consulting again. an orbital ct scan requested by the referring ophthalmology service showed an expansile, mildly enhancing soft tissue mass with few peripheral foci of calcifications measuring 8.2 x 4.4 x 6.4 cm (figures 1 a, b) completely occupying the left maxillary sinus and extending up to the infero-lateral aspect of the left orbital cavity. there was erosion of the lateral portion of the left orbital floor and disruption of the frontal process of the left zygomatic bone with obliteration and effacement of the left pterygopalatine fossa. our physical examination revealed a firm, fixed, nontender 4x4cm left inferior orbital mass with serosanguinous discharge and a bulging lateral nasal wall. epiphora from the left eye suggested nasolacrimal duct obstruction but vision and extraocular movements were intact. caldwell-luc biopsy surprisingly yielded only necrotic and inflammatory tissues despite generous samples from multiple sections of the maxillary portion and inflammatory polyps from the intranasal component. at surgery after a few weeks, the mass still occupied the entire left maxillary sinus despite the previous biopsy which had removed a significant amount of tumor. furthermore, the mass now extended beyond the maxillary sinus into the left upper gingivobuccal area through the previous maxillary window. the entire clinically aggressive maxillary sinus mass was removed under endoscopic guidance but the final histopathology report was still similar to the inflammatory pseudotumor of the maxillary sinus johann f. castañeda, md jeffrey s. concepcion, md ricardo l. ramirez jr., md kirt areis delovino, md department of otorhinolaryngology head and neck surgery st. luke’s medical center correspondence: johann f. castañeda, md department of otorhinolaryngology head and neck surgery st. luke’s medical center 279 e rodriguez sr. ave., quezon city 1102 philippines telefax (632) 723 0101 local 5543 email: jong_castaneda@yahoo.com reprints will not be available from the author. philipp j otolaryngol head neck surg 2009; 24 (2): 38-39 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 39 philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 featured grand rounds previous findings of necrotic and inflammatory tissues. a month after surgery, the patient was seen at the emergency room for left infraorbital swelling and discharge. contrastenhanced mri of the nasopharynx showed a large expansile left maxillary sinus lesion bulging into the nasal cavity, extending into adjacent lateral orbital soft tissue and extending into the buccal space through an apparently disrupted left inferolateral maxillary wall. intravenous antibiotics and a high-dose steroid trial resulted in complete disappearance of the left infraorbital mass and discharge within a week and the patient was discharged on a tapering steroid dose. discussion inflammatory pseudotumor is a quasi-neoplastic lesion that has been reported to occur in nearly every site in the body, most commonly involving the lung and the orbit, and rarely the maxillary sinus.1 its diagnosis is usually by exemption since clinical and histopathologic findings are sometimes vague and inconsistent. the exact etiology of these lesions is not clear. it has been postulated that they might be the result of a postinflammatory repair process, a metabolic disturbance or an antigen-antibody interaction with an agent that was no longer identifiable in aspiration or biopsy material.3 the clinical findings in a patient with an inflammatory pseudotumor are variable depending on the growth rate of the lesion and the specific structures that have been affected. inflammatory pseudotumors have been reported to cause chronic cough (as a result of endobronchial growth), dry cough, fever, pleuritic pain, right upper quadrant or epigastric pain and several constitutional symptoms such as malaise, weight loss, fatigue and syncope. inflammatory pseudotumors have been found incidentally during imaging examinations for other reasons.3 extraorbital inflammatory pseudotumor of head and neck can occur in the nasal cavity, nasopharynx, maxillary sinus, larynx and trachea. perineural spread along maxillary, mandibular and hypoglossal nerves had been described. sinonasal inflammatory psuedotumors do not affect a particular age group and cause no systemic symptoms. however, they have a more aggressive appearance than those of the orbit with bony changes such as erosion, remodelling and sclerosis usually seen on radiographic studies.4 on cat scans, a moderately enhancing soft tissue mass is usually seen accompanied by bony changes common among malignant processes.5 on cut sections, inflammatory cells dominate as well as necrotic tissues. in some patients, laboratory findings are normal; in others, there might be an elevated erythrocyte sedimentation rate and c-reactive protein level and sometimes a high white blood cell count.3 however, none of the published reports on inflammatory pseudotumor have mentioned any presence of positive tumor markers. complete surgical resection if possible is the treatment of choice for sinonasal inflammatory pseudotumors, followed by corticosteroids in cases of incomplete excision. response to steroids is often unpredictable but these drugs are the primary treatment method for orbital inflammatory pseudotumor. the only cases in which radiation therapy is indicated are those patients for whom surgery or corticosteroid therapy is unsuccessful or contraindicated.6 references 1. agarwal a. orbital pseudotumor; diagnosis on fine needle aspiration cytology. j cytol 2008 apr; 25(2):67-69. 2. narla ld, newman b, spottswood ss, narla s, kolli r. inflammatory pseudotumor. radiographics 2003 may-jun; 23(3): 719-729. 3. restrepo s, mastrogiovanni lp, palacios e. inflammatory pseudotumor of the trachea. ear nose throat j. 2003 jul; 82(7): 510-2. 4. de vuysere s, hermans r, sciot r, crevits i, marchal g. extraorbital inflammatory pseudotumor of the head and neck: ct and mr findings in three patients. am j neuroradiol 1999; 20:1133-1134. 5. park sb. lee jh, weon yc. imaging findings of head and neck inflammatory pseudotumor. am j roentgenol. 2009 oct; 193(4): 1180-1186. 6. ruaux c, noret p, godey b. inflammatory pseudotumor of the nasal cavity and sinuses. j laryngol otol. 2001; 115:563-566. a b figure 1 (a, axial view; b, coronal view) contrast paranasa sinus ct scan showing expansile, mildly enhancing soft tissue mass with few peripheral foci of calcifications measuring 8.2 x 4.4 x 6.4 cm completely occupying the left maxillary sinus and extending up to the infero-lateral aspect of the left orbital cavity. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 philippine journal of otolaryngology-head and neck surgery 37 practice pearls high flow arteriovenous malformations (avms) are infiltrative, invading tissue planes and structures and may be life threatening when they bleed.1 they have a feeding artery and an anomalous capillary bed shunting blood from the arterial system to the venous system.1 the present trend of management of small avms is surgical excision with a high success rate. the problematic cases are diffuse avms infiltrating structures that render them impossible to totally extirpate surgically without causing much blood loss and tissue damage. the mainstay of management is embolization, surgical resection and reconstruction.2 ligation or proximal embolization (alone) of feeding vessels should never be done because such maneuvers result in rapid recruitment of new vessels from adjacent arteries to supply the avm nidus.2 incomplete surgical excision definitely leads to recurrences making this type of avm very difficult to manage. what is the point of this paper? the complete destruction of the “nidus” of the avm from the artery to the capillary to the venous component is the only potential cure.3 well and good if there could be a way of doing this by sclerosing the entire vascular malformation. but since sclerosis only works well in low flow vascular malformations and tumors like hemangiomas and poorly or not at all in high flow lesions,4 we have to convert this high flow avm into a “no-flow” or “low flow” avm by ligating the feeding and draining vessel and injecting the sclerosant intra-arterially thereafter at a dose sufficient enough to blanch out the avm even up to its peripheral branches. this paper aims to demonstrate how we do this. definition of terms vascular malformation: they are a result of abnormal development of vascular elements during embryonic or fetal stages of life.2 they originate from mesenchymal cells at an early stage of embryogenesis3 and most are present at birth but there are several case reports of these lesions presenting after trauma in adults.1 some avms appear as part of a familial genetic disorder called angiomatous syndrome i.e. rendu-osler-weber syndrome presenting with telangiectasia of the skin and mucous membranes.3 some propose that a defect in vascular stabilization like tgfbeta signaling could be a cause of avm development.5,6 still, progesterone receptors have been isolated in avms explaining their expansion during puberty.7 hemangioma: these are vascular tumors that exhibit endothelial proliferation.2 a hemangioma of infancy usually undergoes three stages: a proliferative phase of rapid growth up to 10 to 12 months of age; an involuting phase where growth slows down and signs of regression appear usually at 1 to 7 years; and an involuted phase.2 sclerosants: agents used in sclerotherapy that induce a toxic effect on the vascular endothelium and results in fibrosis. there are three types: detergents that disrupt cell membranes by protein theft desaturation i.e. ethanolamine oleate, sodium morrhuate, polidocanol, sodium tetradecyl sulfate; osmotic agents i.e. sclerodex; and chemical irritants that damage cell walls by direct contact i.e. chromatin glycerine, polyiodinated iodine.8 sclerodex: an osmotic sclerosant that is a combination of dextrose monohydrate 250mg/ ml and sodium chloride 100mg/ml. it shifts water balance through cellular gradient (osmotic) dehydration that leads to endothelial destruction. since component materials are naturally occurring bodily, it has no molecular toxicity in calibrated dosages. if extravasated, it could cause tissue necrosis.8 it is manufactured by omega laboratories, ltd. montreal, qc, canada. feeding and draining vessel ligation with sclerotherapy of high flow arteriovenous malformations in the head and neck correspondence: dr. felix d. ayahao department of ent-hns baguio general hospital and medical center governor pack road, baguio city, benguet 2600 philippines telefax: (074) 444 4176 reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2014; 29 (1):37-40 c philippine society of otolaryngology – head and neck surgery, inc. felix d. ayahao, md department of ear nose throat – head neck surgery baguio general hospital and medical center philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 practice pearls 38 philippine journal of otolaryngology-head and neck surgery review of present practice and literature the first task of the physician is to establish a diagnosis whether the lesion is a vascular malformation or a vascular tumor. taking the history of the patient could point to a diagnosis as vascular tumors like hemangiomas usually proliferate and involute from the time of infancy to about the age of 10. vascular malformations grow as the child grows and do not involute. vascular malformations have an arterial supply and a venous drainage and are classified into high or low flow. capillary, venous and lymphatic types are low flow while arteriovenous malformations are usually high flow. a high flow avm has an arterial blood supply and a venous drainage. in rare instances, a vascular malformation could co-exist with a hemangioma forming a mass effect.2 on physical examination, a bruit and a strong pulsation (thrill) is appreciated. the head and neck is the most common location of avms at 70%. when fully developed, they are deeper in color with increasing erythema, local warmth, palpable mass and a bruit.9 these malformations are composed of vascular channels lined by flat mature epithelium and are not hypercellular and not proliferative.10 schobinger proposed a staging system for head and neck avm. stage 1 are avms that are quiescent and remain stable for long periods of time. stage 2 is a time for expansion followed by pain and bleeding. stage 3 is heralded by destruction of adjacent tissues and ulceration. stage 4 is presented by decompensation where symptoms of cardiac failure are present.11 ultrasound with color doppler imaging, magnetic resonance imaging and phlebography (arteriography/venography) contribute to diagnosis, classification and management.3 in our setting were we do not have the facilities, we use ctangiography. these imaging modalities should be used to evaluate the characteristics of the lesion, such as size, flow velocity, flow direction, relation to surrounding structures and lesion content.3 ultrasound demonstrates flow rates, contrast-enhanced magnetic resonance imaging (mri) shows presence or absence of a mass and ct angiography reveals the arborization (the blood supply and drainage) of the vascular anomaly. vascular tumors like hemangioma, if located in non-strategic areas where function is not impaired can be observed over its developmental phases until involution at about 10 years old.2 for hemangiomas that impair function or are possibly life threatening because of potential hemorrhage, these tumors are treated with the following modalities: 1) intralesional corticosteroids i.e. triamcinolone; 2) systemic corticosteroids in a tapered dose like prednisolone and some second choice pharmacotherapeutics like interferon, vincristine; and 3) propranolol. surgery is indicated in ulcerating, bleeding and life threatening lesions like airway obstruction.2 over 90% demonstrate dramatic reduction in size of hemangioma in one to two weeks from the above medical therapeutic modalities. propranolol has been successfully used as hemangioma treatment since 2008 and is believed to have an antiproliferative effect on the vascular endothelium. the mechanism of action may involve the regulation of growth factors.1 low flow vascular malformations are treated with sclerotherapy or surgical excision for accessible tumors. these malformations do not regress like hemangioma but grow in time. high flow avms are treated with surgical excision if they have limited extent and are surgically accessible. embolization before surgery decreases bleeding and is the standard. embolization followed by repeated sclerotherapy is recommended for surgically inaccessible areas.4 there is a 64 to 96% response rate, defined as improvement in symptoms or a reduction in the lesion size after ethanol sclerotherapy of venous low flow malformations.3 partial surgical excision leads to only temporary improvement followed by re-expansion of tumor overtime.9 sometimes, complete resection is not possible in diffuse or infiltrating avms and surgery can result in severe disfigurement and impairment of function of involved structures.9 methods after establishing the diagnosis of a high flow avm with identification of an arterial feeding vessel and a venous draining vessel, surgery is commenced away from the malformation to expose the arterial and venous supplies. the procedure is done under general anesthesia because sclerotherapy of large malformations and vascular tumors is very painful. we do this because we have no interventional radiology services in our hospital. we ligate the feeding artery and if possible, the draining vein to convert the avm into a “ low or no flow” and to allow ample contact time between the sclerosant (sclerogen) and the vessel endothelium. the sclerosant is then injected intravascularly distal to the ligation until all visible malformation blanches out. aspirating the blood content of the ligated (arterial supply and venous drainage) malformation before introduction of the sclerosant will further potentiate the action of the sclerosant. while injecting the sclerosant slowly, the patient’s vital signs are monitored. a drop in the pulse rate is a signal to stop or slow down the injection of the sclerosant because it may be a sign that some sclerosant is escaping the venous drainage and reaching the general circulation in a concentration picked up by the sensors of the vascular system. injections resume in a slower manner as the vital signs revert to normal. our sclerosing agent sclerogen is an osmotic agent composed of sodium chloride and dextrose which are naturally present in our body so they are not toxic in manageable concentrations. other sclerosants can be nephrotoxic so we must be very careful in injecting not to overload the vascular system. the objective is to push the sclerosant to all branches of the malformation to eliminate all possible nidus. the end point of injection is when all cutaneous or mucosal components of the malformation blanch out. injection of the sclerosant intravascularly is done under direct visualization to prevent extravascular introduction. a review of literature has this to say about sclerotherapy. extravascular injection of the sclerosant causes tissue necrosis.4 ethanol injection to high flow fistulous lesions is contraindicated because of high risk of ”early wash“ into the systemic circulation.4 sclerosants could cause hemolysis, denaturation of blood proteins, thrombus formation and nephrotoxicity.3,4,12 ethanolamine oleate, in comparison to ethanol, has less effect in the deep vascular layer and no penetrative effect. it is not associated with neuronal side effects despite of the proximity of the nervous system to the vascular system.3 philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 philippine journal of otolaryngology-head and neck surgery 39 practice pearls cases our first case was a 62-year-old woman with a pinna and periauricular vascular malformation, noted since five years prior to consultation. the inferior concha was bulging and pulsating with a strong bruit. the periauricular area was elevated with microvascular malformations in reddish discoloration. the left posterior auricular artery was identified as the feeding artery and the diagnosis was a high flow avm. she consulted a hospital in sacramento, california where she worked and was advised to have a resection of her left ear. she got frightened and decided to come home to the philippines for a second opinion. i suggested our procedure which she gladly accepted but warned her of possible pinna necrosis. at least, she said, it is just a possibility and not an outright pinna loss. i dissected 1 cm below the malformation avoiding any of its extensions below the pinna and mandibular angle and moved towards the external carotid. i immediately located the pulsating, abnormally dilated posterior auricular artery feeding vessel and ligated it. further dissection deep towards the styloid process revealed the venous drainage that penetrated the mastoid bone toward the direction of the sigmoid sinus. i, too, did the venous drainage ligation. i injected sclerogen distal to the posterior artery ligation after aspiration of 8 cc of avm blood until all the malformation main mass and the peripheral branches blanched out. total volume of sclerosant was 10 cc. there was no change in the vital signs as i slowly introduced the sclerosant. i closed the surgical defect and observed the patient for three days in the hospital. there was postoperative pain and swelling in the sclerosed malformation relieved by ice packs and celecoxib 200 mg every 12 hours. after three days, the swelling started to subside and the pain lessened so the patient was sent home. she followed up in a week and the malformation had shrunk. sutures were removed. two weeks postoperatively, the malformation was just a trace skin discoloration with no tissue necrosis, no more bulge and pulsations and no pain. she asked permission to go back to work the following week in california. our second case was a 13-year-old girl with a right tonsillar and hypopharyngeal vascular malformation. she had recurrent bleeding episodes necessitating blood transfusions in their province. i suggested our procedure which the parents and the patient consented to. we did surgery, ligating the right external carotid artery and external jugular vein and introduced the sclerosant (sclerogen) slowly until the tonsillar and hypopharyngeal malformation blanched out. there was no abnormal fluctuation of the patient’s vital signs. after closing the surgical access wound, i did tonsillectomy of the right since the bulging tonsillar malformation was obstructing the airway. there was very minimal bleeding and i was able to cauterize the remaining sclerosed malformation not included in the tonsil with ease. two weeks post-surgery, she followed up with healed tonsillectomy wound and a disappearing malformation. she, however, had gastritis because of her co-amoxiclav antibiotic and her inability to eat well because of pain in swallowing. she eventually recovered from her gastric problems. at one-month follow-up, there was no trace of the malformation on visual examination. looking back, doing tonsillectomy in an avm would have been very bloody without sclerotherapy. our third case was a nasopharyngeal av malformation in a 35-yearold woman. she had episodes of severe bleeding requiring emergency tracheostomy, oral packing and blood transfusions. ct-angiography revealed two feeding vessels, one from the left external carotid artery and a minor one from the internal carotid artery. we decided to sclerose the left external carotid artery and see what happened to the internal carotid artery branch that could not be accessed. since ct angiography did not identify the venous drainage, we introduced the sclerosant (sclerogen) very slowly, stopping when the pulse rate started to drop below 60 beats per minute and resuming slow injection when the pulse rate was normal. oxygen saturation was noted to be stable at 98 to 100 %. we stopped when the avm blanched out, injecting 15 ml of sclerosant. in two weeks time, the avm shrank except for a 1 x 1 cm bulge at the left posterior nasopharynx that was supplied by the internal carotid artery branch that could not be sclerosed at the time of surgery. the patient was decannulated from tracheostomy and was able to resume normal diet and activity. she is on regular follow-up and is being maintained with propranolol 40 mg once a day hoping that it may work as it does in hemangioma. one year postoperatively, the bulge has not grown nor disappeared. looking back, had we done surgery as suggested by colleagues, we could have encountered massive bleeding, inability to take the avm all out and eventual recurrence. pondering upon the case of a second arterial blood supply of the avm, the malformation could have recruited this second blood supply. the forward force of introduction of the sclerosant was not able to overcome the arterial pressure of the internal carotid artery feeding branch so the sclerotherapy effect stopped where the flow forces where at equilibrium. note that in this case, we did not ligate the specific venous drainage as the ct-angiography did not identify it. figure 1. ct-angiography of 35-year-old woman with nasopharyngeal avm (case 3). it shows a nasopharyngeal vascular malformation with two arterial blood supplies-one from the left external carotid artery as the main blood supply and another from a branch of the left internal carotid artery. philippine journal of otolaryngology-head and neck surgery vol. 29 no. 1 january – june 2014 practice pearls 40 philippine journal of otolaryngology-head and neck surgery acknowledgements i wish to acknowledge my anesthesiologist dr. julius apostol who encouraged me to try new things and promised to research on management of possible egress of sclerosants in the systemic circulation as he puts my patients to sleep. my residents at the department of otolaryngology-head and neck surgery, baguio general hospital did the preand post-operative patient care while i was away, and the photography: dr. carlo pagalilauan, chief resident and photographer, dr. sherwin valdez, dr. beverly carbonel, dr. jeff peckley and dr. wingleaf yu who are my assistants. thank you. references richter gt, friedman ab. hemangiomas and vascular malformations: current theory and 1. management. int j pediatr. 2012;2012:645678. doi: 10.1155/2012/645678. epub 2012 may 7. marler jj, mulliken jb. current management of hemangiomas and vascular malformations. 2. clin plast surg. 2005 jan; 32(1): 99-116. hyodoh h, hyodoh k. arteriovenous malformation: ethanolamine oleate sclerotherapy dept. 3. of radiology, sapporo medical university, japan udk 616-131-14-007-085-089.819. wakita s, harii k, furuya f, ooura n. percutaneous monoethanoleamineolate injection 4. sclerotheraphy for hemangiomas. reconstructive aesthetic surgery. amsterdam, new york: kugler publications 1995. p. 289. corti p, young s, chen cy, patrick mj, rochon er, pekkan k, 5. et al. interaction between alk1 and blood flow in the development of arteriovenous malformations. development. 2011 apr; 138(8): 1573-1582. kim h, weinsheimer s, pawlikowska l, su h, young wl. brain arteriovenous malformation 6. pathogenesis: a response-to-injury paradigm. acta neurochir suppl. 2011; 111: 83-92. duyca lj, fan cy, coviello-malle jm, buckmiller l, suen jy. progesterone receptors identified 7. in vascular malformations of the head and neck. otolaryngol head neck surg. 2009 oct; 141(4): 491-495. cronenwett jl, johnston kw. ruthersford’s vascular surgery. philadelphia: saunders elsevier. 8. 2014 apr. [cited 2014 may 28] available from: http//www.elsevier.com.rutherfords-vascular surgery./cronenwett/9. sloan sb, wilk r, butler df, eisen d, quirk cm, james wd, 9. et al. oral hemangioma treatment and management. c1994-2014 [updated 2014 jan 30] [cited 2014 may 28] available from http:// emedicine.medscape.com/article/1080571-treatment. speer al, panossian a, arkader a, stanley p, anselmo dm, stillmant rm, 10. et al. vascular surgery for arteriovenous malformation. medscape medpulse. 2012;8 [updated 2012 nov 8]. [cited 2014 may 28] available from: e medicine.medscape.com/article/459927. kohout mp, hanen m, pribaz jj, mulliken jb. arteriovenous malformation of the head and neck: 11. natural history and management. plast reconstr surg. 1998 sept; 102(3) 643-54. yakes wf, haas dk, parker sh, gibson md, hopper kd, mulligan js, 12. et al. symptomatic vascular malformations: ethanol embolotherapy. radiology. 1989 mar; 170(3 pt 2):1059-1066. discussion managing avms that are diffuse and infiltrative can be very difficult. surgical extirpation of all the nidus may not be possible and will surely lead to recurrences. besides, malformations located in functionally strategic areas may present with structural deformities and functional disturbances when they are damaged by surgery. small avms can be resected with high rates of success and no recurrences. in one series, all 16 patients with surgically accessible, localized, non-infiltrating avms who underwent angio-embolization with subsequent surgical excision demonstrated no evidence of recurrence on angiography during follow-up averaging 24.3 months.9 in low flow venous malformations, sclerotherapy administered by trans-arterial, trans-venous or direct puncture injection without embolization or feeding vessel ligation has a 64 to 96% response rate, defined as improvement in symptoms or reduction of the lesion and not necessarily cure.3 the cure rate for small malformations was 69% with excision only and 62% for extensive lesions with combined embolization and resection. at 6 years average follow-up, cure rate was 75% for stage 1; 67% for stage 2; and 48% for stage 3 malformations. the outcomes were not significantly affected by age at treatment, schobinger stage or treatment method.11 embolo-sclerotherapy is a new therapeutic modality for surgically inaccessible lesions like diffuse and infiltrating avms.4 this procedure is done repeatedly since the embolus recanalizes and the sclerosant is injected distal to the embolus. this method is reserved as an adjunct to subsequent surgical resection.4 our immediate results for ligation of feeding artery or draining vein before sclerotherapy were dramatic without functional or anatomic compromise. with sclerogen whose components exist in the body naturally, we found no significant complications in our three cases. this technique could be ideal for diffuse and infiltrating avms. it is more effective if the feeding artery and the draining vein are identified and ligated so that the sclerosant can be pushed to all branches of the avm. with a “no-flow or a slow-flow” avm, we are able to prolong the contact of the sclerosant with the vascular endothelium thereby increasing the success rate of totally eliminating the nidus of the vascular malformation. more studies and experience are needed to prove the durability of this technique. are we able to eliminate all the nidus of the avm if we are able to ligate all feeding arteries and draining veins before sclerotherapy? our center is not so equipped so more technically advanced institutions dealing with vascular tumors and malformations can validate the efficacy of this technique. after all, it might not be bane to ligate avm feeding and draining vessels if we are able to destroy the entire nidus of the avm by whatever means like sclerotherapy in this case. figure 2. transoral view of the same patient showing a dark discolored bleeding nasopharyngeal mass visible from the oropharynx. we secured the airway with tracheostomy. figure 3. the same patient 2 weeks post sclerotherapy of the nasopharyngeal avm. note the disappearance of the bulk of the avm except for a 1x1 cm discolored bulge at the left posterior nasopharynx. she was weaned off tracheostomy and decannulated. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 24 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2013; 28 (1): 24-27 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to present a case of carcinoma ex pleomorphic adenoma in the parapharyngeal space and discuss its management. methods: design: case report setting: tertiary government teaching hospital patient: one results: a 40-year-old male patient with dysphagia for three months and a left-sided mucosacovered oropharyngeal mass was found to have a prestyloid parapharyngeal lesion on ct scans. fine needle aspiration cytology (fnac) revealed a pleomorphic adenoma. with a past history of parapharyngeal pleomorphic adenoma excised transorally three years before, the present mass was excised by mandibular swing approach. post-operative recovery was uneventful but the final histopathological report was carcinoma ex pleomorphic adenoma. conclusion: malignant transformation should be suspected in recurrent salivary tumors in the parapharyngeal space. provided there was truly no pre-existing malignant focus in the originallyexcised tumor, and that early recurrence was not due to inadequate initial excision, this patient had a rare condition where the same tumor underwent malignant transformation within three years only. to the best of our knowledge, such an early transformation to malignancy of a minor salivary gland tumor of the parapharyngeal space has not been reported in the english literature. keywords: carcinoma ex pleomorphic adenoma, pleomorphic adenoma, carcinoma, parapharyngeal space, malignant transformation, minor salivary gland tumor, mandibular swing parapharyngeal tumors comprise only 0.5-1% of head-neck neoplasms. most (7080%) are benign and 40-50% of them arise from salivary glands, pleomorphic adenoma being the most frequent variety.1 though salivary gland tumors are the most common group in this location malignant mixed cell tumors are a rare variety. this type of tumor can arise de novo or in a pleomorphic adenoma. complete excision of these malignant masses maintaining oncologically-safe margins is a challenge to the attending headneck surgeon. carcinoma ex pleomorphic adenoma in the parapharyngeal space sudipta pal, ms1 sampurna pati, mbbs1 somnath saha, ms1 vedula padmini saha, ms, mch2 1department of ent, head & neck surgery r g kar medical college, kolkata, india 2department of plastic surgery r g kar medical college, kolkata, india correspondence: dr. sudipta pal 223, lane-3, j.c.khan road p.o.:-mankundu, dist.-hooghly, west bengal pin712139 india e-mail: drsudiptapal@gmail.com phone: +919051757391, +919231535309 reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports philippine journal of otolaryngology-head and neck surgery 25 case report a 40-year-old male patient presented to the outpatient department with the complaint of difficulty in swallowing for the last three months. he had a past history of trans-oral surgical removal of pleomorphic adenoma of oral cavity three years back. on examination there was fullness of the left tonsillar region and the tonsil and uvula were pushed medially to the right. (figure 1) intra-oral palpation revealed a firm, non-tender submucosal mass. examination of the neck was normal. contrast-enhanced ct scan showed a large heterogeneouslyenhancing soft tissue prestyloid mass displacing the carotid sheath posteriorly. the mass involved the entire length of the left parapharyngeal space, extending from the base of skull superiorly to the hyoid bone inferiorly and the left half of the soft palate anteriorly. (figure 2, 3, 4) there was no evidence of bone destruction, carotid sheath or pre-vertebral space involvement. figure 1: clinical photograph of the patient showing the mass pushing the left tonsil medially. figure 2: contrast enhanced ct scan, axial section at the level of the second cervical vertebra showing the mass in the left parapharyngeal space near the skull base. figure 3: contrast enhanced ct scan, axial section at the level of the third cervical vertebra showing the mass with heterogenous density and irregular uptake of contrast extending anteriorly up to the soft palate figure 4: contrast enhanced ct scan, axial section at the level of the fifth cervical vertebra showing the lower extent of the tumor up to the hyoid bone 26 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports free from disease after one year of follow up. (figure 7) discussion according to youngs and scofield, ectopic salivary tissue in the head and neck can arise from remnants of branchial apparatus and defective closure of the precervical sinus of his with internal heteroplasia.2,3 mixed salivary tumors are the most frequent neoplasm arising from ectopic cell rests, having the same recurrence rate but much higher percentage of malignant transformation in comparison to tumors arising from major salivary glands.4 forty to fifty percent of parapharyngeal tumors are salivary neoplasms and are commonly found in the prestyloid region.5 among them, the pleomorphic adenoma is the most common variety. the risk of developing carcinomaex-pleomorphic adenoma from this benign tumor is 5-6% over twenty years.6 the incidence of malignant transformation depends on duration of tumor which is about 2% for tumors present less than five years and 10% for those more than 15 years.6 peculiar in the present case is recurrence and malignant transformation within three years of primary surgery. the first operation was performed through the transoral route in which exposure of the parapharyngeal space is compromised and complete removal of tumor is very difficult. thus, the early recurrence may be attributed to the choice of approach in the first case. however, the malignant transformation of the mass so soon is very difficult to explain and makes this case unique. tumors in the parapharyngeal space are challenging for clinicians with respect to early diagnosis as well as surgical resection. this is primarily due to the insidious onset of the figure 5: histopathologic slide, hematoxylin eosin in low power (10x) revealing characteristics consistent with pleomorphic adenoma. note the presence of polygonal epithelial and spindle-shaped myoepithelial elements in a background of mucoid stroma. figure 7: post operative clinical photograph after one year a trans-oral fnac was suggestive of pleomorphic adenoma. after elective tracheostomy and endotracheal intubation, the mass was excised by paramedian mandibulotomy approach followed by repair of mandible. histology showed features of invasive carcinoma in a background of pleomorphic adenoma. (figure 5) the carcinoma component subtype was carcinoma, not otherwise specified (nos). (figure 6) capsular invasion was grossly evident during excision and microscopically confirmed. the postoperative course was uneventful and the tracheostomy tube was removed after four days. the patient received 60 gy of telecobalt radiotherapy to prevent recurrence, and remained (hematoxylin eosin, 10x) (hematoxylin eosin, 10 x) figure 6: the same slide under a different view revealing carcinomatous components, nos subtype. philippine journal of otolaryngology-head and neck surgery 27 philippine journal of otolaryngology-head and neck surgery vol. 28 no. 1 january – june 2013 case reports references 1. khafif a, segev y, kaplan dm, gil z, fliss dm. surgical management of parapharyngeal space tumors: a 10-year review. otolaryngol head neck surg. 2005 mar;132(3):401-6. 2. hulburt jc. ectopic mixed salivary tumour in the neck. j laryngol otol. 1978 jun;92(6):533-6. 3. youngs la, scofield hh. heterotopic salivary gland tissue in the lower neck. arch pathol 1967 jun;83(6):550-6. 4. caironi cs, canali re, canali b. tumore misto a carcino di ghiandola salviare ectopica. (mixed tumor carcinoma of ectopic salivary gland). minerva chir. 1981 may;36(9): 621-4. 5. pang kp, goh ch, tan hm. parapharyngeal space tumours: an 18 year review. j laryngol otol. 2002 mar;116(3):170–5. 6. lingen mw. head and neck. in: kumar v, abbas ak, fausto n, aster jc, eds. robbins and cotran pathologic basis of disease. 8th ed. philadelphia, pa: saunders elsevier, 2009. p.759 7. jones as. tumours of the parapharyngeal space. in: gleeson m, ed. scott-brown’s otorhinolaryngology, head and neck surgery 7th ed. vol. 2. london: edward arnold, 2008. p.2529 8. bozza f, vigili mg, ruscito p, marzetti a, marzetti f. surgical management of parapharyngeal space tumours: results of 10-year follow-up. acta otorhinolaryngol ital. 2009 feb;29(1):10-5. 9. gooris pj, worthington p, evans jr. mandibulotomy: a surgical approach to oral and pharyngeal lesions. int j oral maxillofac surg 1989 dec;18(6): 359-64. 10. aslan g, kargi e, görgü m, erdoğan b, kilinç h. modified mandibulotomy approach to tumors of the oropharynx. ann plast surg 2001 jan; 46(1):77-9. lesions without any overt clinical symptom as well as the complex anatomy of the space surrounded by vital structures. most patients present with neck swelling (54%) and a few with oropharyngeal swelling (10%), as found in the present case. other than common symptoms like dysphagia and trismus, some cases may present with cranial nerve palsy or rare symptoms like siadh.7 due to their deep location most of these tumors are asymptomatic till they attain a large size. the first and most crucial step for selecting the right surgical approach is anatomical location which relies almost completely on imaging techniques. proper exposure of parapharyngeal tumors is technically demanding. there are various approaches for the prestyloid regiontransparotid, transcervial, transmandibular.8-10 for this case the transmandibular approach was selected as it can provide maximum exposure which is essential for oncologic resection with tumor-free margins. this approach is recommended for large tumors with superior parapharyngeal space extension, vascular tumors, malignant tumors and cases where distal control of the carotid artery at the skullbase is required. malignant transformation in a recurrent salivary tumor is rare and commonly occurs after a long duration of around 20 years. however even early recurrence should be dealt with caution and suspicion for the presence of malignancy as evident in the present case. provided there was truly no pre-existing malignant focus in the originally-excised tumor, and that early recurrence was not due to inadequate initial excision, this patient had a rare condition where the same tumor underwent malignant transformation within three years only. based on a search of medline and scopus using the keywords “ectopic salivary tumour,, “recurrence,” and “malignant transformation,” to the best of our knowledge, such an early transformation to malignancy of a minor salivary gland tumor of the parapharyngeal space has not yet been reported in the english literature. 28 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 surgical innovations and instrumentation abstract objective: to design and test an improvised tracheotomy speaking valve fabricated from recycled parts of an anesthesia airway breathing circuit. methods: design: surgical instrumentation setting: tertiary private hospital subjects: speaking valves fabricated from discarded anesthesia breathing circuit parts were pilot-tested on three patients: one with vocal fold paralysis, another with a supraglottic mass and one post hemi-laryngectomy. results: the improvised tracheotomy speaking valve was inexpensive and relatively easy to assemble. all three patients tolerated speech well through the speaking valve and were pleased to reestablish their means of verbal communication. maximum phonation time (mpt) averaged 8 seconds for all three subjects. conclusion: in our local setting, improving the quality of life of tracheotomized patients should be accessible to all, hence the value of an improvised speaking valve. it provides a more affordable means of restoring speech and because it is made from recycled materials, it is ecofriendly. our improvised speaking valve is also a cheaper but viable alternative to more expensive commercially available ones. clinical trials with standardized feedback questionnaires, multiobserver perceptual evaluation with a system such as the grbas and/or vocal acoustic measures in a speech laboratory should be made to assess long term use, efficiency and safety measures. keywords: tracheotomy, tracheostomy, speaking valve, speaking device tracheotomy is a common essential surgical procedure that establishes an alternative airway. the disadvantage of this often-lifesaving procedure is altered ability to verbally communicate effectively, which may lead to depression. speech is an integral part of quality of life, and its loss results in psychological and emotional strain. various devices have been developed over the years to improve speech in cognitive, tracheotomized patients. from aesthetic to functional accessories, the speaking tracheotomy tube has evolved to what we know now as the speaking valve. a tracheotomy speaking valve works by allowing inspired air to pass through it and the tracheotomy tube whilst directing exhaled air towards the glottis to provide pulmonary airflow for phonation. however, the high cost of these devices limits their availability to only a select few in a developing country like the philippines. there is thus a need for an affordable yet durable alternative, without compromising pulmonary function and aesthetic value. we designed and pilot-tested an improvised tracheotomy speaking valve fabricated from recycled parts of an anesthesia airway breathing circuit, as a cheaper substitute to commerciallyavailable speaking valves. an improvised tracheotomy speaking valvekirt areis e. delovino, md william s. lim, md department of otorhinolaryngology head and neck surgery st. luke’s medical center correspondence: dr. kirt areis e. delovino department of otorhinolaryngology head and neck surgery st. luke’s medical center 279 e. rodriguez ave, quezon city 1102 philippines fax: (632) 723 0101 local 5543 e-mail: edot_ii@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the instrumentation paper research contest, philippine society of otolaryngology head and neck surgery annual convention, crowne plaza galleria, pasig city, philippines, october 11, 2010 editor’s note: the philippine journal of otolaryngology head and neck surgery publishes innovations in surgical technique and instrumentation that may be particularly relevant to developing-world settings, especially where they involve the use of recycled materials to produce a low-cost device, as in this case. publication of these innovations in no way constitutes scientific endorsement of the device(s) described, by the publisher, editors and reviewers, and readers are reminded to exercise due caution in evaluating the device(s) described, and in their subsequent use. philipp j otolaryngol head neck surg 2012; 27 (2): 28-31 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 29 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 surgical innovations and instrumentation methods the primary materials used (1, 2) were taken from discarded anesthesia breathing circuits: endotracheal tube external adaptor (portex tracheal tube 1. 7.5mm soft seal cuff oral, smiths medical international ltd., brisbane, australia) airway breathing circuit elbow connector (anesthesia 2. breathing circuit a10007183, inspired medical, vincent medical manufacturing co., ltd., kowloon, hong kong) transparency ohp acetate film clear, a4 210mm x 297mm 3. 100 micron (star 360 philippines inc, quezon city, philippines) fine-toothed hacksaw blade (eclipse all hard power hacksaw 4. blades, model: ecl.ae 353k blade size 400 x 32 x 1.60 mm; 16” x 1 ¼” x 0.06” teeth per inch: 10 (neill tools, spear & jackson, sheffield, england) multipurpose cutter no. 760 (kw-trio company ltd, taiwan)5. silicone carbide abrasive sand paper 320c (crocodile brand, 6. korea) the anesthesia airway breathing circuit (abc) elbow connector has a universal inner diameter size of 15mm which is commonly used with most endotracheal tubes (ett) and tracheostomy tubes. endotracheal tube external adaptors and tracheostomy tubes on the other hand, have standard outer diameters of 14mm which fit snugly in place with abc elbow connectors. with a fine-toothed saw, the abc elbow was cut just before the bend so that a plastic cylinder, open at both ends, was produced. (figures 1-2) to hold a flap that could seal one end of this cylinder during breathing, a 2mm thickness was then trimmed from the distal end of the ett external adaptor to make a ring. (figure 3) with a cutter, a circular flap with a small protruding tongue was then fashioned from a sheet of acetate. the flap was positioned with the tongue ready to be wedged between the ring and the cylinder. the ring was then inserted tightly with the acetate flap at the distal portion of the cylinder to hold the flap tongue in place and to serve as a stopper during exhalation. (figures 4-5) during inhalation the flap moves towards the patient allowing free flow of air and conversely, during exhalation, the acetate flap shuts off securely against the inner ett ring creating unidirectional airflow. during exhalation, the air is directed towards the glottis to provide pressure for phonation. (figures 6-7) with informed consent, the device was then pilot-tested on three patients from the social service outpatient department of the st. luke’s medical center. (figure 8) one patient had bilateral vocal fold paralysis, another had a supraglottic mass and the third was a post hemifigure 1. the airway breathing circuit (abc) elbow was cut before the angle so that a cylinder is produced. figure 2. the rough edges of the cylinder were evened out using a multipurpose cutter and sand paper. inset shows circular acetate flap with extension strip figure 3. a 2mm-thick ring was tailored from the distal end of the endotracheal tube external adaptor figure 4. this ring was poised to fit snugly inside the abc cylinder at the distal end and serve as a “stopper” to hold the flap in position 30 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 surgical innovations and instrumentation laryngectomy patient, all of whom required long-term tracheotomy. using a fenestrated inner cannula and tracheotomy tube with inflated cuff, the subjects were seated upright and under normal breathing circumstances were asked to speak. we observed the quality of their voices and obtained feedback on the ease of use of the improvised speaking valve. we also obtained a three-trail average maximum phonation time (mpt), the maximum length of time (in seconds) in which a person can sustain a vowel sound on one deep breath at a comfortable pitch and loudness, which is acceptable if greater than 7 seconds, in patients where glottic efficiency is poor.6 figure 7. mechanism of flap movement with airflow during inhalation and exhalation figure 8. the device was pilot-tested on three patients from the social service out-patient department of our hospital figure 5. a circular acetate flap was positioned with the small tongue extension wedged between the cylinder and the ring figure 6. finished product; the acetate flap moves freely with airflow, being wedged only by the small tongue results all three patients tolerated speech using the improvised tracheotomy speaking valve without difficulty of breathing. although with a harsh and breathy quality, their voices were clearly understood. our subjects verbalized that the device was easy to use. they also liked the fact that they did not have to manually occlude the tube anymore while speaking. one patient who previously utilized intermittent corking of the tracheotomy tube during speech claimed to have decreased breathing effort after using the device, because inspiration with corking required more effort to overcome upper airway resistance. using our device made it easier and more comfortable for the patients to breathe freely without the need for manual occlusion of their tracheotomy tubes. it was easily adapted and did not require any special training or breathing exercises. maximum phonation time (mpt) averaged 8 seconds in all three patients. even if we had used a new endotracheal tube external adaptor & abc elbow connector, the production cost of the innovative speaking philippine journal of otolaryngology-head and neck surgery 31 philippine journal of otolaryngology-head and neck surgery vol. 27 no. 2 july – december 2012 surgical innovations and instrumentation references 1. elpern eh, scott mg, petro l, ries mh. pulmonary aspiration in mechanically ventilated patients with tracheostomies. chest 1994 feb; 105(2):563–566. 2. suiter dm, mccullough gh, powell pw. effects of cuff deflation and one-way tracheostomy speaking valve placement on swallow physiology. dysphagia 2003 fall; 18(4):284–292. 3. hess dr. facilitating speech in the patient with a tracheostomy. respir care 2005 apr; 50(4): 51925. 4. stachler rj, hamlet sl, choi j, fleming s. scintigraphic quantification of aspiration reduction with the passy-muir valve. laryngoscope 1996 feb;106 (2 pt 1):231-4. 5. elpern eh, borkgren okonek m, bacon m, gerstung c, skrzynski m. effect of the passy-muir tracheostomy speaking valve on pulmonary aspiration in adults. heart lung 2000 jul-aug; 29(4):287–293 6. graham williamson, mpt as a measure of vocal function. speech therapy and information resources, 2008 [cited 2008 november 24] 22:11 available from: http://www.speech-therapyinformation-and-resources.com/maximum-phonation-time.html table 1. cost of production material price endotracheal tube (external adaptor) p400 * airway breathing circuit (elbow connector) p350 * transparency ohp acetate film p 45 fine-toothed hacksaw blade p 25 multipurpose cutter p 35 abrasive paper (sandpaper) p 15 total p870 *price based on brand new item valve would have been a mere php 870 (table 1) a great difference from commercially available speaking valves which range from php5,000 to 10,000 each depending on the brand and number of accessories. discussion tracheotomies are performed for a variety of indications and maintained for different durations. when prolonged tracheotomy is necessary, it becomes disabling and adversely affects the patient’s capability to effectively communicate verbally. this impacts on quality of life and may lead to psychosocial complications. in our study, the patients became accustomed without difficulty to the use of our “lowcost” improvised device. furthermore, the patients expressed ease of use and comfort during phonation. voice production requires good pulmonary support. in spontaneously-breathing patients with tracheotomy tubes this is made possible by adding a valve that will allow air to pass through the larynx during phonation. the speaking valve directs the exhaled air through the upper airway allowing the patient to speak. although many patients may benefit from a speaking valve, there are also contraindications to its use. according to hess3 speaking valves should only be used in fully conscious patients who are able to follow commands and attempt to communicate. airway clearance should be assessed completely as secretions may obstruct airflow and compromise the airway. upon application of the speaking valve, the patient’s ability to breathe should be carefully assessed as many patients require long periods before acclimatization. in our subjects, the use of the improvised device was easily adopted. neither further adjustments nor exercises were necessary to familiarize with its use. although flap malfunction from adherence to the stopper due to tracheal secretions was theoretically possible, the patients were cautioned to immediately remove the device as a precautionary measure in such an eventuality. during the assessment no adverse events were observed. commercially-available speaking valves are much more expensive, precluding their availability to financially-disadvantaged patients. our improvised speaking valve provides an alternative to restoring speech without causing undue financial burden. we were able to improvise a tracheotomy speaking valve devised from recycled materials which was functional and eco-friendly. the patients had their hands free to do other things while speaking. the device was easily adopted even without special preparations. maximum phonation time averaged 8 seconds indicating efficiency of its use. formal clinical trials are recommended to assess long term use, efficiency and safety issues especially regarding materials fatigue and maintenance procedures for daily care of the device. a standardized feedback questionnaire, and multi-observer perceptual evaluation with a system such as the grbas and/or vocal acoustic measures in a speech laboratory should be utilized in these trials. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles 18 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2010; 25 (2): 18-22 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to determine patient satisfaction with the informed consent process in ear, nose and throat (ent) diseases requiring surgery. specifically, to determine relationships between educational levels of patients and their satisfaction with information given by doctors versus self-gathered information; whether complications of the operation were explained to, and could be listed by patients; the types of complications patients expected to be informed about and the importance of this information to them; their familiarity with the term “informed consent” and their preference for written or spoken information; and whether they were convinced about what they consented to. methods: design: cross-sectional descriptive study setting: tertiary public hospital population: one hundred results: there were 55 males and 45 females (average age 26.7 years, range 4 74 years). ten percent (all children) had no formal education, 56% had primary to high school education, 23% had certificate level education and 11% had a baccalaureate or masters degree. ninety-five percent claimed they knew what informed consent was. ninety percent were satisfied with the information given to them by doctors. eighty percent, mainly with educational levels of high school and above preferred to receive written information from doctors. twenty three percent accessed other sources of information. those with certificate level education talked with previously operated patients (10%) or read magazines (2%) while the internet was favored by almost all of those with baccalaureate degrees (8%) and all those with masters degrees (2%). of those who accessed self-gathered information, 21% were not satisfied while only 2% were satisfied. seventy percent considered the information given by doctors very important. similarly, seventy percent (mostly from the higher educational levels) considered the impact of information provided by the doctor completely convincing for decision making while 30% (mostly from lower educational levels) only found the information partly convincing. forty nine percent (again from the lower educational levels) could not list even a single complication. nineteen percent with educational levels of certificate and above wanted to know all complications of surgery including those that were very rare while 56% wanted to know most of the complications. informed consent in patients undergoing ent surgery: what do patients want to know? bikash lal shrestha, mbbs, ms (ent-hns)1 1department of otorhinolaryngology kathmandu university hospital     dhulikhel, kathmandu, nepal correspondence: bikash lal shrestha, mbbs, ms (ent-hns) department of otorhinolaryngology kathmandu university hospital, dhulikhel gpo.11008 kathmandu, nepal phone: (977)-11-490497 fax: (977)-11-490707 email: bikash001@hotmail.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles philippine journal of otolaryngology-head and neck surgery 19 conclusion: we should not underestimate the importance of the outpatient consultation, the importance of written material and non medical information sources as patients’ expectations are quite high and the majority of them want to be informed about most complications. we should also find ways to improve the provision of patient information where possible and appropriate as per specific patient groups. keywords: informed  consent,  otorhinolaryngology,  surgical  procedures. informed consent is the permission given by the patient/relatives after being given appropriate information about a proposed medical/ surgical intervention. the process is called the informed consent process.1 it may be obtained in one sitting or over a period of time, either orally or in writing or as a combination of the two.2 studies suggest that in practice only minimal formal efforts are made to obtain informed consent for routine interventions.3,4 some have suggested using the “prudent patient standard,” in which the physician must disclose all risks so that a reasonably prudent patient would make a decision whether to undergo or refuse a particular procedure.5,6,7 others have hypothesized that better informed consent could improve the patientphysician relationship, establish trust, increase patient compliance, and provide information that could reduce medical error.2,8 still others state support that a reasonably prudent physician would disclose to his or her patient.6,7 the informed consent process may be influenced by the educational level of the patient. studies have suggested that patients with higher education levels tended to have better understanding of informed consent, grasped more information and also had better recall than those with no formal education.9,10 the aim of this present study was to determine patient satisfaction with the informed consent process in ear, nose and throat (ent) diseases requiring surgery. specifically, the study sought to determine relationships between educational levels of patients and their satisfaction with information given by doctors about their recommended operation versus self-gathered information (if any); whether complications of the operation were explained to, and could be listed by patients; the types of complications patients expected to be informed about and the importance of this information to them; their familiarity with the term “informed consent” and their preference for written or spoken information; and whether they were convinced about what they consented to. methods this study was carried out among 100 patients in the department of ent, kathmandu university hospital, dhulikhel from january to may 2010. all the patients posted for elective surgery were included. the study was performed in the following phases: questionnaires were constructed inspired and based on the study performed by adhikari et  al.11 and albera et  al.12 a statistician and the department of community medicine were consulted regarding the validity and reliability of the questionnaire but no pre-tests were conducted. the survey questionnaires were framed in english and translated into native nepali but were not back-translated. questions covered demographic data and satisfaction with information obtained from doctors; whether complications of the operation were explained by doctors and could be listed by patients; the types of complications patients expected to be informed about and the importance of this information to them; knowledge of the term “informed consent,” whether they were convinced about what they consented to; whether they looked for further information regarding the surgical procedure; the sources of and satisfaction with self-gathered information; and modes of information patients prefer from doctors (appendix). patients who opted for modalities of management other than surgery were excluded from the study. during the outpatient examination, the patients were given explanations about their disease, the risks and benefits of the recommended surgery, alternative methods of management and costs of surgery to reach the ultimate decision. questionnaires were handed over to nursing staff with clear instructions on how to complete them for patients to complete prior to discharge. patients with no formal education and children whose parents had no formal education were assisted in accomplishing the questionnaires. these records were collected and analyzed by simple manual analysis using frequencies and percentages. results results were obtained from the sample of 100 subjects. there were 55 males and 45 females with an average age of 26.7 years and a range of 4 to 74 years. seventeen percent were children. ten percent (all children) had no formal education, 56% had primary to high school education, 23% had certificate level education, and 11% had a baccalaureate or masters degree.  (table  1)  ninety-five percent of the patients claimed they knew what informed consent was. (table  2) ninety percent of our patients were satisfied with the information given to them by doctors.  (table  3) eighty percent of patients, mainly with educational levels of high school and above, preferred to receive written information from doctors. (table  4)  twenty three percent of patients accessed other sources of information. those with certificate level education talked with previously operated patients for information (10%) or read magazines (2%), while the internet was philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles 20 philippine journal of otolaryngology-head and neck surgery favored by almost all of those with baccalaureate degrees (8%) and all those with masters degrees (2%). (table 5) of the patients who accessed self-gathered information, 21% were not satisfied while only 2%, (both with certificate educational level) were satisfied. (table  6)  seventy percent considered the information given by doctors very important, 29% considered such information important and only one considered it somewhat important. more importance seemed to be accorded by those with higher educational levels. (table  7) similarly, 70% of the patients (mostly from the higher educational levels) considered the impact of information provided by the doctor completely convincing for decision making, while 30% (mostly from lower educational levels) only found the information partly convincing. (table 8) forty nine percent of patients (again from the lower educational levels) could not list even a single complication while an increasing number of complications could be listed by those with increasing levels of education (table 9). nineteen percent of our patients with educational levels of certificate and above wanted to know all complications of surgery including those that were very rare while 56% wanted to know most of the complications. (table  10) discussion the components of informed consent include a description of the patient’s condition and the proposed treatment, the benefits of proposed treatment and the discussion of alternative treatment including the implications of no treatment. almost all our patients replied that they knew what informed consent was, echoing findings of other studies.6, 11 the majority of our patients (90%) were satisfied with the information given by doctors before surgery, similar to findings in previous studies by adhikari et  al.11 and albera et  al.12 on the other hand, 80% of our patients preferred to receive written information from physicians, in complete contrast to another study12 which showed that only 20% preferred the written form. it may be because our patients think that the written form of information instilled trust and hope. less than one fourth (23%), mainly the well-educated patients, looked for further information regarding the surgical procedure. these are less than the figures of burns et  al.6 where two thirds of patients sought information elsewhere prior to signing their consent form, but more than those of adhikari et  al.11 and comparable to those of lavelle –jones et  al.13 this may suggest a need to increase awareness and interest among our patients and exert more effort to help nonformally educated patients understand their disease. obtaining proper informed consent and good communication should be practiced not only because it forms a part of a good medical practice; it also reduces legal problems. although the problem of litigation in nepal is not very high, there recently seems to be an increasing trend in this direction. table 1. educational level of patients-participants, n = 100 level of formal education number of patients per level no formal education primary/high school certificate baccalaureate masters total 10 56 23 9 2 100 table 2. patient awareness of the informed consent process, n =100 level of formal education aware no formal education primary/high school certificate baccalaureate masters total 5 56 23 9 2 95 not aware 5 0 0 0 0 5 total 10 56 23 9 2 100 table 4. patient preference for mode of delivery of information , n=100. table 3. patient satisfaction with information provided by the doctor, n=100. level of formal education satisfied no formal education primary/high school certificate baccalaureate masters total 10 56 17 6 1 90 not satisfied 0 0 6 3 1 10 total 10 56 23 9 2 100 table 5. other sources of information accessed by the patients-participants, n=100 level of formal education other patients no formal education primary/high school certificate baccalaureate masters total 10 10 magazines 2 1 3 internet 8 2 10 total 12 9 2 23 level of formal education mode of delivery no formal education primary/high school certificate baccalaureate masters total 46 23 9 2 80 spoken 8 10 18 no particular preference 2 2 total 10 56 23 9 2 100 written philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles philippine journal of otolaryngology-head and neck surgery 21 interestingly, our results showed that patients were not satisfied with self-gathered information compared to information provided by doctors, reminiscent of findings by georgalas et al.14 it may be because they believe more in the information provided by doctors rather than that acquired from other sources. moreover, the risk with this selfgathered type of information is that it frequently is of variable quality, and patients in another study graded it as the worst quality among all the information sources.14 also consistent with the literature12 were our findings that 70% of patients believed it was very important for them to be informed about their procedure and 70% of patients were completely convinced about what they consented to. this may be because our patients had trust in their doctors. almost half (49%) of our patients, mainly those with no formal education and educational levels of primary/high school could not list even a single complication while 33% who listed one complication only mainly had primary/high school and certificate level education. only 3% listed 3 complications and they had either master or baccalaureate level education, consistent with the findings of gongal et  al.9 and hekkenberg et  al.15 which showed better levels of understanding in patients who had higher education. defining which risks are significant is arguably the most crucial aspect of informed consent law.6,16 adhikari et  al.11 showed that 90% expected to know all complications, while burns et  al.6 showed that 73.0% of those questioned expected to be informed of all known complications, even if the incidence was less than one percent. our study showed that only 19% who were among the more educated expected to know all complications even if rare. it may be because our patients had less enthusiasm and more anxiety about knowing the rarest complications. most patients incorrectly believe that informed consent serves only to protect a physician’s right but the process of informed consent gives patients an understanding of a procedure17 so that they can adequately make an informed decision. while mention of extremely rare complications such as death may only serve to unjustly increase patient anxiety; the argument that stating uncommon risks may cause undue patient anxiety has been disproved.17 when discussing complications with a patient, it is not clear whether one should present his or her incidence of a complication or that found in the literature. though only few of our patients wish to be informed of all known complications, we must raise awareness of patients and improve our communication regarding most major complications. we should not underestimate the importance of the outpatient consultation, the importance of written material and non-medical information sources. it is up to us to understand and use these table 6. satisfaction with self-gathered information, n=100 level of formal education satisfied certificate baccalaureate masters total 2 0 0 2 not satisfied 10 9 2 21 total 12 9 2 23 table 8. impact of information provided by the doctor on decision-making, n = 100 level of formal education completely convincing no formal education primary/high school certificate baccalaureate masters total 36 23 9 2 70 partly convincing 10 20 30 not convincing total 10 56 23 9 2 100 table 7. importance given by patients to the information provided by doctors, n = 100 level of formal education very important no formal education primary/high school certificate baccalaureate masters total 36 23 9 2 70 important 9 20 29 somewhat important 1 1 not important total 10 56 23 9 2 100 table 9. patient recall of the possible complications explained by the doctor, n=100. level of formal education cannot recall any no formal education primary/high school certificate baccalaureate masters total 10 39 49 can recall only 1 17 16 33 can recall 2 7 8 15 can recall at least 3 1 2 3 total 10 56 23 9 2 100 recall of complications table 10. number of patients who would like to be told of surgical complications whose incidence rates fall within a certain range only, n = 100. level of formal education 50-75% no formal education primary/high school certificate baccalaureate masters total 41 15 56 25-50% 5 15 20 10-25% 4 4 all 8 9 2 19 total 10 56 23 9 2 100 incidence rate of complications 5-10% 1 1 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles 22 philippine journal of otolaryngology-head and neck surgery alternative information channels appropriately. patients’ expectations are quite high and the majority of them want to be informed about most complications. we should also find ways to improve the provision of patient information where possible and appropriate as per specific patient groups. references 1. mark js, spiro h. informed consent for colonoscopy. a prospective study. arch intern med. 1990 apr;150(4):777-80. 2. lidz cw, appelbaum ps, meisel a. two models of implementing informed consent. arch intern  med. 1988 jun; 148(6):1385-9. 3. hopper kd, tenhave tr, hartzel j. informed consent forms for clinical and research imaging procedures: how much do patients understand? ajr am j roentgenol. 1995 feb;164 (2):493-6. 4. braddock ch 3rd, edwards ka, hasenberg nm, laidley tl, levinson w. informed decision making in outpatient practice: time to get back to basics. jama. 1999 dec 22-29; 282(24):231320 5. wolf js, chiu ag, palmer jn, o’malley bw jr, schofield k, taylor rj. informed consent in endoscopic sinus surgery: the patient perspective. laryngoscope. 2005 mar; 115(3):492-494. 6. burns p, keogh i, timon c. informed consent: a patient’s perspective. j  otolaryngol. 2005 jan; 119(1):19-22. 7. baker ch. comment: informed consent: obligation on opportunity. j health hosp law. 1993 jul; 26(7):214-215. 8. kuyper ar. patient counseling detects prescription errors. hosp pharm. 1993 dec;28 (12):11801, 1184-9. 9. gongal r, bhattarai p. informed consent: is it really understood? kathmandu univ med j (kumj). 2005 jul-sep; 3(3):271-73. 10. falagas me, akrivos pd, alexiou vg, saridakis v, moutos t, peppas g et al. patients’ perception of quality of pre-operative informed consent in athens, greece: a pilot study. plos one. 2009 nov 26;4(11):e8073. 11. adhikari p, pradhananga rb. patients’ expectation on informed consent before ent surgery.intl.  arch. otorhinolaryngol.2007;11(1):51-53. 12. albera r, argentero p, bonziglia s, de andreis m, preti g, palonta f, et al. informed consent in ent: patients’ judgement about a specific consensus form. acta otorhinolaryngol ital. 2005 oct; 25(5):304-11. 13. lavelle-jones c, byrne dj, rice p, cuschieri a. factors affecting quality of informed consent. bmj  1993 apr 3; 306(6882):885-90. 14. georgalas c, ganesh k, papesch e. the information and consent process in patients undergoing elective ent surgery: a cross sectional survey. bmc ear nose throat disord. 2008 sep 17;8:5. 15. hekkenberg rj, irish jc, rotstein le, brown dh, gullane pj. informed consent in head and neck surgery: how much do patients actually remember? j otolaryngol.1997 jun;26(3):155-9. 16. palisano dj, lauve r. informed consent update for louisiana: reducing the risk of malpractice suits.j la state med soc.1994 sep; 146(9):399-401. 17. stanley bm, walter dj, maddern gj. informed consent: how much information is enough? aust  n z j surg.1998 nov; 68(11):788-91. appendix questionnaire name: age: sex: religion: education: guardian name (if children): relation: operation name: date: 1. were you satisfied by the information given to you by the doctors about your operation? yes ( ) no ( ) 2. have you looked for any further information regarding your operation? yes ( ) no ( ) list: other patients ( ), magazines ( ), internet ( ) 3. were you satisfied with self-gathered information? yes ( ) no ( ) 4. do you know what informed consent is? yes ( ) no ( ) 5. did your doctor explain the complications of your procedure? yes ( ) no ( ) 6. can you list any of complications regarding your operations? yes ( ) no ( ) list: 7. how frequent the complications you expect to know from your doctors? <1%, 1-5%, 5-10%, 10-25%, 25-50%, 50-75%, all. 8. how important is it for you to be informed about: a. very much b. enough c. a little d. not at all 9. were you convinced about what you consented to? a. yes, completely b. yes, partly c. no 10. would you prefer to receive written or spoken information from the doctor? a. written b. spoken c. it’s the same. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 surgical innovations and instrumentation philippine journal of otolaryngology-head and neck surgery 27 abstract objective: to design inexpensive, easily fabricated stoma buttons for post-laryngectomy patients with stomal stenosis and patients who require prolonged tracheotomy. methods: design: surgical instrumentation setting: tertiary government hospital subjects: tracheostoma buttons fabricated from 3 or 5 cc disposable plastic syringes were tested on two post-laryngectomy patients with stomal stenosis and a tracheotomized patient with bilateral vocal cord paralysis. results: the tracheostoma buttons were inexpensive and relatively easy to fabricate. they were easily inserted and well tolerated by all three patients, compared to previously-used commerciallyavailable tracheotomy tubes. conclusion: in a developing country setting, improvised tracheostoma buttons made from disposable plastic syringes may be viable alternatives to commercially-available stoma buttons or tracheotomy tubes. clinical trials on more subjects should be conducted to assess parameters for use and long-term efficacy and safety issues. key words: stomal stenosis, tracheostoma/stoma button an improvised tracheostoma button fabricated from disposable plastic syringe reynerio m. vencio, md emmanuel tadeus s. cruz, md department of otorhinolaryngology head and neck surgery quezon city general hospital philipp j otolaryngol head neck surg 2009; 24 (1): 27-31 c philippine society of otolaryngology – head and neck surgery, inc. correspondence: reynerio m. vencio, md department of otorhinolaryngology-head and neck surgery quezon city general hospital seminary road, edsa, quezon city 1106 philippines phone: 4261314 local 221 email: reynerio_md@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product cited in this report. presented at the surgical instrumentation contest (1st place) philippine society of otolaryngology head & neck surgery annual convention, sofitel philippine plaza manila december 1, 2007 philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 28 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation tracheostomal stenosis (stomal stenosis) is a not uncommon complication following total laryngectomy. its management varies with severity of respiratory compromise and different surgical techniques such as single or double zplasty and lateral skin flap technique (after montgomery, 1963)1 have been advocated for correction, the main objective being to allow patients to breathe and function comfortably. the prospect of another surgical procedure causes undue psychological and financial stress and anxiety for many patients. but commercially-available post-laryngectomy products such as silicone laryngectomy tubes, stoma buttons or tracheostoma vents2 which are alternatives to repeat surgery are not readily available in the local market and quite expensive. in our setting, surgeons have resorted to long-term tracheotomy tubes to avoid stenosis but they have been observed to cause persistent cough due to chronic irritation of the tracheal wall. we propose an improvised stoma button fabricated from disposable plastic syringes as inexpensive alternatives to prevent stomal stenosis for post-laryngectomy patients and for those who require prolonged tracheotomy for such conditions as tracheal stenosis and bilateral vocal cord paralysis. materials and methods materials (figure 1): 1. 3 and 5 cc disposable plastic syringes (terumo, japan) 2. cutter 3. pen marker 4. ruler 5. cotton tip applicators 6. compact 8 micromotor and hand drill (soniford maeller corp., phil.) 7. leukoplast™ adhesive tape (bsn medical, malta) 8. open flame candle or alcohol burner 9. cloth tracheotomy tie or tiny gauze strips procedure: 1. with informed consent , the tracheostomal diameter of each patient was measured to determine the needed syringe size, 3 or 5 cc. the distance from the anterior edge of the stoma to the posterior tracheal wall was estimated with a cotton tip applicator (figure 2) to determine the length of the stoma button minus half a centimeter to avoid contact with the posterior tracheal wall (figure 3 a,b). 2. the plunger was detached from the plastic syringe barrel and the distal end of the syringe barrel was cut diagonally at a 40o angle with a cutter (figure 4). 3. holes for the attachment of strings were created on both sides of the neck plate of the barrel using a hand drill (figure 5). 4. sharp edges of the cut syringe were smoothened with flame (figure 6). 5. the stoma button was now ready to use (figure 7). 6. the appliance was inserted and with the aid of a penlight, the stomal edges and trachestoma button were examined for adequate dilation and retention, then secured with a cloth tracheotomy tie. results the improvised stoma buttons were used by two postlaryngectomy patients with stomal stenosis (figure 8 a,b) and one tracheotomized patient with bilateral cord paralysis (figure 9). the buttons were relatively easy to fit and fabricate improving with the learning curve. without need for stomal dilation, they were easily inserted in all three patients who all reported that the stoma button fit very well with less insertion pain and less foreign body sensation compared with their previous tracheotomy tubes. the patients also claimed to breathe better because of the wider diameter and absence of an indwelling cannula. the patients were followed up for four months with no noted complications. discussion stomal stenosis is an often encountered problem following laryngectomy3. short of performing surgical stomal revision or importing expensive, locally unavailable commercial stents, the improvised stoma button made from plastic syringe is a wise alternative. the materials are readily available in the hospital setting and are inexpensive. different plastic syringe sizes make it a versatile appliance to fit varying sizes of stoma and the procedure is easy to follow and can be duplicated. among the advantages of the improvised stoma button are: first, its length which is shorter than the usual tracheotomy tube resulting in less tracheal irritation; second, its lighter weight and smaller size make it more comfortable and acceptable to the patient; and third, its accessibility make it easier to clean when there are secretions. because it is shorter than a tracheotomy tube, the danger of philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 philippine journal of otolaryngology-head and neck surgery 29 surgical innovations and instrumentation figure 4. diagonal cut made on the distal end of the barrel at a 40o angle. figure 3a-b. the measurement determines the length of the stoma button minus half a centimeter to avoid contact with the posterior tracheal wall a. b. figure 2. the distance from the anterior edge of the stoma to the posterior tracheal wall was measured with a cotton-tip applicator figure 1. materials being dislodged during forceful coughing is greater. this can be minimized by tightening the button strings around the neck and by holding the button firmly against the stoma whenever coughing is anticipated. matching the syringe size with stomal diameter to ensure a snug fit may also minimize accidental extrusion. complications from long-term use of the stoma button may include biofilm formation and stomal edge abrasions and granulation tissue. periodic monitoring, daily cleaning and early intervention may prevent these complications. the shorter length of the stoma button and clearer plastic make such monitoring and cleaning easier. clinical trials on more subjects should be conducted to assess parameters for use and long-term efficacy and safety issues including frequency of replacement. improvements in design can evolve with experience. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 30 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation figure 5. holes for string attachment created on both sides of the neck plate of the barrel using a hand drill. figure 6. sharp edges of the cut syringe smoothened with a flame. figure 7. the improvised tracheostoma button. figure b. 65 year old female, 4 months after total laryngectomy, pre (top) and post (above), button insertion figure a. 72 year old female 7 months after total laryngectomy, pre (top) and post (above), button insertion figure 8. post-laryngectomy patients with stomal stenosis philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 surgical innovations and instrumentation philippine journal of otolaryngology-head and neck surgery 31 references 1. lore jm, medina je. an atlas of head and neck surgery. 4th ed. philadelphia: elsevier saunders; 2005 2. messing bp, hirata rm. (kirklin clinic head and neck cancer support group, birmingham, al). tracheostomal stenosis. sanders pw, editor. headlines: american cancer society; march 2005 3. griffith gr, luce ea. tracheal stomal stenosis after laryngectomy. plast reconstr surg 1982; 70(6). 694-698 figure 9. tracheotomized patient with bilateral vocal cord paralysis, pre (top) and post (above), button insertion philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 11 abstract objective: to review cases of adult patients who develop hungry bone syndrome (hbs) after parathyroidectomy for primary hyperparathyroidism (phpt) in a tertiary care center in the philippines and describe the clinical features, pre-operative preventive measures done and risk factors for hbs. methods: design: retrospective case note review setting: tertiary private hospital participants: chart review of adult filipino patients who underwent parathyroidectomy for phpt at makati medical center from january 2011 to december 2016 was conducted and evaluated according to the inclusion and exclusion criteria. medical information obtained included clinical parameters, biochemical results, operation performed, pathology, length of hospital stay and complications if with any. results: from among 20 adult filipino patients (mean age 55 years; 13, 65% female) who underwent parathyroidectomy for phpt, hbs was found in 7 (35%). most common pre-operative symptoms of hypercalcemia were musculoskeletal complaints. to prevent hbs, all were hydrated prior to surgery while some were given bisphosphonates and diuretics. the most common parathyroid gland imaging used for pre-procedure localization was tc 99m sestamibi scan with single photon emission computed tomography (spect) and 19 (95%) had parathyroid adenoma on post-operative histopathologic report. among biochemical and clinical factors that may be risk factors for hbs, those with hbs had significantly lower pre-operative 25-hydroxyvitamin d, higher bun, phosphate and alkaline phosphatase (alp) than those without hbs. of these, only alp showed significant association with hbs (or = 107.17, p = <0.0001). length of hospital stay was longer among those with hbs although not statistically significant. conclusion: knowledge on post-parathyroidectomy hbs for phpt may aid clinicians on preoperative prevention and post-operative monitoring. thirty-five percent (7) of our patients presented with hbs post-parathyroidectomy for phpt from 2011 to 2016. an abnormal alp level pre-operatively may be a risk factor in developing hbs post-parathyroidectomy for phpt. hungry bone syndrome (hbs) in patients operated for primary hyperparathyroidism (phpt): a six-year experience rhoda zyra m. padilla-baraoidan, md maria jocelyn capuli-isidro, md beinjerinck ivan b. cudal, md ayezl a. embestro-pontillas, md department of medicine section of endocrinology diabetes, and metabolism makati medical center correspondence: dr. rhoda zyra m. padilla-baraoidan department of medicine section of endocrinology, diabetes and metabolism makati medical center #2 amorsolo st., legaspi village, makati city 1229 philippines phone: +63-917-598-2520 email: rzpadillamd@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at psedm 17th endocrine fellows research forum at innogen office, february 16, 2017. brgy. sacred heart, quezon city, philippines presented at makati medical center annual fellows’ scientific paper presentation. june 1, 2017. legaspi village, makati city, philippines philipp j otolaryngol head neck surg 2017; 32 (2): 11-16 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles 12 philippine journal of otolaryngology-head and neck surgery keywords: primary hyperparathyroidism, hungry bone syndrome, philippines primary hyperparathyroidism (phpt) is the most common etiology of hypercalcemia with a reported prevalence of 21 per 100,000 in minnesota between 1999 – 2001.1 it is caused by excessive and uncontrolled secretion of parathyroid hormone (pth) by an abnormal parathyroid gland. parathyroidectomy remains the treatment of choice for phpt but it is not without risks.1 one common complication of parathyroid surgery is the development of hypocalcemia postoperatively.2 when hypocalcemia is severe, defined as serum total calcium concentration below 2.1 mmol/l and lasts for more than 4 days post-parathyroidectomy, patients are deemed to have hungry bone syndrome (hbs).3 a 2016 study in turkey noted the incidence of hbs post parathyroidectomy for phpt was 13.4%.2 another 2012 study in thailand reported the hbs incidence post-parathyroidectomy for phpt was 22%.4 identified risk factors for the development of hbs include parathyroid hyperplasia and presence of osteoporosis. identified biochemical predictors for hbs were higher preoperative pth, alp and bun values. moreover, hbs was more common in patients who had thyroidectomy together with parathyroidectomy.2 a search of local (herdin) and international databases (pubmed medline, google scholar and sciencedirect) using the following keywords: hungry bone syndrome, primary hyperparathyroidism and philippines revealed only one reported case in 2010 of phpt with classic and severe skeletal involvement who underwent parathyroidectomy and developed hbs 7 days post-operatively5 but yielded no other articles on the incidence and risk factors of hbs post parathyroidectomy for phpt in our country. increasing identification of hypercalcemia from primary hyperparathyroidism and the importance of equipping clinicians with knowledge on preoperative prevention and post-operative monitoring of hbs after parathyroidectomy prompted this study. our aim was to review the cases of adult patients who developed hbs after parathyroidectomy for phpt in a tertiary care center in the philippines and to describe the clinical features, pre-operative preventive measures done and risk factors for hbs. methods study design and subjects this retrospective case note review considered filipino adults 18-years-old and above, admitted under or referred to the section of endocrinology, diabetes and metabolism of the makati medical center in the philippines between january 2011 to december 2016 who underwent parathyroidectomy for primary hyperparathyroidism. primary hyperparathyroidism was defined as a primary abnormality of parathyroid tissue that leads to inappropriately high serum concentration of pth with hypercalcemia, hypophosphatemia, loss of cortical bone and hypercalciuria. discharge diagnoses in the chart included all possible terms that could include parathyroidectomy in our institution, coded as either primary hyperparathyroidism, neck exploration, parathyroidectomy or parathyroid biopsy. patients diagnosed to have secondary hyperparathyroidism due to end-stage renal disease, sarcoidosis, familial hypocalciuric hypercalcemia, tertiary hyperparathyroidism or recurrent or persistent hyperparathyroidism after parathyroidectomy (as these patients would have been previously diagnosed with phpt and may have undergone parathyroidectomy but have persistently elevated post-operative calcium and pth levels and re-operation increases their risk for permanent hypocalcemia and not just hbs) were excluded. this study was approved by the institutional review board of the makati medical center (protocol number mmcirb 2016-109). data collection the general endocrine cases census from the annual reports of 2011-2016 of the section of endocrinology, diabetes and metabolism of makati medical center were retrieved. all related medical information were obtained including the following: demographic data, clinical presentation, comorbidities, method of localization used to identify the abnormal parathyroid gland, preoperative medications given to prevent hbs, preoperative and postoperative blood chemistry results, operation performed with operative findings, pathology, length of hospital stay and post-operative complications, if any. demographic data consisted of gender, age, and other comorbidities. clinical presentation was divided into the effect of calcium on the organ systems: skeletal, renal, neuromuscular, neuropsychiatric, gastrointestinal, and nonspecific symptoms. chemistry findings included pre-operative and post-operative serum calcium (total or ionized), albumin, magnesium, phosphate, alkaline phosphatase (alp), intact parathyroid hormone (ipth), bun, creatinine and serum 25-hydroxyvitamin d. postoperative blood chemistry was recorded until discharge. imaging modalities for localization was accounted for and its volume was computed using the ellipsoid model formula (length x width x height x 0.52). normal range of the laboratory parameters were established as follows: ipth: 15-65 pg/ml, total calcium: 8.6 – 10.2 mg/dl, ionized calcium: 1.12 – 1.32 meq/l, phosphorus: 2.75 – 4.5 mg/dl, albumin: 3.5 – 5.2 g/dl, magnesium: 1.6 – 2.6 mg/dl, alkaline phosphatase: 30 – 130 iu/l, bun: 6 – 20 mg/dl, tsh: 0.27 – 4.2 uiu/ml, ft4: 12 – 22 pmol/l, 25philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 13 ohd: 30 – 100 ng/ml, tsh-irma (nuclear medicine): 0.27 – 3.75 uiu/ml, ft4-ria (nuclear medicine): 8.8 – 33 pmol/l. calcium levels were calculated with the corrected calcium formula based on the patient’s albumin levels if with abnormal albumin results. the formula used was as follows: corrected calcium (mg/dl) = [0.8 x (4 – patient’s albumin)] + serum calcium level. statistical analysis data encoding, processing and analysis were performed using microsoft excel for mac 2015 version 15.13.3 (microsoft corporation, washington, usa). continuous data were presented as means and standard deviation (sd) while categorical data were presented as frequencies and sd or 95% confidence intervals (cis) as appropriate. fisher exact test was used for assessment of association of categorical data and student t-test for two-group comparison of continuous variables. risk factors associated with hungry bone syndrome were determined with exact logistic regression analysis using the software stata 15 (statacorp llc, texas, usa). significance level was set at 5%. results out of 20 adult filipino patients who underwent parathyroidectomy for primary hyperparathyroidism at the makati medical center from january 2011 to december 2016, seven (35%) were found to have hungry bone syndrome (hbs). the 20 participants included in this study had a mean age of 55years-old with a range of 36 to 69 years and female predominance of 2:1. the most common pre-operative symptoms of hypercalcemia were renal calculi, osteoporosis, myalgia, neck mass, pathologic fracture and constipation. (figure 1) the most common co-morbidities by frequency of mention were hypertension (15; 70%), diabetes mellitus type 2 (8; 40%) and myocardial infarction (5; 25%). to prevent hbs, all were hydrated preoperatively, 7 (35%) were given bisphosphonates and 6 (30%) were given diuretics. a few were given calcitonin (3; 15%) calcimimetics (3; 15%) and vitamin d (3; 15%). (figure 2) the most common parathyroid gland imaging used for pre-procedure localization was tc99m sestamibi scan with single photon emission computed tomography (spect). (figure 3) all patients with phpt underwent parathyroidectomy involving removal of only one culprit parathyroid gland. ninety-five percent (19/20) were found to have parathyroid gland adenoma on post-operative histopathology report. sixty-percent (12/20) of patients had a concomitant subtotal (3; 15%) or total (9; 45%) thyroidectomy for a separate thyroid pathologic indication. of the 12 patients that underwent thyroidectomy, 2 had papillary thyroid cancer and the rest had multinodular goiter. none had abnormal thyroid figure 1. pre-operative symptoms of hypercalcemia among included patients figure 2. medications given pre-operatively for hypercalcemia management and hbs prevention figure 3. distribution of pre-operative parathyroid gland localization imaging study used in patients included in the study philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles 14 philippine journal of otolaryngology-head and neck surgery function tests pre-operatively. table 1 compares values of selected pre-surgical biochemical and clinical risk factors of hbs. from among these factors, only 4 variables showed significant association with hbs at the 95% confidence level (p <0.05): 25-hydroxyvitamin d, bun, phosphate and alp. those with hbs had significantly lower pre-operative 25-hydroxyvitamin d, higher bun, phosphate and alp than those without hbs. to determine independent risk factors for hbs, we employed exact binary logistic regression for small sample sized data sets. the four variables which showed significant p values from the bivariate analysis were included in logistic regression analysis. full model exact binary logistic regression using continuous data did not produce viable estimates. when only alp was placed in the model, the analysis showed significant results (p <0.0001). considering only this model, it was found that the odds of having hbs increased by 9% with every unit increase in alp. (table 2a) table 2a shows that viable estimates for alp were produced when only categorical variables were used. if the full model is considered, the association between hbs and alp status is shown to be insignificant (p = 0.08). understandably, when each variable is taken out of the model one by one, the odds ratio (or) increased. when placed in a model with hbs, alp showed a significant association with the said outcome variable (p <0.0001). odds ratio was 107.17, which means hbs was 107.17 times more likely to occur given an abnormal level of alp than with a normal level. (table 2b) the length of hospital stay in days was longer among those with hbs with a mean of 10.86 ± 6.15 vs. 6.77 ± 3.98 although the value did not reach statistical significance (p = 0.085). discussion primary hyperparathyroidism (phpt) is an endocrine disorder characterized by autonomous production of parathyroid hormone. in the united states of america, the estimated incidence of phpt between 1998-2010 was approximately 50 per 100,000 person years in the general population.6 the increase in pth secretion in primary hyperparathyroidism is hypothesized to be secondary to an elevation in set-point with a documented variable shift to the right in the slope of the calcium – pth curve due to relative non-suppressibility of pth secretion. the increase in the set-point is the primary determinant of the degree of hypercalcemia.1 parathyroidectomy is the definitive management for phpt with the aim of removing the culprit abnormal parathyroid gland, however, postoperative severe and prolonged hypocalcemia (hbs) may occur. this is a consequence of the sudden withdrawal of pth signal post surgery table 1. pre-operative biochemical and clinical risk factors of hbs after parathyroidectomy for phpt risk factors* (-) hbs n = 13 (+) hbs n = 7 p value thyroid stimulating hormone (tsh) (uiu/ml), mean, sd free thyroxine (ft4) (pmol/l), mean, sd calcium (mg/ dl), mean, sd parathyroid hormone (pth) (pg/ml), mean, sd 25-hydroxy vitamin d(ng/ ml), mean, sd blood urea nitrogen (bun) (mg/dl), mean, sd phosphorous (mg/dl), mean, sd magnesium (mg/dl), mean, sd creatinine (mg/ dl), mean, sd alkaline phosphatase (iu/l), mean, sd parathyroid gland adenoma volume (cm3), mean, sd with thyroidectomy, n (%) 1.66 + 1.12 16.55 + 3.21 10.81 + 1.04 175.19 + 132.03 24.15 + 7.81 14.95 +4.36 2.79 + 0. 89 2.01 + 0.29 0.94 + 0.32 79.77 + 24.96 1.34 + 0.92 7 (54%) 1.65 + 0.85 18.18 +3.32 10.73 + 0.87 441.61 + 603.35 11.39 + 2.36 43.84 + 23.00 4.03 + 1.71 1.99 + 0.46 2.29 + 2.52 161.86 + 17.37 3.18 + 3.66 5(71%) 0.992 0.299 0.859 0.136 0.00057 (s) 0.00029 (s) 0.04110 (s) 0.882 0.067 <0.0001 (s) 0.097 0.642 *student’s t-test for test of association of continuous variables (i.e. those with means and sds); fischer’s exact test for categorical data (i.e. those with frequency count) (s): significant p value (p <0.05) at 95% confidence interval that effects abrupt discontinuation of excessive osteoclastic activity from the hyperparathyroid state. with the advent of wide availability and utilization of biochemical tests performed even among asymptomatic patients, hypercalcemia from phpt is now identified with increasing frequency. in our institution, it was noted that there has been a steady increase in the philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surger 15 number of performed parathyroidectomies per year from 2 cases in 2011 to 8 cases in 2016. in this investigation, 35% (7/20) of patients who underwent parathyroidectomy for phpt in our institution from 2011 to 2016 were found to have hbs. the mean age was in the fifth decade of life with females comprising the majority at 65% (13/20). these findings are comparable with the results of several authors. one study in 2016 reported an incidence of hbs post-parathyroidectomy for phpt at 13.4%.2 yeh et al. in 2013 noted that majority of cases occured in patients over the age of 50-65 years with women being affected twice as often as men.7 among asians in thailand, the reported hbs incidence postparathyroidectomy for phpt was 22%. the subjects had a median age of 49 years (range 15 to 89 years) with female predominance at 3:1.4 in terms of clinical pre-operative symptoms of hypercalcemia, since calcium homeostasis is important to normal cellular function, the manifestations of phpt may present as musculoskeletal, renal, gastrointestinal, cardiovascular, neuromuscular and neuropsychiatric symptoms.1 the abnormalities directly associated with hyperparathyroidism are nephrolithiasis and bone disease due to prolonged pth excess. among our patients included in this study, the most common presenting symptoms were renal, musculoskeletal and gastrointestinal in nature. phpt diagnosis is made by biochemical testing. localization studies are only recommended if the patient will undergo surgery. commonly used and available imaging methods include neck ultrasound, tc99m sestamibi scintigraphy with spect or subtraction thyroid scan and mri of the neck. sestamibi scintigraphy combined with spect has the highest positive predictive value of the available imaging techniques.8 in our institution, the practice was at par with the recommendations for pre-operative parathyroid gland localization as majority of the patients were likewise subjected to tc99m sestamibi scan with spect. even the findings of the parathyroid gland histopathology post-operatively among our patients were consistent with the literature that single adenomas account for up to 80 – 85% of cases of phpt and mostly consist of parathyroid chief cells.1 in a 2013 meta-analysis on measures that can be instituted preoperatively to prevent hbs, it was recommended to supplement vitamin d pre-parathyroidectomy to normalize levels as depleted vitamin d has been postulated as a risk factor for the development of hbs. other agents that may be used with good level of evidence are bisphosphonates that best address bone resorption. intravenous pamidronate given 2 days pre-operatively decreased serum calcium pre-surgery and decreased calcium requirements postprocedure while intravenous zoledronate lowered hbs frequency post-operatively by as much as 4%.3 on one end of the spectrum, preparation for parathyroidectomy in patients is not limited to prevention of hbs but also involves controlling elevated calcium levels to prevent occurrence of hypercalcemic crisis pre-operatively. in 2011, a study enumerated the treatment needed in the correction of hypercalcemia which includes adequate hydration, stimulation of calcium excretion by forced diuresis, inhibition of osteoclast effect on bone resorption through bisphosphonates or calcitonin and use of estrogens in menopausal women or calcimimetics like calcitonin.9 these were the rationale for the pre-operative preparation of our patients wherein most received hydration, diuretics, anti-resorptive agents, vitamin d and calcimimetics. several authors investigated possible risk factors for the development of hbs post-parathyroidectomy for phpt and in 2016, the following were identified: histopathologic finding of parathyroid hyperplasia and presence of osteoporosis pre-operatively. the hbs biochemical predictors were higher pre-surgery pth, alp and bun values. in addition, hbs was more common in patients who had parathyroidectomy concomitantly with thyroidectomy.2 another article presented the following risk factors: older age at the time of surgery, higher pre-operative levels of serum calcium, pth, alp, decreased serum levels of magnesium and albumin and depleted vitamin d status.3 radiographic evidence of phpt-associated bone pathology was likewise deemed to be a risk factor for hbs development. it was also reported that the volume and weight of the removed parathyroid adenomas were higher among patients who had hbs than those who had an uncomplicated post-operative course.3 apart from the documented increased risk of hbs if parathyroidectomy is performed table 2a. results of exact binary logistic regression to determine independent risk factors of hbs pre-operatively using continuous variables risk factors* odds ratio (or) sufficient suff.2* pr(suff ) 95% ci alk phosphatase (alp) 1.09* 1133 0.0000 1.03 +inf *median unbiased estimates (mue) table 2b. results of exact binary logistic regression to determine independent risk factors of hbs pre-operatively using binary variables (normal/abnormal) variable odds ratio sufficient suff.2* pr(suff ) 95% ci alk phosphatase (alp) 107.17* 7 0.0000 9.91 +inf *median unbiased estimates (mue) philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles 16 philippine journal of otolaryngology-head and neck surgery references melmed s, polonsky ks, larsen pr, krokenberg h, editors. williams textbook of endocrinology. 1. 13thed. philadelphia: elsevier, inc. 2016. kaya c, tam aa, dirikoc a, kilicyazgan a, kilic m, turkolmez s, ersoy r, cakir b. hypocalcemia 2. development in patients operated for primary hyperparathyroidism: can it be predicted preoperatively? arch endocrinol metab. 2016 oct; 60 (5): 465-471. doi: 10.1590/23593997000000207. epub 2016 oct 10. pmid: 27737322. witteveen je, van thiel s, romjin ja, hamdy na. hungry bone syndrome: still a challenge in the 3. post-operative management of primary hyperparathyroidism: a systematic review of literature. eur j endocrinol. 2013 feb 20; 168(3): r45-r53. doi: 10.1530/eje-12-0528. pmid: 23152439. prasarttong-osoth p, wathanaoran p, imruetaicharoenchoke w, rojananin s. primary 4. hyperparathyroidism: 11-year experience in a single institute in thailand. int j endocrinol. 2012; 2012: 952426. doi: 10.1155/2012/952426. pmid: 22701120 pmcid: pmc3369527. sandoval ma, paz-pacheco e. primary hyperparathyroidism with classic and severe skeletal 5. involvement. bmj case rep. 2010 aug 26; 2010. doi: 10.1136/bcr.04.2010.2929. pmid: 22767476. pmcid: pmc3028290. griebeler ml, keams ae, ryu e, hathcock ma, melton lj, wermers ra. secular trends in the 6. incidence of primary hyperparathyroidism over five decades (1965 – 2010). bone. 2015 apr; 73: 1 – 7. doi: 10.1016/j.bone.2014.12.003. epub 2014 dec 11. pmid: 25497786; pmcid: pmc4445941. yeh mw, ituarte ph, zhou hc, nishimoto s, liu il, harari a, et al. incidence and prevalence of 7. primary hyperparathyroidism in a racially mixed population. j clin endocrinol metab. 2013 mar; 98 (3): 1122-1129. doi: 10.1210/jc.2012-4022. pmid: 23418315. pmcid: pmc3590475. eslamy hk, ziessman ha. parathyroid scintigraphy in patients with primary hyperparathyroidism: 8. 99mtc sestamibi spect and spect/ct. radiographics. 2008 sep-oct; 28 (5): 1461 – 76. doi: 10.1148/rg.285075055. pmid: 18794320. zivaljevic v, kalezic n, jovanovic d, sabljak v, diklic a, paunovi i. preoperative preparation of 9. patients with hyperparathyroidism as comorbidity. acta chir iugosl. 2011; 58 (2): 109-115. doi: 10.2298/aci1102109z. pmid: 21879659. tachibana s, sato s, yokoi t, nagaishi r, akehi y, yanase t, et al. severe hypocalcemia complicated 10. by postsurgical hypoparathyroidism and hungry bone syndrome in a patient with primary hyperparathyroidism, graves’ disease, and acromegaly. intern med. 2012; 51 (14): 1896 – 1873. epub 2012 jul 15. doi: 10.2169/internalmedicine.51.7102. pmid: 22821103. rolighed l, rejnmark l, sikjaer t, heickendorff l, vestergaard p, mosekilde l, et al. vitamin 11. d treatment in primary hyperparathyroidism: a randomized placebo controlled trial. j clin endocrinol metab. 2014 mar; 99 (3): 1072 – 1080. epub 2014 jan 13. doi: 10.1210/jc.2013-3978. pmid: 24423366. with thyroidectomy, it is prudent to include thyroid function tests in the biochemical investigation prior to parathyroidectomy as concomitant graves’ disease or hyperthyroidism can exacerbate the increased bone turnover state in phpt.10 in our investigation, there were 4 identified possible biochemical risk factors that may predict hbs pre-operatively: 25-hydroxyvitamin d, bun, phosphate and alp. however, only abnormal alp showed a significant association with hbs after further analysis. serum alp levels can serve as a marker of bone remineralization. preoperative serum alp levels thereby reflect bone turnover status and directly relates to the osteoclastic activity and degree of bone resorption.2,3 as for the other three risk factors identified but that did not show significant results after exact logistic regression tests, a possible theoretical explanation could be that low vitamin d levels in phpt could mean more advanced disease reflecting higher bone resorption, reduced bone mineral density, post-operative hypocalcemia and higher pth levels.11 moreover, low serum levels of 25-hydroxyvitamin d cause decreased fractional calcium absorption leading to suboptimal bone mineralization.3 in hbs, the elevated bun as a risk factor can develop due to the advanced age of patients and the effects of hypercalcemia on renal blood flow and renal tubular function.2 while an increased pth level would theoretically inhibit proximal tubule reabsorption of phosphate leading to hypophosphatemia, the elevated pre-operative levels of phosphate in patients who developed hbs post-parathyroidectomy for phpt in our cases could be secondary to the effect of high pth on the bones that influences higher bone turnover releasing calcium and phosphate from the bone matrix into the circulation.1 this study has several limitations. the retrospective design did not give the researchers the opportunity to validate the symptoms of hypercalcemia pre-operatively or the hungry bone syndrome manifestations post-operatively. the sample size of 96 that was needed to show accurate estimates of incidence and identify significant predictors was not achieved in this study and potential significant associations among variables could have been masked. future researchers may consider a prospective study on the outcomes of patients undergoing parathyroidectomy for phpt or extend the study period to achieve the target sample size. the establishment of a multicenter case registry may provide a means for collaboration among different centers in the country for a more accurate estimate of epidemiology and better understanding of the clinical features of hbs post-parathyroidectomy for phpt. in conclusion, our study found that thirty-five percent (7/20) of our patients developed hbs post-parathyroidectomy for phpt between 2011 and 2016. our findings suggest that an abnormal alp level pre-operatively may be a risk factor for developing hbs postparathyroidectomy for phpt. knowledge of post-parathyroidectomy hbs for phpt may aid clinicians in pre-operative prevention and postoperative monitoring. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 under the microscope philippine journal of otolaryngology-head and neck surgery 51 this 52-year-old male underwent fine needle aspiration biopsy of a 2-cm diameter parotid mass that was firm, well-delineated and vaguely moveable, the mass was not painful and was noted for about a year. the aspiration biopsy smear was quite cellular and showed fragments of spindle-shaped cells with cigar shaped nuclei and scanty to indistinct cytoplasms. nuclei were vesicular and verocay-like bodies were identified by cell patterns. the biopsy was read as a benign spindle cell tumor, probably a schwannoma. excision of the mass revealed a typical schwannoma by histopathology. schwannomas of the parotid gland are rare1 and arise from the intraparotid branches of the facial nerve. clues to the cytologic diagnosis include the cellular but benign spindly cell population clustered into verocay body patterns and evidence of cyst degeneration in the form of histiocytes and even lymphocytes.2 main differential diagnoses include the predominant spindle cell myoepitheliomas3 and some of the low grade sarcomas that may arise from the parotid gland. the even rarer schwannomalike mixed tumor of the parotid4 gland must be also considered. jose ma. c. avila, m.d. department of pathology college of medicine university of the philippines manila fine needle aspiration cytology of schwannoma of the parotid gland correspondence: jose ma. c. avila, m.d. university of the philippines manila college of medicine department of pathology 547 pedro gil st. ermita, manila, 1000 phone (632) 526 4550 fax (632) 400 3638 philipp j otolaryngol head neck surg 2008; 23 (2): 51 c philippine society of otolaryngology – head and neck surgery, inc. references: 1. falconi m, russo a, taibah a, sanna m. facial nerve tumors. otol neurotol. 2003 nov; 24(6):942-7 2. maly b, maly a, doviner v, reinhartz t, sherman y. fine needle aspiration biopsy of intraparotid schwannoma-a case report. acta cytol. 2003 nov-dec;47(6):1131-4. 3. siddaraju n, badhe bahe ba, fonrepanavar m, mishra mm. preoperative fine needle aspiration cytology diagnosis of spindle cell myoepithelioma of the a parotid gland: a case report. acta cytol. 2008 may-jul; 53(4):495-9. 4. kajor m, gierek t, markowski j, pajak j. schwannomalike mixed tumor of the parotid gland: a case report. acta cytol. 2006 sep-oct; 50(5):529-30. 400x, diff-quik stain philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 34 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to report a case series of tessier 3, 4, 7 and combined 4,7 craniofacial clefts, their clinical presentations, surgical approaches and outcomes in light of the current literature. methods: design: case series setting: tertiary government hospital subjects: five patients results: five patients aged 3 to 14-years-old with tessier 3, 4 (2 cases), 7 and combined 4,7 were included in this study: tessier 3 – medial orbitomaxillary cleft extending through the bony skeleton traversing obliquely across the lacrimal groove, tessier 4 – median orbitomaxillary cleft traversing vertically through the inferior eyelid, infraorbital rim and orbital floor extending to the lip between the philtral crest and the oral commissure (2 cases), tessier 7 macrostomia and cleft oral commissure and combined tessier 4 and 7, combining features described above. four underwent 2or 3-stage surgeries while one declined. conclusion: five craniofacial clefts were presented. because of the varying patterns of craniofacial deformities, a series of surgical procedures, tailor-made for each individual were performed on four. otolaryngologists who perform maxillofacial and cosmetic surgery should have good background knowledge about craniofacial defects and be familiar with the surgical approaches at their disposal to yield favorable results that are appropriate to their local contexts. keywords: tessier clefts no. 3, 4 and 7, oculoplasty, commisuroplasty, alar transpositional flap, canthopexy craniofacial clefts are among the rare congenital malformations with an incidence of between 1.43 to 4.85 per 100,000 births.1 to our knowledge, less than 50 cases of tessier no. 4 clefts have been reported.1 the tessier classification system is a craniofacial cleft nomenclature devised by paul tessier in 1976 wherein he assigned a specific number to the site of each malformation based on its relationship to the sagittal midline of the facial bone.2 aside from genetic factors, environmental factors and the interplay of the two may contribute to the development of facial clefts.3 although new cases of craniofacial clefts are encountered locally, few are documented in the literature. for instance, we only found two local articles on facial clefts by tian et al.4 and chiong et al.5 in this journal. because of improvements in perinatal and pediatric care, there is a good possibility that more affected individuals will seek reconstructive surgery. we present five such cases, their clinical presentations, surgical approaches and outcomes. a case series of tessier 3, 4, 7 and combined 4, 7 craniofacial clefts karen adiel d. rances, md1 emmanuel tadeus s. cruz, md1, 2 arsenio l. pascual, md1 jomar s. tinaza, md1 1department of otorhinolaryngology head & neck surgery quezon city general hospital and medical center 2department of otorhinolaryngology head & neck surgery manila central university-filemon d. tanchoco medical foundation correspondence: dr. arsenio l. pascual department of otorhinolaryngology-head & neck surgery quezon city general hospital and medical center seminary road, munoz, quezon city 1106 philippines phone: (632) 426 1314 local 232 fax: (632) 920 7081; 920 6270 email: orl_hns_qcgh@yahoo.com.ph reprints will not be available from the author the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at philippine society of otolaryngology head and neck surgery descriptive research contest, september 19, 2013. natrapharm, the patriot bldg., km 18 slex, paranaque city. philipp j otolaryngol head neck surg 2015; 30 (1): 34-38 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 35 case reports case 1 a 3-yearold boy with a tessier 4 cleft had the following deformities: inferior eyelid coloboma on the right eye, bilateral cleft along the lateral margin of the cupids bow, epicanthal fold and microphthalmia on the left and cleft palate. (figure 1a) he had undergone facial repair with an interdigitating local flap 3 years ago and palatoplasty the following year. present examination revealed inferior eyelid coloboma of the right eye, epicanthal fold and microphthalmia on the left. (figure 1b) because of the redundant skin flap over the right inferior orbital rim from the previous surgery, revision was performed using transposition of upper-lid pedicle flap. (figure 2) after two weeks, the flap was resected horizontally at the midline to facilitate eye opening. case 2 a 3-year-old boy with tessier 4 cleft underwent cheiloplasty in 2010 and palatoplasty in 2011. the patient had a bilateral lower eyelid coloboma and corneal exposure. a simultatneous revision palatoplasty for oronasal fistula and oculoplasty via bilateral canthopexy were performed. (no consent was given to reproduce his photos). case 3 a 14-year-old boy with a tessier 3 cleft presented with bilateral lower eyelid coloboma, distortion of the frontal process of the maxilla on the right, coloboma of the nasal ala and midline cleft lip with absence of philtrum. the cleft passed across the lacrimal segment through the soft tissue vertically extending to the alar base. (figure 3) transposition of eyelid pedicle flap and medial canthopexy were done on both eyes. for the naso-malar component, soft tissue dissection and alar transposition advancement flap was done. the cleft lip was repaired with a straight-line closure. ct scan two days after surgery revealed hypoplasia of naso-maxillary bone and alveolar process. (figure 4) a structural rhinoplasty and scar revision will be performed in the future. case 4 a 4-year-old boy with a tessier 7 cleft presented with unilateral minor macrostomia (cleft length of 1-2 cm), left oral commissure cleft and preauricular skin tag. left lateral oral commisuroplasty was done and the preauricular skin tag was excised. (figure 5) case 5 a 5-year-old girl with combined tessier 4 and 7 unilateral clefts on the left presented with an orbitomaxillary cleft that traversed the inferior eyelid and infraorbital rim extending onto the lip between the philtral figure 1. case 1. a. facial cleft tessier 4 at 6-months-old b. facial cleft tessier 4 at 3-years-old, s/p facial repair with an interdigitating local flap and palatoplasty. present examination revealed inferior eyelid coloboma of the right eye, epicanthal fold and microphthalmia on the left. photos printed in full with permission. figure 2. a & b. note the redundant skin flap over the right inferior orbital rim from the previous surgery c & d. revision reconstruction using pedicled upper eyelid flap after a week; resected eyelid flap. e. resected eyelid flap after 3 months. photos printed in full with permission. a a c d e b b philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 36 philippine journal of otolaryngology-head and neck surgery original articles a b figure 3. case 3. (upper row) comparative views of the 14-year-old boy with facial cleft tessier 3 before (bottom row) three weeks after surgery a. frontal views b. antero-inferior views c. right lateral views of orofacial deformity. photos printed in full with permission. figure 4. three-dimensional reconstruction ct scan of the tessier 3 patient. note hypoplasia of naso-maxillary bone and alveolar process and cleft between the upper central incisors. figure 5. case 4: the boy with tessier 7 cleft. left, macrostomia, commissure cleft and preauricular skin tag;(center) after commisuroplasty; (right) two weeks after the surgery. photos printed in full with permission. c philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 37 discussion facial clefts may be defined as a gap (hypoplasia), misshapen face (dysplasia), interruption or deficiency in the continuity of a soft tissue (coloboma) or fissure in the soft tissue, bone or a combination of both. it may be located in the forehead, eyes, cheeks, mouth, nostrils and lips.6 craniofacial defects may be diagnosed or classified under the tessier classification. this is the most widely used system which schematically assigns and designates numbers to describe craniofacial clefts.2 based on this classification, the patients in this study include a tessier 3 cleft – medial orbitomaxillary cleft that extends through the bony skeleton as a paranasal cleft traversing obliquely across the lacrimal groove with often complete absence of the anterior and medial wall of the maxillary sinus; two tessier 4 clefts – medial orbitomaxillary cleft traversing vertically through the inferior eyelid, infraorbital rim extending to the lip between the philtrum crest and the oral commissure; a tessier 7 (lateral or transverse cleft) macrostomia and cleft oral commisure and presence of preauricular skin tag; and a combined tessier 4 and 7 cleft, with features as described above. four cases underwent 2or 3-stage surgeries while one case declined. in a recent study, butow proposed a new classification of lateral facial clefts based on the direction of the anatomical appearance as follows: t7.1 superiorly rotated, t7.2 – middle positioned, t7.3 inferiorly rotated and t7.4, agenetic type.7 a for embryology, a tessier 3 cleft results from failure of closure of the naso-optic groove between the frontonasal and medial maxillary processes; a tessier 4 cleft has been ascribed to primary arrest of development, neurovascular insufficiency or a result of tears in the developing maxillary process; while a tessier 7 cleft may result from incomplete fusion of the mesodermal merging of the maxillary and mandibular processes.3 figure 6. case 5: a 5-year-old female with combined tessier 4 & 7 cleft. the parents refused surgery. photos printed in full with permission the etiology of orofacial clefts is multifactorial. environmental factors include exposure to radiation and chemicals, intake of teratogenic drugs (retinoic acid, phenytoin, valproic acid and corticosteroid), maternal cigarette smoking, and folate deficiency during pregnancy.3 genetic factors also play a role in the development of facial clefts. other than embryologic abnormalities in the fusion of frontonasal and maxillary processes, the size of the facial processes affects facial morphology and susceptibility to develop a cleft. a smaller median nasal process or midface among asians and flat nasal structures may predispose to orofacial cleft development while the reverse is true for africans with broad, larger noses and increased facial widths representing well developed median nasal processes and a decreased propensity for clefting.3 a comprehensive discussion on the incidence, etiology, inheritance, transmission risks of orofacial clefting by eppley is available in the literature.3 case 1 (tessier no. 4) was previously repaired with interdigitating local flaps but the result was not satisfactory due to scarring. case 2 (tessier no. 4) had bilateral lower eyelid colobomas and corneal exposure. some surgeons would consider a mustarde cheek rotational flap to reconstruct such large defects of the cheek as the upper flap edge will provide tissue for the lower eyelid.1 other have utilized z-plasty, advancement flap of the cheek and tissue expansion methods to close the defect.8 we employed an upper-lid pedicle flap for the first case and bilateral canthopexy to reduce corneal exposure on our second case. (figures 2, 3) features of a tessier 3 cleft include inferior displacement of medial canthus, superior displacement of the alar base, cleft lip and palate, coloboma of the lower eyelid, nasolacrimal abnormality, disruption of medial wall of antrum, cleft of inferomedial wall of the orbit and telorbitism.9 anophthalmia or microphthalmia may be a feature of tessier 3 clefts.9 our third case had bilateral lower eyelid coloboma, distortion of the frontal process of the maxilla on the right, coloboma of the nasal ala and midline cleft lip with absence of philtrum. cizmezi8 performed an alar transposition flap and irregular z plasty in a patient with tessier 3 cleft. because of the severe facial disfigurement, the patient had dropped out from school due to low self-esteem and isolation from his peers. after a series of surgeries, his cosmetically acceptable appearance provided renewed self-confidence and hope for a brighter future. in our case, transposition of eyelid pedicle flap and medial canthopexy were done on both eyes and soft tissue dissection and alar transposition advancement flap were employed for the nasomalar component. the cleft lip was repaired with a straight-line closure. a structural rhinoplasty and scar revision will be performed in the future. (figure 5) crest and the oral commisure. she also had ipsilateral macrostomia and a cleft oral commissure. (figure 6) unfortunately, her family refused surgery. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 38 philippine journal of otolaryngology-head and neck surgery original articles acknowledgements the authors would like to thank dr. peter ayliffe who performed surgery on two patients (cases 1 and 3) and for his inputs in the course of preparing the manuscript, and dr. lhea descartin for the photographs of the three patients (cases 1, 2 and 3). references 1. coruh a, gunay gk. a surgical conundrum: tessier number 4 cleft. cleft palate craniofac .j. 2005 jan; 42(1): 102-106. 2. greenberg am, prein j. craniofacial reconstructive and corrective bone surgery: principles of internal fixation using the ao/asif technique. new york: springer, 2002. pp 23-37. 3. eppley bl, van aalst, ja, robey a, havlik rj, sadove am. the spectrum of orofacial clefting. plast reconstr surg. 2005 jan; 115(7): 101-113. 4. tian pg, chua ah, nolasco fp. clefts beyond the lip and palate: a case series on facial clefts. philipp j otolaryngol head neck surg. 1999 jan-mar; 14(1): 28-33. 5. chiong at, guevarra es, zantua rv. oblique facial cleft. philipp j otolaryngol head neck surg. 1982; 88-93. 6. smith pb. tessier clefts. american cleft palate foundation. [cited 2003 jan]. available from: www. cleftline.org/docs/tessierinfo.pdf. 7. butow kw, botha a. a classification and construction of congenital lateral facial clefts. j craniomaxillofac surg. 2010 oct; 38(7): 477-84. 8. cizmeci, o, kuvat sv. tessier no. 3 incomplete cleft reconstruction with alar transposition and irregular z-plasty. plast surg int. 2011; 2011: 596569. 9. wenbin z, hanjiang w, xiaoli c, zhonglin l. tessier 3 cleft with clinical anophthalmia: two case reports and a review of literature. 2007 jan; 44(1): 102-105. 10. mishra rk, purwar r. formatting the surgical management of tessier cleft 3 and 4. indian j plast surg. 2009 oct; 42 suppl: s174-83. 11. shires cb, hodges jm, thompson j, gorman m, stocks r. tessier 7: a case report and literature review. laryngoscope. 2009; 119: 148. 12. gokrem s, ozdemir om, katircioglu a, sen z, ersoy a, can z., et. al. a rare craniofacial cleft: tessier no. 7: a retrospective analysis. j ankara med sch. 2002 oct; 24(2): 63-68. gokrem reported five cases of tessier 7 lateral facial clefts on the left or right oral commissure managed with the skoog technique that utilizes z-plasty in the skin closure.12 a commisureplasty was performed in our patient. we presented five cases of craniofacial clefts. because of the varying patterns of craniofacial deformities, a series of surgical procedures was tailor-made for each individual. soft tissue reconstruction was the common denominator used in the surgical techniques of the four cases operated on while others would integrate bone, cartilage grafts or implants in the reconstruction of such defects. (table 1) orofacial clefts involve the skin, subcutaneous tissue, muscle and mucosa and do not necessarily extend to the bony structures. to document bony involvement, ct scan evaluation is required. among our five cases, only the patient with a tessier 3 cleft had a post-operative ct scan that revealed hypoplasia of the right nasomaxillary and upper alveolar process hypoplasia. a limitation of this series is that none of the patients were preoperatively evaluated for bony involvement. whether such evaluation should be routine in low-income settings such as ours where costs outweigh benefits is arguable. surgical management of orofacial clefts is complicated, challenging and requires experience, expertise and craft. otolaryngologists who perform maxillofacial and cosmetic surgery should have good background knowledge in dealing with these deformities and be familiar with the conventional and contemporary diagnostic and surgical approaches to yield favorable results that are appropriate to their local contexts. table 1. summary of the clinical features and surgery of the 5 patients case age/ sex tessier features management 1 2 3 4 5 3/m 3/m 14/m 4/m 5/f 4 4 3 7 4,7 lower eyelid coloboma, right epicanthal fold; bilateral cleft through the lateral margin of the cupids bow; microphthalmia, left; cleft lip and palate lower eyelid coloboma, bilateral; corneal exposure; cleft lip and palate bilateral lower eyelid coloboma, distortion of frontal process of maxilla on the right, coloboma of the nasal ala, midline cleft lip with absence of philtrum; the cleft passes across the lacrimal segment through the soft tissue vertically extending to the alar base. unilateral macrostomia, left oral commissure cleft and preauricular skin tag. orbitomaxillary cleft that traverses vertically involving the inferior eyelid, infraorbital rim extending onto the lip between the philtrum crest and the oral commisure, macrostomia and cleft oral commisure cheiloplasty with facial repair using interdigitating local flap, , uranoplasty; upper lid pedicle flap cheiloplasty; uranoplasty; canthopexy transposition of eyelid pedicle flap and medial canthopexy, straight line closure technique; soft tissue dissection and alar transposition advancement flap lateral commisuroplasty via straight-line closure none mishra and purwar proposed formatting a ‘split approach’ for the surgical management of tessier 3 and 4 clefts in which the affected areas of the cleft were divided into three: lid, lip and nasomalar components. the formatting is done to segregate the cleft into different compartments. afterwards, the surgical blueprint is drawn and performed one after the other. they concluded that formatting provides technical ease with pleasing surgical results after doing surgery in seven cases of tessier 3 and 4.10 the tessier 7 cleft is the most common among orofacial clefts with an incidence of 1 in 3000 neonates and is often associated with multiple congenital syndromes. it rarely occurs bilaterally (10-20% of cases).11 it has been described as craniofacial macrostomia, first and second branchial arch syndrome and otomandibular dysostosis.12 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports philippine journal of otolaryngology-head and neck surgery 27 abstract objective: to report a case of extramedullary plasmacytoma, a rare localized tumour involving the head and neck region in a 56-year -old gentleman. methods: design: case report setting: tertiary university referral center patient: one result: the patient presented with a 5-month history of right-sided nasal obstruction and intermittent epistaxis in 2003. nasal endoscopy revealed a friable, dark red mass arising from the roof of the nasopharynx, occluding the right choana. no invasion of adjacent tissues or cervical lymphadenopathy was evident. a biopsy of the mass was diagnosed as plasmacytoma. serum and urine electrophoresis failed to detect any monoclonal bands. all other screening tests to rule out multiple myeloma were negative. these findings confirmed the diagnosis of extramedullary plasmacytoma. he recieved radiotherapy to the nasopharynx of 50 gy for a total of 23 fractions. no recurrence was noted at 7-year follow-up. conclusion: extramedullary plasmacytoma of the nasopharynx represents a tumour with good prognosis but requires long term follow up in anticipation of local recurrence and progression to multiple myeloma. keywords: extramedullary, plasmacytoma, nasopharynx plasmacytomas are discrete tumours of solitary neoplastic plasma cells occuring in the bone (solitary plasmacytoma) or other soft tissues (extramedullary plasmacytoma). extramedullary plasmacytoma is a rare localized tumour, first described by schridde in 19051. three clinical manifestations exist: solitary, aggressive and disseminated. it is a rare neoplastic lesion that may occur in the head and neck region.1 these lesions account for 4% of all nonepithelial tumors of the nasal cavity, paranasal sinuses and nasopharynx and they represent 0.4% of all head and neck malignancies.1 they have a slight predilection to men with peak incidence in patients aged 50 to 60 years.2 extramedullary plasmacytoma can occur synchronously with multiple myeloma or can be antecedent to multiple myeloma years after, hence, the role of comprehensive multidisciplinary approach in long term management of such patients. the interrelationship between these different neoplastic plasma cell disorders was first described by batsakis in 1983.3 the development of multiple myeloma has been observed in 8 to 36% of patients with extramedullary plasmacytoma. 1,2 whilst plasmacytomas tend to be discrete and solitary, multiple myeloma is diagnosed when there is diffuse infiltration of the marrow with neoplastic plasma cells.3 extramedullary plasmacytoma of the nasopharynx: a rare tumour with 7-year follow up mawaddah azman, md1 balwant singh gendeh, mbbs, ms (orlhns)1 siti aishah mat ali, mbbch, dcp2 1department of otorhinolaryngology head and neck surgery faculty of medicine, universiti kebangsaan malaysia kuala lumpur, malaysia 2department of pathology faculty of medicine, universiti kebangsaan malaysia kuala lumpur, malaysia correspondence: dr. mawaddah azman department of otorhinolaryngology-head and neck surgery 9th floor clinical block, faculty of medicine, universiti kebangsaan malaysia medical centre jalan yaakob latiff, bandar tun razak 52000 cheras, kuala lumpur, malaysia tel: +60163061959 fax: +60391456675 email: mawaddah1504@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (1): 27-30 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 28 philippine journal of otolaryngology-head and neck surgery case reports case report a 56-year-old gentleman with multiple co-morbidities presented to us in april 2003 with a 5-month history of right sided progressively worsening nasal blockage associated with intermittent self limiting epistaxis. this was associated with anosmia and occasional right sided temporal headaches. there was no history of loosening of teeth, facial swelling, diplopia or blurring of vision. examination revealed a friable, dark red mass arising from the roof of the nasopharynx, completely occluding the right choana (figure 1). intraorally, there was inferior extension of the mass to the soft palate. there was no palpable cervical lymphadenopathy and cranial nerve examination was unremarkable. no other lesions were found in the head and neck region. he had a background history of hypertension, ischaemic heart disease and was an ex-chronic smoker. computed tomography showed a heterogeneously enhancing soft tissue density mass measuring 2.5 cm in its largest dimension, arising from the right post nasal space. no associated bony erosion or cervical lymphadenopathy was present. biopsy of the mass revealed a nodular grayish tissue microscopically showing diffuse infiltration of the submucosal layer with plasma cells. the plasma cells were mature in appearance with eccentric nuclei and clock face chromatin pattern. immunohistochemical studies revealed strong positivity towards lambda restriction and were negative for kappa, lca, b and t cell markers as well as cytokeratin. a histopathological diagnosis of extramedullary plasmacytoma of the nasopharynx was entertained. urine and plasma electrophoresis were performed following this histological diagnosis, revealing no evidence of monoclonal band. bone scan of the paranasal sinuses and skeletal surveys showed no lytic bony lesions suggestive of multiple myeloma. he underwent bone marrow and trephine biopsy to rule out marrow involvement. however, he developed cardiogenic shock secondary to unstable angina immediately following the procedure necessitating resuscitation and inotropic support. the bone marrow and trephine biopsy showed only occasional abnormal plasma cells of less than 5%. he recovered from the cardiac event and was offered curative radiotherapy in view of his poor general medical condition. he subsequently underwent curative radiotherapy of 50 gy for a total of 23 fractions to the nasopharynx. he was well post radiotherapy with no further episodes of epistaxis or nasal obstruction. total resolution of the mass was observed following radiotherapy with no subsequent evidence of local recurrence. figure 4 shows an endoscopic view of the right choana 7 years post irradiation. this patient is receiving surveillance follow up from both the otorhinolaryngology and hematology teams. up till his last visit at 7 years post irradiation, surveillance endoscopy, urine and serum paraprotein showed no significant evidence of local recurrence or development to multiple myeloma. figure 1: endoscopic view (l, lateral; m, medial) showing a friable mass completely occupying the right choana (arrowheads), extending inferiorly into the oropharynx (op). discussion plasma cell neoplastic disorders are important for otorhinolaryngologists to recognize since according to wiltshaw in 1976, 80% of extramedullary plasmacytomas occur in the head and neck and 10-20% of cases may present with multiple lesions.6 the etiology of extramedullary plasmacytoma is unknown. proposed risk factors include chronic antigenic stimulation such as osteomyelitis, cholecystitis, rheumatoid arthritis and bacterial flora. plasmacytoma philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports philippine journal of otolaryngology-head and neck surgery 29 formation has been demonstrated in laboratory mice treated with salmonella flagellar antigen and with bovine serum albumin. genetic factors, radiation exposure, smoking and occupational exposures have also been implicated in the myeloma literature as possible etiologic agents. 3,7,8 wax, et al. in 1993 reviewed similar cases and found that 75% of extramedullary plasmacytomas occurred in the sinonasal or nasopharyngeal area, 12% in the oropharynx, 8% in the larynx, and other sites in the head and neck including the tongue, minor salivary glands, thyroid, parotid, orbit and temporal bone.10 outside of the head and neck, extramedullary plasmacytoma has been reported in the pleura, mediastinum, spermatic cord, ovary, intestines, kidney, pancreas, breast, and skin.10 most of the symptoms related to extramedullary plasmacytoma can be related to their specific location in the head and neck. cervical lymph node metastasis is reported to occur in 12-26% of cases at initial presentation. biopsy of the lesion is the first step in confirming the diagnosis. deep biopsies must be taken since the tumor is submucosal and the mucosa may be thickened from an inflammatory reaction.1 histological subtypes of plasmacytoma including plasmacytic, plasmablastic and anaplastic subtypes have been described. however, these subtypes are neither indicative of prognosis or increased risk of recurrence.1,3 local amyloid deposits have been found in 11-38% of cases but systemic amyloidosis is very rare. similar to multiple myeloma and other b cell neoplasms, a monoclonal staining pattern demonstrating either one heavy chain class, one light chain type or both can be demonstrated from immunohistochemical techniques.3,7,8 with new advances in immunophenotyping, cd 138 has been recognized as a marker for neoplastic plasma cells.17 however, it was not available in our centre at the point of diagnosis. our immunohistochemical staining showed strong positivity to lambda restriction. in a 1988 review of plasma cell disorders, abemayor, et al. recommend a complete blood count with white blood cell count and platelet count, bone marrow biopsy, serum biochemistry including calcium, blood urea nitrogen, creatinine, uric acid, serum protein, serum and urine electophoresis, and a skeletal survey to rule out multiple myeloma.7 galieni et al. suggested certain diagnostic criteria for solitary extramedullary plasmocytoma. they include biopsy of tissue showing monoclonal plasma cell histology, bone marrow plasma cell infiltration showing less than 5% of all nucleated cells, absence of any osteolytic bone lesion, absence of hypercalcemia or renal failure and low levels of paraprotein concentration if present.12 our case satisfied all the criteria described above. high levels of paraprotein in the serum or urine should raise the clinician’s suspicion of a disseminated process, since paraprotein levels correlate directly with tumor burden. a review of therapeutic approaches to extramedullary plasmacytoma of the nasopharynx in published reports in the past ten years is discussed. although similar cases have been described as early as 40 years ago, treatment has remained controversial. they include figure 2: computed tomography, axial and coronal sections, showing mass arising from the right postnasal space extending inferiorly to the oropharynx without any bony involvement. curative radiotherapy, curative surgical resection, salvage surgery and chemotherapy.13 while it is agreed that extramedullary plasmacytomas are radiosensistive, there is no consensus in the literature about the ideal dose of radiation therapy. residual tumor is observed in 20% of patients after radiotherapy, so additional courses are sometimes necessary.14 alexiou et al. suggested that surgery alone gave the best results for extramedullary plasmacytoma of the upper aero-digestive tract when resectability is good. however, if complete surgical resection was not possible or doubtful, and/or lymph nodes were affected, then combined therapy (surgery and radiation) was recommended.15 there are very few reports of local recurrence of plasmacytomas treated primarily by surgery.16 most authors recommended salvage surgery if there is local failure following additional courses of radiotherapy. salvage surgery following radiotherapy often yields more amyloid component rather than tumour tissue, suggesting its radiosensitive properties.11 rubin et al. in 1990 reviewed 14 series and 219 cases of extramedullary plasmacytoma of the head and neck in the literature. they found that 55% of patients treated with radiotherapy alone and 54% of patients treated with surgery alone had no evidence of 30 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports recurrence post treatment. mortality and recurrence were also noted to not be significantly different between the two groups. chemotherapy and bone marrow transplantation is reserved for disseminated disease or progression to multiple myeloma.9 factors associated with poor prognosis in the literature include the presence of bone destruction, large primary tumor, recurrence, and tumors located in the sphenoid, maxillary sinus, orbit, and larynx.6 histologic appearance and lymph node involvement are not reported to be of any prognostic significance. because extramedullary plasmacytoma can recur as disseminated multiple myeloma long term follow-up likewise in our patient is important. cases of recurrence have been reported 28 and 36 years after initial treatment in the literature.6 while most diseases are considered treated following five years of being recurrence free, such is not the case in plasmacytoma. therefore, we plan for lifetime follow up in this patient, diligently anticipating any possible recurrence or progression to multiple myeloma. extramedullary plasmacytoma of the nasopharynx represents a tumour with good prognosis but requires long term follow up in anticipation of local recurrence and progression to multiple myeloma. figure 4: endoscopic view of the right choana, 7 years post irradiation (2010) showing no evidence of local recurrence. l: lateral wall of the nasal cavity m: medial wall of the nasal cavity figure 3: diffuse infiltration of the submucosal layer with plasma cells seen under high power view (hematoxylin eosin staining, magnification 100x). the latter showing immunohistochemical staining positive towards lambda restriction (magnification 100x) references 1. miller fr, lavertu p, wanamaker jr, bonafede j, wood bg. plasmacytomas of the head and neck. otolaryngol head neck surg 1998 dec; 119(6):614-18. 2. paris j, dessi p, moulin g, chrestian ma, braccini f, zanaret m. extramedullary plasmacytoma of the nasal cavity: a case report. rev laryngol otol rhinol 1999; 120(5): 343-5. 3. batsakis jg. plasma cell tumors of head and neck. pathology consultation. ann. otol. rhinol. laryngol. 1983 may-jun;92:311–313. 4. knowling ma, harwood ar, bergsagel de. comparison of extramedullary plasmacytomas with solitary and multiple plasma cell tumors of bone. j clin oncol 1983 apr; 1(4):255-62. 5. holland j, trenker da, wasserman th, fineberg b. plasmacytoma. treatment results and conversion to myeloma. cancer 1992 mar 15; 69 (6): 1513-17. 6. wiltshaw e. the natural history of extramedullary plasmacytoma and its relation to solitary myeloma of bone and myelomatosis. medicine (baltimore) 1976 may; 55(3): 217-38. 7. abemayor e, canalis rf, greenberg p, wortham dg, rowland jp, sun nc. plasma cell tumors of the head and neck. j otolaryngol. 1988 dec; 17(17):376-381. 8. batsakis jg, fries gt, goldman rt, karlseberg rc. upper respiratory tract plasmacytoma. arch otolaryngol. 1964 jun; 79:613-618. 9. rubin j, johnson jt, killeen r, barnes l. extramedullary plasmacytoma of the thyroid associated with a serum monoclonal gammopathy. arch otolaryngol head neck surg. 1990;116(7):855-859. 10. wax mk, yun kj, omar ra. extramedullary plasamacytomas of the head and neck. otolaryngol. head neck surg. 1993 nov;109(5):877–888. 11. hidaka h, ikeda k, oshima t, ohtani h, suzuki h, takasaka t. a case of extramedullary plasmacytoma arising from the nasal septum. j laryngol otol. 2000 jan; 114(1):53-5. 12. galieni p, cavo m, pulsoni a, awisati g, bigazzi c, neri s, et al: clinical outcome of extramedullary plasmacytoma. haematologica 2000 jan; 85(1): 47-51. 13. yavas o, altundag k, sungur a. extramedullary plasmacytoma of nasopharynx and larynx: synchronous presentation. am j hematol 2004 apr; 75 (4): 264-5. 14. tesei f, caliceti u, sorrenti g, canciullo a, sabbatini e, pileri s, et al. extramedullary plasmocytoma (emp) of the head and neck: a series of 22 cases;. acta otorhinolaryngol ital. 1995 dec; 15 (6): 437-42. 15. alexiou c, kau rj, dietzfelbinger h, kremer m, spiess jc, schratzenstaller, et al. extramedullary plasmacytoma; tumour occurrence and therapeutic concepts. cancer 2000 jan 1; 88(1): 240-242. 16. soesan m, paccagnella a, chiarion-sileni v, salvagno l, fornasiero a, sotti g, et al. extramedullary plasmacytoma: clinical behaviour and response to treatment. ann oncol. 1992 jan; 3(1) :51-57. 17. o’connell fp, pinkus jl, pinkus gs.). cd138 (syndecan-1), a plasma cell marker immunohistochemical profile in hematopoietic and nonhematopoietic neoplasms. am. j. clin. pathol. 2004 feb; 121 (2): 254–63. (hematoxylin-eosin, 100x) (immunohistochemical stain, lambda restriction, 100x) philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 original articles philippine journal of otolaryngology-head and neck surgery 13 abstract objective: to test the antibacterial properties of three commercially available nasal corticosteroid preparations containing mometasone furoate (mf), fluticasone propionate (fp) and fluticasone furoate (ff) against s. pneumoniae, s. viridans, s. aureus, h. influenza, p. aeruginosa and e. coli. methods: study design: experimental in vitro study using the disc diffusion method. clinical isolates of streptococcus pneumoniae, hemophilus influenzae, streptococcus viridans, staphylococcus aureus, pseudomonas aeruginosa, and escherichia coli were inoculated on separate plates. 0.15 ml of nasal corticosteroid preparations containing mf, fp and ff were applied to blank paper discs, then placed on the plates, including an empty disc. following 24 and 48 hours of incubation, the inhibition zones were measured to the nearest mm from the point of abrupt inhibition of growth. results: after 24 and 48 hours of incubation, s. pneumoniae, s. viridans, and s. aureus showed inhibition zones to all three preparations. s. aureus and s. viridans show the largest zones of inhibition at 24 and 48 hours respectively. h. influenza, p. aeruginosa and e. coli were negative. the inhibition zones of each bacteria were shown to be statistically different. the preparation containing fp had the largest zone of inhibition at 24 and 48 hours, although post hoc tests showed their difference was not significant. conclusion: the present study demonstrates possible antimicrobial properties of commerciallyavailable nasal corticosteroid preparations. however, it is unclear whether these can be attributed to the steroids, their excipients, or both. further studies testing each component may offer better insights into their therapeutic use. keywords: mometasone furoate, fluticasone propionate, fluticasone furoate, antibacterial, nasal corticosteroids, allergic rhinitis, acute bacterial rhinosinusitis in vitro antibacterial activity of mometasone furoate, fluticasone propionate and fluticasone furoate nasal preparations against streptococcus pneumoniae, hemophilus influenzae, streptococcus viridans, staphylococcus aureus, pseudomonas aeruginosa, and escherichia coli philip lance a. liu, md rose lou marie c. agbay, md samantha s. castañeda, md department of otolaryngology head and neck surgery the medical city correspondence: philip lance a. liu, md department of otorhinolaryngology head and neck surgery the medical city ortigas avenue, pasig city 1600 philippines telefax: (632) 687 3349 email: lancealiu@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interests with any organization that may have direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at the analytical research contest (1st place), philippine society of otolaryngology head and neck surgery, glaxo smith kline (gsk) bldg. chino roces ave., makati city, philippines october 21, 2009 and 14th asian research symposium on rhinology, new world hotel, ho chi minh city, vietnam march 27, 2010. philipp j otolaryngol head neck surg 2010; 25 (1): 13-16 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 original articles 14 philippine journal of otolaryngology-head and neck surgery health care experts estimate that in the united states, acute and chronic rhinosinusitis affects an estimated 14% of the population.1 unfortunately, there is no precise local information. although nasal corticosteroids are generally not used in acute infections because of adverse effects, their adjunct use in acute sinusitis has been proposed because of their decongestant and anti-inflammatory properties.3 double-blind study data have shown that the addition of topical corticosteroids to oral antibiotics have a positive effect in the treatment of acute exacerbations of chronic rhinosinusitis.4 in addition to decongestant and anti-inflammatory properties, recent data suggest that corticosteroids may also demonstrate antibacterial properties against common ear, nose, and throat pathogens. in a recent in vitro study, viability of s. pyogenes was reduced by 99.00% by 0.01% mometasone furoate (mf), by 99.90% by 0.1% mf, and by 99.99% by 0.5% mf after 24 hours of incubation.2 in a similar study, dexamethasone (0.1%) killed s. milleri and a. flavus after incubation periods of 24 to 48 hours.5 this added property may modify the heretofore adjunct therapeutic role of topical corticosteroids in the management of acute sinusitis and other common ent infections. a literature search of ovid, pubmed and herdin databases using the terms “mometasone furoate,” “fluticasone propionate,” “fluticasone furoate” yielded no other studies on the possible antibiotic properties of other intranasal corticosteroids such as fluticasone propionate (fp) and fluticasone furoate (ff). this study aims to investigate the antimicrobial activity of locally available commercial nasal corticosteroid preparations containing mometasone furoate (mf), fluticasone propionate (fp) and fluticasone furoate (ff), against common bacteria causing bacterial sinusitis.6 specific objectives: 1. to measure the zone of inhibition from nasal corticosteroid preparations containing mf, fp and ff on s. pneumoniae, s. viridans, s. aureus, h. influenza, p. aeruginosa and e. coli at 24 and 48 hours; and 2. to determine if there is a significant difference among the inhibition zones of s. pneumoniae, s. viridans, s. aureus, h. influenza, p. aeruginosa and e. coli produced by the three preparations containing mf, fp and ff. methods bacterial strains from clinical isolates were inoculated and evaluated using the vitek 2 compact system (biomerieux, inc. durham, nc, usa) to verify the identity of the bacteria. guided by the manual on antibacterial susceptibility testing7 each organism was inoculated on three separate plates, to allow for randomization.2 inoculation was done onto the following media: freshly prepared mueller-hinton agar (s. aureus, p. aeruginosa, and e. coli), sheep mueller-hinton agar (s. pneumoniae, and s. viridans), and commercially prepared chocolate agar plate (h. influenza). disc diffusion susceptibility testing using the kirby bauer inoculation method was performed.8 using a micropipette, 0.15 ml of commercially prepared intranasal corticosteroids were applied on separate 6.0 mm sterile blank paper discs (becton, dickenson & company, sparks md 21152 usa). the preparations used were mometasone furoate 0.05% (nasonex™, merck & co), fluticasone propionate 0.05% (flixotide™, glaxosmithkline) and fluticasone furoate 27.5 µg/actuation (avamys™, glaxosmithkline). the discs were placed individually and distributed evenly into each plate. a blank paper disc was included to serve as a control. the plates were placed in a co 2 incubator (memmert model tv50u, bavaria, germany) set to 35 to 37 °c within 15 minutes after the discs were applied. following 24 and 48 hours of incubation, the diameter of each zone of inhibition was measured with a ruler from the edges of the last visible colony-forming growth. the results were recorded in millimeters (mm). data was verified and tabulated using excel, version 2007 (microsoft corporation), then analyzed using spss for windows version 16.0.2. results after 24 hours of incubation, plates with s. pneumoniae, s. viridians and s. aureus, showed inhibition zones to mf, fp, and ff. plates with h. influenzae, p aeruginosa and e coli were negative for inhibition (table 1). s. aureus with fp showed the highest difference from baseline (3mm). consistently, across other specimens, discs containing fp had the largest zones of inhibition at 24 hours (table 2). after 48 hours of incubation, plates with s. pneumoniae, s. viridans, and s. aureus showed inhibition zones to mf, fp, and ff. plates with h. influenzae, p aeruginosa and e coli were negative for inhibition (table 1). s. viridans showed the largest inhibition zone regardless of the steroid. consistently, fp registered the largest reaction to s. pneumoniae, s. viridians and s. aureus (table 2). at 24 hours, anova detected significant differences among the specimens regardless of the corticosteroid preparation (p-value 0.00). post hoc (multiple comparison) test showed h. influenza, p. aeruginosa, e. coli and the control were similar to each other, but significantly different from the group s. pneumoniae and s. viridians, and that both groups were significantly different from s. aureus. at 48 hours, anova detected significant differences among the specimens (p-value 0.00). post hoc test showed that s. viridans has the highest reaction to the corticosteroid preparations at 48 hours, followed philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 original articles philippine journal of otolaryngology-head and neck surgery 15 by s. aureus, then s. pneumoniae. however h. influenzae, p. aeruginosa, e. coli and the control did not show any difference at 48 hours. at 24 hours, anova did not detect a significant difference among the inhibition zones regardless of the specimen (p-value 0.161). although fp descriptively registered the highest reaction from the baseline (followed by mf then ff), post-hoc test showed that the differences were not significant. at 48 hours, anova did not detect a significant difference among the preparations (p-value 0.390). the post-hoc test also showed that the difference among the three corticosteroid preparations was not significant. discussion nasal corticosteroids have been a mainstay of therapy for allergic rhinitis with persistent symptoms.9 the use of nasal steroids (particularly with intramaxillary instillation) may be beneficial in chronic rhinosinusitis, with no side effects or increased signs of infection.4 while it is common practice to treat acute bacterial rhinosinusitis empirically with antibiotics,2 the idea that steroids may play a role in controlling infection as an adjunctive or first-line treatment is novel. such a role may find application in treating patients suffering from allergic rhinitis and bacterial sinusitis as well as in other ent infections. several locally available, commonly prescribed nasal corticosteroid sprays currently used for allergic rhinitis include mf, fp and ff. this study suggests that these preparations may possess antimicrobial properties against s. pneumoniae, s. viridans, and s. aureus. although the mechanism of action of steroids on bacteria is relatively unknown, the results of this, as well as other studies suggest susceptibility of streptococcus and staphylococcus species to corticosteroids. this may be due to the general effects of corticosteroids.3 a recent study on dexamethasone suggests that it may have to do with the steroid’s action on the cell wall or cytoplasmic membrane, as well as the transcription and translation machinery of the microorganisms.5 to the best of our knowledge, no other studies have investigated the antibacterial properties of fp or ff. all three preparations tested contain benzalkonium chloride as an excipient. benzalkonium chloride is a quarternary ammonium compound commonly used to prevent bacterial contamination as an antimicrobial additive, rendering solutions bacteriostatic or bactericidal according to concentration. since 1982, benzalkonium chloride has been approved by the us food and drug administration as an “inactive ingredient” for prescription drugs.14 it is not clear whether the antibacterial properties exhibited by all three preparations of intranasal corticosteroids can be attributed to the steroids, the excipient, or both. while the study shows the preparations themselves have antibacterial properties, further studies testing their components separately are in order. table 1. average size of inhibition zones of the steroid preparations on the different bacterial specimens after 24 and 48 hours of incubation time 24 hrs 48 hrs average size (in mm) specimen steroid fluticasone furoate fluticasone propionate mometasone fluticasone furoate fluticasone propionate mometasone s aureus 7.67 9.00 7.67 8.33 9.00 8.00 s viridans 6.67 7.33 7.00 12.67 13.33 9.00 s. pneumoniae 6.33 8.33 7.00 6.33 8.33 7.00 h. influenzae 6.00 6.00 6.00 6.00 6.00 6.00 p. aeruginosa 6.00 6.00 6.00 6.00 6.00 6.00 e. coli 6.00 6.00 6.00 6.00 6.00 6.00 control 6.00 6.00 6.00 6.00 6.00 6.00 table 2 average difference of inhibition zones from the baseline of 6mm (blank paper disc diameter). the table shows fp registered the largest reaction to s. pneumoniae, s. viridians and s. aureus at 24 and 48 hours (indicated by an asterisk) time 24 hrs 48 hrs average difference from the baseline of 6mm (in mm) specimen steroid fluticasone furoate fluticasone propionate mometasone fluticasone furoate fluticasone propionate mometasone s aureus 1.67 3.00* 1.67 2.33 3.00* 2.00 s viridans 0.67 1.33* 1.00 6.67 7.33* 3.00 s. pneumoniae 0.33 2.33* 1.00 0.33 2.33* 1.00 h. influenzae 0.00 0.00 0.00 0.00 0.00 0.00 p. aeruginosa 0.00 0.00 0.00 0.00 0.00 0.00 e. coli 0.00 0.00 0.00 0.00 0.00 0.00 control 0.00 0.00 0.00 0.00 0.00 0.00 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 original articles 16 philippine journal of otolaryngology-head and neck surgery acknowledgement the authors wish to thank dr. german b. castillo, sr., chair of the department of laboratories of the medical city, and the staff of the section of microbiology for the use of the equipment and facilities. references 1. ryan d. management of acute rhinosinusitis in primary care: changing paradigms and the emerging role of intranasal corticosteroids. prim care respir j. 2008 sep;17(3):148-55. 2. benninger ms, sedory holzer se, lau j. diagnosis and treatment of uncomplicated acute bacterial rhinosinusitis: summary of the agency for health care policy and research evidencebased report. otolaryngology head and neck surgery. 2000 jan; 122(1):1-7. 3. neher a, gstöttner m, scholtz a, nagl m. antibacterial activity of mometasone furoate. arch otolaryngol head neck surg. 2008 may;134(5):519-21. 4. parikh a, scadding gk, darby y, baker rc. topical corticosteroids in chronic rhinosinusitis: a randomized double-blind, placebo-controlled trial using fluticasone furoate aqueous nasal spray. rhinology. 2001 jun; 39(2)75-9. 5. neher a, arnitz r, gstöttner m, schäfer d, kröss em, nagl m. antimicrobial activity of dexamethasone and its combination with n-chlorotaurine arch otolaryngol head neck surg. 2008 jun;134(6):615-20. 6. wald er., microbiology of acute and chronic sinusitis in children and adults. am j med sci. 1998 jul;316(1):13-20. 7. lalitha mk. manual on antimicrobial susceptibility testing. 1st ed. vellore, tamil nadu: department of microbiology, christian medical college: 2008. pp.10-13. 8. bauer aw, kirby wm, sherris jc, turck m. 1966. antibiotic susceptibility testing by a standardized single disk method. am. j. clin. pathol. 45:493-496. 9. bousquet j, khaltaev n, cruz aa, denburg j, fokkens wj, togias a, et al. allergic rhinitis and its impact on asthma (aria) 2008 update (in collaboration with the world health organization, ga(2)len and allergen allergy. 2008 apr;63 suppl 86:8-160. 10. graf p. benzalkonium chloride as a preservative in nasal solutions: re-examining the data. respir med. 2001 sep;95(9):728-33. 11. marple b, roland p, benninger m., safety review of benzalkonium chloride used as a preservative in intranasal solutions: an overview of conflicting data and opinions, otolaryngol head neck surg. 2004 jan;130(1):131-41. 12. patarca r, rosenzwei ja, zuniga aa, fletcher ma benzalkonium salts: effects on g proteinmediated processes and surface membranes. crit rev oncog. 2000;11(3-4):255-305. 13. seymour sb. disinfection, sterilization, and preservation. 5th illustrated ed. philadelphia (pa) lippincott williams & wilkins; 2001. pp311. 14. graf p. adverse effects of benzalkonium chloride on the nasal mucosa: allergic rhinitis and rhinitis medicamentosa, clin ther. 1999 oct; 21(10):1749-55. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 case reports philippine journal of otolaryngology-head and neck surgery 23 abstract objectives: to report the case of a congenital nasal chondromesenchymal hamartoma in a oneyear-old female and review the literature, identifying problems encountered in confirming the diagnosis and in treatment of this patient. methods: design: case report setting: tertiary public general hospital patient: one results: a one-year-old female with an intranasal mass noted at birth and with subsequent unilateral maxillary enlargement is described. computed tomography showed calcifications and erosion of adjacent bony structures. histopathology and immunohistochemistry of an intranasal biopsy were interpreted as chordoma, a malignant tumor. following surgical excision, the final histopathologic diagnosis was chondroid hamartoma. conclusion: only 20 cases of nasal chondromesenchymal hamartoma have been reported in the literature worldwide. these tumors may present clinically, histopathologicaly and radiologically as malignant tumors and may mislead even the experts. the whole clinical picture should be taken together to avoid misdiagnosis as a malignancy and to facilitate appropriate management. keywords: nasal chondromesenchymal hamartoma, nasal masses in infancy, nasal chondroid lesions nasal masses in infancy are infrequently encountered. most are developmental anomalies such as encephalocoeles, gliomas and nasolacrimal duct cysts. the rest are neoplasms, primarily composed of teratomas and dermoid cysts. occasionally, a variety of benign and malignant soft tissue tumors occur in children.1 the majority of head and neck neoplasms in children are benign. primary malignant neoplasms of the head and neck are not common and account for about 5 % of neoplasms congenital nasal chondromesenchymal hamartoma ruth s. estimar, md mario adrian m. zafra, md ramon antonio b. lopa, md department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: ruth s. estimar, m.d. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax: (632) 525 5444 e-mail: orlpgh@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed disclosures that they have no proprietary or financial interest with an organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at the interesting case contest, philippine society of otolaryngology-head and neck surgery midyear convention, baguio country club, baguio city, philippines april 20, 2007. philipp j otolaryngol head neck surg 2009; 24 (2): 23-26 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 case reports 24 philippine journal of otolaryngology-head and neck surgery occurring in childhood.2 in children, the neoplasms are more frequently reticuloendothelial, neural or mesenchymal, as opposed to the predilection for epithelial neoplasms in adults.1 chondrogenic tumors of the maxillofacial region may be difficult to differentiate histologically and radiologically as to whether they are benign or malignant. we present the case of an infant with a nasal chondromesenchymal hamartoma which was confused with a malignancy. this clinicopathologic entity is remarkable not only because of its rarity but also because it may present a diagnostic dilemma with major implications in management. case report a term female was born at home with the assistance of a traditional birth attendant to a then 23-year-old g2p1 (1001) mother. because of cyanosis and dyspnea at birth, the baby was rushed to a local hospital where physicians were unable to pass a suction catheter through the right nasal cavity. glatzel’s mirror test showed no misting from the nostrils, and a whitish mass was noted in the right nasal cavity. subsequently, chronic mucoid discharge from the right nostril and a progressively bulging right maxilla were noted. a computed tomography (ct) scan of the paranasal sinuses at three months of age revealed a mixed-enhancing, soft tissue mass at the right nasal antrum with irregular foci of calcifications, measuring 2.2 x 3.22 x 3.03 cm. the mass pushed the nasal septum medially and the medial wall of the right maxillary sinus laterally. no bony erosions, intraorbital or intracranial extensions were seen. considerations were an ossifying fibroma, calcifying polyp or dentigerous cyst. surgery was advised but deferred by the mother. at eight months of age, repeat ct scans revealed a 3.0 x 3.95 x 3.33 cm mass, now occupying the right maxillary and ethmoid sinuses with extension in the anteromedial portion of the right orbit (figure 1). there had been an increase in size of 83.7% over the past five months. they finally agreed to admission, and repeat ct scans revealed a 3.20 x 4.03 x 3.4 cm ethmoidal mass (a 103 % volume increase in 9 months), with lysis of the right lamina papyracea, extension into the right intraorbital extraconal compartment with involvement of the medial rectus and inferior oblique muscle, and thinning of the medial wall of the right maxillary sinus (figure 2). no intracranial extensions were noted. the radiological impression was an ethmoidal mass with malignant features. an intranasal punch biopsy was interpreted as a mesenchymal neoplasm compatible with chordoma, a diagnosis later supported by slide review. immunohistochemical stains were strongly positive to s100 and vimentin with non-immunoreactivity to cytokeratin. these findings were still interpreted as consistent with a chordoma. considering a highly malignant tumor, a right medial maxillectomy figure 1. paranasal sinus ct scan (a, coronal and b,axial cut) at 8 months of age showing an ethmoidal mass with extension into the right maxillary and ethmoid sinuses and the anteromedial portion of the right orbit figure 2. pns ct scan(a, axial cut, bone window; b, axial cut with contrast) at one year of age showing an ethmoidal mass with lysis of the right lamina papyracea and extension into the right intraorbital extraconal compartment and thinning out of the medial wall of the right maxillary sinus figure 3. a right lateral rhinotomy with a lynch extension revealed a well-circumscribed mass in the ethmoid sinus extending to the maxillary sinus and medial wall of the orbit via right lateral rhinotomy combined with a lynch incision was performed (figure 3). intra-operatively, an eggshell-thin anterior maxillary wall, a whitish mass filling the right ethmoid and maxillary sinuses, and septum deviated to the contralateral side were noted. the orbital wall was intact but the nasal roof showed small thinned-out areas. the patient tolerated the procedure without any problems or post-operative complications. grossly, the mass was cream to tan-colored, firm and wellphilippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 case reports philippine journal of otolaryngology-head and neck surgery 25 circumscribed, measuring 4 x 3.5 x 3 cm. the surface was smooth, but gritty and irregular when cut (figure 4). no tumor hemorrhages were noted. histologically, nodules of hyaline cartilage ranging from fairly immature looking chondroid stroma to islands of mature hyaline cartilage were found in a variably cellular stroma that was fibrocytic in some areas and loose and myxoid in others (figure 5). bundles of dense collagen as well as occasional spicules of bone were also noted. the histopathologic diagnosis at this institution was a mesenchymal neoplasm with chondroid differentiation. further analysis at the memorial sloan-kettering cancer center and impath laboratories new york yielded a final pathologic diagnosis of chondroid hamartoma with osseous metaplasia. discussion nasal chondromesenchymal hamartoma (ncmh) is a rare, destructive yet benign, tumefactive lesion involving the nasal cavity and paranasal sinuses. the term was first coined by mcdermott et. al. in 1998 to describe a distinct clinicopathological entity composed of a proliferation of mesenchymal and cartilaginous elements.4 nasal chondroid lesions, nasal hamartoma, chondroid hamartoma and mesenchymoma are other terms used to refer to this disease entity. it usually affects infants less than 3 months of age although there have been reports of occurrence in adolescents and young adults.5 one case series reports occurrence in a 69-year-old female.6 presently, there have figure 5. ncmh in this patient showing nodules of hyaline cartilage ranging from (a) fairly immature looking chondroid stroma to (b) islands of mature hyaline cartilage. stroma is (c) fibrocytic in some areas and (d ) loose and myxoid in others figure 4. gross appearance of the ethmoidal mass measuring 4 x 3.5 x 3 cm. (a) whole specimen; (b) cut surface a b c d philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 case reports 26 philippine journal of otolaryngology-head and neck surgery references 1. thawley se, panje wr, batsakis jg. comprehensive management of head and neck tumors. 2nd edition. wb saunders company; 1999. p. 1843-44, 1876-78. 2. cummings cw, flint pw, haughey bh, harker la, richardson ma, schuller de et al. otolaryngology head and neck surgery. 3rd ed. mosby-year book, inc; 1998. p. 1212, 3988, 418385. 3. terris mh, billman gf, pransky sm. nasal hamartoma: case report and review of the literature. int j pediatr otorhinolaryngol 1993; 28:83–88. 4. mcdermott mb, ponder tb, dehner lp. nasal chondromesenchymal hamartoma: an upper respiratory tract analogue of the chest wall mesenchymal hamartoma. am j surg pathol 1998; 22:425–433. 5. alrawi m, mcdermott m, orr d, russel j. nasal chondromesenchymal hamartoma presenting in an adolescent. int j pediatr otorhinolaryngol 2003; 67: 669-672. 6. ozolek ja, carrau r, barnes el, hunt jl. nasal chondromesenchymal hamartoma in older children and adults. arch pathol lab med 2005; 129:1444–1450. 7. kato k, ijiri r, tanaka y, hara m, sekido k. nasal chondromesenchymal hamartoma of infancy: the first japanese case report. pathol int 1999; 49:731–736. 8. kim dw, low w, billman g, wickersham j, kearns d. chondroid hamartoma presenting as a neonatal nasal mass. int j pediatr otorhinolaryngol 1999; 47:253-259 9. hsueh c, hsueh s, gonzalez-crussi f, lee t, su j. nasal chondromesenchymal hamartoma in children: report of 2 cases with review of the literature. arch pathol lab med 2001; 125:400– 403. 10. kim b, park s, min hs, rhee js, wang kc. nasal chondromesenchymal hamartoma of infancy clinically mimicking meningoencephalocele. pediatr neurosurg 2004; 40:136–140. 11. norman es, berhman s, trupiano jk. nasal chondromesenchymal hamartoma: report of a case and review of the literature. pediatr dev pathol 2004; 7:517–520. 12. shet t, borges a, nair c, desai s, mistry r. two unusual lesions in the nasal cavity of infants: a nasal chondromesenchymal hamartoma and an aneurysmal bone cyst like lesion: more closely related than we think? int j pediatr otorhinolaryngol 2004; 68:359–364 13. ozolek ja, carrau r, barnes el, hunt jl. nasal chondromesenchymal hamartoma in older children and adults. arch pathol lab med 2005; 129:1444–1450. 14. johnson c, nagaraj u, esguerra j, wasdahl d, wurzbach d. nasal chondromesenchymal harmartoma: radiographic and histopathologic analysis of a rare pediatric tumor. pediatr radiol 2007; 37:101-104. only been 20 cases of ncmh reported in english medical literature.4, 5, 7-14 due to the paucity of cases, the pathogenesis of ncmh is not well understood. hamartomas are characterized by an abnormal mixture of tissues indigenous to that area of the body, but with an excess of one or more of the tissue types. the development of hamartomas may involve errors during fetal growth or disturbances of immature tissues in the post-natal period.4 it is believed that fibroblasts and myofibroblasts are the major component cells in ncmh.9 ncmh was initially thought to be present at birth, indicating a developmental or congenital origin. however, with reports of occurrence in adolescents and adults, alternative explanations such as the role of inflammation, cytokines, and growth factors or the association with hormonal stimulation are being investigated.11, 13 differentiation between ncmh and a malignant lesion like a chordoma may be difficult. ncmh have a seemingly infiltrative nature. as such, it may mimic malignant tumors in its clinical, radiologic or even histopathologic presentation. in the literature, presenting symptoms included a nasal mass, nasal obstruction, respiratory distress and a maxillary bulge which were all present in this patient. orbital involvement can result in proptosis, enophthalmos or impairment of eye movement. intracranial extension of the tumor can result in neurologic manifestations such as hydrocephalus and oculomotor disturbance.10 our patient had no ocular or neurologic symptoms or actual orbital invasion despite a preoperative ct scan suggesting intraorbital involvement. radiologically, ncmhs may be nonencapsulated and ill defined, containing both solid and cystic portions. calcifications may be present.4 the adjacent paranasal sinuses are frequently involved and erosion of the surrounding bone and extension to the skull base and orbital region are not uncommon. in a review of 19 cases by johnson et. al.,14 67% demonstrated bony remodeling, thinning or erosion and 53% demonstrated intracranial extension through the cribriform plate to the anterior cranial fossa. 50% revealed internal calcifications while 40% revealed cystic components. in this patient, the rapid growth of the mass, calcifications and destruction of adjacent bony structures were interpreted as consistent with a malignancy. biopsy results may also be misleading. histologically, ncmh is comprised of a variety of mesenchymal components with a focally lobular architecture of irregular islands of hyaline cartilage with occasional binucleated chondrocytes and cartilaginous islands.4 thus, ncmh may morphologically overlap with chondroid lesions including malignancies such as chondrosarcoma and chordoma (figure 6). immunohistochemistry may be helpful if the initial histological picture is unclear. chordomas, which are tumors arising from embryonic notochordal remnants, and ncmh both stain positive for s100 and vimentin which are markers for neuroepithelial cells and mesenchymal cells respectively. however, chordoma stains positive for cytokeratin while ncmh is negative. 9 negativity to cytokeratin in this case should have been a strong reason to discount a chordoma, a diagnosis which was strongly maintained by the pathologist. taking all these into account may elucidate how a nasochondromesenchymal hamartoma, a rare but benign lesion, was mistaken for a chordoma, an aggressive and malignant tumor. accurate differentiation between ncmh and malignant tumors is very important, as a hamartoma’s capacity for growth is usually limited and its biologic behavior is typically benign,8 making complete surgical excision sufficient therapy. when as in our case, a misdiagnosis of malignancy is made, excessively radical surgery and possibly, potentially harmful neo-adjuvant radiotherapy may result. despite its relatively low prevalence, ncmh should be considered as a differential diagnosis in patients with chondroid lesions in the maxillofacial region, particularly in infants. caution should be exercised in diagnosing radiologically and histologically aggressive-looking maxillofacial tumors as malignant especially in infants. ancillary studies may be necessary to further confirm a malignancy. as in all cases, individualized treatment of patients with head and neck tumors is very important. factors such as age, co-morbid illnesses and location of the tumor should be considered in choosing treatment approaches. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 26 philippine journal of otolaryngology-head and neck surgery case reports abstract objective: to describe a case of a papillary thyroid carcinoma presenting with a preauricular and an intracranial mass and review the literature on the metastatic nature and invasiveness of papillary thyroid carcinoma. methods: design: case report setting: tertiary private hospital patient: one results: a 46-year-old female with a 12-year anterior neck mass and a two-year right pre-auricular pleomorphic adenoma on fine needle aspiration biopsy was found to have an intracranial mass on ct-scan. total thyroidectomy and section biopsy of the preauricular mass yielded a final histopathologic report of follicular variant of papillary carcinoma, thyroid gland; and metastatic papillary thyroid carcinoma, follicular type, pre-auricular mass. the condition of the patient precluded neurosurgical intervention and rai therapy and she underwent 23 sessions of external radiotherapy using 46gy with significant diminution in size of the intracranial metastasis. conclusion: papillary thyroid malignancy may be an indolent tumor but it is capable of distant metastasis. we should be alerted by host and tumor factors which can be predictors of a more radical papillary malignant disease whose management entails proper staging evaluation and good communication of prognostic data and available, realistic therapeutic options to patients using a multidisciplinary approach. keywords: papillary thyroid carcinoma; papillary thyroid carcinoma metastasis; infratemporal metastasis; brain metastasis of papillary carcinoma. thyroid malignancy is seventh among malignant lesions based on 1998 philippine department of health statistics,1 of which papillary thyroid carcinoma (ptc) is the most common, representing 82% of all thyroid cancers.2 ptc is believed to carry a good prognosis: overall mortality is 5% or less with long term follow up,3 with a survival rate for stage i and ii disease (american joint committee on cancer staging) reaching up to 95% to 100%.4 ptc also has the lowest distant metastasis rates, ranging from 3% to 10%, with the majority of lesions affecting lungs and bone. while ptc is generally considered a malignant disease with a rather “benign” clinical character, surgeons should be aware of its dichotomous behavior. while some patients have excellent outcomes, others may surprisingly have a more aggressive disease. this case reminds us of the clinically important dimorphism of ptc. the atypical dissemination to an unlikely anatomical region made this case interesting. moreover, the remarkably silent yet amazingly extensive distant disease and manner of spread put to question the validity of common beliefs among regarding the clinical characteristics and behaviour of ptc. this paper will review available literature associated with remote spread of disease even when clinical warning signs are papillary thyroid carcinoma presenting with a right preauricular and intracranial mass renato c. pascual jr., md johann f. castañeda, md joel a. romualdez, md department of otorhinolaryngology head and neck surgery st. luke’s medical center correspondence: renato c. pascual jr., md department of otorhinolaryngology head and neck surgery st. luke’s medical center 279 e. rodriguez sr. boulevard, quezon city 1112 philippines phone: (632)723-0101 e-mail address: natopascual@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with an organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at clinical case report contest, philippine society of otolaryngologyhead and neck surgery mid-year convention, bohol tropics hotel, april 24, 2009. philipp j otolaryngol head neck surg 2010; 25 (1): 26-30 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 case reports philippine journal of otolaryngology-head and neck surgery 27 lacking, and explore plausible mechanisms for the pathogenesis of the extraordinary dissemination observed in this case. case report a 46-year-old female consulted for a gradually-enlarging anterior neck mass of 12 years duration and a 2-year right pre-auricular mass. examination revealed a 7.0 cm x 5.0 cm anterior neck mass that was firm, non-tender and moved with deglutition. there were no palpable cervical lymph nodes. the firm, non-movable and non-tender preauricular mass measured 5.0 cm x 5.0 cm (figure1). thyroid function tests were normal. fine needle aspiration biopsy (fnab) of the anterior neck mass was read as follicular neoplasm, while that of the pre-auricular mass was signed out as consistent with pleomorphic adenoma. a computed tomography (ct) scan revealed a large enhancing lobulated soft tissue mass in the right pre-auricular area measuring 5.9 cm. x 6.33 cm. x 6.79 cm. (figures 2 a, b). superiorly, the mass extended into the right temporal lobe associated with lytic destruction of the squamous and mastoid portions of the temporal bone. inferior extension reached the level of the mandibular ramus. the masseter appeared infiltrated. there was erosive destruction of the zygomatic arch, greater sphenoid wing, right anterior skull base and anterior wall of the glenoid fossa of the temporomandibular joint. posteriorly, there were erosive changes along the anterior wall of the mastoid bone. the lesion abutted the anterior surface of the parotid gland without infiltration. another similarly enhancing lesion was noted on the midoccipital region, measuring 2.96 cm. x 3.66 cm with extension into the posterior fossa, adjacent to the confluence of sinuses, associated with right anterolateral displacement of the torcula of herophilii and lytic occipital bone destruction. the right lobe of the thyroid gland was enlarged measuring approximately 6.0 cm. x 3.6 cm. x 2.7 cm. there were hypodense lesions seen in the right lobe, some with dense peripheral calcifications; the largest measuring 3.4 cm. x 3.1 cm. x 2.2 cm. the left lobe was normal in size with inhomogenous density and a focus of calcification. a total thyroidectomy and section biopsy of the preauricular mass were performed. final histopathologic report for the thyroid gland lesion was follicular variant of papillary carcinoma with note of lymphatic and vascular invasion and thyroid capsular spread. the preauricular mass was signed out as consistent with metastatic carcinoma, follicular pattern, thyroid in origin. the final diagnosis was papillary thyroid carcinoma, right and left thyroid gland with brain (temporal and occipital lobes) metastases; t4an0m1; stage ivc (ajcc classification, 2002). total body scans revealed functioning thyroid tissue remnants in the anterior neck, with no evidence of distant thyroid cancer metastasis (figure 3). the patient was subjected to 23 sessions of external beam radiotherapy (ebrt) at 46gy per session with focus on the right pre auricular region and mid occipital area. after one month of ebrt, the pre-auricular and occipital mass had significantly decreased in size (figures 4 a, b). discussion the presence of distant metastasis from ptc is unusual. dinneen et al. described the distribution of distant metastasis from ptc among a hundred cases during a five decade period.6 the most commonly involved organs were the lungs (77%) and bone (20%). other sites include the mediastinum (10%), adrenals (1%), skin (1%) and liver (1%). the brain is only involved in 1% of cases. despite multiple large intracranial masses, this patient did not have any sign or symptom of increased intracranial pressure nor focal neurologic sign on examination. in a study by chiu et al. among ptc patients with brain metastasis, 23% of the study population (11 out of 47 patients) also had no clinical evidence of distant brain metastasis, with most only diagnosed post mortem.7 this was probably because the mass usually lysed cranial bones, the “auto-craniotomy” dissipating intracranial pressure into the more distensible scalp tissue. most patients with clinically evident brain metastasis were those who developed deeply-seated brain lesions with practically no calvarial bone involvement, thereby increasing intracranial pressure. the mechanism of distant spread of papillary thyroid carcinoma has been postulated to be due mainly to lymphatic and vascular invasion by the tumor, following pre-formed neural and lymphovascular anatomical pathways through natural foramina, fissures and hollow fascial spaces.9 the mean time for development of distant metastasis was noted to be around seven to eight years after diagnosis of early stage disease.8 in our case, it took 10 years for distant metastasis to be evident. dineen 6 showed that age at the time of distant metastasis diagnosis was a strong predictor of ptc survival after distant metastasis with a 10-year survival rate of 82% for those less than 40 years of age compared with only 18% for the group aged 65 years and older at the time of distant metastasis. gender did not significantly influence ptc survival after distant metastasis. distant metastasis in other organs in the body may be related to brain metastasis; dineen’s study showed that in patients who were positive for distant organ involvement, the brain had the highest risk for development for a second organ or succeeding metastases.6 our patient only had brain metastasis without the more common involvement of lung and bone. the predilection of ptc to spread through the lymphatic more than the hematogenous route has been well established. hall showed that intratumoral lymphatic proliferation and invasion of new lymphatics in and around the enlarging malignant tumor may facilitate distant spread.9 moreover, enormously large loads of malignant cells in the lymphatics may cause indirect vascular invasion as lymphatic channels ultimately drain into vascular channels. the intratumoral lymphatic invasion seen in our histologic specimen may explain its aggressiveness. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 28 philippine journal of otolaryngology-head and neck surgery case reports figure 2b. contrast ctscan of head, coronal section showed an enhancing soft tissue mass measuring 5.99 x 6.37 x 6.79 cm. extending superiorly to the right temporal lobe and inferiorly to the level of the mandibular ramus. figure 3. total body scan (i-131). this showed intense tracer uptake in the anterior neck. pinhole imaging in this area shows 3 foci of increased tracer deposition in midline measuring 1.6x1.1cm, 1.2x2.0cm, 1.1x1.2cm as well as a faint focus in the superior aspect. there is also a focus of tracer localization in the right thyroidal bed measuring 1.0x1.0cm. functioning thyroid tissue remnants in the anterior neck. no evidence of distant thyroid cancer metastasis. figure 1. preauricular mass. patient had a right pre-auricular mass measuring approximately 5x5cm. figure 2a. contrast ctscan of head, axial section showed an enhancing lobulated soft tissue mass,involving right masseter and temporalis muscles, measuring 5.99 x 6.37 x 6.79cm. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 case reports philippine journal of otolaryngology-head and neck surgery 29 intrathyroidal evidence of vascular invasion as predictive of disease recurrence among their patient population. this mode of malignant dissemination may better explain the intracranial metastasis in our case in the absence of clinical cervical node involvement. another factor which may explain the aggressiveness of the papillary thyroid carcinoma in this case was the extracapsular invasion. according to machens et al11 extrathyroidal growth consistently emerged as the most significant factor for increased likelihood of distant metastasis in ptc. extracapsular and extrathyroidal spread give the malignant cells more avenues for lymphatic and vascular dissemination through adjacent tracheal, strap muscles, nerve tissue and other contiguous structures. the notion of follicular variant of papillary thyroid carcinoma (fvptc) having a more aggressive clinical nature than the pure type of ptc has been disproved.12 even with a predominant follicular component, lesions with papillary features behave clinically as true papillary carcinoma. a clinico-pathologic analysis of 243 patients with pure versus follicular variant papillary thyroid carcinoma by jamal et al showed that pathologic and clinical behaviours of ptc and fvptc were comparable.12 prognostic factors, treatment and survival also were similar between the two forms. the follicular variant seen in our patient may therefore not relate as much to tumor aggressiveness. while the usual therapeutic modality for high-risk papillary thyroid carcinoma is total thyroidectomy with radioactive iodine (rai) ablation, the management of brain metastasis may relate more to palliation than cure. although surgical resection has been shown to prolong survival by nearly three-fold7 in 47 cases of thyroid malignancy with brain metastasis, our neurosurgery service advised against surgery due to multifocal brain involvement, uncertainty of complete resection and absence of neurological deficit. initial radiation therapy prior to rai ablation was advised because the intracranial lesion was in very close proximity to the venous confluence of sinuses which could swell with rai and result in massive cerebral edema. radiotherapy was probably a reasonable option as previously recommended for patients unable to undergo surgical therapy and who had disseminated or inaccessible intracranial lesions that precluded metastasectomy.7 our patient underwent 23 sessions of ebrt using 46gy with subsequent remarkable decrease in the size of the brain metastatic lesions. as of this writing, she was asymptomtic and awaiting possible rai therapy to further decrease the size of the intracranial lesions. in summary, while brain metastasis from a ptc is unusual, several features of the host (older age, long duration of disease and presence of distant metastasis) and the tumor pathology (presence of intratumoral lymphatics, vascular invasion and extrathyroidal invasion) may alert the clinician to the risk for intracranial spread and possible need for a cranial ct or mri. while the prognosis may be dismal, surgical resection offered a significant longer survival for most patients in the literature. figure 4 a, b. post-radiation contrast ct scan of head, axial and coronal sections showed an interval decrease in size of the previously noted avidly enhancing lobulated soft tissue mass. it now measures 4.5cm x 4.3cm x 3.6cm. a b the aggressiveness of ptc in this case may be further related to actual vascular invasion demonstrated in our thyroid specimen. vascular invasion in ptc occurs in only 2 to 14% of cases. gardner et al. highly correlated vascular invasion, whether intrathyroidal or extrathyroidal, with more aggressive local disease and a greater predisposition for distant metastasis at diagnosis. 10 their study also identified 30 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 case reports references 1. department of health, philippines. disease and health condition advisories. [updated 2009 february] available from http://www.doh.gov.ph/taxonomy/term/329?page=1 2. silva jv, zantua rv, arevalo ae. profile of patients with thyroid malignancy at a university-based tertiary hospital: a six year retrospective study (1995-2000) philipp j otolaryngol head neck surg 2002; 17(3-4):163-168. 3. hay id, bergstralh ej, goellner jr, ebersold jr, grant cs. predicting outcome in papillary thyroid carcinoma: development of a reliable prognostic scoring system in a cohort of 1779 patients surgically treated at one institution during 1940 through 1989. surgery 1993 dec;114(6):1050-7; discussion 1057-8. 4. hundahl sa, fleming id, fremgen am, menck hr. a national cancer data base report on 53,856 cases of thyroid carcinoma treated in us., 1985-1995. cancer. 1998 dec 15; 83(12): 26382648 5. cohen sm, burkey bb, netterville jl. surgical management of parapharyngeal space masses. head neck. 2005 aug; 27(8):669-675. 6. dinneen sf, valimaki mj, bergstralh ej, goellner jr, gorman ca, hay id. distant metastasis in papillary thyroid carcinoma: 100 cases observed at one institution during 5 decades. j clin. endocrinol. metab. 1995 jul; (80)7;2041-2045. 7. chiu ac, delpassand es, sherman si. prognosis and treatment of brain metastases in thyroid carcinoma. j. clin. endocrinol. metab.. 1997 nov; 82(11): 3637-3642 8. mazzaferri el, young rl. papillary thyroid carcinoma: a 10 year follow-up report of the impact of therapy in 576 patients. am j med. 1981 mar;70(3):511–517. 9. hall ft, freeman jl, asa sl, jackson dg, beasley nj. intratumoral lymphatics and lymph node metastases in papillary thyroid carcinoma. arch otolaryngol head neck surg, 2003 jul; 129 (7);716-719 10. gardner re, tuttle rm, burman kd, haddady s, truman c, sparling yh, et.al. prognostic importance of vascular invasion in papillary thyroid carcinoma. arch otolaryngol head neck surg 2000 mar; 126(3): 309-312 11. machens a, holzhausen hj, lautenshlager c, thanh ph, dralle h. enhancement of lymph node metastasis and distant metastasis of thyroid carcinoma: a multivariate analysis of clinical risk factors. cancer. 2003 aug 15;(98)4: 712-719 12. zidan j, karen d, stein m, rosenblatt e, basher w, kuten a. pure versus follicular variant of papillary thyroid carcinoma: clinical features, prognostic factors, treatment, and survival. cancer. 2003 mar 1;(97)5: 1181-1185 13. misaki t, masahiro i, kanji k, junji k. brain metastasis from differentiated thyroid cancer in patients treated with radioiodine for bone and lung lesions. ann nucl med 2000 apr;14(2): 111114 other palliative management such as rai ablation and radiotherapy remain as possible options should the situation preclude surgical intervention. this case study serves to remind otolaryngologists to be more vigilant in the diagnosis and management of patients with ptc. increasing numbers of ptc cases in our institution are displaying more aggressive behaviour. their management entails proper staging evaluation and good communication of prognostic data and available, realistic therapeutic options to patients using a multidisciplinary approach. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 practice pearls philippine journal of otolaryngology-head and neck surgery 39 rigid bronchoscopy is a procedure that is performed in order to directly visualize the upper and lower airway and is carried out for either a diagnostic or therapeutic purpose. suspected foreign body (fb) aspiration is the most common indication for performing this procedure in the pediatric age group at the philippine children’s medical center where a recent census (may 2008 to april 2009) showed that of 21 cases where rigid bronchoscopy was performed, 10 were for suspected fb aspiration. a review of 101 cases in the same institution showed that the average age of patients with fb aspiration was 2 years and the most common item aspirated was a peanut followed by the atis (sweetsop) seed and chicken bone chips. the most common inorganic foreign body was an earring and “whistle” (which broke off from a toy).1 it is more common in males probably because of their usually more active nature and is frequently found in the right mainstem bronchus where the fb more easily lodges being straighter, shorter and wider in diameter. fbs are life-threatening events in children that require early diagnosis and prompt successful management.2 a good history, physical examination and analysis of diagnostic tests are vital in every situation. in most cases, the child’s aspiration of the foreign object is a witnessed event 3 and this history of aspiration is the most sensitive diagnostic tool. the main symptoms include choking, prolonged cough and dyspnea. abnormal physical examination findings are found in 67% to 80% of cases and include unilaterally decreased breath sounds, wheezing and stridor.2,4 radiographic procedures may show abnormal findings in only about 68-86% of cases.4,5 the most useful radiographs requested are the chest posteroanterior (anteroposterior in infants and small children) and lateral views which may help localize the impaction site when the object aspirated is radiopaque.3 however, most inhaled fbs are radiolucent and their presence can be suspected by obtaining inspiration and expiration views to demonstrate unilateral hyperinflation. other suggestive features include atelectasis, pneumothorax and pneumonia. these indirect radiologic features of fb inhalation are present in 76% of cases.2, where inspiration and expiration views cannot be obtained, as in very young children, left and right decubitus views may be helpful. 6 fluoroscopic studies may also be obtained along with the plain radiographs, however, specificity and sensitivity are not very high.4 virtual bronchoscopy may also be used in patients with suspected fb aspiration. virtual bronchoscopy which uses multislice computerized tomography (mdct) with realistic 3-dimensional reconstruction may be helpful in detecting and localizing the fb prior pediatric rigid bronchoscopy for foreign body removal maria rina t. reyes-quintos, md, mclinaud1,2 1department of otorhinolaryngology college of medicine philippine general hospital university of the philippines manila 2philippine national ear institute national institutes of health university of the philippines manila correspondence: maria rina t. reyes-quintos, md, mclinaud department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 philippines phone: (632) 526-4360 fax: (632) 525-5444 email: rinatrq@yahoo.com reprints will not be available from the author. no funding support was received for this study. the author signed a disclosure that she has no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. philipp j otolaryngol head neck surg 2009; 24 (1): 39-41 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 practice pearls 40 philippine journal of otolaryngology-head and neck surgery to any surgical procedure and thus decreasing the number of patients needing diagnostic bronchoscopies.7 flexible fiberoptic bronchoscopy under local anesthesia and premedication may also be performed in cases of suspected fb aspiration wherein clinical and radiologic findings are not consistent with fb aspiration. when no fb is visualized, the patient is saved a rigid bronchoscopic procedure under general anesthesia.8 flexible fiberoptic bronchoscopy is also used therapeutically to remove fbs in the bronchus, however, successful removal is more common with rigid bronchoscopy. all the necessary instruments needed for the procedure must be prepared. as much as possible two of each instrument are prepared: two bronchoscopes (one estimated from the age and size of the child and one smaller than that – just in case!), two suction devices (if one gets clogged up, the other one is ready) and two forceps. the peanut forceps is ideal, not only for peanuts but usually for other nuts as well. the alligator forceps is useful for relatively flat foreign bodies while the “jaw type” forceps appears to be useful for everything else.9 the instruments are then tried, to check if they are in working order before commencement of anesthesia. this involves checking the transparency of the glass window plug, ensuring that the light source and the proximal prismatic light deflector are both illuminating and trying out all the forceps and suction tips. it is best to try the instruments on an object similar to what the child aspirated.3 the surgical assistant, nurse and instruments are usually on the right (if the surgeon is right-handed) and anesthesiologist on the left. the suction and bronchoscope are then made ready. knowledge of the anatomy of the tracheobronchial tree is imperative to be able to navigate through this area while looking for the fb. the use of optical forceps with mounted rod-lens telescopes has made the removal of airway fbs simpler, quicker and safer. these new devices have led to decreased complication rates and fewer missed or incomplete fb removals. while access to fbs located in the distal small segmental bronchi especially in very young children may be limited with the use of optical forceps,10 this can be overcome by removal of the connecting bridge to allow the optical forceps to be passed distal to the tip of the bronchoscope. an anesthesiologist familiar with the procedure must be called in. it is very important to have discussed the case and the procedure with the anesthesiologist prior to the operation to minimize confusion and promote harmony. most anesthesiologists have become at ease with giving intravenous general anesthesia which circumvents the use of potentially noxious gases. assisted spontaneous ventilation can avoid the need for muscle relaxation and paralysis so that the wake-up time is shortened. intravenous general anesthesia with propofol and assisted spontaneous ventilation is currently the frequently used anesthetic technique for rigid bronchoscopy although volatile agents and gases are still used.11,12 the patient is placed supine on the operating table. a shoulder roll is not required. after induction of anesthesia, the patient is hyperventilated to 100% oxygen saturation to take full advantage of operating time.3 a topical anesthetic (lidocaine or tetracaine) is sprayed into the laryngeal area and distally into the trachea to lessen stimulus and pain, thus lowering the level of the anesthetic agent used and minimizing the possible occurrence of laryngospasm after the procedure.12 the state of dentition is inspected and a tooth guard placed over the upper teeth. although it is possible to do bronchoscopy directly without using a laryngoscope, it is more expedient to use the laryngoscope (with the left hand) to visualize the larynx. the assistant (most likely the orl resident but occasionally, a nurse) hands over the bronchoscope (to the right hand) without the glass window plug initially (because it may fog up or fall off ) and the bronchoscope is inserted by looking through the bronchoscope as it passes through the larynx. rotating the bronchoscope by 900 (with the axis of the lip in the anteroposterior axis of the glottis chink) is often useful for easier bronchoscopic insertion.2 never force the bronchoscope into the larynx. if there is difficulty, reposition the laryngoscope to better visualize the larynx. where exposure of the larynx is adequate, inability to pass the bronchoscope may be due to the bronchoscope lip hitting a vocal fold instead of entering the glottic chink. another possibility is that the bronchoscope is too large to fit through a narrowed subglottis. the laryngoscope is removed once the bronchoscope has been inserted and the anesthesiologist connects the anesthetic tube to the standard 15-mm adapter of the bronchoscope and the glass window plug is inserted. (this is again removed when the forceps is introduced or suctioning needed). a 0o telescope of the appropriate size may be inserted at this time or even during the initial insertion of the bronchoscope. the left hand is placed over the tooth guard and the thumb and index finger are used to support the bronchoscope being held in the right hand, much like a billiard cue. the left thumb lifts the bronchoscope off the tooth guard to enable the bronchoscope to be advanced without resistance. the bronchoscope is advanced slowly, always ensuring that the lumen is clearly in view and suctioning whenever needed. once the carina is seen, the main bronchus, where the fb is likely to be located, is then entered. turn the head to the left to enable passage into the right main bronchus and then to the right to enter the left main bronchus. some degree of neck flexion can also be helpful in aligning the main bronchus. the bronchoscope is advanced until it is as near philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 philippine journal of otolaryngology-head and neck surgery 41 practice pearls as possible to the fb to allow accurate suction of secretions so that the surgeon can determine how best to orient the forceps during application. the bronchoscope is then slightly withdrawn to allow the forceps to be freely inserted beyond the bronchoscope. the forceps are opened as widely as possible as this stretches the airway walls and allows the foreign body to fall into the jaws of the forceps which is then firmly grasped. care must be taken not to push the fb further down the airway. if the fb fits through the bronchoscope, then it is pulled right through without removing the bronchoscope. however, if the fb does not fit through the bronchoscope, then the bronchoscope has to be withdrawn with the fb trailing behind held by the forceps. it is important to keep your eyes (and hands) on the bronchoscope and forceps at all times. the fb may become caught in the larynx or dropped into the trachea, causing complete airway obstruction. this possibility should always be anticipated and equipment be able to deal with this needs to be readily at hand. to prevent the fb being lost at the laryngeal inlet, the bevel of the bronchoscope is moved around over the fb by rotating the bronchoscope 900 and the bronchoscope is slightly tilted down at this area. a firm grip on the forceps with the fb must be maintained and hopefully, it is still there when the forceps is removed from the oral cavity. if the fb has been removed from the tracheo-broncial tree, but is not found in the forceps, the naso-oro-hypo pharynx should be checked in addition to a repeat bronchoscopy. all throughout the procedure, it is imperative to listen to the sound of the oxygen saturation monitor for signs of desaturation and to inquire from the anesthesiologist regarding the condition of the patient. if desaturation occurs, the bronchoscope is moved back out of the bronchus and into the trachea to allow the anestheshiologist to ventilate the patient through the bronchoscope adaptor. if this is due to a large fb that slipped while in the trachea, then, the fb must be removed right away or pushed back into the bronchus to regain the airway. once the fb is removed, a second bronchoscopic examination is done to check for any pooling of secretions or blood that may need to be suctioned or for any remnant of the fbwhich may have accidentally separated from the bigger piecethat has to be retrieved. small pieces can often be removed by suctioning. rarely, a tracheostomy may have to be performed for a fb that, during extraction, will not fit through the laryngeal inlet. tracheotomy is performed while the bronchoscope is in place and with the forceps grasping the fb. the fb is extracted through the tracheostoma. afterwards, tracheostoma is closed with sutures and regular wound care is initiated. if the procedure took less that an hour with minimal trauma, then the child is assisted with ventilation until he/she recovers references 1. jurado ab. review of 101 cases of foreign body aspiration in the philippine children’s medical center. unpublished manuscript presented at the 10th asean otolaryngology, head & neck surgery congress, brunei darussalam. january 2003. 2. pinzoni f, boniotti c, molinaro sm, baraldi a, and berlucchi m. inhaled foreign bodies in pediatric patients: review of a personal experience, int j pediatr otolaryngol, vol. 71, issue 12, december 2007, pp. 1897-1903. 3. gibson se and shott sr. foreign bodies of the upper aerodigestive tract. in: myer cm, cotton rt and shott sr, eds. the pediatric airway: an interdisciplinary approach. philadelphia: j.b. lippincott company, 1995. 4. lea e, nawaf h and talmon yoav, et al., j pediatr surg. vol. 40, issue 7, july 2005, pp. 1122-1127 5. heyer cm, bollmeier me and rossler l, et al., evaluation of clinical, radiologic and laboratory prebronchoscopy findings in children with suspected foreign body aspiration. j pediatr surg. volume 41, issue 11, november 2006, pp 1882-1888. 6. poznanski ak. radiology: holinger ld, lusk rp and green cg, ed. pediatric laryngology and bronchoesophagoscopy. philadelphia: j.b. lippincott-raven company, 1997. 7. cevizci n, dokucu ai and baskin d, et al., virtual bronchoscopy as a dynamic modality in the diagnosis and treatment of suspected foreign body aspiration. eur j pediatr surg. vol. 18, issue 6, december 2008, pp 398-401. 8. righini ca, morel n and karkas a, et al., what is the diagnostic value of flexible bronchoscopy in the initial inestigation of children with suspected foreign body aspiration? int j pediatr otorhinol. volume 71, issue 9, september 2007, pp 13831390. 9. holinger ld and green cg. instrumentation, equipment and standardization: holinger ld, lusk rp and green cg, ed. pediatric laryngology and bronchoesophagoscopy. philadelphia: j.b. lippincott-raven company, 1997. 10. lano cf, smith tl and holmes dk. rigid bronchoscopic removal of multiple airway foreign bodies. in: diagnostic and therapeutic endoscopy, vol. 4, pp. 95-99 (c) 1997 opa (overseas publishers association). 11. colt hg. rigid bronchoscopy: intubation techniques. uptodate website. 7 august 2007 http://www.uptodate.com/patients/content/topic.do?topickey=~in6iaceyvjpr qz 12. hall sc and green cg. anesthesia: holinger ld, lusk rp and green cg, ed. pediatric laryngology and bronchoesophagoscopy. philadelphia: j.b. lippincott-raven company, 1997. 13. shlizerman l, mazzawi s and rakover y, et al “foreign body aspiration in children: the effects of delayed diagnosis.” am j otol head and neck med and surg. 23 april 2009 <nttp://www. sciencedirect.com> full spontaneous respiration. a dose ofteroids may also be given (i.v. dexamethasone, 1.0 to 1.5 mg/kg; maximum, 20 mg). the patient is brought to the post-anesthesia room and observed. delayed diagnosis and intervention (24 hours or more) were found to be related to higher complication rates such as recurrent or chronic pulmonary infections and prolonged hospital stay.13 thus, the need for early diagnosis and treatment of cases with suspected fb aspiration. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 from the viewbox philippine journal of otolaryngology-head and neck surgery 37 the determination of the presence of acquired cholesteatoma in the middle ear and mastoid is one of the most common indications for computerized tomographic (ct) imaging of the temporal bone. while the presence of a soft tissue density in the mesotympanum, epitympanum or antrum is a feature of cholesteatomatous disease, ct imaging cannot reliably differentiate soft tissue densities caused by cholesteatoma, middle ear effusion or fluid completely filling the middle ear and mastoid air cell system, granulation tissue, brain, or other soft tissue densities that may fill the air-containing space.1,2 bone erosion is the radiologic sine qua non of a cholesteatoma. in the absence of bone erosion, a cholesteatoma may be present but cannot be diagnosed on ct imaging studies. one of the earliest abnormalities of a cholesteatoma that can be appreciated on a ct scan is erosion of the scutum, which is the medial aspect of the roof of the external auditory canal, and where the tympanic membrane attaches superiorly. scutum erosion is most easily seen on coronal ct images.2 nathaniel w. yang, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila blunting of the scutum: a key feature in the radiologic diagnosis of acquired cholesteatoma correspondence: nathaniel w. yang, md department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 phone: (632) 526 4360 fax : (632) 525 5444 emai: nwyang@gmx.net reprints will not be available from the author. figure 1. this is a coronal ct image of a temporal bone with no known middle ear pathology. it passes through the temporal bone at the level of the cochlea, and uses a bone window algorithm with a window width of 4,000 h. the scutum can be identified as the sharp-edged superomedial border of the external auditory canal (white arrowhead). philipp j otolaryngol head neck surg 2008; 23 (1): 37-38 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 38 philippine journal of otolaryngology-head and neck surgery from the viewbox references: 1 johnson dw, voorhees rl, lufkin rb et al. cholesteatomas of the temporal bone: role of computed tomography. radiology 1983; 148: 733-737. 2 weissman jl. hearing loss. radiology 1996; 199: 593-611. figure 2. this is a coronal ct image passing through the level of the internal auditory canal in a patient with known middle ear disease. the epitympanum is occupied by a soft tissue density (white arrow). the scutum (white arrowhead) is blunted, very much like the tip of a used, unsharpened pencil. clinical examination and surgical findings confirm the presence of an acquired cholesteatoma in the epitympanum and mastoid antrum. figure 3. this is a coronal ct image passing through the level of the cochlea in a patient with chronic middle ear effusion. the tympanic membrane was intact, with no evidence of attic retraction pockets. the ct scan was taken four days after myringotomy with aspiration of the middle ear fluid. persistent clear fluid draining from the ear raised the suspicion of a csf leak. this scan was radiologically interpreted as a case of cholesteatoma, although the scutum is not blunted (white arrowhead), and clinical examination did not show any evidence of such pathology. this case illustrates the need for clinicians to be vigilant in corroborating a radiologic diagnosis of cholesteatoma. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 invention and innovation: novelty and necessity “you’re a wave, met you on the shore though we’ve met before; keep coming back for more and more each day, you brighten up my eye; sparkle in your eye, star to steer me by”1 as oft-unheralded offspring of necessity, inventions may appear innocuously or glaringly on our horizon, adding new color to our world. whether emerging a brilliant sunburst topping majestic clouds, or a subtle ray filtering through shadowy groves, inventions bring light to life and have the potential to forever change the previous world order. serendipity and inspiration play their role in sparking the creative imagination; but inventions would barely see the light of day were it not for the persistence, perspiration and dogged determination that formed them while burning the proverbial midnight oil. actualization marks the subtle difference between invention and innovation. “invention is the first occurrence of an idea for a new product or process, while innovation is the first attempt to carry it out into practice”2 according to masnick, “plenty of people or companies who ‘invented’ an idea were never able to capitalize on the idea at all. it took others who actually innovated and built off that idea to make a product that actually had an impact on the world.”3 in business terms, invention is “the formulation of new ideas for products or processes;” innovation is “all about the practical application of new inventions into marketable products or services.”4 schrage hits the nail on the head when he observes that “the technical excellence of an invention matters far less than the …willingness of the customer or client to explore it.”5 he continues: “we have no shortage of good inventions. what we need are better ways to bring them to customers.”5 innovation involves creativity, but is not identical to it. according to davila and others, “often, in common parlance, the words creativity and innovation are used interchangeably. they shouldn’t be, because while creativity implies coming up with ideas, it’s the “bringing ideas to life” . . . that makes innovation the distinct undertaking it is.”6 our journal has a long and proud tradition of encouraging scholarly dissemination of discoveries. far from being a purely academic exercise, making such novelty public is a necessary contribution to new knowledge, skills and attitudes of our readers. rather than coming to rest in library shelves or databases, we hope these data and devices come alive in the minds, hearts and hands of physicians and surgeons, and are put to good use to ultimately benefit the patients, families and communities they serve. never mind that we can ill-afford the costly and tedious processes of international patent application, or that our innovations seem “backward” from a “developed country” perspective; we hope they will be as relevant and appropriate as they are useful to our people and locoregional situation. i am pleased and proud to announce that the philipp j otolaryngol head neck surg is now also indexed on philippine journals on line (philjol)available at http:// www.philjol.info/ and supported by the international network for the availability of scientific publications (inasp) http://www.inasp.info/. this additional indexing service greatly increases our visibility and accessibility to such search engines as google and google scholar. our journal is available on http://www.philjol.info/index.php/ pjohns/index. jose florencio f. lapeña, jr., ma, md editorial 4 philippine journal of otolaryngology-head and neck surgery 1lapeña jf. “you’re a wave” [unpublished song] manila: 1983 2fagerberg j. (2004). “innovation: a guide to the literature”. in fagerberg, jan, david c. mowery and richard r. nelson. the oxford handbook of innovations. oxford university press. pp. 1-26. 3masnick m. the difference between innovation and invention. ramblings [serial on the internet] 2005 march 22 [cited 2009 may 18]; available from:http://www.techdirt.com/ articles/20050322/1528251_f.shtml 4tutor2u [website on the internet] invention and innovation [cited 2009 may 16]; available from:http://tutor2u.net/business/production/invention-and-innovation.htm 5schrage m. much ado about invention. technology review published by mit [serial on the internet] 2004 may [cited 2009 may 19]; available from http://www.technologyreview. com/business/13595 6davila t, epstein mj, shelton r. (2006). making innovation work: how to manage it, measure it, and profit from it’’. upper saddle river: wharton school publishing. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 philippine journal of otolaryngology-head and neck surgery 9 original articles abstract objective: to compare the results of auditory steady-state response (assr) and click auditory brainstem response (click abr) among infants and young children tested at the ear unit of a tertiary general hospital. methods: design: cross-sectional study setting: tertiary general hospital population: within-subject comparisons of click auditory brainstem response (click abr) thresholds and auditory steady-state response (assr) thresholds among 55 infants and young children, 2 months to 35 months of age referred to the ear unit for electrophysiologic hearing assessment. results: click abr showed strong positive correlation to all frequencies and averages of assr. highest correlation was noted with the average of 1-4 khz assr results with pearson r = 0.89 (spearman r=0.80), the average of 2-4 khz had strong positive correlation r = 0.88 (0.79). correlation was consistently strong through all assr frequencies (0.5 khz at r=0.86 (0.74), 1 khz at r=0.88 (0.78), 2 khz at r=0. 87 (0.79), 4 khz at r=0.85 (0.76)). average differences of click abr and assr thresholds were 8.2±12.9db at 0.5 khz, 8.6±12.6db at 1 khz, 5.3±11.8db at 2 khz and 7.8±13.4db at 4 khz. among patients with no demonstrable waveforms by click abr with maximal click stimulus, a large percentage presented with assr thresholds. of these, 80.5% (33 of 41) had measurable results at 0.5 khz with an average of 107.3±11.1db, 85.4% (35 of 41) at 1 khz with an average of 110.5±11.8db, 73.2% (30 of 41) at 2 khz with an average of 111.2±11.1db and 63.4% (26 of 41) at 4 khz with average of 112.2±8.21db. auditory steady-state response results were comparable to auditory brainstem response results in normal to severe hearing loss and provided additional information necessary for complete audiologic assessment especially among patients with severe to profound hearing loss wherein click abr showed no responses. up to 85.4% of patients that would have been noted to have no waveforms by click abr still demonstrated measurable thresholds by assr. conclusion: our study suggests that assr may be the best available tool for assessing children with severe to profound hearing loss, and is a comparably effective tool in overall hearing assessment for patients requiring electrophysiological testing. the advantages of assr over click abr include: 1) detection of frequency-specific thresholds and; 2) the detection of hearing loss thresholds beyond the limits of click abr. key words: auditory steady-state response, assr, auditory brainstem-evoked response, abr, hearing thresholds, electrophysiologic testing comparative study of the auditory steady-state response (assr) and click auditory brainstemevoked response (click abr) thresholds among filipino infants and young children laurence ian c. tan, md1 maria rina t. reyes-quintos, md, mclinaud1,2 maria leah c. tantoco, md, mclinaud2 charlotte m. chiong, md1,2 1 department of otorhinolaryngology philippine general hospital university of the philippines manila 2philippine national ear institute national institutes of health university of the philippines manila correspondence: laurence ian c. tan, md department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax: (632) 525 5444 reprints will not be available from the author. funding for this study was supported by hearing international and the philippine national ear institute. hearing international provided the training for assr as well as financial support for purchase of the equipment. the philippine national ear institute provided the venue for testing of the children and also partly funded the research by way of salaries of the data collectors. the authors signed a disclosure that they have no proprietary or financial interest with any other organizations that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at the analytical research contest (1st place) philippine society of otolaryngology head and neck surgery, glaxo-smith-kline bldg., auditorium, chino roces avenue, makati city. october 23, 2008 philipp j otolaryngol head neck surg 2009; 24 (1): 9-12 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 original articles 10 philippine journal of otolaryngology-head and neck surgery hearing screening has been employed in the philippines for more than a decade with recent efforts to promote universal newborn hearing screening. despite detrimental effects of childhood hearing loss documented among filipino children,1 we still lack widespread use of newborn and infant hearing screening programs. advocacy and active promotion have resulted in increasing popularity of the use of otoacoustic emissions (oae) and auditory brainstem-evoked response (abr). however, auditory steady-state response (assr) has only recently become available in the philippines despite its well established use. for instance, it has been incorporated in hearing screening programs in the united kingdom since 2007.2 auditory steady-state response (assr) and auditory brainstem response (abr) are both electrophysiologic tests with very similar basic principles. the eeg waveforms generated from the auditory stimulus are assumed to correspond to certain portions of the auditory brainstem pathway. the presence or absence of these waveforms in response to a stimulus determines the estimated threshold of the patient for abr. click abr is still the most commonly used electrophysiologic test to evaluate the auditory pathway’s integrity among infants and young children. click stimuli used for abr are broad frequency over the spectrum 1k-4 khz.3 tone-burst abr has been shown to have good correlation for low frequency range of 250 hz.4 tone-burst abr and assr have frequency specific stimuli and have been shown to have accurate correlation.5 tone-burst abr’s need for new instrumentation and technical expertise has limited it’s application locally. moreover, abr requires experience in waveform analysis and can be prone to reader error. assr employs an objective, sophisticated, statistics-based mathematical detection algorithm to detect and define hearing thresholds. this objectivity provides an added advantage over abr. several studies have confirmed the correlation of abr to assr results,5,6,7,8,9 as well as correlation to pure-tone thresholds.10,11,12 hearing loss beyond 95db are beyond the limits for abr stimulus presentation. compared to the limitation of click abr, assr signal intensity can be as high as 120 db. despite the acceptance of assr as a diagnostic test in the evaluation of hearing loss, there has been no local investigation on assr in filipino hearing-impaired children. the results of this study can be used to estimate thresholds in cases where abr flat waves have been recorded. these will provide information that may be important for counseling parents and clinicians regarding the rationale for hearing aid fitting and its settings in patients who would have been deprived of knowing the extent of residual hearing in areas where as yet no assr services are available. the objectives of this study are 1) to compare the results of assr and click abr among filipino infants and young children tested at the ear unit in the philippine general hospital; 2) to correlate the click abr and assr and; 3) to describe the assr results among patients with nonreactive waveforms on maximal click abr stimulus. methods subjects all patients who failed a hearing screening and who were referred to the ear unit of the philippine general hospital for electrophysiologic testing were considered and informed consent was obtained. excluded were patients who could not undergo electrophysiological testing either due to external ear abnormalities, inability to be fit with electrodes/ear inserts or undergo sedation. fifty five patients were included, aged 2 months to 35 months. the majority of patients referred could not undergo behavioral testing. hearing assessment was conducted in a soundproof room. electrophysiological audiologic assessment was performed in the same session and administered by the same tester. patients were tested under sedation using chloral hydrate or in natural sleep state when consent for sedation was not given. abr stimulation and recording click abrs were recorded using the bio-logic master system (biologic systems corporation, mundelein, il). click abrs were measured with electrodes affixed to the vertex and to the mastoid processes. either the forehead or the contralateral mastoid process served as ground. electrode impedances never exceeded 3000 mω. responses were measured to 100 ms rarefaction clicks presented monaurally. abrs were obtained initially at 30 db or 70db depending on the clinical presentation of the patient. one thousand twenty four stimulus presentations were included in each average response which was replicated at least once. waveforms recorded with artifacts of movement were re-sampled. a 10 db increment or decrement was used to determine the threshold. the threshold was determined at the lowest level at which an abr wave v was present as determined by visual inspection of the waveforms displayed on the computer screen. assr stimulation and recording assr testing immediately followed the click abr for patients who were still asleep or sedated. the same surface electrodes used in abr were also used for assr, which was measured using a predefined program of the same bio-logic master apparatus. patients were tested at 10db below previously determined abr thresholds when available. increments/decrements of 10 db were used depending on the required number of sweeps per frequency and threshold. patients tested for thresholds of 80db and above were tested monaurally and one frequency at a time. the master system takes into account the variance of the noise along with the variance of the response and determines significance using an f-test. results fifty five patients, aged 2 months to 35 months with mean age at 18 ± 9 months were included in this study (table 1). one patient was tested unilaterally due to aural atresia which prevented placement of ear inserts in the affected ear. five patients woke up during abr testing, completing only one of the ears tested. one patient did not complete assr testing for one ear. a total of 103 ears were tested for both abr philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 original articles philippine journal of otolaryngology-head and neck surgery 11 and assr. abr test results were compared to assr results at 500hz, 1,000hz, 2,000hz and 4,000 hz when available. statistical analysis was done with pearson and spearman correlation using graphpad prism version 5.00 for windows, (graphpad software, san diego california usa,www.graphpad.com). table 2 lists the correlation data and values. abr showed strong positive correlation to all frequencies and averages of assr. highest correlation was noted with the average of 1-4 khz assr results (figure 1) with pearson r = 0.89 (spearman r = 0.80), the average of 2-4 khz (figure 2) had strong positive correlation r = 0.88(0.79). these results, however, are less than those determined by previous studies (pearson r=0.92).13 correlation was consistently strong through all assr frequencies (table 2, figure 3). all correlations were significant at a 0.01 level of significance (2 tailed). differences between the click abr and assr thresholds were also noted (table 3). the average differences of click abr and assr thresholds were 8.2 ± 12.9db for 0.5 khz, 8.6 ± 12.6db at 1 khz, 5.3 ± 11.8db at 2 khz and 7.8 ± 13.42db at 4 khz. forty-one patients were non-responsive (nr) or exhibited no recognizable waveforms with maximal stimulus by click abr. two test ears were non-responsive (nr) by both click abr and assr. of 41 test ears non-responsive (nr) by click abr, 39 had results with assr for at least one frequency. among patients with no demonstrable waveforms by click abr, a large percentage presented with assr thresholds. of these, 80.5% (33 of 41) had measurable results at 0.5 khz with a mean of 107.3 ± 11.1db, 85.4% (35 of 41) at 1 khz with an average of 110.5 ± 11.8db, 73.2% (30 of 41) at 2 khz with a mean of 111.2 ± 11.1db and 63.4% (26 of 41) at 4 khz with mean of 112.2 ± 8.2db (figure 4). discussion this study confirmed that assr is comparable to click abr as a measure of hearing thresholds for filipino children. the highest correlation was found to be with the average of 1-4 khz followed by the average of 2-4 khz due to the nature of the click stimulus being within the high frequency range. these results were very similar to those demonstrated in 48 infants and young children by swanepoel and ebrahim.8 the click stimulus, as described earlier, does recruit the cochlear range of 1-4k. it could be recommended that click abr be compared to the averages of high frequency assr rather than to a single frequency. the means of the differences (table 4) between click abr and assr test frequencies were minimal (less than 10db), which is the increment used in clinical practice. with the hearing thresholds 0-40db and 6180db, assr averages were generally higher by approximately 10db and 15db. these differences varied in the higher sound intensities. assr much more closely approached thresholds obtained by click abr in the severe to profound hearing levels, though the limited number of patients with recordable thresholds by click abr may have influenced results greatly. the over-estimation of thresholds may have been influenced by machine calibration or affected by the statistical elimination of eeg noise which is especially prominent among lower intensity thresholds.13 these results of over-estimation of thresholds figure 3. shows the distribution of the assr against the abr. figure 3. scatter plot of assr frequencies vs abr abr in decibels a b r i n d e c ib e ls figure 2. shows the distribution of the average threshold of 2-4 khz assr against the abr. figure 2. scatter plot of 2-4 khz average assr vs abr abr in decibels a b r i n d e c ib e ls figure 1. shows the distribution of the average threshold of 1-4 khz assr against the abr. figure 1. scatter plot of 1-4 khz average assr vs abr abr in decibels a b r i n d e c ib e ls philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 original articles 12 philippine journal of otolaryngology-head and neck surgery best demonstrate the limitation of testing with abr for patients with profound hearing loss in the range of the click stimulus. notably, up to 85.4% of patients that would have been noted to have no waveforms by click abr still demonstrated measurable thresholds by assr. figure 4 shows the results of patients that still had assr thresholds but had no waveforms by click abr. the majority of thresholds were distributed at 110-120db but the variation of assr thresholds varied widely especially among the lower frequencies. it may therefore be necessary that patients noted to have no waveforms by abr be crosschecked by assr. the recommendation is that assr testing be done in patients who fail to demonstrate waveform responses by click abr. our study suggests that assr may be the best available tool for assessing children with severe to profound hearing loss and is a comparably effective tool in overall hearing assessment for patients requiring electrophysiological testing. the advantages of assr over click abr (table 4) include: 1) detection of frequency-specific thresholds and; 2) the detection of hearing loss thresholds beyond the limits of click abr. however, it is our view that assr not be taken as a replacement for the click abr but as a complement to the audiologic armamentarium. table 1. classification of patients’ hearing hearing status (abr thresholds) total no. of ears 0-40db 41-60db 61-80db 81 and above db no response all thresholds 41 8 9 4 41 103 average age months 15 ± 9 11 ± 7 18 ± 10 22 ± 8 22 ± 8 18 ± 9 table 2. correlation of click abr to assr thresholds pearson correlation spearman correlation sig. (2-tailed) n 0.5 khz .86 .74 .00 62 1 khz .88 .78 .00 62 2 khz .87 .79 .00 62 4 khz .85 .76 .00 62 1-4 khz .89 .80 .00 62 2-4 khz .88 .79 .00 62 table 4. comparison of click abr to assr detection of retrocochlear pathology neural/ auditory neuropathy intraoperative monitoring estimation of hearing thresholds normal hearing severe to profound hearing loss ski slope hearing frequency range simultaneous testing click abr sensitivity of >90%14 identified with wave i yes15 accurate accurate only to moderate hl limited to 95db15 results not representative of hearing loss 1-4 khz no assr no studies available cannot differentiate sensory from neural no tendency for over-estimation if patient not sedated accurate from moderate to profound hl frequency-specific thresholds 0.25-4 khz up to 8 frequencies at a time13 are consistent with results from several studies.11,12 the approach of the average assr threshold to the click abr may also be due to the effect of saturation of assr thresholds noted at higher frequencies when using sweeps of intensities as noted by picton.13 for patients without demonstrable abr waveforms at maximal click intensity, a large percentage showed residual hearing at 500hz at a mean close to the limit of the abr. from 1k to 4 khz, there were a decreasing number of patients with responses to assr. these results table 3. mean differences between assr and click abr 0-40db 41-60db 61-80db 81db and above all thresholds n 41 8 9 4 62 hearing thresholds 0.5 khz 8.8±11.6 8.1±18.9 10.±11.2 -1.2±18.0 8.2±12.9 1 khz 8.2±10.9 3.8±16.2 17.3±13 2.5±15.6 8.6±12.6 2 khz 6.2±9.5 0.6±14.74 8.9±13.2 -2.5±22.2 5.3±11.8 4 khz 8.3±9.3 2.5±17.3 15±20 -2.5±19.4 7.8±13.4 1-4 khz 7.6±8.8 2.3±12.9 13.7±12.4 -0.8±19.0 7.2±11.0 2-4 khz 7.3±8.9 1.6±13.6 11.9±13.4 -2.5±20.7 6.6±11.4 difference in decibels (db) references 1. chiong c, ostrea e jr, , reyes a, llanes eg, uy me, chan a. correlation of hearing screening with developmental outcomes in infants over a 2-year period. acta otolaryngol. 2007 apr;127(4):3848. 2. stevens j, sutton g, wood s, mason s. guidelines for the early audiological assessment and management of babies referred from the newborn hearing screening programme. [database on the internet] newborn hearing sscreening program c2002-2005 – [update 2007 march; cited 2008 september 3]. available from:http://hearing.screening.nhs.uk. 3. ponton c. w. ; moore j. k.; eggermont j. j.; auditory brain stem response generation by parallel pathways : differential maturation of axonal conduction time and synaptic transmission. ear and hearing 1996;(17):402-410. 4. gorga m. p.; johnson t. a.; kaminski j. r.; beauchaine k. l.; garner c. a.; neely s. t.; using a combination of clickand tone burst-evoked auditory brainstem response measurements to estimate pure-tone thresholds. ear and hearing 2006 feb;27(1):60-74. 5. johnson t. a.; brown c. j.; threshold prediction using the auditory steady-state response and the tone burst auditory brainstem response: a within subject comparison. ear and hearing 2005 dec; 26(6):559-76. 6. lin y-h, ho hc, wu hp, comparison of auditory steady-state responses and auditory brainstem responses in audiometric assessment of adults with sensorineural hearing loss, auris nasus larynx (2008), 2008 jul 11. [epub ahead of print] 7. firszt j, gaggl w, runge-samuelson c, burg l, wackym p. auditory sensitivity in children using the auditory steady-state response arch otolaryngol head neck surg. 2004;130:536-540. 8. swanepoel d, ebrahim s auditory steady-state response and auditory brainstem response thresholds in children eur arch otorhinolaryngol 2008 june 17 [epub ahead of print]. 9. rance g, tomlin d, and rickards f. comparison of auditory steady-state responses and toneburst auditory brainstem responses in normal babies ear & hearing 2006; 27: 751–762. 10. swanepoel d, hugo r,roode r. auditory steady-state responses for children with severe to profound hearing loss arch otolaryngol head neck surg. 2004;130:531-535. 11. duarte jl, alvarenga kf, garcia tm, costa filho oa, lins og. auditory steady-state response in the auditory evaluation: clinical application (original title: a resposta auditiva de estado estável na avaliação auditiva: aplicação clínica). pró-fono revista de atualização científica. 2008 abrjun;20(2):105-10. 12. herdman at, stapells dr. thresholds determined using the monotic and dichotic multiple auditory steady-state response technique in normal-hearing subjects. scand audiol. 2001;30(1):41-9. 13. picton tw, roon p, and john ms. human auditory steady-state responses during sweeps of intensity. ear & hearing 2007;28:542–557. 14. zappia jj, o’’connor ca, wiet rj, dinces ea. rethinking the use of auditory brainstem response in acoustic neuroma screening. laryngoscope. oct 1997;107(10):1388-92 15. katz j. handbook of clinical audiology, fourth edition. baltimore, md:. lippincott williams & wilkins;1994. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 rhetoric and reality: nomenclature and notoriety “we spin a web of dreams in our mind; the silken rainbow threads make us blind; and so we travel on, but we never find; the things in life we left behind1.” the act of naming establishes a power relationship between “namer” and “named.” in the patriarchal tradition, for instance, man’s dominion over the rest of nature was symbolized by the privilege of naming “all the cattle and the fowl of the heavens and all the beasts of the field.”2 we bestow names not only on our children, but on our pets, properties and subordinates. the terms “nabinyagan” or “nabansagan” refer to the informal process of such social assignations. the “namer” assumes dominance in the relationship over the “named.” the process is not reciprocal (at least not overtly). in filipino culture, as in other verticallyoriented societies, subordinates/youth do not address superiors/elders solely by name, but by appending a title denoting the relationship between both parties (lolo/lola tatay/nanay, tiyo/tiya, kuya/ate, diko/ ditse, sanko/sanse, sir/ma’am) such practices are less evident in more horizontally oriented socio-cultural contexts such as north america, where grandparents and parents-in-law may be addressed by their first name alone. the act of naming may also define3 (de, “completely” + finire, “to limit, set bounds, end”) reality for the bestower. whether such nomenclature pertains to stars and planets, taxonomies of flora and fauna, the pharmacopoeia or computer language, recognition and use of a name allow one to understand it and to know some of its secrets. like a magic key, using a name unlocks a relationship between the user and the person, animal or object named. agreement on and shared use of such “rhetoric” by other observers constitutes “objectification” of what would hitherto be “subjective” reality, but may also promote “shared delusion” as was the case with the proverbial “emperor’s new clothes.”4 in such a situation, courage can hardly begin to describe the one who dares speak out, as he or she promptly becomes fair game for those who would prefer the delusions of darkness to the harsh realities of light. and prophets and bearers of bad news are notoriously unwelcome in their own country. as is the case with any organization, professional associations are made up of individuals and aggrupations bound by shared interests as much as (or more than) by shared friendships. these shared interests find expression in shared terminologies, while concealing self-serving agendas. what happens when rhetoric does not match reality? to call a spade a spade may be considered “impolite” and “undiplomatic,” yet coming “out of the mouths of babes” is refreshingly, disarmingly direct. such requires the childlike ability to say things as they are, without rancor or hidden agenda. how often do we encounter empty words and phrases, devoid of meaning because the realities they supposedly point to do not really exist? how often do we ourselves silently conspire, by omission if not commission, to uphold such vacuous rhetoric? and in so doing, how much of our power do we invest in and ascribe to that which does not really exist? does the fact that there are many of us sharing the same delusions make us less deluded? were we more transparent in our dealings, would reality be more apparent? this issue pays tribute to three colleagues who passed away this year, and coinciding with the 12th asian research symposium in rhinology, features a meta-analysis on intranasal corticosteroids for the medical management of nasal polyps in adults, a case report of intravascular lymphoma of the inferior turbinate, a grand rounds discussion of rhinophyma, a histopathologic case of sinonasal teratoid carcinosarcoma and practice pearls on nasal saline lavage. in addition, we have original and review articles in otology and audiology, a case report in oropharyngology, surgical innovations and instrumentation in otology and laryngology, and a radiologic discussion of ossifying fibroma. of the manuscripts submitted for possible publication, many did not comply with our instructions to authors, did not submit or revise in time to complete the editorial and review process, or did not comply with the process itself. in some cases, reviewers were not accorded the professional courtesy they deserved, considering their stature in their respective fields, and their kindness in performing the reviews gratis et amore. to them, we can only apologize in behalf of these authors, and reiterate our gratitude for their generous support. to the authors whose manuscripts are still in process, we look forward to seeing your articles in print in forthcoming issues, and thank you for “plodding on with us” as we strive to continue publishing a journal worthy of your scholarly efforts. in this regard, thanks are also due to our pso-hns president eutrapio s. guevara, and the board of trustees for the continuing financial and management support. may we continue to receive this same support from you, our valued contributors and readers. jose florencio f. lapeña, jr., ma, md editorial 4 philippine journal of otolaryngology-head and neck surgery 1“castles in the clouds” lapeña jf, [unpublished song] manila: 1978. 2 torah (the pentateuch): b’reishit (genesis) 2:19-20 the judaica press complete tanakh with rashi. available from: http://www.chabad.org/library/article cdo/aid/8166/jewis/chapter-2.htm 3available from: http://www.etymonline.com/index.php?search=define&searchmode=nl 4 andersen hc. keiserens nye klæder (the emperor’s new clothes) in eventyr, fortalte for børn (fairy tales, told for children) first published 1837; paull hp, translator. andersen’s fairy tales, 1872. “the emperor’s new suit” in owen l, editor. the complete hans christian andersen fairy tales. new york: random house (gramercy) 1993: 438-440. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 case reports 22 philippine journal of otolaryngology-head and neck surgery abstract objective: to describe a case of chronic cough due to pedicled uvular mucosal flap design: case report. setting: a tertiary military hospital patient: one (1) result: a mucosal flap was seen arising from the uvula on oropharyngeal examination with a tongue depressor. nasopharyngoscopy documented its extension to the tongue base and hypopharynx. it was excised under local anesthesia with amelioration of complaints and cessation of cough. conclusion: the etiology of chronic cough not attributable to chronic rhinosinusitis, asthma, gastroesophageal reflux, tuberculosis, dysfunctional swallowing or cigarette smoking should be investigated further. a simple oropharyngeal examination (as in this case) may reveal the cause and a simple solution may be obtained, avoiding unnecessary investigations and treatment. key words: mucosal flap, uvula, chronic cough, pedicle. chronic cough is defined as cough for more than four weeks. with careful history-taking and appropriate investigations, a single cause can be found in up to 82% of cases1. the majority of these can be successfully treated. the elongated uvula is previously reported in children as a cause of chronic cough2-6 even though it is an unusual reason for chronic cough in adults. to our knowledge this is the first reported case of chronic cough due to a uvular mucosal flap. pediculated mucosal flap of the uvula: an unusual cause of chronic cough in an adult murat enoz, md department of otolaryngology head & neck surgery maresal cakmak military hospital, erzurum, turkey. correspondence: murat enoz, md department of otolaryngology head & neck surgery maresal cakmak military hospital, 25700 yenisehir, erzurum, turkey phone: +905554293937 fax: +902123439040 email: muratenoz@gmail.com reprints will not be available from the author. no funding support was received for this study. the author signed a disclosure that he has no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this report. philipp j otolaryngol head neck surg 2007; 22 (1,2): 22-23 c philippine society of otolaryngology – head and neck surgery, inc. figure i: all oropharyngeal structures seem normal without tongue depression (a). thin, flaccid mucosal flap of the uvula (black arrow) with its pedicle is shown after tongue depression. the pedicle extended to the tongue base and hypopharyngeal structures (b). philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 case reports philippine journal of otolaryngology-head and neck surgery 23 case report a 26-year-old male was referred to our clinic for evaluation of non productive chronic cough more than three years. the patient was neither a smoker nor drinker and had no pertinent medical history. a cursory oropharyngeal examination (without using a tongue depressor) suggested that all oropharyngeal structures were normal (figure ia). however, depressing the tongue revealed a thin, flaccid mucosal flap extending from the uvula toward the tongue base (figure i-b). fiberoptic nasopahryngoscopy confirmed attachment of the pedicle to the tongue base and lateral pharyngeal walls. endoscopic laryngoscopy and the rest of the orl hns exam were normal. the mucosal flap was excised under the local anesthesia and his complaints were ameliorated. the patient was followed up for six months during which time, his cough did not recur. discussion an elongated uvula can flop down and touch various structures including the posterior pharyngeal wall, epiglottis, and vocal cords. irritation of these structures can lead to chronic cough, which can be relieved by uvulectomy or uvuloplasty4, 5. in our case, not just a long uvula, but a pedicled uvular flap was irritating various structures in the upper airway, leading to chronic cough. the treatment of chronic cough should always be preceded by a systematic effort to exclude serious underlying illness and establish the cause of the cough. the etiology of chronic cough not attributable to chronic rhinosinusitis, asthma, gastroesophageal reflux, tuberculosis, dysfunctional swallowing or cigarette smoking should be investigated further. a simple oropharyngeal examination (as in this case) may reveal the cause and a simple solution may be obtained, avoiding unnecessary investigations and treatment. references: 1. irwin rs, boulet lp, cloutier mm, fuller r, gold pm, hoffstein v, et al. managing cough as a defense mechanism and as a symptom. a consensus panel report of the american college of chest physicians. chest. 1998 aug;114(2 suppl managing):133s-181s. 2. pai v, thomas h, stewart c. long uvula: an unusual cause of chronic cough. postgrad med j. 2004 feb;80(940):116. 3. najada a, weinberger m. unusual cause of chronic cough in a four-year-old cured by uvulectomy. pediatr pulmonol. 2002 aug;34(2):144-6. 4. shott sr, cunningham mj. apnea and the elongated uvula. int j pediatr otorhinolaryngol. 1992 sep;24(2):183-9. 5. miller fr, tucker hm. an elongated uvula producing chronic cough. otolaryngol head neck surg 1993;109:954–5. 6. landau li. acute and chronic cough paediatr respir rev. 2006;7 suppl 1:s64-7. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 the recent dismissal of charges of plagiarism made against no less than a justice of the supreme court of the republic of the philippines2 and subsequent retaliatory threats against protesting faculty of the college of law of the university of the philippines3 are matters of grave concern in a country where even the capital crime of plunder can be so blatantly disregarded. not surprisingly, these misdemeanors share a similar etymology. plagiarism comes from the “latin plagiarius ‘kidnapper, seducer, plunderer,’ used in the sense of ‘literary thief ’ by martial, from plagium ‘kidnapping,’ from plaga ‘snare, net.’”4 according to the world association of medical editors, “plagiarism is the use of others’ published and unpublished ideas or words (or other intellectual property) without attribution or permission, and presenting them as new and original rather than derived from an existing source.”5 just as ignorance of the law is not an excuse to violate it, the misconduct of plagiarism is not contingent on whether it was committed intentionally or unintentionally. technical plagiarism “occurs when one inadvertently fails to properly cite, credit, and/or integrate a source, be it text, computer code, graphic, audio, or video information into one’s work … (and) can range in severity from an errant footnote, to incomplete citation information to “forgetting” to cite altogether.”6 five general types of plagiarism have been identified by barnbaum:7 “cut and paste,” “word-switch,” “style,” “metaphor,” and “idea.” the first two are easy to understand, the first referring to literally lifting and applying words, phrases, sentences or paragraphs while the second involves substituting words or paraphrasing without attribution. but even following the flow of thought or reasoning style of another, substituting your own words sentence after sentence or paragraph after paragraph is “style plagiarism” and the same holds true when the metaphors or ideas of another are used without proper acknowledgement.7 the bottom line is that plagiarism gives the false impression that the words, ideas, composition or creation are those of the plagiarizer and not someone else’s, or misleads the recipient about the nature of the plagiarized material.5 editorial 4 philippine journal of otolaryngology-head and neck surgery correspondence: jose florencio f. lapeña, jr. ma, md department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft ave., ermita, manila 1000 philippines phone (632) 526 4360 fax (632) 567 9508 email lapenajf@upm.edu.ph reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: professor lapeña is secretary-general of the asia pacific association of medical journal editors (apame), and a member of the world association of medical editors (wame), which have policy positions against plagiarism that he echoes. he has no other relevant conflicts of interest to declare. jose florencio f. lapeña, jr. ma, md1,2 1department of otorhinolaryngology college of medicine philippine general hospital university of the philippines manila 2department of otorhinolaryngology head and neck surgery east avenue medical center diliman, quezon city, philippines plagiarism and plunder: fabrication and falsification “you, who are on the road must have a code that you can live by and so, become yourself because the past is just a good bye”1 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 editorial philippine journal of otolaryngology-head and neck surgery 5 there is even “self-plagiarism,” which “refers to the practice of an author using portions of their previous writings on the same topic in another of their publications, without specifically citing it formally in quotes,”5 and may give the impression that the present work is new and original, when in fact it is not. according to scanlon,8 while the whole issue of self-plagiarism “raises knotty conceptual, legal, ethical, and theoretical questions … we do and should give writers legal and ethical latitude for limited self-copying, although certainly not for egregious duplication.” barring situational concessions for limited selfand technical plagiarism in exceptional contexts, plagiarism generally involves fabrication and falsification, which in science (as in law) are misconducts of the highest degree, regardless of the presence or absence of “malicious intent.” the code of conduct and best practice guidelines for journal editors of the committee on publication ethics (cope) outlines the duties of editors in pursuing such misconduct: 9 pursuing misconduct editors have a duty to act if they suspect misconduct. this duty extends to both published and unpublished papers. editors should not simply reject papers that raise concerns about possible misconduct. they are ethically obliged to pursue alleged cases. editors should first seek a response from those accused. if they are not satisfied with the response, they should ask the relevant employers or some appropriate body (perhaps a regulatory body) to investigate. editors should follow the cope flowcharts where applicable (link to flowcharts). editors should make all reasonable efforts to ensure that a proper investigation is conducted; if this does not happen, editors should make all reasonable attempts to persist in obtaining a resolution to the problem. this is an onerous but important duty. if this “onerous but important duty” applies to scientific misconduct, how much more to an institution whose very foundations are based on ethics and morality and whose raison d’etre is their upholding? where resides this institution’s moral authority, if it cannot set the example it ought to? it is not right to take what is not yours without permission; that is thievery at best. it is even worse to shamelessly appropriate for yourself, that which belongs to others; that is looting and piracy. but the large-scale wanton stripping of intellectual (and other) properties and subsequent justification with legalese that violate the very roots of academic (and other) freedoms for present and future generations are tantamount to no less than pillage and plunder. references 1 nash g. “teach your children.” crosby d, stills s, nash g, young n, (producers) [sound recording] from the album déjà vu. lp. atlantic records, 1970 may. 2 supreme court, republic of the philippines, manila. (en banc). a.m. no. 10-7-17-sc october 15, 2010. in the matter of the charges of plagiarism, etc., against associate justice mariano c. del castillo. [cited 2010 november 08]. available from http://www.lawphil.net/ judjuris/juri2010/oct2010/am_10-7-17-sc_2010.html 3 dedace sm. “supreme court threatens to sanction law faculty critics.” gmanews.tv [homepage on the internet]. gma network, inc. 2010 october 20 [cited 2010 november 08]. available from: http://www.gmanews.tv/story/203873/supreme-court-threatens-to-sanction-law-facultycritics 4 ”plagiarism,” in online etymology dictionary. douglas harper, historian. [cited 2010 november 06]. available from http://www.etymonline.com/index.php?term=plagiarism 5 “publication ethics policies for medical journals” prepared by the world association of medical editors publication ethics committee. [cited 2010 november 06]. available from http://www. wame.org/resources/publication-ethics-policies-for-medical-journals#plagiarism 6 marlboro college graduate school [homepage on the internet]. vermont, usa: marlboro college graduate school; [cited 2010 november 07]. available from:http://gradschool. marlboro.edu/resources/legal 7 barnbaum c. “plagiarism: a student’s guide to recognizing it and avoiding it” [monograph on the internet]. georgia: valdosta state university department of physics and astronomy. [cited 2010 november 06]. available from: http://www.valdosta.edu/~cbarnbau/personal/teaching_ misc/plagiarism.htm 8 scanlon pm. “song from myself: an anatomy of self-plagiarism.” plagiary: cross-disciplinary studies in plagiarism, fabrication, and falsification. [serial on the internet] 2007; [cited 2010 november 08] 2 (1): 1-11. available from: http://www.plagiary.org/papers_and_ perspectives2007.htmhttp://www.plagiary.org/papers_and_perspectives2007.htm 9 committee on publication ethics [homepage on the internet]. “code of conduct” and “best practice guidelines for journal editors” uk: committee on publication ethics. [cited 2010 november 08] available from: http://publicationethics.org/guidelines philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 case reports philippine journal of otolaryngology-head and neck surgery 25 abstract objective: to present the case of an adult patient with end stage renal disease who underwent total parathyroidectomy with autotransplantation for uncontrolled secondary hyperparathyroidism methods: design: case report setting: tertiary hospital patient: one result: total parathyroidectomy with autotransplantation resulted in decrease in parathyroid hormone from a pre-operative value of 1,347pg/ml (15-65 pg/ml) to 28.05 pg/ml. pruritus disappeared two days after the surgery. phosphorus and calcium levels were within normal values four days and two months post-operatively, respectively. conclusion: total parathyroidectomy with autotransplantation may be a viable surgical option for controlling secondary hyperparathyroidism associated with end stage renal disease and may play an important role in reducing morbidity and mortality among patients with end-stage renal disease. keywords: secondary hyperparathyroidism, parathyroidectomy, autotransplantation, endstage renal disease, hungry bone syndrome, parathyroid hormone total parathyroidectomy: a surgical management for uncontrolled secondary hyperparathyroidism in a patient with end stage renal disease jeanne o. madrid, md celso v. ureta, md department of otorhinolaryngology head and neck surgery veterans memorial medical center correspondence: jeanne o. madrid, md department of otorhinolaryngology head and neck surgery veterans memorial medical center north avenue, diliman quezon city 0870 philippines phone: (632) 927 6426 local 1359 telefax: (632) 426 9775 http://enthns-vmmc.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. presented at the interesting case contest (2nd place), philippine society of otolaryngology – head and neck surgery midyear convention, baguio city, philippines, april 20, 2007. philipp j otolaryngol head neck surg 2008; 23 (1): 25-27 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 case reports 26 philippine journal of otolaryngology-head and neck surgery secondary hyperparathyroidism (2˚ hpt) is a complication of end stage renal disease (esrd) wherein parathyroid hormone (pth) elevates in a hypocalcemic setting. coronary artery calcification and calciphylaxis or purplish skin discoloration progressing to non-healing ulcers are secondary hyperparathyroidism complications that contribute to its high mortality rate. 1 medical treatment to control pth level in esrd patients usually fails. thus, surgical parathyroidectomy is resorted to. 2 in the philippines, parathyroidectomy is performed for symptomatic primary hyperparathyroidism while surgery for 2˚ hpt due to renal failure is virtually nonexistent. an adult patient in whom parathyroidectomy was performed for 2˚ hpt is presented. case report a 51-year-old filipino on six years’ hemodialysis for end stage renal disease from hypertensive nephrosclerosis had generalized pruritus refractory to medication for five years. four months before admission, he was referred to the department due to a markedly high parathyroid hormone level of 1,347pg/ml (normal values: 15-65pg/ ml). investigations revealed hypocalcemia, increased phosphorus and elevated alkaline phosphatase; enlarged parathyroid glands, a left thyroid nodule and right thyromegaly on neck ultrasonography; and concentric left ventricular hypertrophy and aortic sclerosis on twodimensional echocardiogram. he had undergone a thyroidectomy in 1988. on physical examination, he had ash-colored dry skin with scratch marks, a thyroidectomy scar, hyperpigmented papules over the scapular area, upper and lower extremities, pale palpebral conjunctivae, a globular abdomen, an arterio-venous (a-v) shunt on the right arm and grade i bipedal edema. informed consent was obtained, and he was admitted for surgery with the diagnoses of end stage renal disease secondary to hypertensive nephrosclerosis with uncontrolled secondary hyperparathyroidism (2˚ hpt); nodular non-toxic goiter, left; status post thyroidectomy (1988); hypertension stage ii, controlled. a bilateral neck exploration, total parathyroidectomy with sternocleidomastoid muscle parathyroid gland autotransplantation and right subtotal thyroid lobectomy were performed. results intraoperatively, extensive fibrosis made recurrent laryngeal nerve and parathyroid gland localization particularly complex. the left thyroid lobe was surgically absent, contrary to the ultrasound report. the right thyroid gland solid nodule measured 10 mm x 10 mm. four hypertrophied parathyroid glands respectively measured: 35 x 25 x 12 mm (left superior); 25 x 18 x 17 mm (left inferior); 5 x 5 x 5 mm (right superior) and 25 x 20 x 15 mm (right inferior). their average size was 20 mm x 20 mm x 10 mm compared to the normal size of 6 mm x 2 mm x 3 mm. 3 a 20 mm3 section of the smallest parathyroid gland was cut into 20 parts of 1 cu mm apiece, and autotransplanted into each sternocleidomastoid muscle. all submitted parathyroid and thyroid tissues were histopathologically benign. following surgery, hypocalcemia (1.7 mmol/l) lower than preoperative levels was noted after 12 hours and eventually corrected with intravenous and oral calcium. hemodialysis was resumed after 24 hours. pruritus disappeared on the second post-operative day, although soft-tissue calcification remained. serum phosphorus and calcium levels normalized on the 4th post-operative day, and pth levels normalized two months later, although serum alkaline phosphatase levels remained elevated (table 1). discussion biochemical values parameters normal pre-operative post-operative (4th day) serum phosphorus 0.8–1.6 mmol/l* 2.9 mmol/l 1.1 mmol/l (60th day) serum parathyroid 15-65 pg/ml† 1,347 pg/ml 28.05 pg/ml hormone level (4th day) serum calcium 2.1-2.5 mmol/l 1.9 mmol/l 2.4 mmol/l (60th day) serum alkaline 25-90 g/l‡ 174 g/l 191 g/l * mmol/l – millimoles per liter † pg/ml – picagrams per milliliter ‡ g/l – grams per liter table 1. patient’s biochemical parameters the indications for parathyroidectomy included pth levels more than 1000 pg/ml refractory to medication, debilitating pruritus, marked soft tissue calcifications, and hyperphosphatemia.2 high serum pth and phosphorus levels particularly increase sudden cardiac-related death risks from coronary artery disease4 and their control can reverse left ventricular hypertrophy.5 increased alkaline phosphatase levels suggested increased bone resorption rates, and anemia probably resulted from esrd and high pth levels inhibiting red blood cell production. bilateral neck exploration was certainly the procedure of choice over unilateral neck dissection or minimally invasive parathyroidectomy in this case. it allowed direct visual assessment of all four hypertrophied parathyroid glands, facilitating their removal in a single operation. this eliminated the need for costly, preoperative technetium 99-sestamibi imaging which is unavailable in this institution. ultrasonography, which was available, has been reported to have a wide sensitivity range of 27% 97 % in identifying parathyroid pathology.6 in this case, it did identify enlarged parathyroid glands, although it curiously failed to note the surgically absent thyroid lobe. the postoperative hypocalcemia reflecting a dramatic calcium uptake by bone following post-parathyroidectomy drops in high pth levels has been termed the “hungry bone syndrome”.7 autotransplanted parathyroid gland functions 60 days post-operatively philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 case reports philippine journal of otolaryngology-head and neck surgery 27 acknowledgement we thank joselito a. mora, md, fpcp, consultant nephrologist, veterans memorial medical center, who was the primary attending physician who referred and co-managed this patient with us. references 1. beus ks, stack bc. calciphylaxis. otolaryngol clin n am. 2004 aug;37(4):941-48. 2. rashed a, fahmi m, elsayed m, aboud o, asim m. effectiveness of surgical parathyroidectomy for secondary hyperparathyroidism in renal dialysis patients in qatar. transplant proc. 2004 jul-aug;36(6):1815-7. 3. gray h. endocrine system: principles of hormone production and secretion. in standring s, editor. gray’s anatomy: the anatomical basis of clinical practice. 39th ed: churchill livingstone: elsevier; 2004 4. ganesh sk, stack ag, levin nw, hulbert-shearon t, port fk. association of elevated serum po4, ca x po4 product, and parathyroid hormone with cardiac mortality risk in chronic hemodialysis patients. j am soc nephrol. 2001;12:2131-38. 5. achinger s, ayus j. left ventricular hypertrophy: is hyperphosphatemia among dialysis patients a risk factor? j am soc nephrol 17: s255-s261. 6. meilstrup j. ultrasound examination of the parathyroid glands. otolaryngol clin n am.2004;37:763-78. 7. drueke t. diseases of bone and calcium metabolism. hyperparathyroidism in renal failure. 2004 apr; chapter 3d:[about 1 p.]. available from: http://www.endotxt.com/. 8. carty s. prevention and management of complications in parathyroid surgery. otolaryngol clin n am.2004;37:897-908. 9. lando m, hoover la, zuckerbraun l, goodman d. autotransplantation of parathyroid tissue into sternocleidomastoid muscle. arch otolaryngol head neck surg.1988 may;114:5. 10. chandran pk. biochemical changes following parathyroidectomy. int j artif organs. 1993 oct;6(10):700-3. 11. rivet j, lebbé c, urena p, cordoliani f, martinez f, baglin ac, et al. cutaneous calcification in patients with end-stage renal disease: a regulated process associated with in situ osteopontin expression. arch dermatol. 2006;142:900-906. and bars permanent hypoparathyroidism as pth levels normalize and serum calcium and phosphorus levels improve.8 sternocleidomastoid autotransplantation ensures accessibility under local anesthesia should recurrent 2˚ hpt or 3˚ hpt manifests. it utilizes the same operative site, and is associated with less graft ischemia, low infection incidence, and high graft survival rates. 9 elevated alkaline phosphatase levels are expected to normalize after 3 months.10 pruritis disappears, improving quality of life while residual soft tissue calcifications no longer progress to more severe calciphylaxis. 11 total parathyroidectomy with autotransplantation may be a viable surgical option for controlling secondary hyperparathyroidism associated with end stage renal disease and may play an important role in reducing morbidity and mortality among patients with end-stage renal disease. abstract objective: to present a case of amyotrophic lateral sclerosis (als) with an unusual initial presentation of dysphagia. methods: design: case report setting: private tertiary university hospital patient: one results: a 78-year-old female with two years’ progressive dysphagia thrice refused biopsy of a right oropharyngeal bulge recommended by three different otorhinolaryngologists. slurring developed, but normal cranial ct scans cleared her of a cerebrovascular event. subsequent marked weight loss, dysarthria and lower extremity weakness led to tests including an electromyogram and nerve conduction velocity study (emg-ncv) consistent with amyotrophic lateral sclerosis (als). conclusion: awareness of neurologic disorders that cause dysphagia may prevent unnecessary diagnostic interventions. algorithms for evaluation and management of dysphagia may also reduce misdiagnosis and consequent mismanagement. als may be considered whenever symptoms of dysphagia present with subsequent development of other motor neurologic signs of denervation such as fasciculation, weakness and atrophy. otorhinolaryngologists play a vital role in the als team in light of the need for thorough swallowing evaluation and airway support. key words: dysphagia, amyotrophic lateral sclerosis (als), bulbar-onset als, oropharyngeal mass dysphagia is the perception of an impediment to the normal passage of swallowed material which can occur anywhere from the oral cavity to the esophagus.1 evaluation of dysphagia must first focus on the basic physiology of swallowing, as an accurate assessment of the type of dysphagia (oropharyngeal vs. esophageal) can be made with careful history alone in about 80–85% of cases.2 dysphagia as the initial presenting symptom of amyotrophic lateral sclerosis adrian f. fernando, md antonio h. chua, md department of otorhinolaryngology head and neck surgery university of the east – ramon magsaysay memorial medical center correspondence: adrian f. fernando, md department of otorhinolaryngology head and neck surgery, university of the east – ramon magsaysay memorial medical center, aurora blvd., quezon city 1114 philippines telefax: (632) 716 1789 e-mail: ianfernando_md@yahoo.com reprints will not be available from the authors. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product cited in this report. philipp j otolaryngol head neck surg 2008; 23 (2): 28-31 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports 28 philippine journal of otolaryngology-head and neck surgery this case describes how amyotrophic lateral sclerosis or als can initially present with dysphagia and how its associated physical manifestations can be mistaken for an oropharyngeal malignancy. the standard approach to dysphagia evaluation and management as well as the role of otorhinolaryngologists in als management will be discussed. case report a 78-year-old diabetic female was referred to our out-patient clinic for progressive dysphagia of two years. she initially had difficulty initiating swallowing solids, leading to coughing, choking and occasional nasal regurgitation. a year after, her endocrinologist noted slurring of speech and persistence of dysphagia. a cerebrovascular event was ruled out by a neurologist following a cranial ct-scan and she was referred to an otorhinolaryngologist. videolaryngoscopy revealed right oropharyngeal wall bulging with narrowing of the oropharynx. she refused the recommended biopsy and eventually consulted another otorhinolaryngologist whose recommended biopsy she also refused. five months later, she had marked weight loss and generalized body weakness. ct scans revealed soft tissue fullness of the right oropharynx contiguous with the tongue base, vallecula and prevertebral soft tissue interpreted as a right oropharyngeal mass. she again refused the recommended biopsy. she consulted us wheel-chair bound, with marked body weakness and dysarthria. oropharyngeal examination (figure 1) revealed a smooth, non-tender right bulge with same consistency as adjacent oropharyngeal structures causing marked narrowing of the oropharyngeal area. videolaryngoscopy (figure 2) also revealed bilateral mobile vocal folds with no glottic lesion or aspiration. her tongue slightly deviated to the left, with weak protrusion and fasciculations. her gag reflex was normal, her uvula midline and the rest of the cranial nerve examination was unremarkable. there was left lower extremity atrophy with grade ¾ motor strength. she had no sensory deficits. the cerebellar exam was also normal. the previous neck ct-scan (figure 3) was reviewed and again interpreted as a right oropharyngeal mass, but instead of recommending a biopsy, we requested electromyography and nerve conduction velocity (emg-ncv) tests and results suggested a purely motor neuron denervation disease consistent with amyotrophic lateral sclerosis or als. after appropriate disclosure and counseling, an elective tracheotomy and percutaneous gastrostomy (peg) were performed. after 5 months, she has gained weight and markedly improved nutritional status. however, oropharyngeal narrowing (figure 4) has increased, tongue fasciculations and atrophy are more prominent and drooling is evident. quarterly follow-up consultations at the otorhinolaryngology, neurology and medicine out-patient clinics have been scheduled. discussion a large number of adults beyond the 5th decade of life andand approximately 25% of hospitalized patients experience dysphagia.3 it can be caused by numerous etiologies (figure 5) generally localized figure 1. tongue atrophy, with normal gag, presence of tongue fasciculation, and narrowing of the oropharyngeal area. uvula still visualized. (arrow) s figure 2. video laryngoscopy at time of admission showing a bulge at the right posterolateral oropharyngeal wall and narrowing of the oropharygeal area. figure 3. post contrast neck ct scan, dated july 5, 2007 showing narrowing of the oropharyngeal area due to the presence of a non-enhancing oropharyngeal bulge at the right posterolateral oropharyngeal wall extending to the base of the tongue contiguous with the prevertebral soft tissues. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports philippine journal of otolaryngology-head and neck surgery 29 in the oropharynx or esophagus.4 neurologic causes should always be considered in the absence of signs of obstruction along the upper gastrointestinal tract (table 1). motor neuron disorder (mnd) is a possible neurologic cause of dysphagia after the exclusion of stroke as 80% of all mnd patients develop bulbar problems. among the different conditions under mnd, als is known to cause both upper and lower motor neuron affectations. als was first described in 1869 by the french neurologist jeanwas first described in 1869 by the french neurologist jean-was first described in 1869 by the french neurologist jeanmartin charcot and is called charcot’s disease in europe. it is also known as lou gehrig’s disease in the united states, after the famous baseball player who died of pulmonary complications a few years after he was diagnosed with als.5 als is a fatal neurodegenerative disease occurring in 5 out of 100,000. the male to female ratio is approximately 1.6:1 andthe male to female ratio is approximately 1.6:1 and the average age of onset is in the fourth to seventh decades of life. thethe hallmark signs of als are progressive weakness of the extremities with later development of muscle cramps, fatigue, twitching and atrophy evident in the arms, shoulders and tongue. a variant called bulbara variant called bulbar-ulbaronset als occurs in 25% mnd cases and only 6 to 10% of reported als cases causing primary affectation of the muscles of mastication, the pharynx, the tongue or the face.6 �hile familial, juvenile-onset als�hile familial, juvenile-onset als patients have been reported to survive for longer periods of about 2 to 3 decades, bulbar-onset als has a more rapid progression. averageverage 5-year-life expectancy is 50 to 60% and only 20% survive longer than 5 years.7 understanding the physiology of swallowing is the primary tool in the localization of dysphagia and an algorithm (figure 6) can serve as a useful guide in its diagnosis and management, reducing the chances of misdiagnosis and consequent mismanagement. the role of otorhinolaryngologists in als encompasses evaluation and supportive care. it becomes more critical in cases of bulbar-onset als where thorough swallowing evaluation and airway management are primary concerns.8 careful history remains the most important localizing tool aided by videolaryngoscopy, functional endoscopic evaluation of swallowing (fees) and/or barium swallow. radiographic studies like ct scans and mri help in exclusion of other diseases. the “oropharyngeal mass” on ct scans of our patient was a non-enhancing soft tissue fullness contiguous and with the same tissue density as adjacent oropharyngeal structures. absence of a definite delineating border further made an actual mass unlikely. it is plausible that the oropharyngeal bulge was simply caused by sagging of weakened orpharyngeal constrictor muscles. emg-ncv is still the key test in the evaluation of nerve and muscle function that shows the pathognomonic denervation exhibited by als.9 once a diagnosis of als is established, family counselling should be conducted to explain its nature and course, with a discussion of management options. as in our case, peg tube insertion provides a permanent route for nutrition while elective tracheotomy prevents further airway compromise since respiratory failure is the leading cause of death among patients with mnd.10,11 recurrent pulmonary infection is the leading cause of morbidity among als patients and nearly all als patients die of respiratory failure within 2 to 5 years after the onset of the disease.12 figure 4. noted is the persistent narrowing of the oropharyngeal area (arrow), and the tongue atrophy. tongue fasciculations were grossly appreciated. s figure 5. differentiating symptoms of dysphagia. information from castell do. approach to the patient with dysphagia. in: yamada t, ed. textbook of gastroenterology. 2d ed. philadelphia: lippincott williams & wilkins, 1995. see table 1 table 1. information from castell do, donner mw. evaluation of dysphagia: a careful history is crucial. dysphagia 1987; 2:65-71. neurologic disorders and stroke: cerebral infarction peripheral neuropathy brain-stem infarction intracranial hemorrhage parkinson’s disease multiple sclerosis amyotrophic lateral sclerosis poliomyelitis dermatomyositis postinfectious myasthenia gravis dementias selected causes of oral and pharyngeal dysphagia structural lesions: thyromegaly cervical hyperostosis congenital web zenker’s diverticulum ingestion of caustic material inflammatory mass neoplasm psychiatric disorder: psychogenic dysphagia connective tissue diseases: polymyositis muscular dystrophy iatrogenic causes: surgical resection radiation fibrosis medications philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports 30 philippine journal of otolaryngology-head and neck surgery references 1. malagelada jr, bazzoli f, elewaut a, fried m, �rabshuis jh, lindberg h, et al. dysphagia: �orldmalagelada jr, bazzoli f, elewaut a, fried m, �rabshuis jh, lindberg h, et al. dysphagia: �orlddysphagia: �orld gastroenterology organisation practice guidelines. �orld gastroenterology organization 2007:1 2. spieker m. evaluating dysphagia. am fam physician. 2000, jun 15; 61 (12):2. 3. layne �a, losinski ds, zenner pm, ament ja. using the fleming index of dysphagia to establish prevalence. j am diet assoc. 1989; (4):39. 4. brin mf, younger d. neurologic disorders and aspiration. otolaryngol clin n am. 1988; 21:6919. 5. logroscino g, armon c. amyotrophic lateral sclerosis: a global threat with a possible difference in risk across ethnicities. am acad neuro. 2007; 17:68. 6. johnson j. practical management strategies for dysphagia in motor neuron disease andjohnson j. practical management strategies for dysphagia in motor neuron disease and amyotrophic lateral sclerosis. clinical speech and language therapy lecture series. �ings college hospital. 2007:16. 7. �utzke jf: epidemiology of amyotrophic lateral sclerosis. advanced neurology. 1982; 36: 281. 8. logemann j. mechanism of normal and abnormal swallowing. otolaryngology head andlogemann j. mechanism of normal and abnormal swallowing. otolaryngology head and neck surgery. 4th ed. cummings c�, pa: elsevier mosby. 2005; (2):1437-45. 9. talbot �, ansorge o. recent advances in the genetics of amyotrophic lateral sclerosis andtalbot �, ansorge o. recent advances in the genetics of amyotrophic lateral sclerosis and frontotemporal dementia: common pathways in neurodegenerative disease. human molecular genetics. 2006; 15(2):2-9. 10. smith pf. practical problems in the respiratory care of patients with muscular dystrophy.smith pf. practical problems in the respiratory care of patients with muscular dystrophy. new engl j med. 1987; 316:1197-1205. 11. braverman j. airway clearance needs in neuromuscular disease: an overview. hill-rom. 2006;braverman j. airway clearance needs in neuromuscular disease: an overview. hill-rom. 2006; 1:2. 12. lechtzin n. respiratory effects of amyotrophic lateral sclerosis: problems and solutions.lechtzin n. respiratory effects of amyotrophic lateral sclerosis: problems and solutions. respir care j. 2006 aug; (8):51 13. ertekin c, aydogdu i, yüceyar n, �iylioglu n, tarlaci s, uludag b. pathophysiological mechanisms of oropharyngeal dysphagia in amyotrophic lateral sclerosis. brain 2000 jan; 123 (1):125-40. 14. reichenberger e. understanding als. als hope foundation. 2008 mar. available from: http:// www.alshopefoundation.org the progressive, disabling nature of als and the absence of cure make it difficult to manage. diverse clinical presentations of variousiverse clinical presentations of various diseases causing dysphagia should always be considered.13 bulbaronset als can cause dysphagia as the sole initial symptom prior to the onset of other neurologic signs necessitating careful and immediate ent evaluation. a team-approach is important in the evaluation and management of dysphagia and als, involving specialists in neurology, gastroenterology, pulmonology, otorhinolaryngology, speech/ swallowing therapy and nursing. considering that 6 out of the 14 most frequent als symptoms (table 2) excluding late-onset dysphagia in classic als are all ent-related symptoms, otorhinolaryngologists are a vital part of the als team.14 figure 6. summary of the clinical approach and key objectives in the management of oropharyngeal dysphagia. information from the world gastroenterology organisation (wgo) practice guidelines on dysphagia. 2007. adapted from: cook, ij, kahrilas, pj. aga: technical review: management of oropharyngeal dysphagia. gastroenterology 1999; 116:455. note: the objective is to reach a box targeted by terminal arrow which equates to a specific management strategy. the arrows indicate a suggested pathway to proceed with the evaluation. cns: central nervous system; rx: therapy; cva: cerebrovascular accident. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports philippine journal of otolaryngology-head and neck surgery 31 philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 passages 40 philippine journal of otolaryngology-head and neck surgery by how he is remembered --and by how much he is missed: this, i submit, is the ultimate measure by which we can gauge the impact of a man’s labor on his world and the import of his life on the people he left behind. that dr. abelardo b. perez will be remembered, there is no question. the fact alone that he had been in practice for close to four decades guarantees the grateful remembrance of at least a thousand patients whose afflictions he has healed, whose pains he has eased. likewise, he will be remembered wistfully by hundreds of what were once clear-eyed, smart talking young men and women who considered him at that time a terror to be avoided at all cost, but who-now older, thinner of hair and thicker around the waist – cannot praise him enough for providing them with the instruction and the discipline to become themselves, doctors of medicine, hopefully in the same mold, of the same class as dr. abelardo b. perez. but nowhere will the memory of dr. abelardo b. perez be held in deeper reverence and in greater love than in the philippine board of otolaryngology which he conceptualized, organized and institutionalized to elevate the specialization to the eminence it deserves. i should think that as the pbo was the passion of dr. perez’s life, in his death we should dedicate it as a monument to this gifted head and neck surgeon. thus, will dr. abelardo b. perez be remembered – as a long-time medical practitioner, an expert ent specialist. a stern and no-nonsense professor, a dauntless champion of the crusade to keep inviolate the quality and the integrity of the diplomate, the founding father and the moving spirit of the pbo and an indefatigable worker in the unending task of healing the wounds and easing the pains of man and his world. yet the warranty of remembrance does not really assuage the sense of loss. it is well and good that the world remembers dr. abelardo b. perez; but the knowledge that it does in no way mitigates the ache in martha’s heart for the warmth of abe’s touch or renders less difficult for us the task of administering pbo affairs without his counsel and guidance. indeed, the name of dr. abelardo b. perez will long be remembered; but we will still sorely miss the man who looked eternally youthful, who loved good music, fine dining, pleasant company, who took such great joy in beholding the wonders of creation, in confronting the challenges of the world, in living life fully, with a song in his heart, in recognition of its preciousness and in gratitude for its gift… the world will remember the physician named dr. perez; we will miss the man we called abe…. abelardo b. perez, md (1932 – 2007) the man we call abe…. by remigio i. jarin, md president philippine board of otolaryngology head & neck surgery philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 featured ground rounds philippine journal of otolaryngology-head and neck surgery 33 case a 46-year-old filipino male with no known co-morbidities was referred for progressive deformity of his nose over a 19month period. he was initially treated by dermatology for a few months with topical 1% hydrocortisone cream and various antibiotics including oral tetracycline 250 mg twice a day, but the condition persisted (figure 1). he was diagnosed to have rhinophyma which was excised using coblation®, and the deformity was reshaped to a normal nasal contour (figure 2). antibiotic-impregnated non-adherent gauze was applied, and wound care continued until re-epithelialization occurred in three to four weeks (figure 3). there was no recurrence of the rhinophyma on follow-up at 6 months (figure 4). discussion rhinophyma is a descriptive term from the greek word “rhis” meaning nose and “phyma” meaning growth.1 common among white males between 40 and 60 years of age, it is characterized by soft-tissue hypertrophy of the nose due to progressive thickening of nasal skin. males are predominantly afflicted with a ratio to females of about 5:1 to 30:1.2 it may also be stephanie s. santiago, md department of otolaryngology head and neck surgery east avenue medical center correspondence: stephanie s. santiago, md department of orl-hns east avenue medical center east avenue, diliman, quezon city, 1100 philippines phone: (632)9280611 local 324 email: stg_md@yahoo.com reprints will not be available from the author. rhinophyma philipp j otolaryngol head neck surg 2007; 22 (1,2): 33-34 c philippine society of otolaryngology – head and neck surgery, inc. figure 1: pre-operative photograph figure2: 3 days post-operative photographs figure 3: 1 month post-operative photograph figure 4: 6 months postoperative photograph philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 featured ground rounds 34 philippine journal of otolaryngology-head and neck surgery found in children, although rarely.3 rosacea progressing to acne rosacea is the only clearly associated entity and precursor of rhinophyma. this begins as an increased facial redness in adolescents and young adults and can involve other facial regions. the vessels of the nose would become progressively dilated, skin thickening occurs, and may become oily. the nose thickens at the tip and the sebaceous glands hypertrophy. as the deformity worsens, fissures, pits, lobulations and pedunculations grotesquely change the shape of the nose. rebora described four stages: the pre-rosacea stage where frequent facial flushing is seen; the vascular rosacea stage of thickened skin, telangiectasias, and erythema; the inflammatory stage with erythematous papules and pustules; and the fourth stage, which he described as rhinophyma.2 the pathophysiology begins with vascular instability leading to a loss of fluid into the dermal interstitium, which causes inflammation and fibrosis. there is sebaceous gland hyperplasia and hypertrophy and the ducts become elongated, dilated and plugged.1 rhinophyma has two distinct histopathologic appearances. the most common shows histopathologic features of rosacea and the second pattern shows telangiectasia, diffuse dermal fibrosis with abundant mucin, and a virtual absence of pilosebaceous structures.4 this can also occur with cyclosporine use.5 demodex folliculorum mites regularly reside in the pilosebaceous units and may be seen in histologic sections.1 grahan and mc gavran (1964)2 demonstrated that basal cell carcinomas occur in direct proportion to the concentration of sebaceous glands in sunexposed skin. medical treatment has been limited to avoidance of stimulation factors, appropriate cleanliness, and treatment of secondary infection and inflammation with topical and systemic antibiotics and steroids.1 once the violaceous, hypertrophic, bulbous stage of the disease becomes manifest, only surgical manipulation (of which many methods exist) can reverse the deformity.1 originally, all surgeries were skin grafted, as this condition would recur. the first and oldest method of excision is the cold knife technique which has less risks of scarring and hypo pigmentation according to redett.2 linehan demonstrated faster re-epithelialization with similar aesthetic results compared to electro-surgery, which was first reported for rhinophyma in 1950 by rosenberg2. the latter’s main advantage was hemostasis. the co 2 laser was first reported by shapshay in 19802 who claimed that it was more hemostatic, with easier postoperative care. in 1983, wenig2 was the first to use argon laser for rhinophyma and advocated its use for hemostasis and on telangiectasias but states that it is a poor instrument for debulking. eisen2, in 1986, reported the use the shaw scalpel (hemostatix™ medical technologies, bartlett, tn) for rhinophyma. the yag laser was used by wenig in 1993 with equally cosmetic results and shorter healing times compared to c02 laser2. dermabrasion is another technique used in rhinophyma, usually as an adjunct to other methods2. the bovie® (bovie medical corporation, st. petersburg, fl) coagulator readily destroys sebaceous glands by low temperature, forming the theoretic basis for cryosurgery with the advantage of minimal bleeding and pain. the microdebrider6 and floseal (fusion medical technologies inc, mountan view, ca) are also adjuncts in the surgical treatment of rhinophyma which provide satisfactory results. coblation® (arthrocare corporation, austin, tx) is a relatively new technique in soft tissue surgery that was introduced in 19977-8. the dissection technique involves passing bipolar radiofrequency energy to ablate and coagulate soft tissue without thermal energy. this supposedly results in less surrounding tissue damage producing less pain, less bleeding and shorter operating time. since there appears to be no distinct advantages in the different therapeutic modalities, no one modality is universally endorsed. acknowledgement : i would like to give my heartfelt thanks to dr. natividad a. aguilar, dr. joselito f. david, dr. ryan neil c. adan, dr. cristopher d. urbis, dr. terence jason j. flores and my co-residents who made this discussion possible. references 1. zane r. rhinophyma [database on the internet]. houston: baylor college of medicine. c1992 [updated 2006 feb 15]. available from: http://www.bcm.edu/oto/grand/102992.html 2. alexander s, marks r. a rosacea-like eruption of children. br j dermatol. 1972;87:425-429. 3. tope w, sangueza o. rhinophyma’s fibrous variant. histopathology and immunohistochemistry. american journal of dermatopathology.1994; 16(3): 307-10. 4. shahan f, roenick h. management of benign facial lesions. head and neck surgery – otolaryngology 3rd edition. 2001; 187(2):2432-50. 5. fumk e. rhinophyma [database on the internet]. houston: baylor college of medicine. c2004 [updated 2007 oct 19]. available from: http://www.bcm.edu/oto/grand/102992.html 6. tahery j, kaushik v, malik th. new surgical adjuncts in the treatment of rhinophyma: the microdebrider and floseal [database on the internet]. the journal of laryngology & otology. 2003 jul;117(7):551-2. 7. tan ak, hsu pp, eng sp, ng yh, et al. coblation vs electrocautery tonsillectomy: postoperative recovery in adults. otolaryngology-head and neck surgery. 2006 nov; 135(5): 699-703. 8. chang kw. randomized controlled trial of coblation versus electrocautery tonsillectomy. otolaryngology-head and neck surgery.2005 feb; 132(2): 273-80. philippine journal of otolaryngology-head and neck surgery 39 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports abstract objectives: to share our experience in managing a rare involvement of phrenic nerve injury in laryngeal trauma. methods: design: case report setting: tertiary referral centre patient: one results: a 23-year-old male sustained blunt laryngeal trauma associated with phrenic nerve injury leading to silent traumatic diaphragmatic paralysis. he underwent tracheotomy and surgical repair of schaeffer class iv laryngeal injuries, and conservative therapy for the diaphragmatic paralysis, which eventually resolved. conclusion: patients with laryngeal trauma may have concomitant phrenic nerve injury causing diaphragmatic paralysis. the diagnosis should be considered particularly if the patient has respiratory problems despite securing the airway by tracheotomy. a high index of suspicion is required in diagnosing such an association. patients should be closely monitored even though most will recover as some may present with later morbidities. a search of pubmed and ovidsp using the terms “larynx,” “laryngeal trauma” and “phrenic nerve” did not yield any report of phrenic nerve injury in association with laryngeal trauma. to our knowledge, this is may be the first reported case of phrenic nerve injury in association with blunt laryngeal trauma. keywords: larynx, trauma, phrenic nerve the incidence of laryngeal trauma in association with phrenic nerve injury is rarely reported in the literature. phrenic nerve injury may lead to diaphragmatic paralysis. it is usually overlooked as associated laryngeal injuries commonly cause more alarming respiratory difficulties. the pathophysiology of nerve injury may include stretching, transection or compression. we report a case of phrenic nerve injury seen in laryngeal trauma. methods of diagnosing diaphragmatic paralysis secondary to phrenic nerve injury are also briefly discussed. case report a 23-year-old male was involved in a motor vehicle accident when he was riding a motorbike, travelling at medium velocity behind a bus which suddenly stopped. the rear engine hood opened unexpectedly and hit the patient’s anterior neck. he had no loss of consciousness but complained of throat pain associated with hoarseness. there was no associated neck pain or paraesthesia or weakness of limbs. on examination, the patient was fully conscious. he was not laryngeal trauma with phrenic nerve injury: a rare associationnoor dina hashim, md mohd razif mohamad yunus, mbbs, ms (orl-hns) marina mat baki, md, ms (orl-hns) mazita ami, mbchb, ms (orl-hns) department of otorhinolaryngology universiti kebangsaan malaysia medical centre kuala lumpur, malaysia correspondence: mohd razif mohamad yunus, mbbs, ms (orl-hns) department of otorhinolaryngology universiti kebangsaan malaysia medical centre jalan yaacob latiff, bandar tun razak 56000 cheras, kuala lumpur, malaysia phone: +60391455555 ext 6845 fax: +60391737840 email : razif72@gmail.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2010; 25 (2): 39-41 c philippine society of otolaryngology – head and neck surgery, inc. 40 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports in respiratory distress. his voice was hoarse, and his neck appeared swollen with subcutaneous emphysema on the right side. there was no open wound but anterior neck bruises were apparent at the level of the hyoid bone which was tender on palpation. laryngeal crepitus was absent with loss of thyroid prominence. laryngeal injury was suspected. the trachea was midline. lung examination showed reduced air entry to the right lower lobe. other physical examinations were otherwise normal. during the primary survey, the patient was self-ventilating with no signs of distress. an emergency tracheotomy was performed for airway protection. after the patient was stabilized and the severity of injury identified clinically, he was put under general anaesthesia with ventilation via tracheotomy tube, and direct laryngoscopy and neck exploration was performed. the aryepiglottic folds were oedematous with haematoma collection and mucosal lacerations over the right ventricle and right aryepiglottic fold exposing the right arytenoid cartilage. there were comminuted fractures of the thyroid cartilage. vocal cord mobility could not be determined due to distorted anatomy at the supraglottic level. there also was a small haematoma on the left strap muscles. the findings were consistent with laryngeal injury schaeffer-fuhrman class iv according to the laryngotracheal injury classification proposed by trone and schaefer1 and modified by fuhrman et al.2 the fractured thyroid cartilages were repaired with prolene 4/0 (ethicon inc, a subsidiary of johnson & johnson) and the mucosal lacerations sutured with vicryl 6/0 (ethicon inc, a subsidiary of johnson & johnson) to cover exposed cartilage. he was also started on intravenous ciprofloxacin and metronidazole in view of the exposed cartilage. a pre-operative chest radiograph (figure 1) showed an elevated, immobile right hemi-diaphragm, fixed at the level of the seventh right posterior rib. an abdominal ultrasound confirmed the immobility of the right hemi-diaphragm, but there was no evidence of solid organ injury, organ eventration or free fluid in the abdomen. a cervical ct scan showed no fracture of the cervical spine. a diagnosis of laryngeal trauma with right hemi-diaphragmatic paralysis secondary to traumatic right phrenic nerve palsy was made. pre-morbidly, this patient had no significant previous respiratory symptoms and he was an active young man. the patient was subjected to vigorous chest physiotherapy, and started on naso-gastric tube feeding to allow recovery of the larynx. he also developed hospital-acquired pneumonia which resolved with intravenous antibiotics. the patient was carefully monitored and continued to make an otherwise uneventful recovery. a repeat chest xray one month after the trauma showed a normal diaphragmatic level. two months after the trauma, decannulation of the tracheotomy tube was done successfully. a swallowing examination showed adequate laryngeal function with minimal pooling, and the tube feeding was gradually discontinued. at six months, indirect laryngoscopy showed excellent healing of laryngeal wounds and normal mobility of bilateral vocal cords. the patient remains asymptomatic after six months. discussion the phrenic nerve which is formed from c3, c4, and c5 nerve fibres, descends along the anterior surface of the scalenus anterior muscle of the neck, deep to the sternocleidomastoid muscle, later sandwiched between the subclavian vessels on its way into the thorax. it carries motor and sensory fibres to the diaphragm. its anatomic location in the neck makes it vulnerable to traumatic injury. traumatic phrenic nerve injury is commonly caused by penetrating injury to the neck, blunt trauma to the chest,3 jugular or subclavian catheterization, cardiovascular surgery or birth trauma.4 injury may occur at any level along the course of the nerve including neck, chest, heart and abdomen. in trauma cases, hyperextension of neck, cervical injury, chest trauma with rib or lung injury, cardiac trauma such as cardiac tamponade or diaphragmatic rupture may lead to phrenic nerve injury. the pathophysiology of nerve injury may include stretching, transection or compression of the nerve5,6 as well as chemical injury of the myelin sheaths from cold topical cardioplegia as seen in lung transplants.7 in this particular case, the mechanical force that caused severe laryngeal structure injury may explain involvement of the phrenic nerve. the great impact on the anterior neck may have caused sudden hyperextension. neck hyperextension could have led to overstretching figure 1. preoperative chest radiograph showing an elevated right hemi-diaphragm at the level of the seventh right posterior rib. philippine journal of otolaryngology-head and neck surgery 41 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports of the phrenic nerve axons without disrupting the integrity of the nerve. the time for recovery would therefore depend on the distance of the nerve injury to the diaphragm, as well as the rate of regeneration.8 although there is also a possibility that phrenic nerve injury may have been due to compression by hematomas of the anterior scalenus or sternocleidomastoid muscles as the nerve runs along these muscles, no severe haematoma of the neck muscles was noted intra-operatively. most cases of laryngeal injury present as airway emergencies, obscuring the possibility of respiratory distress contributed by diaphragmatic paralysis following phrenic nerve injury. most patients with traumatic unilateral diaphragmatic paralysis are usually asymptomatic at the time of the incident. some will develop dyspnoea with reduced effort tolerance on exertion. a small number of patients may present with respiratory, gastrointestinal or cardiovascular embarrassment as a result of organ eventration, immediately or delayed, months after trauma.6 more intense symptoms are observed in patients with bilateral diaphragmatic paralysis. clinical examination of the chest in a patient with diaphragmatic paralysis often reveals dullness with reduced movement of the affected chest. diagnosis is also supported by plain chest radiography which shows an elevated hemi-diaphragm. lung infection could be a consequence of the paralysis of the hemi-diaphragm whereby the dome lies high in the thorax producing atelectasis and shunting of pulmonary blood flow which can lead to lung infection.9 hemi-diaphragmatic elevation in trauma cases seen in plain radiographs could be caused by phrenic nerve injury causing diaphragmatic paralysis as explained above or may be due to diaphragmatic rupture. diaphragmatic paralysis may closely mimic diaphragmatic rupture or vice versa.5 valuable information can be obtained from plain chest radiographs. asymmetry of a hemi-diaphragm is easily seen. the presence of abdominal organs or the placement of a nasogastric tube in an herniated stomach may help in the diagnosis of diaphragmatic rupture. 10 ct imaging has increasingly become the mainstay of investigations for suspected diaphragmatic injury. an abrupt discontinuity of the diaphragm and waist like constriction (collar sign) of herniated organs are well seen in cases of diaphragmatic rupture. sagittal, coronal, and 3-dimensional reformation ct scans may improve sensitivity.10 multiplanar imaging mri scanning provides a definitive diagnosis of diaphragmatic rupture, and can show intrathoracic herniation of the abdominal viscera.10 however, mri may not readily available in every centre. other useful ancillary investigations to confirm or exclude diaphragmatic paralysis or rupture include fluoroscopy and ultrasonographic assessment during respiration. absent or decreased diaphragmatic motion on these studies is suggestive of diaphragmatic injury. the less popular but valuable barium studies confirm the diagnosis by showing herniated viscera above the diaphragm and constriction through the diaphragmatic tear. as in our case, the main aim of treatment is to secure the airway. most laryngeal trauma requires emergency tracheotomy in the setting of an edematous and severely deformed airway. subsequently, a thorough examination can be done under general anaesthesia via direct laryngoscopy and the laryngeal injury repaired accordingly. the patients are usually put on a feeding tube as to allow adequate healing of laryngeal injuries. decannulation trials may be successful 2-3 months after injury. many patients, however, may recover normal diaphragmatic function in 6-12 months.8 some will recover much earlier with no subsequent complications as seen in our case. a small percentage of patients unfortunately may later present with respiratory or cardiac morbidities. it is therefore advisable to continue seeing these patients longer as not to miss any possible late complications of diaphragmatic trauma and to accommodate the required voice or speech rehabilitation and airway management. a search of pubmed and ovidsp using the terms “larynx,” “laryngeal trauma” and “phrenic nerve” did not yield any report of phrenic nerve injury in association with laryngeal trauma. given the limited sources, it was a challenge to plan an ideal management of this case. to our knowledge, this is may be the first reported case of phrenic nerve injury in association with blunt laryngeal trauma. references 1. fuhrman gm, stieg fh 3rd, buerk ca. blunt laryngeal trauma: classification and management protocol. j trauma. 1990 jan; 30(1):87-92. 2. trone th, schaefer sd, carder hm. blunt and penetrating laryngeal trauma: a 13-year review. otolaryngol head neck surg. 1980 may-jun; 88(3):257-61. 3. iverson li, mittal a. dugan dj, samson pc. injuries to the phrenic nerve resulting in diaphragmatic paralysis with special reference to stretch trauma. am j surg. 1976 aug; 132(2):263-269. 4. nakwan n. a rare case of diaphragmatic paralysis due to isolated phrenic nerve palsy in neonate. sajch. 2008 mar; 2(1): 28-29. 5. bell d, siriwardena a. phrenic nerve injury following blunt trauma. j accid emerg med. 2000 nov; 17(6): 419-420. 6. snyder rw, kukora js, bothwell wn, torres gr. phrenic nerve injury following stretch trauma: case reports. j trauma. 1994 may; 36(5):734-736. 7. maziak de, maurer jr, kesten s. diaphragmatic paralysis: a complication of lung transplantation. ann thorac surg. 1996 jan; 61(1):170-173. 8. ulku r, onat s, balci a, eren n. phrenic nerve injury after blunt trauma. int surg. 2005 apr-jun; 90(2):93-95. 9. mccaul ja, hislop ws. transient hemi-diaphragmatic paralysis following neck surgery: report of a case and review of the literature. j.r.coll.surg.edinb. 2001 jun; 46(3):186-188. 10. shanmuganathan k, mirvis se, white cs, pomerantz sm. mr imaging evaluation of hemidiaphragms in acute blunt trauma: experience with 16 patients. ajr am j roentgenol. 1996 aug; 167(2):397-402. 11. nahum e, ben-ari j, schonfeld t, horev g. acute diaphragmatic paralysis caused by chest-tube trauma to the phrenic nerve. pediatr radiol. 2001 jun;31(6):444-446. abstract objective: to present a rare case of congenital macroglossia managed with radiofrequency ablation. methods: design: case report setting: tertiary government hospital patient: one results: a case of a congenital macroglossia in a 4-year-old female with beckwith-wiedemann syndrome is presented. neither breathing nor swallowing difficulty was associated with the enlarged tongue. coblation-assisted ablation of the tongue deformity was performed. there was minimal bleeding, pain and swelling postoperatively. tongue mobility and taste sensation were unaffected. conclusion: a new and more conservative approach to surgery for congenital macroglossia using radiofrequency ablation (coblation) has been described. coblation-assisted ablation of lingual tissue may be an effective therapy for patients with macroglossia providing satisfactory functional and cosmetic outcome. key words: macroglossia, beckwith-wiedemann syndrome, coblation a large tongue poses a therapeutic challenge. reduction of tongue size and improvement of function are the goals of management. medical therapy may suffice if tongue enlargement is due to systemic disease, but surgical reduction offers the best functional and cosmetic results. standard surgical procedures directly remove a wedge of tongue muscle and mucosa and are associated with significant morbidity.1 the challenge has been to find a conservative treatment with low morbidity and better results than those achieved with cold steel or diathermy excision. recent studies have advocated the use of a plasma-mediated radiofrequency device (coblation) for tongue reduction. it provides the ability to remove tissue at a low temperature, thereby causing less tissue destruction and resulting edema.1 melanie y. marino, md gil m. vicente, md antonio h. chua, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: melanie y. marino. md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 743 6921 ; (632) 711 9491 loc 320 email: mimimarines@yahoo.com reprints will not be available from the author. the arthocare evac 70 xtra plasma wand and coblator ii surgery system were provided by arthocare corporation, sunnyvale, ca, usa. dr. vicente signed a disclosure that he is a speaker for the arthrocare corporation and does not receive honoraria and travel allowances except for the use of the coblator ii system loaned to him for research purposes. other than this, he does not have any proprietary or financial interests with arthrocare or with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. the other authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. coblation for congenital macroglossia in beckwith-wiedemann syndrome philipp j otolaryngol head neck surg 2008; 23 (2): 38-42 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports 38 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 39 philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports we report a rare case of congenital macroglossia successfully treated with coblation. case report a 4-year-old female was brought for evaluation of macroglossia. the patient was born term, large for gestational age (11.5 lbs) via cesarean section to a 26-year-old primiparous mother. maternal and family histories were unremarkable. a large tongue was noted during physical examination at birth. the left side was slightly larger than the right and one-third of the entire tongue protruded from the mouth. there was no breathing difficulty associated with the enlarged tongue. newborn screening and thyroid function tests were both normal. abdominal ultrasound revealed enlarged kidneys. unfortunately, due to financial difficulties she was unable to continue follow-up visits until she reached four years of age. the patient’s tongue grew in size as she aged, with the anterior 1/3 still protruding from the mouth. she was unable to close her mouth without notable effort and the tongue would always protrude from the mouth, with minimal drooling. speech was intelligible and there was no impairment in swallowing. she was a kindergarten pupil with no observed developmental delay. however, the unsightly physical appearance of the large tongue evidently affected interaction with her peers. physical examination showed a normocephalic child, with growth and development at par with age. intraoral examination revealed a 7 x 4 x 1.5 cm pinkish, smooth, enlarged tongue with good tone and mobility (figures 1 a, b). the left side was prominently larger than the right, with preferential lateralization of the tongue tip to the right upon protrusion. examination of dentition showed an open bite with class iii malocclusion (figure 1 c). inspection of the ears demonstrated posterior helical pits and creases on both earlobes. abdominal findings revealed an omphalocoele (figure 1 d). the left upper and lower extremities were observed to be larger than the right. the rest of the physical examination findings were normal. karyotyping was 46 xx (normal female). non-contrast and contrast-enhanced 64-multislice ct images of the oral cavity revealed a markedly enlarged tongue, left side more than the right, measuring approximately 7.6 cm in length on the unprotruded study and about 8.4 cm on protrusion (figures 2-4). the width of the left side measured about 3.6 cm while the right measured 1.4 cm (figure 4). the left lingual artery and left masseter muscle were noted to be more prominent compared to the right. sleep cine mr sagittal t1 images demonstrated significant glossoptosis with near-complete effacement of the hypopharynx but with intermittent opening. no apneic episodes were noted on limited sleep study. because of the prominent tongue and the associated psychological problems, the patient’s parents decided to seek surgical intervention. she underwent coblation-assisted ablation of lingual tissue under figure 1. a. protruded tongue figure 1. b. incomplete mouth closure figure 1. c. malocclusion figure 1. d. abdominal wall defect philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 40 philippine journal of otolaryngology-head and neck surgery case reports general anesthesia. pre-operative markings delineated the course of the lingual arteries and the desired extent of tongue reduction (figure 5). a midline incision was made 8 cm from the tongue tip. an arthocare evac 70 xtra plasma wand attached to the coblator ii surgery system (arthocare corporation, sunnyvale, ca, usa) at an ablation setting of 7 was inserted into the midline incision and held in place for 10 seconds. it was then advanced 5 mm deep along the midline, with care to stay medial to the marked boundaries of the lingual artery. the tongue incision was left open. the same coblator wand was then introduced into the area demarcating the desired tongue length 5 cm from the tip. trimming of the edges was carried out in full thickness until the desired tongue length was achieved. the tip was closed using absorbable sutures. postoperative bleeding, pain, and edema were minimal. oral antibiotics, steroids and paracetamol were continued until 5 days after discharge. on the 3rd post-operative week, the tongue size on protrusion was 4 x 4 x 2 cm, with good cosmetic result (figure 6). minimal drooling was noted. there was no sensory deficit and no limitation of tongue mobility. the patient did not report any difficulties with swallowing and in manipulating an intra-oral food bolus. there was no change in taste sensation. three months after the operation, tongue size was measured at 3.5 x 3 x 1.5 cm, the left side thicker than the right (figure 7). she had full tongue mobility with no alteration in swallowing, speech and taste sensation. the tongue now fit comfortably in the mouth (figure 8). the parents were satisfied with the result and overall evaluation of the patient’s condition was considered very satisfactory. discussion overgrowth disorders such as beckwith-wiedemann syndrome (bws) can present with an enlarged tongue. the disease was initially described by beckwith in 1963 and wiedemann in 1964. its prevalence is estimated to be approximately 1 in every 17,000 live births, and 97.5% of these patients have macroglossia.3 the syndrome results from chromosomal changes in the imprinted 11p15.5 region that cause increased levels of the fetal growth factor insulin-like growth factor 2.4 the most common clinical findings are the triad of macroglossia, abdominal wall defect (omphalocoele, umbilical hernia, diastasis recti) and macrosomia (prenatal gigantism, postnatal gigantism or both). other clinical findings include neonatal hypoglycemia, renal abnormalities, visceromegaly, hemihypertrophy, nevus flammeus of the forehead, ear anomalies (anterior linear earlobe creases, posterior helical pits) and an increased incidence of childhood neoplasms.4-6 the diagnosis can be established if at least three diagnostic findings are present.4 the effects of an enlarged tongue include airway obstruction, impairment of normal speech and swallowing, maxillofacial abnormalities, and ulceration and necrosis of the exposed tongue. figure 2. axial ct scan of the oral cavity showing prominent tongue. figure 3. coronal and sagittal ct scan of the unprotruded tongue. b a moreover, the psychological consequences arising from the patient’s physical appearance can result in the false impression of mental deficiency, leading to poor social development and low self-esteem. medical management of macroglossia may suffice if it is due to systemic disease. however, surgical reduction offers the best functional and cosmetic result and minimizes morbidity. the indications for surgical tongue reduction include airway obstruction, sleep apnea, philippine journal of otolaryngology-head and neck surgery 41 philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports figure 5. pre-operative markings outlining the course of the lingual arteries (arrowheads) and the desired extent of tongue reduction (big arrow). figure 4. axial and sagittal ct scan with tongue measurement on protrusion. a b speech difficulties, dysphagia, recurrent local trauma, and cosmetic concerns.9 the goal of surgery is to reduce tongue size and improve function, but extensive resection risks damage to the neurovascular bundles and the global nature of the macroglossia poses difficulties in creating a normal tongue. many surgical strategies have been proposed to reduce tongue size. standard surgical procedures are invasive and directly remove a wedge of tongue muscle and mucosa.9-15 significant pain and morbidity are encountered with large incisions in the oral cavity. recent studies have advocated the use of a plasma-mediated radiofrequency device (coblation) for tongue reduction.1,16-19 coblation technology provides the ability to remove tissue at a low temperature, thereby causing less tissue destruction and resulting edema. 1,16,17,19 although most of the present literature center on coblation as a novel surgery for tongue base reduction in obstructive sleep apnea patients, it has been shown to safely reduce lingual volume in a porcine model.17 it has also been used for the treatment of lymphatic malformation in the tongue and lip.16, 19 following our experience, coblation-assisted ablation of lingual tissue may be an effective therapy for patients with macroglossia providing satisfactory functional and cosmetic outcome. figure 6. 3 weeks post-op figure 7. 3 months post-op figure 8. mouth closed post-op philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 42 philippine journal of otolaryngology-head and neck surgery case reports acknowledgment we would like to extend our heartfelt thanks to michael joseph c. david, m.d. for his technical expertise. references 1. maturo sc, mair ea. submucosal minimally invasive lingual excision: an effective, novel surgery for pediatric tongue base reduction. ann otol rhinol laryngol. 2006;115(8):624-630. 2. gupta op. congenital macroglossia. arch otolaryngol 1971;93:378-83. 3. clauser l, tieghi r, polito j. treatment of macroglossia in beckwith-wiedemann syndrometreatment of macroglossia in beckwith-wiedemann syndrome. j craniofac surg. 2006 mar 12(2):369-372. 4. cytrynbaum cs, smith ac, rubin t, weksberg r. advances in overgrowth syndromes: clinical classification to molecular delineation in sotos syndrome and beckwith-wiedemann syndrome. curr opin pediatr. 2005; 17:740-746. 5. sathienkijkanchai a, prucka s, grant jh, robin nh. isolated facial hemihyperplasia: manifestation of beckwith-wiedemann syndrome. j craniofac surg. 2008 jan; 19(1): 279-283. 6. lam wwk, maher er. beckwith-wiedemann syndrome. curr pediat. 1998; 8:117-120. 7. mapfumo chidzonga m, mahomva l, marimo c. gigantic tongue lipoma: a case report. med.med. oral patol. oral cir.bucal (internet). [online]. 2006, vol. 11, no. 5 [cited 2008-04-01], pp. 437-439. available from: <http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s1698-694620060005 00012&lng=en&nrm=iso>. issn 1698-6946. 8. chitayat d, rothchild a, ling e, friedman jm, couch rm, yong s-l et al. apparent postnatal onset of some manifestations of the beckwith-wiedemann syndrome. am j med genet. 1990; 36:434-439. 9. tomlinson jk, morse sa, bernard sp, greensmith al, meara jg. long-term outcomes of surgical tongue reduction in beckwith-wiedemann syndrome. plast reconstr surg. 2007 mar; 119(3):992-1002. 10. morgan w, friedman e, duncan n, sulek m. surgical management of macroglossia in children. arch otolaryngol head neck surg. 1996 mar; 122(3):326-329. 11. harada k, enomoto s. a new method of tongue reduction for macroglossia. j oral maxillofac surg. 1995 jan; 53(1):91-92. 12. gasparini ga, saltarel aa, carboni aa, maggiulli fb, roberto mds. surgical management ofsurgical management of macroglossia: discussion of 7 cases. oral surg oral med oral pathol oral radiol endod. 2002 nov; 94(5): 566-571. 13. siddiqui a, pensler jm. the efficacy of tongue resection in treatment of symptomatic macroglossia in the child. ann plast surg. 1990 july; 25(1):14-17. 14. macedo m, meyer kf. surgical management of macroglossia in children: two case reports. einstein. 2007; 5(2):166-169. 15. lusthaus s, benmeir p, ashur h, neuman a, weinberg a, wexler mr. non-down’s syndrome macroglossia. eur j plast surg. 1994; 17:124-126. 16. cable bb, mair ea. radiofrequency ablation of lymphangiomatous macroglossia. laryngoscope. 2001 oct; 111: 1859-1861. 17. powell nb, riley rw, troell rj, guilleminault c. radiofrequency volumetric reduction of the tongue. a porcine pilot study for the treatment of obstructive sleep apnea syndrome. chest. 1997; 111:1348-1355. 18. blumen m, coquille f, rocchicioli c, mellot f, chabolle f. radiofrequency tongue reduction through a cervical approach: a pilot study. laryngoscope. 2006 oct; 116:1887-1893. 19. edwards pd, rabbar r, ferraro n, burrows p, mulliken jb. lymphatic malformation of the lingual base and oral floor. plast reconstr surg. 2005 june; 115(7):1906-1915. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 17 abstract objective: to determine whether excessive daytime sleepiness (eds) as assessed by the epworth sleepiness scale (ess) is significantly correlated with body mass index (bmi) and apnea-hypopnea index (ahi) in patients suspected of osas and whether obesity as assessed by bmi is associated with ahi. methods: design: non-concurrent cohort study setting: tertiary private hospital population: the charts of 389 patients suspected to have sleep disorders and referred for polysomnography (psg) at the center for snoring and sleep disorders in year 2009 were reviewed. inclusion criteria were patients aged 19 and above with complete data. a total of 238 patient charts were included in the study. results: the study included a total of 238 patient charts. results showed no significant association between ess and ahi (p-value >0.05) even when correlated with the different severities of osas (p-value>0.05). sensitivity and specificity of ess was found to be 54% and 57%, respectively, indicating that ess is not a sensitive and specific tool to predict the presence of osas. these findings suggest that ess may not be able to significantly identify patients with osas. however, bmi showed a significant association with ess (p-value<0.05) representing more patients with eds belonging to the obese category. conversely, obese patients were twice more likely to have eds, represented by ess scores of >=10. bmi was also significantly associated with ahi using oneway anova test. conclusion: this report concludes that the ess alone is insufficient to identify patients with osas. nevertheless, questionnaires like the ess supplement relevant history to help diagnose patients with sleep disorders particularly osas. on the other hand, the ess showed a significant association with bmi representing more obese patients had excessive daytime sleepiness. the likelihood ratio of having excessive daytime sleepiness is two times more for obese patients. bmi was also significantly associated with ahi which confirms the well established relationship of obesity with osas, and shows that obese patients are at higher risk for severe osas. keywords: obstructive sleep apnea syndrome, daytime sleepiness, epworth sleepiness scale, polysomnography, apnea-hypopnea index, body-mass index association of excessive daytime sleepiness and obesity with apnea-hypopnea index in adult patients suspected of obstructive sleep apnea syndrome nikki lorraine y. king-chao, md1 michael a. sarte, md1,2 1department of otorhinolaryngology head and neck surgery the medical city ortigas ave., pasig city, philippines 2department of otorhinolaryngology head and neck surgery rizal medical center pasig blvd., pasig city, philippines correspondence: dr. nikki lorraine y. king-chao department of otorhinolaryngology head and neck surgery the medical city ortigas avenue, pasig city 1600 philippines phone: (632) 635 6789 local 6250 fax: (632) 687 3349 email: nikkilorrainekingmd@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the 28th annual research forum, 17th floor, medical arts tower, the medical city, ortigas ave., pasig city, philippines. december 6, 2012. presented at philippine society of otolaryngology head and neck surgery, analytical research contest (2nd place). october 24, 2013. cet auditorium, glaxosmithkline (gsk) bldg., chino roces ave., makati city philipp j otolaryngol head neck surg 2015; 30 (1): 17-23 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles 18 philippine journal of otolaryngology-head and neck surgery excessive daytime sleepiness and obesity are some of the prominent symptoms of obstructive sleep apnea syndrome (osas). osas is characterized by repeated episodes of upper airway obstruction during sleep, nocturnal hypoxemia and sleep fragmentation.1 patients with osas are at an increased risk for significant morbidity and mortality such as accidents, cardiovascular events and neurocognitive impairment. hence, immediate identification of patients with this syndrome is crucial in preventing severe complications such as respiratory distress and sudden death. most patients seen at a sleep disorder center complain of excessive daytime sleepiness (eds). eds may result in vehicular accidents, poor job performance and adverse consequences in family and quality of life.2 according to johns, “the severity of their chronic daytime sleepiness is an important aspect of each patient’s assessment.”3 he developed a simple, self-administered questionnaire to determine the subject’s general level of daytime sleepiness called the epworth sleepiness scale (ess). in his study of 180 adult respondents, total ess scores distinguished normal subjects from patients with a range of sleep disorders. ess scores were significantly correlated with sleep latency measured during multiple sleep latency test and during polysomnography. ess scores were also significantly correlated with respiratory disturbance index and minimum sao 2 in overnight psg recordings of patients diagnosed with osas.3 however, some studies did not find any significant correlation between ess score and these polysomnographic parameters.1,4 bixler, et al.2 found that excessive daytime sleepiness was more strongly associated with depression and obesity than sleep disorders, and depression was found to be the most significant risk factor for eds followed by body mass index (bmi), age, typical sleep duration, diabetes and smoking before sleep apnea. on the other hand, resta, et al.5 found that morbid obesity can be associated with excessive daytime sleepiness even in the absence of sleep apnea. obesity is a known risk factor for osas across different populations. obesity is commonly measured using body mass index (bmi) defined as an individual’s body mass divided by height squared (kg/m2). the world health organization (2000) proposed a system of classification for obesity based on bmi with the following categories: underweight, normal, pre-obese and obese.6 the national heart, lung and blood institute (1999) with the same criteria used the following terminologies: underweight, normal, overweight and obese.7 in the study by resta, et al.,5 osas was associated with obesity in more than 50% of a population of obese patients with a mean bmi higher than 40.0. this study seeks to determine whether excessive daytime sleepiness (eds) as assessed by the epworth sleepiness scale (ess) is significantly associated with body mass index (bmi) and apnea-hypopnea index (ahi) as identified by polysomnography (psg) to indicate the presence of obstructive sleep apnea syndrome (osas) in suspect patients. the use of the ess, if found to be significantly correlated with the mentioned variables can help physicians identify patients suspected to have osas earlier and shorten delay in management. the ess may also aid physicians decide whether a psg is urgently recommended in these patients. it can guide physicians in discerning which patients need proper advice with regards to the risks associated with excessive daytime sleepiness such as motor or work-related accidents.8 the specific objectives include assessing the association between eds using the ess and ahi together with the different levels of severity of osas among those referred to the center for snoring and sleep disorders in a tertiary private hospital. the study also seeks to ascertain the accuracy of the ess in predicting presence of osas based on ahi by determining sensitivity and specificity of the ess. it also verifies the association between the ess and bmi and between ahi and bmi. the likelihood ratio will be determined if there is any significance found between these variables. methods a retrospective review of the charts of 389 patients suspected to have sleep disorders and referred for polysomnography (psg) at the center for snoring and sleep disorders in a tertiary private hospital in year 2009 was completed. with 95% level of significance, setting the margin of error at ± 5%, the minimum sample size computed was 194. in this study, 238 patients were included who were adults aged 19 and above with complete data. 151 charts were excluded from the study, of which 99 were adult patients with incomplete data and 52 were pediatric patients below 19 years old. those included were 170 males (71%) and 68 females (29%) with ages ranging between 24 and 81. the mean age was 44.19 ± 12.04 years. the center for snoring and sleep disorders is equipped with two patient rooms with one recording machine each and one evaluation room. the following parameters are simultaneously recorded: electroencephalogram, electrooculogram, electromyogram, ecg, oronasal airflow using thermal sensors, oxygen saturation using pulse oximetry, thoracic and abdominal changes using piezoelectric tensions sensors and positional changes. the snoring sound was recorded by attaching a pre-laryngeal microphone. the polysomnography (psg) was conducted in the sleep laboratory using software of alice-5-system (philips respironics). all patients were asked to complete a database form and to answer the self-administered questionnaire ess prior to the start of the psg, thus blinding them to the result of their test. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 19 details about their height, weight, neck size, waistline and abdominal girth were also recorded. after acquiring informed consent from each patient, patients were given instructions and were connected to the different recordings. the duration of the sleep study lasted for 9 hours, between 10 p.m. and 7 a.m. for each patient. the results were then scored and interpreted by one sleep specialist who was blinded to the result of the patients’ ess. according to the international classification of sleep disorders, second edition (icsd-2), there are five principal classifications of sleep-related breathing disorders, namely central sleep apnea syndromes, obstructive sleep apnea syndromes (osas), sleep-related hypoventilation/hypoxemic syndromes, sleep-related hypoventilation/ hypoxemia due to medical condition and other sleep-related breathing disorder.9 the focus in this study was osas which is more prevalent and beneficial when diagnosed early. osas is further categorized as obstructive sleep apnea in adult and pediatric patients. obstructive sleep apnea is defined as repetitive episodes of complete (apnea) or partial (hypopnea) upper airway obstruction occurring during sleep. apneic and hypopneic events should last at least 10 seconds which can occur in any stage of sleep.9 according to the american academy of sleep medicine (aasm) in the manual for scoring of sleep and associated events10 published in 2007, hypopnea has a recommended and alternative definition. the recommended definition is similar to the definition stated in the aasm 2001 position paper: hypopnea scoring is described as ≥30% reduction in nasal pressure signal excursions and associated ≥4% desaturation from baseline. the alternative definition includes ≥50% reduction in nasal pressure signal excursions from baseline and associated ≥ 3% desaturation or arousal. both definitions include a duration of at least 10 seconds or more. either definition can be used at the discretion of the clinician or investigator.10,11 ruehland, et al. compared ahis derived using 3 standard hypopnea definitions published by aasm and found out that the use of different definitions led to marked differences in ahi.11 in its latest definition, hypopnea is defined as reduction of breathing amplitude by ≥ 30% for at least 10 seconds or more and oxygen desaturation of ≥ 3%.12 in this study, the alternative definition for hypopnea was used in scoring the sleep study results. in this article, the apnea-hypopnea index (ahi) was used to represent the presence or severity of osas. the most widely used criteria to represent different levels of osas based on ahi were adapted in this study. ahi which is the averaged frequency of apnea and hypopnea events per hour of sleep is defined as the following: mild sleep apnea if the ahi is 5 to15 events per hour; moderate if the value is more than 15 to 30 events per hour; and severe if ahi is greater than 30 events per hour.9,11,13 body mass index (bmi) as categorized by the international obesity task force of who is classified as underweight, normal, pre-obese and obese.6 in this study, the terminologies used by the national heart, lung and blood institute were applied namely underweight, normal, overweight and obese.7 underweight is defined as a bmi of less than 18.5; normal is within the range of 18.5 to 24.9; overweight ranges from 25 to 29.9 while obesity is a bmi of greater than 30. bmi was gathered from the patients’ charts and used to represent obesity which is also an important risk factor for osas. to quantify daytime sleepiness, the epworth sleepiness scale (ess) developed by murray johns was applied in this study.3 it is a simple, selfadministered questionnaire composed of eight situations to assess a subject’s chance of dozing off in that particular scenario. each situation is graded from 0 to 3 with 0 as having no chance of dozing off and 3 representing a high chance of falling asleep. the score for each situation in the ess was added to give a total score of 0 to 24.3 the ess was found to have a high sensitivity (93.5%) and high specificity (100%) with a cut-off score >10.14 in this study, the cut-off score of less than 10 was used to mean a negative result or absence of daytime sleepiness while more than or equal to 10 as a positive result or presence of daytime sleepiness.15,16,17 the ess has been validated in several studies. according to johns, the ess was the most discriminating test among the three of the most commonly used tests to assess excessive daytime sleepiness namely multiple sleep latency test, maintenance of wakefulness test and ess.14 the ess has also been translated into different languages (filipino, italian, chinese, spanish and greek) and has been ascertained to have high construct validity, test-to-test reliability and internal consistency. in a local study by albay, et al.,18 the validity of the filipino version was established based on internal consistency and construct reliability. the cronbach’s alpha was computed at 0.577 which was lower compared to that of the original english version of the ess. nonetheless, it is still considered acceptable since most surveys use the value of more than 0.45, confirming it as internally consistent and valid. in this study, the english version of the ess was used which had a high cronbach’s alpha. this finding was similar to other studies abroad further validating its clinical use in english-literate patients.18 the study applied a retrospective cohort design using data found in the patients’ records. all data were stored and retrieved electronically philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles 20 philippine journal of otolaryngology-head and neck surgery from the sleep laboratory. data gathered included the patients’ age, sex, height, weight, bmi, neck size, waistline, abdominal girth, baseline and lowest oxygen saturation, ahi and ess. all data were recorded and tabulated in excel worksheet (microsoft office excel 2007). under these circumstances, permission from the institutional review board was requested to use the data for research purposes ensuring patient confidentiality in data collection by assigning numerical values. data collection and tabulation were facilitated by the sleep laboratory technician. data analysis was accomplished by a statistician. continuous variables were presented in mean ± standard deviation while categorical variables were presented in count (percentages %). comparisons between groups of patients with and without excessive daytime sleepiness were statistically determined using chi-square test and independent t-tests. for association between two categorical variables, chi-square test was conducted. for continuous variables with two groups, independent t-tests were used and for continuous variables with more than two groups, anova test was applied. statistical significance was defined as p< 0.05. the odds ratio was computed at 95% confidence interval for significant variables. accuracy tests were done using sensitivity and specificity analysis. results table 1 shows the main demographic characteristics of the patients included in the study categorized according to the presence or absence of eds. age, gender distribution, neck circumference, baseline and lowest sao 2 were similar in both groups. ess, bmi, waistline and abdominal girth were found to have significant difference between the two groups. table 2 presents the correlation of ess with the polysomnographic variable ahi compared using chi-square test to determine significant association. the results show that there is no significant association between ess and ahi (p-value 0.152, siginificant if p-value < 0.05). the findings suggest that ess may not be able to significantly identify patients with osas. table 3 illustrates the correlation of ess with ahi according to the different severities of osas: mild, moderate and severe using chisquare test. the findings are consistent with table 2 and demonstrate no significant difference between ess and different levels of osas which means that ess cannot distinguish between different severities of osas. table 4 shows the sensitivity and specificity analysis of ess in identifying patients with osas based on ahi. the results reveal that table 1. demographic characteristics of patients with and without eds total n = 238 eds n = 120 no eds n = 118 p value* age gender male female neck circumference waistline abdominal girth bmi baseline 02% lowest 02% ess score 44.19 ± 12.04 170 (71%) 68 (29%) 15.72 ± 1.91 38.52 ± 5.65 39.03 ± 5.82 29.43 ± 14.14 97.37 ± 5.94 76.42 ± 23.63 11.04 ± 5.56 43.25 ± 11.32 85 (71%) 35 (29%) 15.94 ± 1.88 39.74 ± 5.74 40.28 ± 6.17 31.47 ± 18.33 96.77 ± 8.21 74.55 ± 22.87 15.28 ± 3.96 45.14 ± 12.71 85 (72%) 33 (28%) 15.5 ± 1.92 37.26 ± 5.29 37.73 ± 5.15 27.33 ± 7.31 97.98 ± 1.58 78.31 ± 24.33 6.72 ± 3.07 ns ns ns 0.001 0.001 0.025 ns ns 0.000 continuous variables presented in mean ± standard deviation categorical variables presented in count (percentage %) ns: nonsignificant, *p-value <0.05 table 2. correlation of ess with ahi ess ahi negative positive total negative n (%) 39 (33) 79 (67) 118 (50) positive n (%) 29 (24) 91 (76) 120 (50) total n (%) 68 (29) 170 (71) 238 (100) p-value 0.152 compared using chi-square test, significant variable if p-value < 0.05 ess is not a sensitive and specific tool to predict elevated ahi and the presence of osas with a sensitivity of only 54% and specificity of 57%. positive predictive value is at 76% implying that only 76% of patients with osa will have excessive daytime sleepiness and yield a positive table 3. correlation of ess and ahi (categorized to mild, moderate and severe) ess scores apnea-hypopnea index (ahi) negative osa (<5) positive osa mild (5-14) moderate (15-30) severe (>30) n = 238 n (%) 68 (29) 170 (71) 38 (16) 42 (17) 90 (38) <10 n (%) 39 (33) 79 (67) 20 (17) 21 (18) 38 (32) ≥10 n (%) 29 (24) 91 (76) 18 (15) 21 (18) 52 (43) p-value 0.291 compared using chi-square test, significant variable if p-value < 0.05 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 21 table 4. accuracy tests for ess to predict osas based on ahi n = 238 (n) % positive predictive value negative predictive value false positive false negative sensitivity specificity (91/120) 76 (39/118) 33 (29/68) 43 (79/170) 46 (91/170) 54 (39/68) 57 table 5. correlation of ess and bmi (based on who criteria for asian population) using chi-square test to compare bmi of patients with and without eds. odds ratio included for bmi as risk factor to eds. ess scores ess scores body mass index (kg/m2)* underweight (17.00-18.49) normal (18.5-24.9) overweight (25-29.9) obese (>30) <10 27.33 ± 7.31 4 (3%) 36 (31%) 45 (39%) 30 (26%) n=238 29.43 ± 14.14 6 (3%) 61 (26%) 84 (36%) 83 (35%) ≥10 31.47 ± 18.33 2 (2%) 25 (21%) 39 (33%) 53 (45%) odds ratio reference 1.26 2.07** 95% ci for or reference (0.64, 2.48) (1.21, 3.55) p-value 0.025* *p-value computed using chi-square test, underweight and normal combined in the analysis. *p-value <0.05 **obese category are 2 times more likely to have ess scores ≥10 (final odds ratio) table 6. correlation of ahi and bmi using one-way anova ess scores ahi negative osa (<5) mild (5-14) moderate (15-30) severe (>30) underweight (17.00-18.49) n=6* n (%) 2 (33.33) 2 (33.33) 1 (16.67) 1 (16.67) normal (18.50-24.99) n=61 n (%) 32 (52.46) 11 (18.03) 9 (14.75) 9 (14.75) overweight (25.00-29.99) n=84 n (%) 24 (28.57) 16 (19.05) 15 (17.86) 29 (34.52) obese (≥30) n=83 n (%) 10 (12.05) 9 (10.84) 15 (18.07) 49 (59.04) p-value 0.002** *read with caution, small base **p-value computed using one-way anova; significant p-value is < 0.05 score (≥10) in the ess. negative predictive value is at 33% which means that 33% of patients with a negative ess score (<10) will not have osas. false positive rate is at 43% which is the proportion of subjects without osas who will yield a positive ess score while false negative rate is 46% which is the proportion of subjects with osas who will have a negative or low ess score. table 5 demonstrates the relationship of the ess with the different categories of bmi namely underweight, normal, overweight and obese. the results reveal a significant difference between the bmi of patients with eds and without eds (p-value = 0.025). more patients with ess score of ³10 belong to the obese category than those with scores of <10 (p-value <0.05). there was no significant difference in the ess scores of patients who were underweight, normal or overweight. based on the significant association of ess score of ³10 with the obese category, odds ratio was computed with a confidence interval of 95%. the results show that those who fall in the obese category are two times more likely to have ess scores of ≥10. table 6 illustrates the correlation of the different categories of bmi namely underweight, normal, overweight and obese with different levels of ahi. the results reveal a significant correlation between the ahi and bmi (p-value = 0.002 using one-way anova). most patients with normal bmi had ahi score of <5 which is negative for osas. on the other hand, majority (59.04%) of obese patients (bmi>30) had ahi of >30 representing severe osas. table 7 elaborates on the significant correlation between bmi and ahi. further statistical analysis using post-hoc tukey hsd test was conducted to determine the specific levels which had significant values using the one-way anova in table 6. subset 1 shows that negative, mild and moderate osas are homogeneous. alternatively, subset 2 exemplifies homogeneity among mild, moderate and severe osas. comparison of the subsets reveal a significant difference between negative (ahi <5) and severe osas (ahi >30). philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles 22 philippine journal of otolaryngology-head and neck surgery discussion controversy exists in the relation of excessive daytime sleepiness as measured by ess with polysomnographic variables such as ahi, oxygen desaturation index, sleep arousal and sleep fragmentation found in patients with osas. some studies found a favorable correlation with these variables3,15,17while others found no evidence of significant association.1, 2, 8 in a study by roure, et al.,16 consecutive patients (n=2,882) with ahi score of more than five were evaluated. eds was assessed using ess and was correlated to ahi. the study found that patients with eds had slightly higher ahi (p<0.005) and arousal index (p<0.001) and lower nadir oxygen saturation (p<0.01).16 the present study was conducted to contribute evidence to the correlation of ess with ahi and bmi. the results show no significant correlation was established between ess and ahi scores in patients with osas. but a significant association was noted between ess scores and bmi. the results of the present study could be partially explained by the fact that a subjective self-administered questionnaire like the ess is dependent on the subject’s personality traits, emotional factors, quality and quantity of sleep the previous night and understanding of the gravity of excessive sleepiness.15 another possible explanation is the sample population was taken from a sleep laboratory rather than a community population in which case some patients may be in denial of their symptoms and underestimate their sleepiness problem while others may not be aware of their daytime sleepiness. walter et al. found that some patients have a tendency to underestimate eds as compared with their bed partners.19 other patients may be so focused on the prominent symptoms of osas such as loud snoring or breathing cessation that they fail to notice their daytime sleepiness until they encounter vehicular accidents while others keep themselves awake by focusing on active tasks. on the other hand, bixler et al. concluded that the presence of eds is more strongly associated with depression and metabolic factors than with sleep-disordered breathing.2 the present study also found that ess has low sensitivity and specificity in identifying patients with osas as evidenced by a rate of 54% and 57%, respectively. on the contrary, johns found a high sensitivity and specificity score for ess at 93.5% and 100%, respectively with a cut-off score of >10.14 correlation of ess with the different levels of osas based on the ahi showed that ess could not distinguish between different severities of osas20 as opposed to the findings of johns.3 obesity is one of the major risk factors for osas as well as of excessive daytime sleepiness.2 obesity is commonly measured using body mass index. in this study, bmi was correlated with ess. the results reveal a significant difference between the bmi of patients with eds and without eds and show that more patients with eds are in the obese category. the findings of this study also show that those in the obese category are two times more likely to have ess scores of ³10 implying that obese patients are twice more likely to have excessive daytime sleepiness than those who are not obese. these results are supported by the evidences found by resta and his group that severe obesity even in the absence of osas is associated with sleep-related disorders and eds. all sleep-related symptoms such as apneas, awakenings, choking and unrefreshing sleep were significantly more frequent in obese patients than controls.21 the significant difference in waistline and abdominal girth support the findings of a statistical difference in bmi between the two groups. sleep apnea patients were found to have a greater amount of visceral fat compared to obese controls (p-value<0.05) and indexes of sleep-disordered breathing were significantly correlated with visceral fat.22 in a local study by mendoza and colleagues, an association between bmi, neck circumference and sleep-disordered breathing was demonstrated suggesting that bmi, weight and neck circumference can be used as clinical predictors of osas.23 the findings in this study agree with their results and show significant association between bmi and ahi especially for patients with severe osas. these findings confirm the well established relationship of obesity as a major predictor of osas.24 this association is also prevalent in asians as exhibited by populationbased epidemiological studies in which an increase in bmi has been consistently associated with an increase in ahi.25 this study concludes that the ess is insufficient to identify patients with osas. nevertheless, subjective data evaluated by questionnaires such as ess contribute supplementary information combined with table 7. homogeneous subsets computed using tukey hsda,b bmi ahi negative osa (<5) mild (5-14) moderate (15-30) severe (>30) sig. n 68 38 41 88 1 25.78 26.70 28.82 .67 2 26.70 28.82 33.70 .05 means for groups in homogeneous subsets are displayed. a. uses harmonic mean sample size = 52.100. b. the group sizes are unequal. the harmonic mean of the group sizes is used. type i error levels are not guaranteed. subset for alpha = 0.05 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 original articles philippine journal of otolaryngology-head and neck surgery 23 clinical symptoms to select patients who are candidates for further work-ups. the ess is particularly useful for clinicians with limited access to more complicated sleep diagnostics such as polysomnography or for patients who need subsequent referrals to sleep specialists. with the adverse impact of eds on quality of life and patient safety, further studies are necessary to identify more sensitive measures of sleepiness specifically in patients with osas. patients with eds should also be assessed for other factors to identify further differentials such as depression and metabolic disorders, particularly obesity and diabetes. the results show obese patients are two time more likely to have eds. the findings in this investigation also confirm the well established relationship of obesity with osas and show that obese patients are at higher risk for severe osas. appendix the ess used in this study is reproduced here with the written persmission of dr. murray johns. acknowledgements the authors acknowledge the contribution of ms. diana locayon in the form of statistical consultation and statistical analysis of the data. they also acknowledge the following clinical investigators: dr. eris llanes and dr. emilio acosta, who served as scientific advisors, and dr. sarah moral, who critically reviewed the study proposal. references bausmer u, gouveris h, selivanova o, goepel b, mann ewl. correlation of the epworth sleepiness 1. scale with respiratory sleep parameters in patients with sleep-related breathing disorders and upper airway pathology. eur arch otolaryngol.2010 oct; 267(10): 1645-1647. bixler eo, vgontzas an, lin hm, calhoun sl, vela-bueno a, kales a. excessive daytime sleepiness 2. in a general population sample: the role of sleep apnea, age, obesity, diabetes and depression. j clin endocrinol metab. 2005 aug; 90(8): 4510-4515. johns mw. a new method for measuring daytime sleepiness: the epworth sleepiness scale. 3. sleep.1991 dec; 14(6): 540-545. chervin rd, aldrich ms. the epworth sleepiness scale may not reflect objective measures of 4. sleepiness or sleep apnea. neurology. 1999 jan 1; 52(1): 125-131. resta o, foschino-barbaro mp, legari g5. , talamo s, bonfitto p, palumbo a, et al.sleep-related breathing disorders, loud snoring and excessive daytime sleepiness in obese subjects. intj obes relat metab disord. 2001 may; 25(5): 669-675. world health organization: obesity, preventing and managing the global endemic. who 6. technical report series no 894, 2000; who, geneva. clinical guidelines on the identification, evaluation and treatment of overweight and obesity 7. in adults-the evidence report. national institutes of health. obes res. 1998 sep; 6 suppl 2: 51s209s. sauter c, asenbaum s, popovic r, bauer h, lamm c, klosch g, et al. excessive daytime sleepiness 8. in patients suffering from different levels of obstructive sleep apnea syndrome. jsleep res. 2000 sep; 9(3): 293-301. hauri pj. american academy of sleep medicine task force. international classification of sleep 9. disorders, 2nd ed: diagnostic and coding manual. american academy of sleep medicine, westchester, il 2005. iber c, ancoli-israel s, chesson a, quan s. for the american academy of sleep medicine. 1st ed. 10. westchester: il: american academy of sleep medicine; 2007. the aasm manual for the scoring of sleep and associated events: rules, terminology and technical specifications. ruehland wr, rochford pd, o’donoghue fj, pierce rj, singh p, thornton at. the new aasm 11. criteria for scoring hypopneas: impact on the apnea hypopnea index. sleep. 2009 feb; 32(2): 150-157. berry rb, brooks r, gamaldo ce, harding sm, marcus cl, vaughn bv. for the american academy 12. of sleep medicine. 2nd ed. dariel, il: american academy of sleep medicine; 2013. the aasm manual for the scoring of sleep and associated events: rules, terminology and technical specifications version 2.0.1. sleep-related breathing disorder in adults: recommendations for syndrome definition and 13. measurement techniques in clinical research. the report of an american academy of sleep medicine task force. sleep. 1999 aug 1; 22(5): 667-89. johns mw. sensitivity and specificity of the multiple sleep latency test (mslt), the maintenance 14. of wakefulness test and the epworth sleepiness scale: failure of the mslt as a gold standard.j sleep res. 2000 mar; 9(1): 5-11. sun y, ning y, huang l, lai f, li z, zhou g, et al. polysomnographic characteristics of daytime 15. sleepiness in obstructive sleep apnea syndrome. sleep breath. 2012 jun; 16(2): 375-381. roure n, gomez s, mediano o, duran j, peña mde l, capote f, et al. daytime sleepiness and 16. polysomnography in obstructive sleep apnea patients. sleep med. 2008 oct; 9(7): 727-731. mediano o, barcelo a, de la peña m, gozal d, aqusti a, barbe f. daytime sleepiness and 17. polysomnographic variables in sleep apnoea patients. eur respir j. 2007 jul; 30(1): 110-113. albay ab jr, sison cm, jorge mc ii. validation of the filipino version of the epworth sleepiness 18. scale. phil j chest dse. 2008; 14(2): 84-88. walter tj, foldvary n, mascha e, dinner d, golish j.. comparison of epworth sleepiness scale 19. scores by patients with obstructive sleep apnea and their bed partners. sleep med. 2002 jan; 3(1): 29-32. smolley la, ivey c, farkas m, faucette e, murphy s. epworth sleepiness scale is useful for 20. monitoring daytime sleepiness. sleep res. 1993; 22: 389. resta o, foschino barbaro mp, bonfitto p, giliberti t, depalo a, pannacciulli n, 21. et al. low sleep quality and daytime sleepiness in obese patients without obstructive sleep apnea syndrome. j intern med. 2003 may; 253(5): 536-543. vgontzas an, papanicolaou da, bixler eo, hopper k, lotsikas a, lin hm, et al. sleep apnea 22. and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia. j clin endocrinol metab. 2000 mar; 85(3): 1151-1158. mendoza mr, cal jh, dela cruz bo,23. guzman-banzon av, limpin meb, lao ly, et al. association of snoring, obesity and daytime sleepiness with severity of sleep-disordered breathing. phil heart center j. 2006; 12(3): 40-47. young t, peppard pe, gottlied dj. epidemiology of obstructive sleep apnea: a population health 24. perspective. am j respir crit care med. 2002 may; 165 (9): 1217-1239. lam b, lam dc, ip ms. obstructive sleep apnoea in asia. 25. int j tuberc lung dis. 2007 jan; 11(1): 2-11. 46 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 featured grand rounds basosquamous carcinoma, a variant of basal cell carcinoma, is rather rare with an incidence of only 1 – 2% of cases. 1, 2 it has a predilection for the head and neck region (95.6%) with primary sites including the nasal, auricular and periocular area with the neck involved in only 1.1%.1 unlike typical basal cell carcinoma, basosquamous carcinoma behaves more aggressively with a higher tendency for metastasis and recurrence. its rarity translates to a lack of management guidelines. because of its pattern of growth and relative aggressiveness, treatment plans must be well laid; recurrence resulting from poor planning may lead to a worse outcome and poorer prognosis. case report a 76-year-old male from western samar presented with a three-year history of a small raised hyperpigmented pruritic lesion in the left lateral neck that gradually enlarged into a non-healing ulcer that bled occasionally. incisional biopsy at a provincial hospital revealed findings consistent with squamous cell carcinoma. the patient was advised surgery but opted to consult at our institution. on examination, a 6 x 4 cm erythematous, non-tender ulcer with raised advancing edges and areas of bleeding was evident on level iii-iv region of the neck on the left overlying the area of the sternocleidomastoid muscle (figures 1 a, b). moreover, a 1 x 1 cm firm, non-tender, slightly movable level v lymph node on the left was noted. the rest of the head and neck examination was non-contributory. a repeat incisional biopsy of the mass revealed basosquamous carcinoma. however, no biopsy of the lymph node was performed. dicussion basosquamous carcinoma has been defined by many authors in various ways and these definitions have changed over the years as advancements in pathology paved the way for better histopathologic studies. when newly documented, basosquamous carcinoma was believed to be a transition between basal cell carcinoma and squamous cell carcinoma. it was later considered as a variant of basal cell carcinoma with features of both basal cell and squamous cell carcinomas. contributions from immunohistochemical studies have recently suggested a continuum of basal cell carcinoma and squamous cell carcinoma, whereby basal cell carcinoma undergoes squamous differentiation leading to the development of basosquamous carcinoma.1,3,4 this differentiation appears to alter not only the histologic appearance but also the normal biologic behavior of the tumor. hence basosquamous carcinoma tends to be more aggressive with higher rates of metastasis and recurrence compared to other variants of basal cell carcinoma (table 1). there are no specific morphological and clinical features to distinguish basosquamous carcinoma from other basal cell carcinoma types and from squamous cell carcinoma, hence, the diagnosis is made only after biopsy. basosquamous carcinoma histologically shows areas with features of basal cell carcinoma (nests of typical basaloid cells that are larger, paler and rounder basosquamous carcinoma of the neck jan warren a. holgado, md joseph e. cachuela, md department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: dr. jan warren a. holgado department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 philippines phone number: (632) 526 8450 e-mail add: wackywarren2009@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (1): 46-48 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 47 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 featured grand rounds than solid basal cell carcinoma with peripheral palisading of cells surrounded by retraction clefts), and areas with features of squamous cell carcinoma (squamoid cells that have abundant eosinophilic cytoplasm).5 a transition zone with intermediate cells is evident between the area of basal cell carcinoma and squamous cell carcinoma tumor cells.1 figure 2 shows the histologic appearance of the patient’s lesion consistent with the aforementioned findings. the apparent discrepancy between the initial incision biopsy interpretation of squamous cell carcinoma and repeat biopsy findings of basosquamous carcinoma may be attributed to several factors. an inherent characteristic of basosquamous carcinoma that may have played a role in this discrepancy is tumor heterogeneity.6 another important factor would be the adequacy of sampling in terms of technique, location, depth and amount of tissue. inadequate tissue biopsy coupled with the characteristic tumor heterogeneity can lead to misdiagnosis if only a portion of the lesion showing features of either basal cell carcinoma or squamous cell carcinoma is sampled. ideally, imaging of the neck, particularly a ct scan, should have been performed in this case to further evaluate for the extent and depth of involvement of the mass as well as to assess for involvement of other cervical lymph nodes. this is particularly important to allow for pre-operative planning of the surgery since the neck involves other vital structures that may need to be preserved or may have to be sacrificed altogether. the discrepancy in histopathologic diagnosis has important implications for management. for both squamous cell carcinoma and basosquamous carcinoma, treatment options would either be wide surgical excision or moh’s micrographic surgery. however, since the patient presents with a relatively large lesion located at an unusual location, the choice between wide excision and moh’s surgery differs with the histopathologic diagnosis. for squamous cell carcinoma, wide surgical excision already offers high cure rates of > 95% comparable to moh’s surgery. where the latter surgery would be time-consuming especially for relatively large tumors, table 1. comparison of squamous cell carcinoma, basal cell carcinoma, and basosquamous carcinoma. squamous cell carcinoma basal cell carcinoma basosquamous carcinoma incidence rate rate of metastasis rate of local recurrence predilection for the head and neck 20% of skin malignancies10 7.9%4 21.9%4 70%10 65% of skin malignancies10 0.09%4 24.2%4 86%10 1-2% of basal cell carcinomas1,2 4 – 8.6%4 45.7%4 95.6% (1.1% for neck only)1 figure 1 a. a prominent ulcer is noted on level iii-iv region of the neck on the left overlying the sternocleidomasoid muscle. figure 1 b. close-up view of the ulcer showing raised advancing edges and areas of bleeding. figure 2. (light microscopy, hematoxylin and eosin stain, high power, 400x): prominent palisading of basaloid cells are seen with cleft-like retraction spaces between the epithelial nests; towards the center of the nests are cells with more cytoplasm resembling squamous cells. (bc, nest of basaloid cells; p, palisading of peripheral cells; c, clefts; sc, atypical squamous cells; tz, transition zone) (hematoxylin -eosin, 400x) philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 48 philippine journal of otolaryngology-head and neck surgery featured grand rounds wide excision is preferred.7 in contrast, basosquamous carcinoma having a higher recurrence rate after wide surgical excision (12-51%) compared to moh’s surgery (4%), the preferred mode of treatment is moh’s surgery.2 identified significant factors for recurrence in general include male sex, positive surgical margins, lymphatic invasion, perineural invasion and tumor size.2 the patient being a male, with possible lymphatic spread, and having a relatively large tumor put him at increased risk for recurrence should surgery be inadequate. cases of recurrence have been noted to be more aggressive than the original tumor.2 moh’s micrographic surgery is the more appropriate mode of treatment for basosquamous carcinoma. the unusual neck location where other vital structures are present, poses the challenge to preserve as many structures free-of-tumor as possible which can be achieved by moh’s surgery. however, since moh’s surgery is not readily available at our institution and due to the relatively large size of the mass, a more plausible technique is excision with 1.5-cm margin of normal tissue with frozen section. recurrence rates following cross-sectional frozen section are comparable to those of moh’s surgery at least for basal cell carcinomas.8 the procedure would however still leave a huge defect in the neck necessitating reconstruction, in our case with a trapezius flap. the presence of possible lymph node metastasis warrants a modified radical neck dissection on the left.2 the patient should then receive a course of adjuvant radiotherapy.2, 9 one vital detail illustrated in this case is the importance of biopsy in suspected skin malignancies. the critical role of an adequate biopsy sample and accurate histopathologic diagnosis cannot be understated as they have direct bearing on management and prognosis of skin malignancies. for a rare and aggressive condition as basosquamous carcinoma, knowledge of its natural history and proper management is essential. references 1. leibovitch i, huilgol sc, selva d, richards s, paver r. basosquamous carcinoma: treatment with mohs micrographic surgery. cancer. 2005 jul 1;104(1):170-5. 2. martin ii rcg, edwards mj, cawte tg, sewell cl, mcmasters km. basosquamous carcinoma: analysis of prognostic factors influencing recurrence. cancer. 2000 mar 15;88(6):1365-9. 3. beer tw, shepherd p, theaker jm. ber ep4 and epithelial membrane antigen aid distinction of basal cell, squamous cell, and basosquamous carcinomas of the skin. histopathology. [serial on the internet] 2000 sep [cited 2010 mar 4];37(3):218-23. 4. mitsuhashi t, itoh t, shimizu y, ban s, ogawa f, hirose t et. al. squamous cell carcinoma of the skin: dual differentiations to rare basosquamous and spindle cell variants. j cutan pathol [serial on the internet] 2006 mar [cited 2010 mar 4];33(3):246-52. available from: http://www3. interscience.wiley.com/journal/118602589/abstract. 5. kumar v, abbas ak, fausto n. robbins and cotran pathologic basis of disease. 7th ed. philadelphia, pennsylvania: elsevier saunders; 2005. 6. johnson bf, moore pj, goepel jr, slater dn. basosquamous carcinoma, a wolf in sheep’s clothing? report of 3 cases. postgrad med j. 1989 october; 65(768):750–751. 7. gross nd, monroe m. skin cancer: squamous cell carcinoma. (article on the internet) 2009 jan 15 [accessed 2010 mar 4]. available from: http://emedicine.medscape.com/article/870430. 8. bentkover sh, grande dm, soto h, kozlicak ba, gillaume d, girouard s. excision of head and neck basal cell carcinoma with a rapid, cross-sectional, frozen section technique. arch facial plast surg [serial on the internet] apr-jun 2002 [cited 2010 sept 21];4(2):114-119. available from: http://archfaci.ama-assn.org/content/4/2/114. 9. ranjan n, singh sk, arif sh. basosquamous carcinoma in an indian patient with oculocutaneous albinism. indian j dermatol [serial on the internet] 2009 [cited 2010 mar 4];54:63-5. available from: http://www.e-ijd.org/text.asp?2009/54/5/63/45460. 10. cummings cw, flint pw, haughey bh, robbins kt, tomas jr, harker la, et.al. otolaryngology head and neck surgery. 4th ed. philadelphia, pennsylvania: elsevier mosby; 2005. 11. garcia c, poletti e, crowson an. basosquamous carcinoma. j am acad dermatol. [serial on the internet] 2009 jan [cited 2010 mar 4];60(1):137-43. available from: http://www.ncbi.nlm.nih. gov/pubmed/19103364. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 40 philippine journal of otolaryngology-head and neck surgery from the viewbox figure. 1 coronal ct image passing through the level of the osteomeatal complex in a patient with severe nasal polyposis. arrows point to a retroverted uncinate process on both sides. recognition of this anatomic abnormality is essential for the determination of surgical landmarks for endoscopic sinus surgery. references 1. bolger we. paranasal sinus bony anatomic variations and mucosal abnormalities: ct analysis for endoscopic sinus surgery. laryngoscope 101:56-64, 1991. 2. freedman hm, kern eb. complications of intranasal ethmoidectomy: a review of 1000 consecutive operations. laryngoscope 89:421-34, 1979. considerable attention has been directed toward analysis of paranasal sinus anatomy through coronal plane computerized tomographic (ct) imaging in this age of functional endoscopic sinus surgery. recently, it has become apparent that anatomic variations are also evident on ct analysis of patients. subtle anatomic features can now be imaged through ct, with a level of clarity previously not afforded by standard sinus radiographs.1 the key to a successful endoscopic sinus surgery is the proper identification of landmarks, and intelligent decision-making should there be any doubts as to what structure lies ahead. the middle turbinate is the main landmark in the region and should be preserved if possible. attention to the limits of the middle turbinate landmark is one of the keys to uncomplicated surgery.2 the presence of a retroverted uncinate process, wherein the uncinate process ( rather than the middle turbinate) is the first bone to encountered, can be misleading to the rhinologic surgeon and lead to inadequate surgery. familiarity with anatomic variations such as the retroverted uncinate process should increase the safety and effectiveness of functional endoscopic sinus surgery. retroverted uncinate process: an anatomic variation armando t. isla jr., md josefino g. hernandez, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila correspondence: armando t. isla jr., md department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax: (632) 525 5444 email: donisla.md@gmail.com reprints will not be available from the author. philipp j otolaryngol head neck surg 2009; 24 (2): 40 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 practice pearls philippine journal of otolaryngology-head and neck surgery 45 olfactory deterioration is a major consequence of total laryngectomy that results from the permanent separation of the upper and lower airways. total laryngectomy not only affects the natural voice lost but it brings about other psychosocial problems. leon et al.1 noted that the inability to detect smoke or other odorous danger signals can threaten the personal safety of patients after laryngectomy. impaired olfactory function adversely impacts their quality of life, which contributes to weight loss and poor nutritional status because the ability to sense different flavors requires a functional olfactory epithelium.1 the inability to detect bodily odors can cause problems in daily life and the inability to perceive agreeable odors or fragrances can be experienced as a significant loss. since the senses called “tastes” are dependent on retronasal stimulation of the olfactory receptors, the perception of such tastes will also be negatively influenced by the loss of the sense of smell.2 olfaction is either a passive or active process. passive olfaction occurs during normal nasal breathing while active processes occur during smelling and sniffing. hilgers et al. 3 noted that total laryngectomy inevitably results in the loss of passive smelling and only a minority of patients are still able to actively smell anything. their study of 63 laryngectomees found that about two thirds of the patients were anosmic and that the rest had difficulty in smelling.3 tests for olfactory acuity different olfactory function tests for patients who underwent total laryngectomy have been developed in the philippines and around the world over the past decades. the jet stream olfactometer (jso, nagashima medical instruments co., japan) was developed as a modification of the t and t olfactometer (takasago industry, tokyo, japan), an olfaction test kit that includes five odorants.4 the jso includes three of the same five odorants; odorant aa dilution of β-phenyl ethyl alcohol, odorant ba dilution of cyclotene and odorant ca dilution of isovaleric acid. concentrations of each odorant range over eight degrees of intensity. these odorants can be sprayed into the nasal cavity and stimulate the olfactory epithelium using the jso apparatus. the detection threshold of each subject is defined as the lowest concentration detectable by the subject, whereas the recognition threshold is defined as the lowest concentration at which the odor can be identified. the subject’s olfaction levels are classified into three groups; threshold decrease by more than degree is defined as “improved”, threshold increase by more than one degree is defined as “worsened” and threshold change within ±1 degree is defined as “stable”. rehabilitation of smell after total laryngectomy ricardo l. ramirez jr, md department of otorhinolaryngology head and neck surgery st. luke’s medical center correspondence: ricardo l. ramirez jr.,md department of otorhinolaryngology head and neck surgery st. luke’s medical center 279 e. rodriguez sr. boulevard, quezon city, 1112 philippines telefax: (632) 723 0101 loc 5543 e-mail: rikrik_2006@yahoo.com reprints will not be available from the author. no funding support was received for this paper. the author signed a disclosure that he has no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this paper. philipp j otolaryngol head neck surg 2010; 25 (1): 45-47 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 practice pearls 46 philippine journal of otolaryngology-head and neck surgery according to the japan rhinology society, the jso is now routinely performed in japan.4 another test developed by fujii et al.4 is the alinamin test, an intravenous olfaction test that uses alinamin, a thiol-type derivative of vitamin b1 that smells like garlic. a dose of 10 mg (2ml) alinamin is injected into the median vein of the left arm at a constant rate over 20s. the latency and duration are measured. the latency interval is the time until recognition of smell while duration is the time from recognition until disappearance of the smell. the usual latency interval is 7-8 seconds and the duration is 1-2 minutes. in laryngectomees, the use of nasal plugs during testing prevents breathing the garlic smell from the trachea-stoma.4 leon et al.1 also developed olfactory function tests for post laryngectomy patients which utilise their orthonasal and retronasal olfaction. orthonasal olfaction tests include the butanol threshold test and odor identification test using common odors developed at the connecticut chemosensory clinical research center (cccrc). in the butanol threshold test, two identical plastic bottles, one containing water and the other containing dilute concentration of butanol are simultaneously presented to the subject. subjects are instructed to occlude one nostril and place the tip of the bottle immediately beneath the other nostril. the bottles are then squeezed at least twice for the odorants to reach the olfactory epithelium. the subject has to choose which of the bottles contain something other than water. the odor identification test uses common household odorants like peanut butter, ivory™ soap, mothballs, vicks™ vaporub, chocolate, baby powder, coffee and cinnamon which are placed in opaque squeezable bottles. the odorants are delivered by squeezing the bottle underneath one nostril while the other nostril is occluded. the subjects then choose from a printed list containing the correct items as well as an equal number of distractor items. possible scores range from 0 to 7 items correctly identified and scores of both nostrils are averaged to arrive at the final scores. the scores from the butanol threshold test and identification tests are subsequently averaged to arrive at a composite score for the orthonasal olfactory ability.1 retronasal olfactory function testing involves different flavoured powders applied on the tongue and then identified using a forcedchoice paradigm. twenty (20) flavoured powders purchasable at a grocery store include garlic, strawberry, milk, lemon, orange, vanilla, cinnamon, cloves, paprika, curry, butter buds, bread, cocoa, celery, chicken bouillon, grape, raspberry, onion, ginger and coffee. a small amount of each flavoured powder is scooped up into the tip of a disposable straw and deposited on the subject’s mid-dorsal tongue. the subject chooses from a printed list of 4 items for each test. answers are scored from 0 to 20 correct item identifications.1 risberg-berlin et al. used the scandinavian odor identification test (soit) in determining the olfactory function of post-larygectomy swedish patients.5 the test involves 16 different odors and 4 alternative responses per odor to choose from. the smell is generated by 5 ml of odor stimulus placed in a 10 ml glass jar. the test has age and sex related cutoff scores and categorizes patients as smellers or non-smellers. smellers are subjects diagnosed with functional hyposmia and normosmia while non-smellers are subjects diagnosed with anosmia. ramirez et al. subjectively and objectively evaluated the olfactory function of filipino post-laryngectomy patients using a questionnaire adapted from that of the smell and taste clinic of hospital of university pennsylvania (hup) and the santo tomas smell identification test respectively.6 each subject is asked to assess their olfactory function and the impact of such on their daily lives including questions on olfactory disorder prior to laryngectomy, sense of smell immediately after laryngectomy, present sense of olfaction, degree of change in olfaction and smell condition after olfactory rehabilitation. olfactory function of each subject is evaluated using the santo tomas smell identification test (st-sit)7 that uses 45 odorants, each enclosed in an opaque polyethylene squeeze bottle. each odorant is smelled by the subject and identified from a written list of choices. the odorants have a corresponding score and the summation of these scores serves to discriminate those with normal olfactory function from those who are hyposmic and anosmic. based on the st-sit, normal individuals score more than 90; hyposmic individuals score 70 to 90 while anosmics score less than 70. intervention different techniques have been developed for improvement of olfaction in post laryngectomy patients. schawrtz8 tried to improve smell by using a “larynx bypass,” in which airflow from the stoma is directed to the mouth, creating an artificial airflow in the nose. however, this method is troublesome and impractical for use in everyday life.8 techniques like “glossopharyngeal press,”9 “buccopharyngeal maneuver” and “buccopharyngeal sniffing” have also been described in different olfactory rehabilitation studies. these are less obtrusive methods that generate some degree of nasal airflow by creating volume changes in the pharynx with the mouth closed, but these are not widely applied. hilgers2 and ramirez et al.10 use the nasal airflow-inducing maneuver to restore nasal airflow by creating underpressure in the oral cavity and oropharynx by having the patient perform an extended yawning movement while keeping the lips securely closed and simultaneously lowering the jaw, floor of the mouth, tongue, base of tongue and soft philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 philippine journal of otolaryngology-head and neck surgery 47 practice pearls palate. the underpressure created generates nasal airflow allowing odorant molecules to reach the olfactory epithelium. the movement is repeated rapidly several times to increase its effectiveness but the technique requires a training period and constant use. conclusion olfactory impairment is common in patients who have undergone laryngectory. different rehabilitation programs address the olfactory deficit of post-laryngectomy patients and aim to prevent or decrease the negative impact on quality of life that loss of olfaction brings. aside from voice and pulmonary rehabilitation, olfactory rehabilitation should routinely be incorporated in the rehabilitation program of postlaryngectomy patients. references 1. leon ea, catalanotto fa, werning jw. retronasal and orthonasal olfactory ability after laryngectomy. arch otolaryngology head and neck surg 2007; 133:32-36. 2. hilgers fjm, van dam fsam, keyzers s, koster mn, van as c, muller mj. rehabilitation of olfaction after laryngectomy by means of a nasal airflow-inducing maneuver. arch otolaryngology head and neck surg 2000; 126: 726-732. 3. van dam fsam, hilgers fjm, emsbroek g, touw fi, van as cj, de jong n . deterioration of olfaction and gestation as a consequence of total laryngectomy. laryngoscope. 1999; 109: 1150-1155 4. fujii m, fukazawa k, hatta c, yasuno h, sakagami m. olfactory acuity after total laryngectomy. chemical senses 2002; 27: 117-121. 5. risberg-berlin b, ryden a, moller ry, finizia c. effects of total laryngectomy on olfactory function, health-ralated quality of life and communication: a 3 year follow up study. bmc ear, nose and throat disorders 2009; 9:8. 6. ramirez rl, panganiban wd, romualdez ja. subjective and objective assessment of olfactory function in post-laryngectomy patients. philipp j otolaryngol head neck surg 24(2): 19-22 december 2009. 7. david j, campomanes b, dalupang j, loberiza f. smell identification test. philipp j otolaryngol head neck surg 1994;62-8 8. schwartz dn, mozell mm, youngentob sl, leopold dl, sheehe pr. improvement of olfaction in laryngectomized patients with the larynx bypass. laryngoscope. 1987; 97:1280-1286. 9. risberg-berlin b, ylitalo r, finizia c. screening and rehabilitation of olfaction after total laryngectomy in swedish patients: results from intervention study using the nasal airflowinducing maneuver. arch otolaryngology head and neck surg. 2006; 132 (3): 301-306. 10. ramirez rl, romualdez ja, casile r. the use of nasal airflow inducing maneuver in olfactory rehabilitation of post laryngectomy patients. unpublished manuscript presented at descriptive research contest (2nd place) philippine society of otolaryngology-head and neck surgery, congo grill restaurant, september 2008. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 under the microscope 56 philippine journal of otolaryngology-head and neck surgery this is from a 39-year-old male with a 26-six-year history of a maxillary mass, recurring after excision, 10cm in widest diameter, solid and cystic. odontogenic ghost cell carcinomas (ogcc) are rare and only a dozen or so have been reported in the literature. this tumor appears to be more common in asians based on the cases that have been reported and is more common in the maxilla than the mandible. histologically, elements of a benign calcifying odontogenic cyst (coc) can be identified in all the malignant variants, either separated or admixed with the malignant epithelial component. the biological behavior of the tumour is unpredictable, with some cases characterized by relatively indolent growth and others by a locally aggressive and potentially fatal course. the tumour apparently arises most often from malignant transformation of a preexisting benign coc, although it may also develop from other odontogenic tumours. the section shows cords and islands of stellate reticulum displaying peripheral palisading of ameloblasts. there are numerous polygonal cells that have eosinophilic cytoplasm and indistinct cellular detail (“ghost cells”). calcified dental matrix is also present. although cytologic atypia appears mild, the borders are infiltrative. odontogenic ghost cell carcinoma of the maxilla ella c. lim, md 1, jose m. carnate jr., md2, jose ma. c. avila, md2 1department of pathology philippine general hospital university of the philippines manila 2department of pathology college of medicine – philippine general hospital university of the philippines manila correspondence: jose m. carnate, jr, md university of the philippines manila college of medicine department of pathology 547 pedro gil st., ermita, manila, 1000 phone: (632) 526 4550 fax: (632) 400 3638 email: jmcjpath@yahoo.com reference: j oral pathol med 1999 aug; 28(7)323-9 philipp j otolaryngol head neck surg 2006; 21 (1,2): 58 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 34 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to describe outcomes of oral propranolol therapy in a series of adult and pediatric patients diagnosed with benign capillary hemangioma of the head and neck. methods: design: prospective case series setting: tertiary government teaching hospital participants: ten (10) patients representing all patients clinically diagnosed with benign capillary hemangioma of the head and neck enrolled in the study from 2012 to 2015. results: two (2) adults and eight (8) children were enrolled in the study. although a decrease in lesion size was observed in half of the participants starting at three months, only one (1) attained complete resolution of the lesion-a 12-year-old girl with hemangioma of the right parotid gland that attained clinical resolution of symptoms after four months of treatment. the remaining nine out of ten (9/10) participants did not attain complete clinical resolution; but there was a decrease in lesion size in four (4) of these participants. for the remaining five (5) participants, there was neither a decrease nor an increase in lesion size. altogether, of the two adult participants, only one responded to therapy while only 4 out of 8 pediatric participants responded to therapy. there were no noticeable differences between adult and pediatric patients in terms of resolution and plateau. aside from mild bradycardia expected with propranolol, no adverse reactions were observed during the course of treatment. conclusions: although half of our participants responded to oral propranolol therapy whether these observations may be attributable to oral propranolol alone cannot be concluded. keywords: hemangioma, capillary; hemangioma; propranolol administration, oral; propranolol benign capillary hemangiomas are one of the most common benign tumors of childhood with an incidence at birth of 1-2 % in white caucasians, asians and blacks reaching almost 10% in the former but significantly lower in the latter two by the end of the first year.1 the incidence is higher in preterm infants less than 1 kg reaching nearly 30%.1 several trials have demonstrated the efficacy of oral propranolol therapy in treating infantile hemangiomas.2-6 however, despite its anecdotal use, we were not aware of evidence supporting the use of oral propranolol for treating hemangiomas in older children and adults with negative results from a search of pubmed, herdin and google scholar using the keywords “hemangioma oral propranolol therapy for benign capillary hemangiomas in a series of adult and pediatric patients gerardo aniano c. dimaguila, md, mph emmanuel s. samson, md department of otolaryngology head and neck surgery pamantasan ng lungsod ng maynila ospital ng maynila medical center correspondence: dr. emmanuel s. samson department of otolaryngology head and neck surgery pamantasan ng lungsod ng maynila ospital ng maynila medical center quirino cor. harrison blvd., malate, manila 1004 philippines phone: (632) 524 6061 local 220 telefax: (632) 523 6681 email: ommc_enthns@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or in electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2017; 32 (2): 34-37 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 35 capillary” “hemangioma” “propranolol administration oral” and “propranolol.” with the question; “will oral propranolol still be effective in treating hemangiomas in older children and adults,” this study aims to describe outcomes in a series of adult and pediatric patients with benign capillary hemangioma of the head and neck. methods with institutional review board approval, this prospective case series considered all patients seen at the out-patient or emergency department of our tertiary government hospital, who were clinically diagnosed with benign capillary hemangioma of the head and neck from 2012 to 2015. to be excluded were patients clinically diagnosed with capillary hemangioma who had undergone other forms of treatment such as, but not limited to use of intralesional sclerosing agents, oral or topical corticosteroids, or recurrence after prior surgical intervention; patients or patients parents/ guardians who would not consent to undergo oral propranolol therapy; and patients in whom oral propranolol therapy was contraindicated or in whom the adverse effects of oral propranolol would greatly outweigh the benefits such as those suffering from asthma. with written informed consent (and assent, where applicable), propranolol 40mg and 10mg tablets were used. for adult patients, propranolol was administered orally in three (3) divided doses daily with reassessment planned weekly for the first month followed by 2-month intervals for a year. for pediatric patients, paper tabletsfinely ground powder that can be dissolved in liquid were used. a written prescription with instructions to the pharmacist to prepare propranolol paper tablets in the computed dose was given to the patient’s parent/ relative/guardian so that they could purchase this at the pharmacy. oral propranolol was given at a dose of 2mg/kg/day in three (3) divided doses daily with reassessment planned weekly for the first month followed by 2-month intervals for a year. prior to initiation of therapy, each patient was evaluated by a cardiologist to obtain baseline data and to ascertain that there were no contraindications to the proposed therapy. patients were observed in the emergency room for 24 hours at the start of therapy with heart rate and blood pressure monitored by the hour. after the first 24 hours, the patients were then discharged and instructed to take propranolol orally every 8 hours with daily visits for the first week followed by weekly visits thereafter. on each follow-up visit, either author evaluated the lesion, focusing on such gross features as size and boundaries, color, induration and consistency. measurements were taken using a vernier caliper 150mm (acosta, taiwan) and cloth tape measure (goldfish, china) and findings were manually recorded with pen and paper. photographs were taken using a 2007 sony ericsson w960 3-mega pixel auto focus led flash camera (sony ericsson, china). qualitative final assessments regarding decrease in lesion size and boundaries, change in color and change in consistency and induration were subjectively classified “yes” or “no” by both authors in consensus based on the recorded measurements and photographs. results a total of 10 patients, two (2) adults (aged 23 and 31, respectively) and eight (8) pediatric patients (aged 3 months to 13 years) were enrolled in the study with none excluded. only one (1) attained complete resolution of the lesion; a 12-year-old female diagnosed with hemangioma of the right parotid gland that attained clinical resolution of symptoms after four months of treatment. (figure 1) including this girl, five of the patients were lost to follow up less than six (6) months after initiating treatment (two at the 2nd month, one at the 3rd month and two at the 4th month, respectively). although the remaining nine out of ten (9/10) patients did not attain complete clinical resolution, there was a decrease in lesion size in four (4) participants starting at three months. one of these, a 31-year-old woman with multiple small capillary hemangiomas of the dorsum of the tongue was observed until the 8th month of therapy. there was marked decrease in the size and number of lesions since the start of the therapy prominently noticed around the 3rd month with markedly less discoloration surrounding the lesions. however, there was no noticeable change in the size of the lesions after the 5th month. (figure 2) another, a four-year-old girl with a lesion of the anterior third of the tongue was observed to have a decrease in lesion size by the 12th month of therapy with plateau occurring by the end of the 15th month. she was initially seen when she was still a year old and presented with a purplish red lesion involving almost the entire dorsum of the tongue. after 12 months of therapy, the lesion started to shrink with areas that started sloughing off. it assumed a wrinkled, prune-like appearance and showed signs of resolving. however by the 15th month, the lesion regained its purplish color and remained unchanged until the patient was last seen at age 4. there were no reported difficulties in speech and feeding. (figure 3) also included in this group was an 8-year-old boy with capillary hemangioma of the right cheek and upper lip. the patient’s lesion showed signs of regression after four months of therapy. the most noticeable change was a decrease in discoloration around the right cheek as well as a decrease in the swelling around the right upper lip after 6 months of treatment. (figure 4) philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 a cb figure 2. a. patient on day 1 of therapy b. after the 64th day of therapy (2 months) and c. after 150 days of therapy (5 months). note little change in the size of the lesion in figures b and c. figure 1. a. patient on day 1 of oral propranolol therapy b. day 78 (end of 2nd month) c. day 121 (end of 4th month). b ca 36 philippine journal of otolaryngology-head and neck surgery original articles the last patient to show a decrease in lesion size was an 11-year-old girl with hemangioma of the right cheek and upper lip with involvement of the buccal mucosa noted around the 3rd month of therapy. also noteworthy was the clearing up of the buccal mucosa involvement to almost near-normal. however, rapid plateau was attained with no decrease in lesion size after the 5th month. she was on continued oral propranolol therapy for 12 months before being lost to follow up. (figures 5 and 6) altogether, of the two adult participants, only one responded to therapy while only 4 out of 8 pediatric participants responded to therapy. there were no noticeable differences between adult and pediatric patients in terms of resolution and plateau. aside from mild bradycardia expected with propranolol, no adverse reactions were observed during the course of treatment. table 1. summarizes our findings patient age/ sex decrease in lesion size/ boundaries? (yes/no) change in color? (yes/no) change in consistency induration (yes/no) duration of participation/ duration of oral propranolol therapy (months) 23/f 13/f 6 mos/m 1/m 12/f 3 mos/f 8/m 31/f 11/f 1/f no no no no yes no yes yes yes yes no no no no yes no yes yes yes yes no no no no yes no yes yes yes yes 2 months 2 months 3 months 4 months 4 months 6 months 6 months 8 months 12 months 36 months figure 3. a. patient on day 0 of therapy b. on day 450 (15 months) of therapy; c. after 720 days (24 months); d. there was almost no change in size of the lesion from 15 months to 24 months except for some areas which had sloughed off. a b c d figure 4. a. day 0 of therapy b. day 120 (4th month) of therapy; note the decrease in discoloration of the right cheek and hemiface. a b figure 5. a. day 0 of therapy b. at approximately 120 days of therapy (4th month). a b figure 6. a. buccal mucosa involvement of our patient depicted above at day 0 b. day 120 (4 months). notice the decrease in the small maculo-papular lesions to near normal mucosa by the 4th month. a b philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 37 references antaya rj. infantile hemangioma. in james wd, wells mj, perry v (editors). medscape. 1. [updated 2017 oct 02; cited 2017 oct 4] available from: http://emedicine.medscape.com/ article/1083849-overview#showall. leaute-labreze c, dumas de la roque e, hubiche t, boralevi f, thambo jb, taieb a. propranolol 2. for severe hemangiomas of infancy. letters to the editor. n engl j med. 2008 jun 12; 358(24): 2649-51. [updated 2008 jun 12; cited 2012 aug 20] available from: http:// authors.nejm.org/ nengljmed358;24. doi: 10.1056/nejmc0708819; pmid: 18550886. zvulunov a, mccuaig c, frieden ij, mancini aj, puttgen kb, dohil m, et al. oral propranolol 3. therapy for infantile hemangiomas beyond the proliferation phase: a multicenter retrospective study. pediatr dermatol. 2011 mar-apr; 28(2): 94-98. doi: 10.1111/j.1525-1470.2010.01379.x; pmid: 21362031. celik a, tiryaki s, musayev a, kismali e, levent e, erqun o. propranolol as the first line therapy 4. for infantile hemangiomas: preliminary results of two centers. j drugs dermatol. 2012 jul; 11(7):808-11. pmid: 22777220. schupp cj, kleber jb, gunther p, holland-cunz s. propranolol therapy in 55 infants with infantile 5. hemangioma: dosage, duration, adverse effects and outcome. pediatr dermatol. 2011 nov-dec; 28 (6):640-4. doi: 10.1111/j.1525-1470.2011.01569.x; pmid: 21995836. al dhaybi r, superstein r, milet a, powell j, dubois j, mccuaig c, codere f. treatment of 6. periocular infantile hemangiomas with propranolol: case series of 18 children. ophthalmology. 2011 jun; 118(6): 1184-8. doi: 10.1016/j.ophtha.2010.10.031; pmid: 21292326. darrow dh, greene ak, mancini aj, nopper aj. diagnosis and management of infantile 7. hemangioma. pediatrics. 2015 oct; 136(4): e1060-e1104. [cited 2017 oct 4]. available from: http://pediatrics.aappublications.org/content/136/4/e1060. doi: 10.1542/peds.2015-2485. sommers-smith s, smith dm. beta blockade induces apoptosis in cultured capillary endothelial 8. cells. in vitro cell dev biol anim. 2002 may; 38(5):298-304. doi: 10.1290/1071-2690(2002)038<0 298:bbiaic>2.0.co;2; pmid: 12418927. zimmerman ap, wiegand s, werner ja, eivazi b. propranolol therapy for infantile hemangiomas: 9. review of the literature. int j pediatr otorhinolaryngol. 2010 apr; 74(4):338-42. doi: 10.1016/j. ijporl.2010.01.001; pmid: 20117846. popoiu cm, stanciulescu c, popoiu a, nyiredi a, re iacob pc, david vl, et. al., treatment of 10. vascular anomalies in children: pros and cons. jurnalul pediatrului. 2014 jul-dec; xvii (67-68) 37-41. [cited 2017 oct]. available from: http://www.jurnalulpediatrului.ro/pages/arhiva/6768/67-68-08.pdf richter gt, friedman ab. hemangiomas and vascular malformations: current theory 11. and management. international journal of pediatrics. volume 2012 (2012): article id 645678. 10 pages. [cited 2017 oct 4]. available from: https://www.hindawi.com/journals/ ijpedi/2012/645678/. doi: http://dx.doi.org/10.1155/2012/645678. discussion out of the ten (10) patients who were enrolled in the study, only half or five (5) showed a decrease in the size of the lesion-one (1) adult and four (4) children. the remaining half did not show any changes in the size of the lesion. given the number of reports on the success of oral propranolol therapy in infantile hemangiomas,2-6 we were expecting a high rate of resolution among older children and adults as well. as our results show though, only half of the patients responded (and most, only partly) to oral propranolol therapy. getting to the bottom of the whys and why nots entail taking a look at how propranolol acts on infantile hemangiomas. the exact mechanism of hemangioma growth and regression is not clearly understood. hemangiomas are a mixture of clonal endothelial cells, pericytes, dendritic cells and mast cells.7 proangiogenic factors such as basic fibroblast growth factor (bfgf) and vascular endothelial growth factor (vegf) have been theorized to play a role in the proliferation and growth of hemangiomas.7 factors that affect involution are downregulation of angiogenesis and upregulation of angiogenesis inhibitors,7,9 the mechanism proposed by some for the success of beta blockers in triggering involution.8 these studies have demonstrated a triggered apoptosis of capillary endothelial cells in adult rat lung tissue with the use of propranolol and documented a decrease in locally produced vegf-1 in hemangiomas upon initiation of propranolol.8 since vegf-1 is a proangiogenic factor, its inhibition results in involution. based on these studies, we thought oral propranolol therapy should work on hemangiomas whether infantile among older children or among adults. yet, only half of the patients in our study responded to therapy. an important limitation of our study may have been our failure to distinguish ‘true’ infantile hemangiomas from other vascular anomalies and malformations.7,11 other studies that have employed oral propranolol therapy would not recommend using it on other vascular anomalies.10 these anomalies behave differently from infantile hemangiomas in that they are not affected by angiogenic factors and can be affected by other factors such as trauma, infection and hormones.7 in retrospect, we could have been dealing with other forms of vascular anomalies in those patients who did not respond to oral propranolol therapy. we recommend that more attention be given to correctly diagnosing infantile hemangiomas in distinction from other vascular anomalies. as for the participants who did respond to therapy, we must consider whether the resolution was indeed due to propranolol therapy or to spontaneous involution. it is well documented that 90% of hemangiomas involute by age 10 years while those that do not involute beyond 10 years have a greater chance of persisting throughout adulthood.7 five (5) of our patients presented with a hemangioma persisting beyond the 10th year of life and the probability of spontaneous involution coinciding with the initiation of propranolol therapy seems slim. in these cases, it would be tempting to consider that the resolution and/or diminution of our patients’ lesions was an effect of propranolol therapy. however, our small sample with cursory documentation and observer bias and no comparator group (inherent to the design of a case series) are limitations that do not allow us to jump to any such conclusions. future, better-designed studies may avoid these limitations and possibly shed light on our research question. our experience with these ten (10) patients has not answered the question of whether oral propranolol therapy will have a good outcome on older children and adults. although half of our participants responded to oral propranolol therapy whether these observations may be attributable to oral propranolol alone cannot be concluded. philipp j otolaryngol head neck surg 2009; 24 (2): 6-13 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: this report aims to determine the clinical manifestations and management of patients with superior semicircular canal dehiscence syndrome (sscds). methods: design: case series setting: tertiary hospitals and private clinics participants: out of 30 patients with vestibular vertigo or otologic symptoms, 14 patients were diagnosed with sscds based on high resolution computed tomographic scan (hrct). the demographic features, incidence of specific signs and symptoms and management of these patients were described, including the audiograms, vestibular evoked myogenic potential (vemp) responses and ancillary tests. results: vertigo was the most common vestibular symptom of sscds. tullio phenomenon was elicited in 50% of patients with confirmed dehiscence on hrct scan. low frequency (250 hz and 500 hz) air-bone gap was noted in 21.4% of patients. lowered vemp responses were also noted in 66.7% of patients with confirmed sscds. severity of symptoms may determine its management. conclusion: the diagnosis of sscds does not conform to a specific clinical presentation or audiologic result and good clinical correlation is needed in order to raise suspicion of the disease and prompt the clinician to order confirmatory imaging by computed tomographic scan or magnetic resonance imaging. the presence of this syndrome in a proportion of children that is greater than previously reported needs further study as these children may be genetically predisposed to have thinned out superior semicircular canals that eventually become dehisced albeit at an earlier age. key words: superior semicircular canal dehiscence, pure tone audiometry, vestibular evoked myogenic potential superior semicircular canal dehiscence syndrome: review of clinical manifestations in adults and children scheherazade c. ibrahim, md1 charlotte m. chiong, md1, 2, 3 nathaniel w. yang, md 1, 2, 4 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2philippine national ear institute national institutes of health university of the philippines manila 3department of otorhinolaryngology manila doctors hospital 4department of otolaryngology head and neck surgery the medical city hospital correspondence: scheherazade c. ibrahim, md ibrahim ent medical clinic corner mabini and sk pendatun sts. cotabato city 9600 philippines phone: (064) 421 5388 email: sche_ibrahim@yahoo.com no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. presented at the descriptive research contest, philippine society of otolaryngology-head and neck surgery, jade valley restaurant, quezon city, philippines, september 25, 2008; the 1st aanoa congress (1st place), dusit thani, makati city, philippines on november 28, 2008 and 10th asia pacific congress on deafness, landmark hotel, bangkok, thailand on august 6, 2009. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles 6 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles philippine journal of otolaryngology-head and neck surgery 7 superior semicircular canal dehiscence syndrome (sscds) is a pathologic condition with vestibular symptoms provoked or exacerbated by sound or pressure stimuli due to the absence of the bony layer covering the superior semicircular canal. this is a recently recognized disease entity that most clinicians may overlook in diagnosing patients presenting with vertigo or nystagmus as some patients may present only with hearing loss and no associated vestibular symptoms. sscds has sparked a lot of interest over the past years leading to research aimed at understanding this abnormality and emphasizing its importance as a cause of intractable vertigo. in 1998, minor et al. reported eight patients with vertigo, oscillopsia or disequilibrium related to sound, changes in middle ear pressure or changes in intracranial pressure.1 they also had vertical-torsional eye movements induced by sound and/or pressure stimuli. high-resolution computed tomographic (hrct) scan of the temporal bone confirmed the presence of a dehiscent superior semicircular canal among these patients. in the philippines, the first case of sscds in an 80-year-old patient was reported in 2003 by ong and chiong from the manila doctors hospital.2 smullen et al. reported the presence of incapacitating vertigo in three patients who were confirmed radiologically to have dehiscent superior semicircular canals.3 in a series of 13 patients by modugno et al.,4 vestibular-evoked myogenic potential (vemp) alterations in response to stimuli of abnormally low intensity has led to the suspicion of the presence of the third window effect. the vestibular dysfunction is linked to the principle of the tullio phenomenon such that there is an abnormal stimulation of the posterior labyrinth due to sound or mechanical pressure. 5 sscds can mimic other otologic entities. the associated vestibular symptoms have been demonstrated in other pathologies such as congenital deafness,4 meniere’s disease,6 perilymph fistula,7 head trauma,8 lyme disease9 and cholesteatoma with semicircular canal erosion and fenestration.10 some patients may present simply with either a sudden hearing loss11 or a conductive hearing loss thus being subjected to surgery such as stapedectomy before being accurately diagnosed.12 given the scanty literature on how patients with sscds may manifest, the diagnosis and management of this disease remains a challenge to clinicians. this report aims to describe filipino sscds patients according to their clinical presentation and diagnostic test results in order to underline the importance of weighing the clinical evidence for a presumptive diagnosis of sscds and choose the proper management for patients with this disease. methods patients suspected to have the clinical manifestations of sscds within the period of 1994-2008 were retrospectively identified. criteria for inclusion were patients with positive dehiscence confirmed on hrct scan or magnetic resonance imaging (mri) of the temporal bone and the presence of at least one of the following: (1) vestibular or auditory symptoms evoked by sound or pressure stimuli, (2) lowered vemp threshold/ enlarged amplitude and (3) presence of air-bone gap at low frequencies on audiometry. the clinical records, audiogram, vemp responses, ct or mri scans as well as other ancillary test results were reviewed to assess the different clinical manifestations and diagnostic results that may indicate the presence of this syndrome. vemp testing was performed with a neuropack meb 2200 and silver (ag) electrodes (nihon kohden, tokyo, japan) using similar parameters as described by other studies. the vestibulocollic reflex was evoked by rarefactive clicks delivered to the ear by calibrated headphones (nihon kohden, tokyo, japan) at 0.1 millisecond duration, stimulation rate of 7 hz and an intensity of 105db normal hearing level down to threshold. the signal was band passfiltered from 20 hz to 3 khz. a total of 100 sweeps were averaged and the responses were reproduced in a second turn. because the vemp equipment was not working for a certain period during the time of this review, the test could not be performed on all patients. results certain cases are presented to emphasize different circumstances wherein superior semicircular canal dehiscence syndrome may occur. the rest of the results of this study are summarized in tables 1 to 5. case report 1 (patient 1) a 30-year-old female complained of vertigo induced by loud sounds. it was so severe that it affected her daily activities such as doing household chores. there were no other associated symptoms or otologic diseases. a temporal bone hrct scan confirmed the presence of a dehiscence on the right superior semicircular canal. there was absence of repeatable wave peaks on the right on vemp testing. audiometry showed low frequency air-bone gap on the involved side. there were also abnormal saccades and smooth pursuit tests. her vertigo was so debilitating that it prompted her to undergo resurfacing combined with plugging of the dehiscent superior semicircular canal through the middle cranial fossa approach. she claimed marked improvement after philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles 8 philippine journal of otolaryngology-head and neck surgery surgery. post-operative audiometry showed closure of previous low frequency air-bone gap. she has remained symptom free for 18 months post-operatively. case report 2 (patient 4) a 34-year-old male first complained of disequilibrium characterized as a feeling of swaying which later on progressed to recurrent vertigo. this was aggravated by exposure to loud sounds. the patient also presented with gaze-evoked tinnitus. examination elicited tullio phenomenon and hennebert’s sign (nystagmus on application of pressure on the external auditory canal). audiometry showed normal hearing acuity in both ears. at this time (1994), he was being managed as an atypical case of meniere’s disease and was put on diuretics for almost four years with relief of symptoms. as the signs and symptoms were recurrent and with the advent of studies introducing the sscds in 1998, a ct scan of the temporal bone was obtained when the patient followed up in 2005 confirming the presence of a dehiscent superior semicircular canal. this patient is presently being managed medically with good control of symptoms. case report 3 (patient 14) a 4-year-old female was brought to the clinic by her parents for complaints of vertigo and vomiting. from the time she was a few months old, her mother noted occasional vomiting not associated with feeding, fever or abdominal pain. the patient would also suddenly close her eyes at times. as she grew up, she preferred tilting her head towards her right. electroencephalography as well as cranial ultrasound revealed normal results. it wasn’t until she was able to talk that she described what she was feeling, saying that her surroundings were “umiikot-ikot,” (rotating). ct scan of the temporal bone confirmed a dehiscent superior semicircular canal on the right. there was a low vemp threshold response on the right. electronystagmography (eng) revealed abnormal saccades and smooth pursuit tests. audiometry showed normal hearing acuity on both ears. currently, the patient’s symptoms are controlled through medical management. descriptive analysis thirty patients who were initially diagnosed with sscds were between 2 to 79 years old with a mean age of 38.7 ± 21.8 (median age= 37.5). there were 24 adult patients (80%) and 6 pediatric patients (20%). seventeen out of the 30 patients were male (56.7%) and 13 out of the 30 were female (43.3%). patients consulted with different presenting symptoms, vertigo being the most common, followed by hearing loss, tinnitus and disequilibrium. only two patients were found to have concomitant sinusitis. patients were grouped according to those with confirmed sscds on hrct scan (table 1), those patients whose ct scans were not available for review but were first reported to have sscds from chart records (table 2) and those without dehiscent superior semicircular canal on hrct scan (table 3). the 14 patients with confirmed sscds had a mean age of 39.8 ± 23.9 (median age= 40) (table 1). eight out of the 14 (57.1%) were female and 6 out of the 14 (42.9%) were male. eleven of the 14 patients (78.6%) were adults and 3 of the 14 patients (21.4%) were children. vertigo was the most common presenting symptom (9 out of 14 patients = 64.3%). the presence of tullio phenomenon was noted in 7 of the 14 patients (50%). only 3 out of the 14 patients (21.4%) showed an air-bone gap at lower frequencies based on audiometry. vemp testing was done in only 6 patients and 4 of these 6 patients demonstrated either a lowered vemp threshold or enlarged amplitude responses (66.7%). based on ct scans, a bony defect on the right was observed in 35.7% patients (5 of the 14 patients), 28.6% on the left (4 of the 14 patients) and 35.7% on both sides (5 of the 14 patients). only one out of the 14 patients underwent surgical intervention (resurfacing combined with plugging of the dehisced superior semicircular canal). only one out of the 14 patients with confirmed sscds showed all the classic hallmarks of sscds including a vestibular symptom, a positive tullio phenomenon, an air-bone gap in lower frequencies on audiometry, a lowered vemp response, abnormal eng findings and normal tympanogram result. the rest of the adult patients as seen on table 1 manifested a combination of signs and symptoms. two out of the three pediatric patients initially presented with hearing loss; in contrast, adult patients usually complained of vertigo. some of the 14 patients with confirmed sscds underwent other ancillary tests. six patients had an eng which all showed abnormal saccade and smooth pursuit results as well as caloric weakness in one out of the six patients (16.67%). only 5 out of the 14 patients had tympanometry which all yielded type a tympanograms. ten patients were initially reported to a have a dehiscent superior semicircular canal but their ct scans were not available for review (table 2). these patients presented with disequilibrium, hearing loss, tinnitus and vertigo. a positive tullio phenomenon was elicited in 3 of the 10 patients (30%). on audiometry, 4 of the 10 patients (40%) showed an air-bone gap on lower frequencies. three out of the 5 patients (60%) who underwent vemp testing had either a lowered vemp threshold or enlarged amplitude responses. eng was done in four of the patients showing abnormal results while tympanometry was done in three patients with normal results. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles philippine journal of otolaryngology-head and neck surgery 9 there were six patients who were considered to have sscds but were proven otherwise on review of their hrct scans (table 3). none of the six patients demonstrated a positive tullio phenomenon. three of the six patients (50%) presented with tinnitus. four out of the 6 patients (66.7%) had an air-bone gap at lower frequencies. the three patients who underwent vemp testing showed normal vemp threshold and amplitude responses. all three of those who underwent eng elicited abnormal responses. three of those who underwent tympanometry showed normal results except for one patient with a possible middle ear problem (type b tympanogram). table 4 summarizes the clinical findings among those with confirmed sscds versus those confirmed to be without sscds and those with presumptive diagnosis of sscds. tullio phenomenon was observed in 50% (7 out of the 14 patients) of confirmed sscds cases, but none among those confirmed without sscds based on hrct scan. lowfrequency air-bone gap was found in more than 20% of sscds patients (3 out of the 14 patients) and a positive vemp response in 67% (4 out of 6 patients); this is in sharp contrast to 67% of those without sscds who have low-frequency air-bone gap (4 out of 6 patients) and negative vemp response (3 out of 3 patients). the proportion of patients with tullio phenomenon, air-bone gap and vemp response among those with presumptive diagnosis of sscds but whose imaging results were not reviewed may mean that this group comprises a mixture of patients with and without sscds. discussion a diagnosis of sscds does not conform to a specific clinical presentation, thus good clinical correlation of the patient’s manifestations and test results is needed to increase the index of suspicion for sscds, which must be confirmed by radiologic imaging. the characterization of superior semicircular canal dehiscence syndrome as a disease entity has just been recently explored. minor et al. in 2005 studied 60 patients who manifested with vestibular symptoms and showed a dehisced superior semicircular canal on imaging.13 this disorder seems to have no predilection for laterality or gender. it is not confined to a certain age group. it usually occurs in adults but can also be present in children as seen in this study, lending support to the possibility of a congenitally thinned out superior semicircular canal that may dehisce at a very early age with minor increases in intracranial pressure. the vestibular symptom of vertigo is the most common clinical manifestation of this disorder which may be induced by sound or pressure stimuli. adults seemed to complain of this symptom more than children. in this series, 2 out of 3 children with confirmed sscds had more prominent hearing loss than vestibular symptoms, and this may have been due to their inability to adequately express what they were experiencing. instead, these patients demonstrated thenunexplainable behavior such as persistent head tilting and frequent closing of the eyes as shown by the youngest patient we presented (case report 3). this vestibular symptom may be attributed to the “third mobile window effect” into the inner ear.14 the first two windows being referred to are the round and oval windows and the third window refers to the dehisced superior semicircular canal. any stimulus that may induce an inward pressure at the round and oval windows (i.e. valsalva maneuver against pinched nostrils) will result in an inward bulging of the membranous canal of the dehiscence and consequent ampullofugal (excitatory) deflection of the cupula of the semicircular canal. on the other hand, the outward pressure (i.e. toynbee maneuver) at the round and oval windows will result to an ampullopetal (inhibitory) deflection of the cupula of the semicircular canal. vertigo and abnormal eye and/or head movements due to loud sounds were demonstrated in fifty percent of the patients with confirmed sscds in contrast to those patients whose hrct scan showed no dehiscence of the superior semicircular canal. these soundinduced vestibular responses were first reported by tullio in 1926 when he studied fistulized labyrinths of pigeons.15 it is postulated that the dehisced bone in the labyrinth allows a second pathway for sound pressure to be dissipated. the vibration at the oval window induces the perilymph fluid to circulate abnormally within the vestibular apparatus to stimulate the hair cells and thus produce the sensation of vertigo. however, this phenomenon has been demonstrated also in patients with other pathologies. the abnormal sound energy transmission within the vestibular apparatus that may connect to the extraocular muscles also explains this occurrence. this phenomenon is also hypothesized to cause tinnitus which can be a complaint in patients with sscds. auditory manifestation (i.e. low frequency air-bone gap) refers to an air-bone gap of 10 db or greater at 250 to 500 hz. the air-bone gap was not due to a disorder in the middle ear conductive mechanism because tympanometry revealed type a tracings among patients with confirmed sscds. middle ear exploration (for those who were not diagnosed primarily with semicircular canal dehiscence) also showed no abnormality.12 the “third window mobile effect” may also explain this such that acoustic energy dissipates through the dehiscence. the energy is shunted away from the cochlea resulting in hearing loss by air conduction.12 as a result there is an increased threshold for air-conducted sounds and a reduced threshold for bone-conducted sounds. hrct scans of the temporal bone have shown a dehisced or thinned philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles 10 philippine journal of otolaryngology-head and neck surgery *f=female m=male; † v=vertigo, t=tinnitus, d=dysequilibrium, hl=hearing loss; †† low frequency is measured at 250 to 500hz; ** (+/-)vemp indicates the presence/absence of either low threshold or enlarged amplitude, na= not available; *** as= abnormal saccade test, asp=abnormal smooth pursuit test, cw=caloric weakness 15 16 17 18 19 20 21 22 23 24 age 38 31 79 34 52 63 30 36 55 6 sex* m m m m m f f f f m left left right bilateral bilateral bilateral left right bilateral bilateral presenting symptom† d hl d d t v t hl t hl low frequency air-bone gap†† (-) (+) (-) (+) (+) (-) (-) (+) (-) (-) vemp response** (+) na (+) (+) na na (-) (-) na na patient laterality associated symptoms† t t none none hl none d v d none tullio phenomenon (+) (-) (+) (-) (-) (-) (-) (-) (+) (-) eng*** na na as, asp cw na na as, asp na as, asp na tympanometry na na na na type a, au na type a, au na na type a, au table 2. patients with possible sscds on hrct scan table 3. patients without sscds as confirmed on hrct scan 25 26 27 28 29 30 age 25 50 37 52 14 2 sex* m m m f m m left left right left left bilateral presenting symptom† v t t t v hl low frequency air-bone gap†† (+) (-) (+) (+) (+) (-) vemp response** (-) na na (-) (-) na patient laterality associated symptoms† v t, hl v d none none tullio phenomenon (-) (-) (-) (-) (-) (-) eng*** na as, asp, cw na pn, cw as, asp na tympanometry type a, ad type b, as type a, au na na na type a, au *f=female m=male; † v=vertigo, t=tinnitus, d=dysequilibrium, hl=hearing loss; †† low frequency is measured at 250 to 500hz; ** negative vemp indicates the absence of either low threshold or enlarged amplitude, na= not available; *** as= abnormal saccade test, asp=abnormal smooth pursuit test, cw=caloric weakness, pn= positional nystagmus history of surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 age 30 78 40 34 57 60 51 36 40 71 49 5 2 4 sex* f f f m m m f m m f m f f f right left bilateral right bilateral bilateral right left bilateral right left left bilateral right presenting symptom† v v d v t v v v v v t hl hl v low frequency air-bone gap†† (+) (+) (-) (-) (-) (-) (-) (-) (-) (+) (-) (-) (-) (-) vemp response** (+) na (+) na (-) na na na na (-) (+) na na (+) (+) (-) (-) (-) (-) (-) (-) (-) (-) (-) (-) (-) (-) (-) patient laterality associated symptoms† hl hl t t v t t t t hl v none none none tullio phenomenon (+) (-) (-) (+) (-) (+) (+) (+) (+) (+) (-) (-) (-) (-) eng*** as, asp na na na as, asp na na na na as, asp as, asp as, asp na as, asp, cw tympanometry type a, au na na na na na na na na type a, au type a, au type a, au type a, au na *f=female m=male; † v=vertigo, t=tinnitus, d=dysequilibrium, hl=hearing loss; †† low frequency is measured at 250 to 500hz; ** (+/-) vemp indicates the presence/absence of either low threshold or enlarged amplitude, na= not available; *** as= abnormal saccade test, asp=abnormal smooth pursuit test, cw=caloric weakness table 1. patients with sscds as confirmed on hrct scan philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 philippine journal of otolaryngology-head and neck surgery 11 original articles table 4. summary of results sscds confirmed by hrct scan (n=14 patients) possible sscds on chart report (n=10 patients) without sscds based on hrct scan (n=6 patients) common presenting symptoms vertigo (9 out of 14 patients = 64.3%) dysequilibrium (3 out of 10 patients = 30%) hearing loss (3 out of 10 patients = 30%) tinnitus (3 out of 10 patients = 30%) tinnitus (3 out of 6 patients = 50%) tullio phenomenon 50% (7 out of 14 patients) 30% (3 out of 10 patients) 0% 21.4% (3 out of 14 patients) 40% (4 out of 10 patients) 66.7% (4 out of 6 patients) vemp response† 66.7% (4 out of 6 patients who had vemp) 60% (3 out of 5 patients who had vemp) 0% low frequency air-bone gap* * low frequency is measured at 250 to 500 hz; † vemp response indicates the presence of either low threshold or enlarged amplitude. *bilateral involvement of the ssc with one side being more symptomatic. patient 3:lowered threshold/ enlarged amplitude on the left>right; patient 5:enlarged amplitude on the right>left; patient 18:enlarged amplitude on the right>left table 5. vemp threshold and amplitude 1 3 5 10 11 14 15 17 18 21 22 25 28 29 laterality ipsilateral vemp amplitude, ad contralateral vemp amplitude, as ipsilateral vemp threshold, ad patient right bilateral* bilateral* right left right left right bilateral* left right left left left contralateral vemp threshold, as no repeatable wave peaks 19.49uv 29.95uv 25.03uv 62.04uv 96.53uv 38.24uv no wavepeaks were noted at 75db 102.8uv 125uv 70.97uv 83.81uv 36.38uv 48.34uv none 88db 85db 85db 95db 75db 95db none 85db 95db 95db 95db 95db 95db 23.56uv 39.68uv 19.58uv 40.42uv 91.08uv 47.59uv 47.19uv no repeatable wave peaks 65.59uv 98.03uv 75.48uv 51.20uv 27.52uv 46.37uv 105db 85db 85db 85db 85db 105db 95db none 85db 105db 95db 95db 95db 95db out (≤0.1mm) semicircular canal in patients with this disorder (figures 1.1, 1.2). in a study of cadaveric temporal bones of adults and children, a dehiscence of the bone overlying the superior canal was found in approximately 0.4–0.5% of temporal bone specimens.16 this has been observed even on temporal bones of infants which may indicate a possible developmental etiology. it used to be that only hrct scans using thin cuts with 0.5-0.8 mm collimation in coronal, axial and saggital reconstructions had proven value in diagnosing sscds. recently however, t2 weighted images on mri have a reported sensitivity of 96% and specificity of 98% versus hrct scans which have a sensitivity and specificity of 100% and 96% respectively.17-18 knowledge of the appearance of the dehiscence on mri will help in identifying this disorder (figure 1.3). this may be helpful in detecting the presence of sscds in patients whose clinical manifestations are suggestive of this disorder but whose symptoms also point to other possible disease entities that are diagnosed by mri so that a single imaging modality may help differentiate one from the other. vemp is an otolith-mediated, short-latency reflex that is recorded from averaged sternocleidomastoid electromyography in response to intense auditory clicks delivered via headphones.19 studies have shown lower vemp thresholds on ears affected with sscds as compared to the normal ears. this test is still not widely available locally so not all patients benefited from testing. six patients with confirmed sscds who underwent vemp testing were noted to have a threshold of 85 db with four patients demonstrating either a lower threshold or enlarged amplitudes of the involved side compared to the contralateral side. two patients were noted to have absent repeatable wave peaks (table 5). the mechanism responsible for the lowered vemp threshold in these patients is likely to be related to the lowered impedance for transmission of sound and pressure stimuli created by the third mobile window.13 other ancillary tests were done to help establish the diagnosis of sscds. eng helped in monitoring the eye movements brought about by dizziness or unsteadiness. tympanometry, on the other hand, helped document the absence of middle ear disease especially in cases where low frequency air bone gap was evident in order to rule out the presence of middle ear disease. management of sscds is primarily conservative, with the use of vestibular suppressants, diuretics, low-salt diet and refraining from carrying heavy objects. however, patients who present with debilitating symptoms affecting their everyday living may have the option to undergo surgical repair. resurfacing and plugging of the superior semicircular canal have been described, most commonly via a middle cranial fossa approach.20 in this report, the only patient surgically philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles 12 philippine journal of otolaryngology-head and neck surgery figure 1.2. arrow indicates a left superior semicircular canal dehiscence as shown by absence of bone by hrct scan (patient 9). figure 1.1. arrow indicates a right superior semicircular canal dehiscence as shown by absence of bone by hrct scan (patient 9). managed for intractable sscds underwent combined resurfacing and plugging of the superior semicircular canal. intraoperative evidence of the dehiscent superior semicircular canal was noted and plugged using bone pate as well as resurfaced with temporalis fascia and a very thin bony plate from craniotomy outer cortex (figure 2). an improvement on her audiogram after the surgery was noted with eventual closure of the air bone gap (figures 3.1, 3.2). this series of cases shows that sscds is not exclusive to adults. children may also have sscds although an initial finding of hearing loss is more common compared to vertigo in adults. minor acknowledged that he has only seen two pediatric patients both in their teenage years since his initial report on this syndrome (personal communication with the co-author cmc, august 2008). close follow-up of these children with sscds is warranted given the significant length of time that the clinical manifestations of sscds might be observed. this series also provides a picture of how patients with sccds may vary with regards to their clinical presentation as well as with the results of the diagnostic tests. the diagnosis of sscds cannot be accepted or excluded by the mere presence or absence of a symptom, sign or audiologic result. on the other hand, the diagnosis based on hrct scan is standard. the important thing is to know when to consider sscds as the patient presents in the clinic and prompt one to ask for a hrct scan or mri. thus, good clinical correlation and increased awareness of the disease will help us in the proper management of sscds patients. s s figure 1.3. arrow indicates a right superior semicircular canal dehiscence on mri as shown by a bone defect (patient 7). s figure 2. intraoperative photograph of patient 1 (case report 1) showing the dehiscent superior semicircular canal with appearance of grayish membranous labyrinth (arrow) against the white solid bone in the rest of the arcuate eminence of the superior canal. s philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles philippine journal of otolaryngology-head and neck surgery 13 figure 3.1 pre-operative audiogram of patient 1 (case report 1) before surgery showing low frequency air-bone gap. figure 3.2 post-operative audiogram of patient 1 (case report 1) after surgery showing an improvement of low frequency air-bone gap. references 1. minor lb, solomon d, zinreich js, zee ds. soundand/or pressure-induced vertigo due to bone dehiscence of the superior semicircular canal. arch otolaryngol head neck surg 1998; 124: 249258. 2. smullen jl, andrist ec, gianoli gj. superior semicircular canal: a new cause of vertigo. j la state med soc 1999; 151(8):397-400. 3. ong et, chiong cm. superior semicircular canal dehiscence syndrome. philipp j otolaryngol head neck surg 2004; 19(3-4): 222-226. 4. modugno gc, brandolini c, savastio g, ceroni ar, pirodda a. superior semicircular canal dehiscence: a series of 13 cases. orl j otorhinolaryngol relat spec 2005; 67:180-184. 5. kwee sl. the occurrence of the tullio phenomenon in congenitally deaf children. j laryngol otol 1976; 90:501-507. 6. halmagyi gm, aw st, mcgarvie la et al. superior semicircular canal dehiscence simulating otosclerosis. j laryngol otol 2003; 117:553-7. 7. fox ej, balkany tj, arenberg ik. the tullio phenomenon and perilymph fistula. otolaryngol head neck surg 1988; 98:88-89. 8. rottach kg, von maydell rd, discenna ao, zivotofsky az, averbuch-heller l, leigh rj. quantitative measurements of eye movements in a patient with tullio phenomenon. j vestib res. 1996; 6:255-259. 9. nields ja. kveton jf. tullio phenomenon and seronegative lyme borreliosis. lancet 1991; 338:128-129. 10. ishizaki h. pyykko i, aalto h, starck j. tullio phenomenon and postural stability: experimental study in normal subjects and patients with vertigo. ann otol rhinol laryngol 1991; 100:976983. 11. calaquian cm, chiong cm, editors. superior semicircular canal dehiscence presenting as sudden hearing loss. proceedings of the 7th hearing international annual meeting; 2006 nov 28dec 1; manila, philippines. 12. mikulec aa, mckenna mj, ramsey mj, rosowski jj, hermann bs, rauch sd, curtin hd, mechant sn. superior semicircular canal dehiscence presenting as conductive hearing loss without vertigo. otol neurotol 2004; 25:121-129. 13. minor lb. clinical manifestations of superior semicircular canal dehiscence. laryngoscope 2005; 115:1717-1727. 14. tullio p. das ohr und die entstehung der sprache und schrift. berlin: urban and schwarzenberg, 1929. cited by ostrowski et al. otol neurotol 22:61-65. 15. kacker s, hinchcliffe r. unusual tullio phenomenon. j laryngol otol 1970; 84:155–166. 16. rottach k, von maydell r, discenna a, et al. quantitative measurements of eye movements in a patient with tullio phenomenon. j vestibular res 1996; 6:255–259. 17. krombach ga, schmitz-rode t, haage p, dimartino k, prescher a, kinzel s, gunther re. semicircular canal dehiscence: comparison of t-2 weighted turbo spin-echo mri and ct. neuroradiology 2004.46:326-331. 18. belden cj, weg n, minor lb, zinreich sj. ct evaluation of bone dehiscence of the superior semicircular canals a cause of soundand/or pressure induced vertigo. radiology 2003; 226:337–343. 19. welgampola ms, colebatch jg. characteristics and clinical applications of vestibular-evoked myogenic potentials. neurology 2005; 64(10):1682-1688. 20. minor lb: superior canal dehiscence syndrome. am j otolaryngol 2000; 21:9-19. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 under the microscope philippine journal of otolaryngology-head and neck surgery 39 jose m. carnate, jr., md1 audie g. silva, md2 1department of pathology college of medicinephilippine general hospital university of the philippines manila 2department of laboratories philippine general hospital university of the philippines manila correspondence: jose m. carnate, jr., md university of the philippines manila college of medicine department of pathology 547 pedro gil st., ermita, 1000 manila phone: (632) 526 4550 fax: (632) 400 3638 email:jmcjpath@yahoo.com reprints will not be available from the author. granular cell tumor presenting as a tracheal mass in a 17-yearold female granular cell tumors involving the trachea are rare. we present the case of a 17-year-old female with a one year history of gradually worsening dyspnea necessitating a tracheotomy. a suprastomal intraluminal tracheal mass was excised. histologic sections (figure 1) show a poorly circumscribed neoplasm infiltrating through the tracheal cartilage. it is composed of polygonal to somewhat elongated tumor cells that have small, dark nuclei. the cytoplasm is ample, eosinophilic and strikingly granular in quality. figure 1 philipp j otolaryngol head neck surg 2008; 23 (1): 39-40 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 40 philippine journal of otolaryngology-head and neck surgery under the microscope figure 2 references: 1. van der maten j, et al. granular cell tumors of the tracheobronchial tree. j thorac cardiovasc surg 2003; 126: 740 – 3. 2. fanburg-smith jc, et al. malignant granular cell tumor of soft tissue: diagnostic criteria and clinicopathologic correlation. am j surg pathol 1998; 22 (7): 779 – 94. 3. barnes l, eveson jw, reichart p, sidransky d (eds).: world health organization classification of tumours. pathology and genetics of head and neck tumours. iarc press: lyon 2005. the cell borders are ill-defined creating a ̀ syncytial’ pattern of dark nuclei scattered in a sea of granular cytoplasm. (figure 2) the diagnosis was a granular cell tumor. immunohistochemistry (figure 2, inset) revealed diffuse strong cytoplasmic positivity for s100 protein, attesting to its neural crest histogenesis. the infiltrative growth pattern may momentarily raise the question of malignancy but this is dispelled by awareness that infiltration is the natural history for all granular cell tumors, benign or malignant. histologically, malignancy is diagnosed if three or more of the following are present: necrosis, spindling of tumor cells, vesicular nuclei with large nucleoli, greater than two mitoses per 10 high power fields, high nucleus-to-cytoplasm ratio and nuclear pleomorphism. none was present in our case. surgical excision remains the mainstay of treatment. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 case reports philippine journal of otolaryngology-head and neck surgery 17 abstract objective: to describe our experience in performing the lower cheek flap for access to the infratemporal fossa combined with the neurosurgical approach. methods: design: case report setting: tertiary referral center patients: two result: two unusual tumours involving the infratemporal and middle cranial fossa were excised using this combined approach. the infratemporal fossa tumour was accessed via the lower cheek flap while the intracranial portion was resected from above via craniotomy. conclusion: the lower cheek flap in combination with the neurosurgical approach allows optimal exposure to tumours involving the infratemporal and middle cranial fossae. it has less complications and better aesthetic outcome compared to other approaches. keywords: lower cheek flap, infratemporal fossa tumour infratemporal fossa tumours are usually extensions of tumours from surrounding structures. tumours extending into this region pose a surgical challenge due to its difficult access and various important structures contained within. we treated two such cases in universiti kebangsaan malaysia medical center (ukmmc) where the tumour involved both the intracranial and the infratemporal fossa. we describe our experience using the lower cheek flap as described by balm et al1 to excise the tumour in the infratemporal region combined with neurosurgical approach. method the patient is placed in supine position with head fixed with the mayfield clamp. incision is made from the mid lower lip down to the neck and continued up to the preauricular region the lower cheek flap combined with neurosurgical approach for infratemporal fossa tumour aneeza khairiyah w. hamizan, md1 mazita ami, mbchb, ms (orl-hns)1 azizi abu bakar, mbbs, ms (surgery)2 mohd razif mohamad yunus, mbbs, ms (orl-hns)1 1department of otorhinolaryngology universiti kebangsaan malaysia medical centre 2department of surgery, neurosurgery unit universiti kebangsaan malaysia medical centre correspondence: mohd razif mohamad yunus, mbbs, ms department of otorhinolaryngology universiti kebangsaan malaysia medical centre, jalan yaakob latiff, bandar tun razak, 56000 cheras, kuala lumpur, malaysia phone: 006039145 5555 ext 6842 email: razif72@gmail.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interests with any organization that may have direct interest in the subject matter of this manuscript, or any product used or cited in this report. philipp j otolaryngol head neck surg 2010; 25 (1): 17-19 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 case reports 18 philippine journal of otolaryngology-head and neck surgery where it is joined with the coronal incision (figure 1). the skin flap is raised in the subplatysmal plane at the upper horizontal neck incision until the lower border of mandible with preservation of the marginal mandibular nerve. a midline lower lip incision is made and extended inferiorly to meet the upper horizontal neck incision. the mucosa is incised intraorally from the midline until the inferior gingivobuccal sulcus posteriorly, exteriorizing the retromolar trigone and maxillary tuberosity. the lower cheek flap is raised subperiosteally from midline to angle of mandible. the mental nerve is sacrificed. muscles attached at the the coronoid process are detached and coronoidectomy is performed to allow good access to the infratemporal fossa (figure 2). a craniotomy incision is then made and continued inferiorly at the preauricular crease to join the neck incision for the excision of the intracranial portion of the tumour. results case 1 a 68-year-old male with recurrent extracranial meningioma presented with swelling at the right temporal region. the mass was partially excised three years prior to the current presentation. figure 1. skin markings for the lower cheek flap combined with craniotomy histopathological examination revealed extracranial meningioma who grade ii. a ct scan showed a mass in the right temporal region with intracranial extension. further assessment with mri revealed a right temporal mass measuring 8.5x2.4x3.0cm extending intracranially through the right pterygomaxillary fissure into the middle cranial fossa causing meningeal thickening. inferiorly, it extended to the infratemporal fossa and superiorly to the level of the temporalis muscle (figure 3). the tumour was excised using the combined approach described above. the patient had an uneventful postoperative recovery and was discharged in stable condition 3 days later. histopathological examination confirmed clear margins. he remains tumour free at 6 months. case 2 a 57-year-old lady presented with a right cheek mass associated with facial numbness, right eye strabismus and diplopia. there was also involvement of the right ii, iii, iv, vi and viith cranial nerves. examination revealed a large cheek swelling with right hard palate mass. a biopsy was taken and histopathological examination reported the mass as chordoma. mri showed a heterogenous mass in the infratemporal fossa measuring 6.8x8.4x12.2cm. it extended intracranially to involve the temporal lobe and basal ganglia. inferoposteriorly it extended into the postnasal and oropharyngeal space. there was no clear demarcation of the tumour from the clivus and and prevertebral space at the region of the first and second cervical vertebrae. tumour debulking was done using this combined approach. she had an uneventful post operative figure 2. infratemporal fossa tumour visualized after coronoidectomy figure 3. mri of recurrent extracranial meningioma in the right temporal region with intracranial (extradural) extension philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 case reports philippine journal of otolaryngology-head and neck surgery 19 recovery with no further neurological deficit. discussion the infratemporal fossa is a deep concealed space in the lateral facial skull bounded by the ramus of the mandible, maxilla, lateral pterygoid plate and sphenoid. tumours of this region are usually an extension from surrounding regions. when dealing with such large tumours preoperative planning is essential to achieve the desired results while maintaining good functional and cosmetic outcome. over the years, various approaches to the infratemporal fossa have been described. in general the infratemproral fossa may be approached anteriorly or laterally.2 the anterior approach is through the maxilla either by a caldwell-luc incision or the weber-ferguson incision. the caldwell-luc incision is most aesthetically pleasing but provides limited exposure and is thus reserved for small tumours. the weber-ferguson approach allows wider exposure but may cause ectropion of the lower eyelid and risks injury to the infraorbital nerve. through the incision the infratemporal fossa is accessed via a maxillectomy or a maxillary swing. this approach allows exposure to the infratemporal fossa medial to the pterygoid plate but only gives a limited view of the lateral regions.3 it is also time consuming with higher morbidity. the lateral approach may be either trans-zygomatic or transmandibular. the trans-zygomatic approach allows good access to the superior part of infratemporal fossa but involves resection of the zygoma. the trans-mandibular approach is achieved via a parotid incision and dissection through the parotid gland thus risking facial nerve injury.4 access to the infratemporal fossa is then gained through the mandible via osteotomy of the condylar or coronoid process or even a mandibular swing for wider access. a mandibulotomy involves sacrificing the inferior alveolar nerve and requires plating which is costly for patients in our center. tumours involving both the infratemporal fossa and the intracranial fossa are best resected by a combined approach with the neurosurgical team. these dumbbell-shaped tumours have been previously described and resected by various methods such as the zygomatic infratemporal fossa approach combined with mandibular osteotomy, zygomatic transpetrosal approach combined with mandibular osteotomy and lateral basal subtemporal approach with resection of the root of zygoma.5 these approaches were tailored to the respective tumour regions with the latter two being more useful for tumours in the posterior cranial fossa. we found the lower cheek flap a useful approach to the infratemporal fossa in our two cases. it allowed optimal exposure to the anterolateral region of infratemporal fossa and and was easily combined with the craniotomy incision. unlike the transparotid approach, there was minimal risk to the facial nerve and neither of the two patients developed facial nerve palsy. it has better cosmesis than the weberferguson incision. furthermore, this incision allows a selective neck references 1. balm ajm, smeele le, lohuis pjfm. optimizing exposure of the posterolateral maxillary and pterygoid region: the lower cheek flap. eur j surg oncol. 2008;34(6):699-703. 2. prades jm, timoshenko a, merzougui n, martin c. a cadaveric study of a combined transmandibular and trans-zygomatic approach to the infratemporal fossa. surg radiol anat. 2003;25(3-4):180-7. 3. honda k, asato r, tanaka s, endo t, nishimura k, ito j. vidian nerve schwannoma with middle cranial fossa extension resected via a maxillary swing approach. head neck. 2008;30(10):138993. 4. huang y-f, kuo w-r, tsai k-b. ancient schwannoma of the infratemporal fossa. j otolaryngol. 2002;31(4):236-8. 5. kouyialis at, stranjalis g, papadogiorgakis n, papavlassopoulos f, ziaka ds, petsinis v, et al. giant dumbbell-shaped middle cranial fossa trigeminal schwannoma with extension to the infratemporal and posterior fossae. acta neurochir(wien). 2007;149(9):959. dissection of level i-iii to be done and may be extended to the upper gingiva allowing a total maxillectomy if needed. using this method, we were able to fully excise the tumour in the first case while the second patient only needed tumour debulking for symptomatic relief. this method is simple and has minimal morbidity compared to other approaches to the infratemporal fossa. as with other approaches, the lower cheek flap also has its own disadvantages. the mental nerve cannot be saved which theoretically will lead to lip numbness. however, neither patient complained of this side effect when questioned. the flap is also raised in the subplatysmal plane risking injury to the marginal mandibular nerve. another concern is that dissection around the pterygoid region may lead to trismus due to scarring of the pterygoid muscles. nevertheless, none of our patients developed trismus. there is also concern of possible brain contamination with the microbial normal flora from the oral cavity. this risk is low in our two cases as there had been no intradural extension of tumour. infratemporal fossa tumours remain a challenge and surgical approaches to this region need to be tailored to patient needs and tumour extension. the lower cheek flap allows optimal exposure to the anterolateral part of the infratemporal fossa with minimal morbidity, is less time consuming and has better aesthetic outcome. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 practice pearls 52 philippine journal of otolaryngology-head and neck surgery cochlear implants are now the treatment of choice for patients with severe to profound hearing loss. inclusion criteria for cochlear implantation have expanded and a whole array of implantable hearing devices have been introduced over the years. to date, more than 250 cochlear implantations have now been performed in the philippines (figure 1). in 2006, the first auditory brainstem implantation, and first vibroplasty or middle ear implantation in the country were done at the philippine general hospital (pgh). in 2008, the first electroacoustic stimulation or partial deafness cochlear implantation surgery in the country was performed at the capitol medical center by professor joachim müeller of the university of würzburg and the author. this concept that cochlear implantation can be performed for patients with residual hearing or only partial deafness is quite novel. there are patients whose low frequency hearing below 1.5 khz is still be quite good while high frequency hearing loss above 1.5 khz is in the severe to profound range (figure 2). for such patients speech discrimination scores will typically fall below 60% at 65 db sound pressure level (spl) in the best aided condition. this technological advancement, often called electroacoustic stimulation (eas), was developed in 1999 after christoph von ilberg demonstrated preserved residual low frequency hearing in a patient who underwent cochlear implantation such that the patient wore a hearing aid in the implanted ear.1 currently, eas devices are available from two manufacturers. contraindications to the use of eas are shown in table 1. candidates for eas devices should have stable low frequency hearing. there should be no progressive or autoimmune sensorineural hearing loss. also there should be no history of meningitis, otosclerosis, or any other malformation that might cause an obstruction. the patient’s air-bone gap should be < 15 db. finally, there should not be any external auditory canal problems that can impede placement of the ear mould for the acoustic component. there are two main components of the eas system (figure 3). the external component is made up of a microphone that picks up sounds and a processor that separately encodes low and high frequency energy. after processing, low frequency energy is converted into an acoustic signal via the loudspeaker located in the ear hook and delivered into the external auditory canal. this acoustic signal will vibrate the tympanic membrane and ossicles so that cochlear fluids as well as the relatively intact structures of the cochlea in the apical region are stimulated. in contrast, high frequency energy is coded into radio-wave-like signals which are transmitted transcutaneously to the internal receiver. there, electric signals are delivered to the electrode array that has been surgically implanted into the cochlea. thus the auditory nerve receives information using two different pathways from low and high frequency sounds and the auditory nerve signals are then transmitted to the brain. combined electric and acoustic stimulation: successful treatment option for partial deafness correspondence: charlotte m. chiong, md department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 philippines fax: (632) 526 4360 email: charlotte_chiong@yahoo.com reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: professor joachim müeller was funded by medical electronics to travel to manila from germany to perform the first eas cochlear implant surgery with the author. the author is occasionally invited as a speaker for med-el for which she receives honoraria and travel allowances. other than this, she does not have any proprietary or financial interests with med— el or with any organization that may have a direct interest in the subject matter of the manuscript, or in any product used or cited in this article. she has no other relevant conflicts of interest to declare. philipp j otolaryngol head neck surg 2010; 25 (2): 52-56 c philippine society of otolaryngology – head and neck surgery, inc. charlotte m. chiong, md1,2,3 1department of otorhinolaryngology college of medicine-philippine general hospital university of the philippines manila 2philippine national ear institute national institutes of health university of the philippines manila 3department of otorhinolaryngology manila doctors hospital manila, philippines philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 philippine journal of otolaryngology-head and neck surgery 53 practice pearls our experience of the more than 100 implantations done under the philippine national ear institute “chip” or cochlear and hearing implants programme only one was a case of eas implantation. this particular case demonstrates key principles and concepts that every otolaryngologist should consider. among these are audiological evaluation, temporal bone imaging, surgical technique for hearing preservation and some quality of life issues. audiological evaluation a 33-year-old man had been seen at the clinic for over seven years, with serial audiograms (figure 4-6) illustrating the presence of good and stable low frequency hearing while high frequency hearing loss increased somewhat. the patient had been continually advised to get the best hearing aids available. however, a series of high-end hearing aids did not solve his problem of poor hearing in noisy places nor his difficulty understanding words when watching television and movies. figure 7a shows the speech perception scores of this patient obtained with a word intelligibility by picture identification (wipi) test, a “closed-set test” using isolated words while figure 7b represents speech scores when “open-set” bamford-kowal-bench (bkb) sentence lists were presented to the listener in both quiet and noise prior to the implantation. temporal bone imaging a combination of high resolution computerized tomography (hrct) of the temporal bone with both coronal and axial cochlear views and t2weighted normal anatomic fast spin echo (t2 fse) or 3d constructive interference in steady state (3d ciss) mri sequences of the inner ear should be done. results from both studies should ascertain whether the cochlear duct is patent, ruling out any cochlear fibrosis or obstructive pathology. this patient’s hrct and 3-d ciss mri studies showed no such cochlear obliteration that would have posed intraoperative difficulties and constituted contraindications to eas surgery (figure 8). surgical technique for hearing preservation a variety of techniques have evolved over the years into what is now commonly called minimally invasive cochlear implantation. using minimally invasive techniques, residual hearing can indeed be preserved in over 80%-90% of patients 3,4 initially, a “soft cochleostomy” technique was introduced. this entailed careful low-speed drilling of the promontory with a skeeter® drill (medtronic xomed, jacksonville fl, usa) followed by the use of a mini-lancet to make an opening in the membranous labyrinth. this method avoids direct suctioning figure 1. cochlear implantation in the philippines figure 2. candidates for eas should have thresholds within the shaded areas. reproduced with permission from med el “eas™ hearing implant systemthe ideal solution for partial deafness” [monograph], innsbruck, austria: med el ©2010 [cited 2010 november 10] available from http://www. medel.com/data/downloads/eas/21707.pdf table 1 . list of contraindications to eas contraindications to eas progressive hearing loss autoimmune disease hearing loss as a result of meningitis, otosclerosis or ossification malformation or obstruction of the cochlea air-bone gap > 15db external ear contra-indications to using amplification devices philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 practice pearls 54 philippine journal of otolaryngology-head and neck surgery and prevents ingress of blood and bone dust into the intracochlear compartment. also for this method, the endosteum is left intact after drilling a cochleostomy antero-inferior to the round window. this allows proper placement of the electrode into the scala tympani with less chance of injury to the basilar membrane. later, a round window approach was introduced, and it also proved to be a reliable way to preserve residual hearing during cochlear implantation. for this method, a more direct round window approach is performed after careful drilling of the round window niche. a limited incision is made just large enough to allow the electrode to be inserted. for both methods, after the endosteal or round window membrane incision is made with a micro lancet, a very flexible electrode of 20 mm length is slowly inserted. during the insertion process, the cochleostomy or round window is kept under direct vision so that insertion forces are minimized. topical antibiotics and steroids are applied at this time to reduce any inflammatory or apoptotic reactions related to the trauma of opening the cochlea and introducing an electrode. finally, a soft tissue plug is placed tightly around the electrode entry point into the membranous labyrinth to prevent perilymph leakage. new electrode designs that are thinner and more flexible are important contributors to the preservation of hearing. postoperative outcomes and quality of life after about 4-6 weeks from the time of surgery the eas implant is switched on. based on our experience and that of others,3 speech perception performance improves with prolonged experience with the implant. roughly 1 ½ years post-surgery this patient has achieved dramatic improvement in hearing both in quiet and in noise using the eas compared to using only the hearing aid component or the ci component alone. figure 9 shows this dramatic improvement in free-field pure tone thresholds. figure 10 demonstrates the speech perception following eas implantation compared to pre-eas implantation. audiologic evaluation done at the pgh ear unit using 20 phonetically balanced filipino words familiar to the patient in quiet and with 55 db masking noise in the side of the implanted ear clearly showed an advantage with the eas configuration compared to either hearing aid or ci component alone. even with noise, this patient actually performed better presumably because he may have concentrated more with the introduction of masking noise. another factor of course is that the words have now become familiar to the patient with the previous testing done in quiet. notably, he reported great subjective improvement after only 10 months post-surgery.5 interestingly the patient’s only complaint during his last follow-up was that he had not been offered bilateral eas figure 3. the combination of acoustic stimulation from the hearing aid and the electric stimulation from the electrode array within the cochlea. reproduced with permission from med el “eas™ hearing implant systemthe ideal solution for partial deafness” [monograph], innsbruck, austria: med el ©2010 [cited 2010 november 10] available from http://www.medel.com/data/downloads/eas/21707.pdf figure 4. audiogram in 2001 figure 5. audiogram in 2003 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 philippine journal of otolaryngology-head and neck surgery 55 practice pearls figure 6. audiogram in 2008 prior to eas surgery figure 7a. closed-set test preeas surgery* * materials used: word intelligibility by picture identification (wipi) unaided test at 100 dbhl in noise at 5 db snr best aided condition at 65 db spl (test dated june 8, 2008) four lists were used no device was worn in the left (non-implanted) ear during all the tests in quiet or noise, preeas implantation figure 7b. open set words in sentences test preeas surgery* * best aided condition at 65 db spl in noise at 5 db snr materials used: bamford-kowal-bench (bkb) sentence lists test dated june 8, 2008 four lists were used no device was worn in the left (non-implanted) ear during all the tests in quiet or noise, post-eas implantation figure 8. coronal hrct of the right cochlea (a) and 3-d ciss mri study of the right cochlea (b) a figure 9. free field pure tone thresholds following eas in quiet (light upper line) and in noise (heavy lower line) figure 10. speech perception scores after eas surgery (july 25,2010)* * words were presented at 65 dbspl in quiet and with masking noise at 55 db spl at the same ear and snr of 10. the patient was not wearing a device in the left (non-implanted) ear. b philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 practice pearls 56 philippine journal of otolaryngology-head and neck surgery acknowledgment dr. maria rina reyes-quintos is gratefully acknowledged for performing all the excellent audiological testing following the surgery while susan javier and angie tongko of manila hearing aid center performed all the audiological testing prior to the surgery. ms. celina ann tobias, professional education manager of med-el is also credited with thanks for preparing the figures, reviewing the manuscript and interviewing the patient regarding his hearing performance following the surgery. references 1. von ilberg c, kiefer j, tillein j, pfenningdorf t , hartmann r, stürzebecher e, klinke r: electroacoustic stimulation of the auditory system. new technology for severe hearing loss. orl j otorhinolaryngol relat spec. 1999 nov-dec;61(6):334-340 2. gstoettner wk, van de heyning p, o’connor af, morera c, sainz m, vermeire k et al.: electric acoustic stimulation of the auditory system: results of a multi-centre investigation. acta otolaryng 2008 sep;128(9):968-975. 3. gstoettner wk, helbig s, maier n, kiefer j, radeloff a, adunka of: ipsilateral electric acoustic stimulation of the auditory system: results of long term hearing preservation. audiol neurootol 2006; 11(suppl 1): 49-56. epub 2006 oct 6. 4. skarzynski h, lorens a, piotrowska a, anderson i. preservation of low frequency hearing in partial deafness cochlear implantation (pdci) using the round window surgical approach. acta otolaryngol 2007 jan;127(1):41-48 5. tobias cam. a new hearing solution. health and lifestyle magazine. [serial on the internet] 2009 december: [cited 2010 september 5] 26-28. available from http://healthandlifestylemagazine. wordpress.com/2009/12/12/a-new-hearing-solution/ implantation. it is always important for the otolaryngologist to consider the quality of hearing and quality of life of patients with hearing loss. intervention should not end with a referral note to a hearing aid center or dispenser. it is important to request proof of improvement not only of hearing thresholds but of speech perception outcomes in quiet and in noise. that is, one should document actual performance with the device in place, regardless of the type of device (hearing aid, an eas device, or a cochlear implant). minimal disturbance of the remaining intact structures of the cochlea of patients with low frequency residual hearing can be achieved by employing a meticulous surgical technique by using the advanced and flexible electrodes developed by some manufacturers and instilling intraoperative antibiotics and steroids. thus, when one is faced with a ski-slope type audiogram it is likely the patient with this audiogram will not benefit from hearing aids. such patients should be offered the option of eas implantation which combines good acoustic stimulation with electric stimulation using a shorter (than conventional cochlear implantation) but very flexible electrode system. counseling must also be done with a special emphasis on the risk of losing residual hearing and noting that post-operative rehabilitation may take a long period of time. this patient now has a better quality of life than was obtainable from the most expensive and advanced hearing aids in the market, and has demonstrated a new implantable solution to partial deafness. truly, eas technology has opened a new era in prosthetic rehabilitation for hearing impaired adults and children.5 philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 52 philippine journal of otolaryngology-head and neck surgery practice pearls the past three years have seen an overwhelming increase in the number of dysphonic patients in our clinics. this phenomenon goes hand in hand with increased opening of call centers nationwide and increased demand for teachers, singers and performers abroad. this article discusses simple steps for the otolaryngologist interested in evaluating these patients with different voice demands. it is important to recognize these common voice problems and address them promptly, or to refer them accordingly to voice centers if necessary. chief complaint the most common chief complaint is change in the quality of the voice or hoarseness. hoarseness means a change in the perception of one’s voice, described as harsh, raspy, “paos” or “malat.” other complaints include breathiness, throat pain, neck pain, inability and unrealibility to reach high notes. inability to reach high notes suggests edema of the vocal folds making them more plump, as can be found in reflux laryngitis, allergies or smoking. lesions such as nodules, polyps and cysts cannot be discounted because they prevent vocal fold closure especially during high notes.1 throat and neck pain without an accompanying history of infection may suggest muscle tension dysphonia, especially in a voice professional who later develops maladaptive ways of talking that could strain other throat and neck muscles in an effort to speak.2 frequent throat clearing, a sensation of phlegm in the throat and cough are also important chief complaints that may lead the otolaryngologist to the cause of the voice problem. in the absence of upper respiratory tract infections and post-nasal discharge, these could be suggestive of laryngopharyngeal reflux.3 history does the hoarseness occur on and off? was it sudden? after shouting in a basketball event? is it becoming worse and permanent? what triggers or relieves it? intermittent hoarseness could be due to voice abuse and misuse especially in a voice professional. sudden hoarseness especially after watching a basketball event could be suggestive of vocal fold hemorrhage. a voice problem becoming worse and permanent could be a growing polyp or cyst, vocal fold paralysis in laryngeal cancer or thyroid cancer. a long lecture triggering the hoarseness and rest relieving it may suggest soft nodules, or reinke’s edema due to vocal fold trauma of voice abuse and misuse. to begin with, it is important to know the occupation of our patient. is our patient a voice professionalsomeone who uses his or her voice for a living? voice demands at work contribute to voice change significantly and voice abuse and misuse is one of the most common causes of hoarseness. what are the other associated symptoms? filipina t. cevallos-schnabel, md, mph1,2,3 1department of otolaryngology head and neck surgery east avenue medical center 2department of surgery, capitol medical center 3department of otolaryngology head and neck surgery faculty of medicine and surgery, university of santo tomas an easy guide for voice evaluation in the clinic correspondence: filipina t. cevallos-schnabel, md, mph rm. 1102 capitol medical center scout magbanua cor. panay ave , q.c. philippines 1103 phone : (632) 372-3825 loc 5102 email : pincevallosmd@yahoo.com reprints will not be available from the author. no funding support was received for this study. the author signed a disclosure that she has no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. philipp j otolaryngol head neck surg 2008; 23 (2): 52-54 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 practice pearls philippine journal of otolaryngology-head and neck surgery 53 medical problems like a recent bout of upper respiratory tract infection and allergies are among the most common causes of hoarseness and should not be discounted immediately. symptoms of hyperacidity are also significant.4 is there a history of breathiness and difficulty of breathing? voice fatigue, tremor, hypo or hypernasal voice? choking, globus, odynophagia or dysphagia? neck pain or head and neck trauma? these questions can give clues to the clinician regarding the possible cause of the problem. past medical history asthma, copd, pulmonary malignancy are associated with voice changes due to decreased airflow. gastric ulcers and gerd can be suggestive of associated laryngopharyngeal reflux disease changing the vocal fold mucosa leading to voice change.3 parkinsonism, myasthenia, traumatic brain injury and movement disorders can cause tremors, weakness or strained voice quality. rheumatoid arthritis, sle and other autoimmune disorders can cause voice changes such as paralysis in ra. endocrine problems such as hypothyroidism can cause edema of the vocal folds leading to decrease in pitch. thyroid cancer can cause vocal fold paralysis. a history of radiation secondary to malignancies in the head and neck can cause vocal fold scarring leading to voice change.1 personality and psychiatric disorders also lead to diagnosis. the outgoing, type a personality usually has vocal fold nodules while inhibited and shy persons have functional dysphonias.5 traumatic life events are also very important to take note of. history of surgery for neck trauma, thyroid nodules or malignancies, spine, cardiac, pulmonary and brain surgeries or previous endotracheal intubation can cause voice changes, usually related to vocal fold mobility problems. 1 medications such as inhalational steroids for asthma can cause fungal laryngitis. arb and ace inhibitors for hypertension can cause non specific vocal fold masses. antitussives, decongestants, antihistamines and vitamin c are known to cause dryness of the vocal folds. pills with sexual hormones can cause either elevations or decreases in pitch.6 smoking can cause polypoid conditions in the vocal folds, premalignant or malignant changes. intake of alcohol, diet and lifestyle can contribute to reflux problems and dysphonia. physical examination hearing the patient and forming a subjective impression of the patient’s voice should automatically be part of the interview process. ranking the voice according to a standard scale is subjective but becomes increasingly reproducible and precise with training and experience. voice can be evaluated according to pitch, loudness and vocal quality. pitch is the highness or lowness of the voice. is the speaking voice too low for the soprano? this could be the problem why a trained singer would have dysphonia. does the woman sound like a man over the phone? this could be reinke’s edema, maybe she is a smoker as well. does the adult male suddenly speak with elevated pitch? this could be vocal fold paralysis. loudness is the power of the voice. this is due to the source of power, the lungs. posture, type of breathing, technique or training can affect this. systemic problems like generalized weakness and cachexia are contributory. of course pulmonary problems can contribute to decreased power. voice quality can be evaluated using the grbas system.7 just hearing the voice and using this system is helpful in making an impression. ggrade rroughness bbreathiness aasthenia sstrain grbas uses a 0 to 3 scale (0= normal or absence of deviance; 1=slight deviance; 2=moderate deviance; 3= severe deviance). grade relates to the overall voice quality, integrating all deviant components roughness breathiness asthenia strain grbas sounds probable conditions grainy quality; diplophonic airy no voice tight quality vocal fold masses such as nodules, polyps, cysts, laryngitis unilateral paralysis, bowing, atrophy, abductor spasmodic dysphonia bilateral paralysis in paramedian position, vocal fold atrophy adductor spasmodic dysphonia, muscle tension dysphonia head and neck examination palpating the neck, especially the base of the tongue and neck muscles which are tense and tender can be suggestive of an ongoing muscle tension dysphonia as a cause of the voice change.8 thyroid masses, neck nodes, etc. can be helpful in leading the clinician to a diagnosis. visualizing the larynx has evolved as advances in technology have improved the understanding of vocal fold anatomy, physiology and voice production. at present, there is no single laryngeal examination tool that is superior to the others. what is important is that it gives a thorough visualization of the anatomy and a good functional evaluation of the larynx. selecting the appropriate instrumentation will be possible if we recognize the advantages and limitations of the diagnostic tool we are using.9 sometimes, a combination of these tools is important to make an accurate diagnosis. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 54 philippine journal of otolaryngology-head and neck surgery practice pearls references: 1. simpson cb, fleming d. medical and vocal history in the evaluation of dysphonia. otolaryngol clin n am 2000; 33(4): 719-750. 2. morrison md, rammage la, belisle gm. muscular tension dysphonia. j otolaryngol 1983; 12:302-306. 3. koufman ja. the otolaryngologic manifestations of gastroesophageal reflux disease (gerd): a clinical investigation of 225 patients using ambulatory 24-hour ph and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. laryngoscope 1991; 101: 1-78. 4. olson nr. laryngeal manifestations of gastroesophageal reflux disease: otolaryngol clin n am 1991; 24: 1201-1213. 5. rosen dc, sataloff rt. psychology of voice disorders. 2006. san diego (ca): plural publishing inc. pp. 729-50. 6. abaza mm, levy s, hawkshaw m, sataloff r. effects of medications on voice. otolaryngol clin n am 2007; 40:1081-1090. 7. dejonckere ph. perceptual and laboratory assessment of dysphonia. otolaryngol clin n am 2000; 33(4): 731-49. 8. sataloff rt, hawkshaw m, divi v, heman-ackah y. physical examination of voice professionals. otolaryngol clin n am 2007; 40: 953-69. 9. rosen c, murry t. diagnostic laryngeal endoscopy. otolaryngol clin n am 2000; 33(4): 751-57. 10. kaszuba s, garrett cg. strobovideolaryngoscopy and laboratory voice evaluation. otolaryngol clin n am 2007; 40: 991-1001. advantages and limitations of the different instruments to visualize the larynx indirect mirror laryngoscopy transnasal flexible laryngoscopy rigid 70 or 90 degrees laryngoscope videostroboscopy10 instrument advantages limitations readily available; inexpensive gives a gross idea of the anatomy; mobility; mucus; and mass (if big enough) helpful for hypergag patients; patients physiology involving the tongue, pharynx and palate are well visualized; can assess paresis from paralysis; can be recorded for review extremely clear and magnified view; less expensive; can be recorded for review provides a slow motion evaluation of vocal fold vibratory pattern, closure, mucosal wave; can differentiate benign vocal fold lesions limited in patients who are hypergag; patient is not in a normal physiologic position; hard to detect paresis and small lesions small lesions are hard to differentiate; color might not be reliable depending on the camera; may be expensive limited in patients who are hypergag; patient is not in a normal physiologic position; hard to detect paresis and muscle tension dysphonia expensive; requires additional training despite technological advances in laryngology, a good history and physical examination are still crucial in the diagnosis of voice disorders. certain clues can be provided by a good history that especially point to a hoarse patient. because no single instrument is superior for visualization of the larynx, it is important to recognize the advantages and limitations of each. some helpful vocal tasks when using a flexible scope: /ii/ sniff hee-hee-hee sniff then /ii/ /ii/ glide form low to high pitch task endoscopic findings adduction abduction either decreased adduction or abduction fatigues the vocal folds; detects paresis/ weakness ability to lengthen the vocal folds philippine journal of otolaryngology-head and neck surgery 31 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports abstract objective: to describe our experience in managing two cases of primary malignant parotid lymphoma. methods: design: case report setting: tertiary university referral center patients: two results: both patients underwent superficial parotidectomy. despite recurrence in one, the disease was controlled with conservative management. however, the disease was more aggressive in the other, requiring additional chemo-radiotherapy. conclusion: malignant parotid lymphoma may present with varying stages, grades and clinical courses, requiring different management approaches. the treatment options are based on grading and staging at diagnosis and should be implemented depending on individual case. keywords: parotid neoplasms, malignant lymphoma the head and neck is the second most common site for extranodal lymphoma after the gastrointestinal tract.1 usually it affects waldeyer’s ring, the nose, the paranasal sinuses and thyroid in descending order of frequency. primary malignant lymphoma is only rarely found in the parotid gland and is mostly of the non-hodgkin b cell type. this type has various subtypes with differences in histology, behaviour, treatment and prognosis. we report two cases of primary malignant parotid lymphoma with different clinical courses and treatments. case reports case 1 a 74-year-old elderly male with diabetes, hypertension and bronchial asthma presented with a 7-year history of a painless, slow growing mass over the right angle of the mandible. he denied any associated constitutional symptoms. on examination, there was a 3x3cm firm, mobile non-tender single lymph node palpable over the right angle of the mandible. a computed primary malignant parotid lymphoma: two case reports with different disease progression and treatment noor dina hashim, md mohd razif mohamad yunus, mbbs, ms (orl-hns) asma abdullah, md, ms (orl-hns) marina mat baki, md, ms (orl-hns) salina husain, md, ms (orl-hns) mazita ami, mbchb, ms (orl-hns) department of otorhinolaryngology universiti kebangsaan malaysia medical centre correspondence: dr. mohd razif mohamad yunus department of otorhinolaryngology universiti kebangsaan malaysia medical centre jalan yaacob latiff, bandar tun razak 56000 cheras, kuala lumpur, malaysia phone: +60391455555 ext 6845 fax: +60391737840 email : razif72@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work; disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (1): 31-33 c philippine society of otolaryngology – head and neck surgery, inc. 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports tomography (ct) scan of neck showed a well-defined enhancing lesion measuring 2.4 x 2.5 cm, located in the superficial lobe of the right parotid gland with multiple subcentimeter lymph nodes seen in the posterior cervical triangle bilaterally. he underwent superficial parotidectomy, yielding a histopathological diagnosis of malignant parotid follicular non hodgkin lymphoma stage i. he was referred to the haematology service and a bone marrow biopsy showed no infiltration of lymphoma cells. in view of localized, early disease and his medical background, watchful observation was recommended. the patient remained well on a regular follow-up until two and a half years later, when he presented with right submandibular and posterior cervical lymphadenopathy. an excision lymph node biopsy showed no malignant cells. however in about six months, the ipsilateral cervical lymphadenopathy had grown bigger and inguinal lymph nodes had also become palpable. excision biopsies from both sites showed recurrent follicular lymphoma. a thorough ct scan showed multiple cervical, axillary, mediastinal and inguinal lymphadenopathies, but no solid organ involvement. there were no distant metastases. after another year, he again presented with right submandibular lymphadenopathy that was confirmed positive for recurrent disease. subsequent ct scan showed similar findings to the previous scan but the lymph node sizes were reduced. the patient has otherwise been well throughout the years despite recurrent disease. the haematological team recommended supportive, palliative treatment in view of his age and multiple medical illnesses. case 2 a 14-year-old girl presented with a painless right pre-auricular swelling which gradually increased in size over six months. she also complained of loss of appetite with significant weight loss. there were intermittent episodes of fever but no night sweats. physical examination revealed a firm, mobile, non-tender mass in the right parotid region measuring about 4 x 4cm. it seemed unattached to overlying skin or underlying structures, and there was no palpable cervical lymphadenopathy. a fine-needle aspiration cytology examination was suggestive of pleomorphic adenoma. she underwent right superficial parotidectomy with a histopathologic diagnosis of diffuse large b cell non hodgkin lymphoma. she was referred to the haematology team and bone marrow aspiration showed no infiltration of lymphoma cells. however, she defaulted soon after. she presented again six months later with bilateral lower limb weakness and back pain. a ct scan showed a residual mass in the right parotid region with bilateral subcentimeter cervical lymphadenopathies from levels i to v. enlarged matted anterior mediastinal lymph nodes were also seen. there were no other solid organ metastases. also noted were multiple lytic lesions in the spine, iliac, ischial and femoral bones. further magnetic resonance imaging (mri) of the spine showed multiple lesions at various levels with collapse of t4 vertebrae and extension into the spinal canal. the patient had five courses of radiotherapy of 20gy to her spine followed by six courses of bleomycin-fluouracilmethotrexate – 90 (bfm -90) regimen chemotherapy. during her first course, a whole body ct scan showed new lesions in both breasts and kidneys with worsening bony lesions. fortunately, after completion of chemotherapy, the positron emission tomography (pet) scan showed that she had responded well and was in remission. post treatment mri showed improvement of both bony and paraspinal lesions. discussion the incidence of primary malignant parotid lymphoma is very rare, accounting for 3-5% of all parotid tumours.1,2 the parotid gland is the commonest salivary gland to be affected by lymphoma, constituting about 91% of all salivary gland lymphoma as reported by hyman et al.3 this is possibly due to the presence of lymph nodes and lymph aggregates in the parotid glands which are not found in the submandibular and sublingual glands. parotid lymphoma may arise from intra-glandular lymph nodes or from the gland parenchyma. parenchymal origin lymphoma is reported to be low grade, localized and often curable. malignant lymphoma of the parotid gland commonly occurs in 50 to 80-year-olds. sex predilection varies in many studies. according to barnes et al.8 parotid lymphoma may be suspected in patients with a parotid mass and: history of malignant lymphoma; or with autoimmune disorders; or a previous diagnosis of benign lymphoepithelial lesion; or with multiple cervical lymphadenopathy; or in patients with multiple unilateral or bilateral parotid masses. it is difficult to identify parotid lymphoma from the clinical history due to its limited value. according to tiplady et al.4 only 12% of patients had systemic ‘b’ symptoms. b -symptoms are a group of symptoms that may be present in individuals with lymphoma which are important in identifying how the cancer is likely to behave. they include fever for three consecutive days, weight loss exceeding 10% of body weight within six months and drenching night sweats. patients with b-symptoms have a little less chance of doing well after treatment. they are more significant in those with extensive disease such as our second patient. a history of autoimmune disease such as rheumatoid arthritis or sjögrens’ might be helpful as up to 44% may have coexistant parotid lymphoma.5 clinically, malignant parotid lymphoma is almost indistinguishable from benign neoplasms. the commonest presentation is painless, philippine journal of otolaryngology-head and neck surgery 33 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports references 1. watkin gt, maclennan ka, hobsley m. lymphomas presenting as lumps in the parotid region. br j surg. 1984 sep;71(9):701-702. 2. mehle me, kraus dh, wood bg, tubbs r, tucker hm, lavertu p. lymphoma of the parotid gland. laryngoscope. 1993 jan;103(1 pt 1):17-21. 3. hyman ga, wolff m. malignant lymphomas of salivary glands. review of the literature and report of 33 new cases, including four cases associated with lymphoepithelial lesion. am j clin pathol. 1976 apr;65(4):421-438. 4. tiplady cw, taylor pr, white j, arullendran p, proctor sj; scotland and newcastle lymphoma group. lymphoma presenting as a parotid tumour: a population-based study of diagnosis, treatment and outcome on behalf of the scotland and newcastle lymphoma group. clin oncol (r coll radiol) 2004 sep;16(6):414-419. 5. wakely p e jr. fine-needle aspiration cytopathology in diagnosis and management of malignant lymphoma: accurate and reliable? diagn cytopathol. 2000 feb;22(2):120-125. 6. sun xf, su ys, liu dg, jiang wq, he yj, lin ty, et al. comparing chop, chop+hd-mtx, and bfm-90 regimens in the survival rate of children and adolescents with b cell non-hodgkin’s lymphoma. ai zheng, 2004aug;23(8):933-938. 7. hirokawa n, hareyama m, akiba h, satoh m, oouchi a, tamakawa m, et al. diagnosis and treatment of malignant lymphoma of the parotid gland. jpn j clin oncol 1998 apr;28(4):245249. 8. barnes l, myers en, prokopakis ep. primary malignant lymphoma of the parotid gland. arch otolaryngol head neck surg. 1998 may;124(5):573-577. 9. vega f, lin p, medeiros lj. extranodal lymphomas of the head and neck. ann diagn pathol. 2005 dec;9(6):340-350 10. fujimura k, yoshida m, sugimoto t, kuroda y, fujiyoshi t. two cases of non-hodgkin’s lymphoma in the accessory parotid gland. auris nasus larynx. 2004 jun; 31(2):195-198. progressively enlarging parotid mass. twenty percent of cases are associated with cervical lymphadenopathy6 which is relatively rarely seen in benign parotid tumour and only 2% in parotid carcinoma. other unusual signs and symptoms at presentation, as described by naoki et al.7 include pain (9%), facial nerve paresis (4-15%) and fixation of mass to overlying skin or underlying structures. hymann and wolff9 proposed three criteria to suggest primary lymphoma of the salivary gland; namely involvement of a salivary gland as the first symptom, histological evidence of lymphoma of the salivary gland parenchyma and presence of architectural and cytological confirmation of malignant nature of the lymphoid infiltrate. a confirmed diagnosis of malignant parotid lymphoma is often made after superficial or total parotidectomy. according to tiplady et al.4 there is no clinical indication for total parotidectomy in parotid lymphoma. partial removal of the gland is recommended as a lower incidence of facial nerve palsy is reported. the author has also pointed out their concern regarding facial cosmesis following total parotidectomy. according to wakely,5 fine needle aspiration cytology (fnac) is a highly specific diagnostic test with 100% specificity and more than 80% sensitivity due to the use of immunophenotyping and cytogenetic techniques. following a diagnosis by fnac, a full staging of disease can be done, avoiding the risk of facial nerve palsy from total parotidectomy. if fnac is non-diagnostic, it is safer to perform partial parotidectomy. however, fnac may still fail to detect the actual diagnosis as seen in our second case. the treatment and prognosis of malignant parotid lymphoma is based on the histological grading and staging at the time of diagnosis. the ann-arbor classification is used for staging and working fomulation (wf) classification is used for histological grading. generally, stages i and ii (localized disease) are treated with postoperative radiation, while multifocal or systemic disease is treated with chemotherapy.8 a study by tiplady et al.4 reported various treatment regimens. those with high grade disease received combination chemotherapy with cyclophosphomide-hydroxydoxorubicin-oncovin-prednisolone (chop) or bfm regimes. patients with low grade lymphoma such as follicular lymphoma, were usually treated with chlorambucil regimens. some underwent parotidectomy alone, others had radiotherapy alone or in combination with radiotherapy. sun et al.6 reported bfm-90 regimen can greatly improve the survival rate of children and adolescents with b-non hodgkin lymphoma (nhl), especially of patients with advanced nhl. chop or combined chop regimens work better for early stage patients, but produce low survival rate for patients with advanced nhl. it is suggested that treatment is given accordingly based on individual staging and grading. case 1 showed the disease may remain quiescent after parotidectomy alone, while in the more advanced case 2, the patient required chemotherapy and local radiotherapy for spinal metastases before achieving remission of the disease. overall survival rate can be predicted from histological grading. the 5-year survival rate for low grade disease is 59%, while it is 37% for high grade disease.3 staging was not found to be statistically significant in determining prognosis in high grade disease but is significant in low grade disease8 where the 5-year survival rate for stage 1 disease is 69% compared with 44 % for higher stages. the prognosis of lymphoma presenting as a parotid mass is favourable especially in low grade disease. therefore, early diagnosis and treatment of malignant parotid lymphoma may ensure an excellent survival. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 from the viewbox philippine journal of otolaryngology-head and neck surgery 35 an ossifying fibroma is a monostotic lesion that occurs in craniofacial bones. it usually presents as a painless well-circumscribed, slow-growing mass in the 3rd and 4th decade. it is a benign fibro-osseous lesion that is part of the bigger spectrum of fibro-osseous lesions which includes fibrous dysplasia, juvenile active ossifying fibroma, psammomatous ossifying fibroma, and extragnathic ossifying fibroma of the skull. an ossifying fibroma, because of its well-circumscribed nature, lends itself to surgery better than does fibrous dysplasia. simple enucleation is usually sufficient for ossifying fibromas whereas curettage is probably better suited for fibrous dysplasia. radiographically, it is seen as a well-demarcated radiolucency in the mandible or maxilla, more common in the former than the latter. it typically measures anywhere from 1 to 5 cm. there may or may not be a central opacity or calcification, depending on the maturity of the lesion. an immature lesion may present as completely radiolucent whereas a mature lesion may be completely radiopaque, although most lesions demonstrate varying degrees of radiopacity. the images above show two samples of the same lesion on opposite sides of the spectrum. both are well-circumscribed but one is relatively radiolucent while the other is floridly sclerotic. is there a pathognomonic finding on x-ray? unfortunately, there is not one single finding that will distinguish an ossifying fibroma from other fibro-osseous lesion. does it matter? yes. x-rays will lead the clinician to one diagnosis or the other and help plan the intended surgery. johanna patricia a. cañal, md, mha department of radiology college of medicine – philippine general hospital university of the philippines manila the spectrum of ossifying fibroma philipp j otolaryngol head neck surg 2007; 22 (1,2): 35 c philippine society of otolaryngology – head and neck surgery, inc. references: dahnert, w. radiology review manual. 5 ed. lippincott, williams & wilkins. philadelphia 2003. gannon fh & thompson ldr. ossifying fibroma of the jaw. ear, nose & throat journal, (online) july 2004. available from http://www.entjournal.com. voytekt m, ro jy, edeiken j & ayala ag. fibrous dysplasia and cemento-ossifying fibroma: a histologic spectrum. am j surg path. vol. 19, no. 7. 1995. lee, kj. textbook of otolaryngology and head and neck surgery. appleton & lange. new york. 1989. toyosawa s, yuki m et al. ossifying fibroma vs fibrous dysplasia of the jaw: molecular and immunological characterization correspondence: johanna patricia a. cañal, md, mha department of radiology philippine general hospital taft ave., ermita, manila 1000 telefax (632) 523-4372 email:joie_canal@yahoo.com reprints will not be available from the author. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 philippine journal of otolaryngology-head and neck surgery 41 passages a strong pillar after completing his residency training program in the united states, dr. napoleon ejercito came back to join the faculty of the then combined department of eye ear nose and throat (eent) at the philippine general hospital. unhappy with the fact that orl in the philippines was not yet a separate and distinct specialty with no existing standard and organized form of training, dr. ejercito and seven other optimistic and young ent surgeons gathered together to form the otolaryngology society of the philippines under the leadership of dr. tierry garcia. these men became the historic pillars of the society. with the birth of this society, the development and maturation of the specialty was simply a matter of time. fifteen years later, dr. ejercito spearheaded the founding of the philippine board of otolaryngology and bronchoesophagology in order to standardize and professionalize the practice of orl. initially composed of diplomates and candidates of the american board of otorhinolaryngology, the rigorous process of accreditation and qualification was patterned after the american board. this organization was subsequently incorporated and evolved into what is now known as the philippine board of otolaryngology head and neck surgery. this board became his youngest child whose growth he fostered and whose interests he promoted and protected. a dedicated leader dr. ejercito was chairman of the department of orl of the up-pgh from 1970 to 1974, when martial law was declared. he was a staunch critic of the marcos regime, but the repression did not deter him from leading the department in achieving its goals. during his time as chair of the department, only a total of 12 residency slots were available. it was dr. ejercito who pioneered the restructuring of the residency training program into three orl residents per year level. furthermore, it was during dr. ejercito’s term that a post-residency graduate was chosen as the chief resident. his integrity was beyond question. rather than face the possibility of naming his eldest son as chief resident, he compelled his son to seek further fellowship abroad. a trailblazer dr. napoleon ejercito can be called the father of head and neck surgery in the philippines. while dr. tierry garcia initiated the expansion of the specialty of otorhinolaryngology to include head and neck surgery, it was dr. ejercito who nurtured and strengthened it to what it is today. as a testament to dr. ejercito’s legacy, the stipend of the fellow of the head and neck program of the department of orl –pgh was made available by an alumnus of the department, and was named after him. his dedication to the discipline was beyond comparison. even when he was the chair, dr. ejercito continued to operate on charity patients and demonstrated operative procedures to residents on a regular basis. his retirement did not dampen his zeal to further the cause of orl. he continued to support the different programs of the society and attended society conventions and departmental conferences whenever possible, which gained the admiration of younger generation of residents. dr. napoelon ejercito: a strong pillar, a dedicated leader, a trailblazer. such a man will truly be missed. napoleon c. ejercito, md (1921 – 2007) strong pillar, dedicated leader and trailblazer by joselito c. jamir, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports philippine journal of otolaryngology-head and neck surgery 23 abstract objectives: to present a case of cervical vagal schwannoma and describe our experience with the clinical presentation, surgical management and outcome of an elderly patient with this pathology. methods: design: case report setting: tertiary public hospital patient: one results: a 65-year-old lady presented with a recently enlarging, pulsatile right sided neck mass that had been asymptomatic for 15 years. contrast ct revealed a circumscribed non-enhancing heterogenous 4 x 4 x 7 cm mass splaying the right internal jugular vein and common carotid artery. a neurogenic tumour was considered, and the mass was excised from the vagus nerve with preservation of adjacent structures. final histopathologic reading was schwannoma. however, the patient succumbed to complications following a second surgery for expanding hematoma. conclusion: schwannomas are benign, slow growing tumours that arise from schwann cells of the nerve sheath. cervical schwannomas originating from the vagus nerve are rare but should be considered in patients presenting with solitary neck masses. surgical extirpation is still the treatment of choice for nerve sheath tumours and recurrence is uncommon. efforts should be made to preserve unaffected structures and patients should be counseled preoperatively on the possible high risk of morbidity especially in the elderly group where close follow up and aggressive rehabilitation should be instituted following surgery. keywords: cervical schwannoma, vagus nerve, neurogenic tumour; parapharyngeal space the head and neck region is a source of swellings of various types of pathology. nonetheless, neurogenic tumours arising from these regions are uncommon in the adult population and are rare in the pediatric group. on the other hand, these tumours are commonly found arising from the parapharyngeal spaces.1 the reported sites of origin of neurogenic tumours are the cranial nerves 9-12, the sympathetic chains, the cervical plexus and the brachial plexus.2-5 cervical schwannomas are rare, slow-growing tumours of nerve sheath origin that may originate from any of these nerves.6 they are also commonly referred as neuromas and neurilemmomas. they are usually asymptomatic benign lesions and complete surgical resection is the treatment of choice. malignant transformation is unusual. no gender predilection is noted and they are usually reported to occur in patients between 34 and 67 years of age.6 we report the case of a patient diagnosed with cervical schwannoma of vagal nerve origin, which is rare. cervical vagal schwannomadoh jeing yong, mbbs, mrcs1 iskandar hailani, mbbs, ms (orl-hns)1 mohd razif bin mohamad yunus, mbbs, ms (orl-hns)2 1department of otorhinolaryngology hospital kuala lumpur, malaysia 2department of otorhinolaryngology universiti kebangsaan malaysia medical centre kuala lumpur, malaysia correspondence: doh jeing yong, mbbs, mrcs department of otorhinolaryngology, hospital kuala lumpur, jalan pahang, 50586 kuala lumpur, malaysia phone: +60122719921 fax : +60326916725 email: drdjyong@gmail.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2010; 25 (2): 23-26 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports 24 philippine journal of otolaryngology-head and neck surgery case report a 65-year-old lady with painless swelling on the right side of the neck for 15 years consulted at our centre for recent enlargement. she had no dysphagia, dyspnoea or other associated symptoms nor was there a past history of cervical trauma. her past medical and surgical histories were unremarkable. on examination, the swelling was oval in shape and situated beneath the upper and middle third of the right sternocleidomastoid muscle. it measured 5 x 3 cm with normal overlying skin. on palpation, the mass was firm in consistency, pulsatile and could be displaced from side to side but not up and down. no bruit was noted on auscultation. regional lymph nodes were not enlarged. the intraoral, indirect laryngeal and post nasal mirror examinations were normal. no cranial nerve deficits or horner’s syndrome were noted. flexible nasopharyngolaryngoscopy showed no significant findings. in view of the pulsatility of the neck mass, contrasted computed tomography scan (ct) of the neck was performed and revealed a well circumscribed non-enhancing heterogenous mass measuring 4x4x7cm over the right side of the neck. it extended from below the mandible to the level above the cricoid cartilage. the mass splayed the right internal jugular vein and right common carotid artery. the patient was diagnosed with neurogenic tumour and underwent surgical extirpation via a transverse right cervical skin incision. all great vessels were isolated and controlled before the mass was excised. intraoperatively, the tumour was tracked to the vagal nerve in origin and separated en-bloc from the vagal trunk. the glossopharyngeal, hypoglossal, lingual, accessory nerves were all preserved. the patient was transferred to the intensive care unit after the operation. laryngeal functions were noted to be normal. during the early postoperative period, the patient developed pneumonia and the neck wound was complicated with an expanding hematoma despite a functioning surgical drain in-situ. the patient underwent a second surgery for wound exploration, hemostasis and hematoma removal after which she was readmitted to the intensive care unit but was not recuperating well. she was kept ventilated and unfortunately succumbed to sepsis secondary to pneumonia one week after surgery. the resected specimen reported findings that were consistent with typical features of schwannoma. discussion schwannomas are rare, benign tumours of nerve sheath origin that may originate from any of the cranial, peripheral or autonomic nerves.1 over the last few decades, much literature has been written on the studies on intracranial schwannoma with regards vestibular neuroma. nonetheless, a majority of schwannomas are non-vestibular and extracranial. kang et al. reported merely 6 cases of vagal schwannoma identified over the period of 10 years retrospective study.6 extracranial non-vestibular head and neck schwannomas usually present as asymptomatic, slow-growing lateral neck masses that can be palpated along the medial border of the sternocleidomastoid muscle. this renders preoperative diagnosis difficult as many vagal schwannomas do not present with any neurological deficits.5 therefore, possible differentials include metastatic cervical lymphadenopathy, malignant lymphoma, carotid body tumour, branchial cyst, as well as aneurysm. when symptoms are present, hoarseness is the most common symptom for vagal schwannomas. occasional palpation of the mass may induce paroxysmal coughing.8 horner’s syndrome may prevail when the tumour has pressured on the cervical sympathetic chains, or when these chains are themselves the origin of the tumour. imaging studies play an important role in the diagnosis of head and neck schwannomas. regardless of the nerve of origin, schwannomas in general are hypodense in relation to muscle tissue on ct without contrast. with contrast, these lesions may show some degree of enhancement, often peripheral.13 more contrast-enhancing lesions should merit differentials of possible vascular lesions. in such instances, angiography or magnetic resonance angiography may be employed to outline the feeding vessels and preoperative embolization could be planned. according to lin et al.1 the site and the way the major neck vessels are displaced could give further clues on the type of schwannoma. vagal schwannomas typically separate the internal jugular vein and carotid arteries but do not usually widen the carotid bifurcation. on the contrary, sympathetic chain schwannomas mildly splay the carotid bifurcation but do not separate the great vessels. the splaying of the carotid bifurcation is usually more prominent in carotid body tumours. this is called the “lyre sign,” which, along with significant contrast enhancement, is rarely associated with schwannoma.14 differentiating amongst the origin of schwannoma can be challenging. in one study, the sympathetic chain was shown to be the most usual site of origin for parapharyngeal schwannoma.4 meanwhile, maniglia et al. stated that the vagus nerve is the site of origin in approximately 50% of cases.10 the identification of the exact nerve trunk from which the schwannoma arises can be difficult to ascertain. anatomic evaluation by direct vision intraoperatively is an acceptable way but may not be feasible in all cases. otherwise, the derivation may be presumed based on the presenting features or postoperative morbidity experienced by the patient.3 nonetheless, adjacent nerves could also be damaged during surgical extirpation, resulting in error of the assumption of origin. therefore, some diagnoses of the site of origin of schwannoma are definitive; others, presumptive.15 histologically, on hematoxylin and eosin staining, schwannomas show typical clusters of alternating areas of compact hypercellular with spindle shape cells (antoni a) with areas of loose hypocellular patterns philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports philippine journal of otolaryngology-head and neck surgery 25 (antoni b). furthermore, schwannomas also show positivity in s100 protein immunohistochemical studies. although neurofibromas are of schwann cell origin, they are differentiated from schwannomas by their lack of true capsules and presence of only loose interlacing bands of spindle cells. moreover, the nerve fibers seen in neurofibromas are found scattered throughout the tumour body whereas those of schwannomas are compressed to one side. treatment of vagal schwannomas should encompass complete surgical extirpation with preservation of the neural pathway, as in this case. if the plane of resection is inadequate and preservation is technically difficult, the involved segment of the nerve trunk may be resected with an end-to-end anastomosis using microsurgical techniques. invariably, this type of procedure will result in vocal cord paralysis or paresis. therefore, aggressive voice and speech rehabilitation should entail after the surgery. morbidities are not uncommon after surgical resection of extracranial nerve sheath tumours. biswas et al.16 reported high complications rates of surgery on benign extracranial nerve sheath tumours. complications like dysphagia, dysphonia, horner’s syndrome, facial myotonia, hypoglossal palsy, facial palsy and keloid formations have been reported.14-15 nonetheless, neural complications could occur as a result of tumour compression. therefore there is a need for relevant head and neck neural assessment prior to the surgery so as to correctly identify post-operative neural morbidity. vascular complications have figure 1. preoperative appearance of the pulsatile right cervical lesion figure 2. contrast computed tomography of the neck, coronal section: well-circumscribed dumbbell-shaped heterogenous density in the right parapharyngeal region splaying the right internal jugular vein (dotted arrow) and right carotid artery (solid arrow) figure 3. histopathology (h&e stain 40x) of resected specimen revealed typical benign looking spindle-shape cells arranging themselves in alternating rows of compact hypercellularity and loose hypocellularity, commonly referred to as antoni cells a (black circle) and antoni cells b (white circle) respectively. courtesy of dr suryati yusof, senior neuropathologist hospital kuala lumpur (slide no 9076/2009) (hematoxylin eosin, 40x) philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 26 philippine journal of otolaryngology-head and neck surgery case reports references 1. lin c, wang c, liu s, wang c, chen w. cervical sympathetic chain schwannoma. j formos med assoc. 2007; 106(11): 956-960. 2. al-ghamdi s, black mj, lafond g. extracranial head and neck schwannomas. j otolaryngol 1992 jun; 21(3): 186-8. 3. daly jf, roesler hk, neurilemmoma of the cervical sympathetic chain. arch otolaryngol 1963 mar; 77:262-6. 4. fluur e. “parapharyngeal” neurogenic tumors. j laryngol otol. 1965; 79:796-805. 5. toriumi dm, anyah ra, murad t, sisson ga. extracranial neurogenic tumors of the head and neck. otolaryngol clin north am 1986 aug; 19(3):609-17. 6. kang gcw, soo kc, lim dth. extracranial non-vestibular head and neck schwannomas: a tenyear experience. ann acad med singapore. 2007 apr; 36(4):233-240. 7. chiofalo mg, longo f, marone u, franco r, petrillo a, pezzullo l. cervical vagal schwannoma: a case report. acta otorhinolaryngol ital. 2009 feb; 29(1):33-35. 8. ford lc, cruz rm, rumore gj, klein j. cervical cystic schwannoma of the vagus nerve: diagnostic and surgical challenge. j otolaryngol. 2003 feb; 32(1):61-63. 9. takimoto t, katoh h, umeda r. parapharyngeal schwannoma of the cervical symphathetic chain in a child. int j pediatr otorhinolaryngol. 1989 sep; 18(1): 53-58. 10. maniglia aj, chandler jr, goodwin wj, parker jc jr.. schwannomas of the parapharyngeal space and mid jugular foramen. laryngoscope. 1979; 89(9):1405-14. 11. agrawal a, pandit l, bhandary s, makannavar jh, srikrishna u. glossopharyngeal schwannoma: diagnostic and therapeutic aspects. singapore med j. 2007 jul; 48(7): e181-5. 12. wilson ja, mclaren k, mcintyre ma, von haacke np, maran agd. nerve-sheath tumours of the head and neck. ear nose throat j. 1988; 67:103-110. 13. furukawa m, furukawa mk, katoh k, tsukuda m. differentiation between schwannoma of the vagus nerve and schwannoma of the cervical sympathetic chain by imaging diagnosis. laryngoscope 1996; 106:1548–52. 14. olsen kd. tumors and surgery of the parapharyngeal space. laryngoscope 1994 may; 104(5 pt 2 suppl 63):1–28. 15. sheridan mf, yim dw. cervical sympathetic schwannoma: a case report and review of the english literature. otolaryngol head neck surg. 1997 dec; 117(6):s206-210. 16. biswas d, marnane c, mal r, baldwin d. benign extracranial nerve sheath tumors of the skull base: postoperative morbidity and management. skull base. 2008 mar;18(2):99-106. 17. sade b, mohr g, dufour jj. vascular complications of vestibular schwannoma surgery: a comparison of the suboccipital retrosigmoid and translabyrinthine approaches. j neurosurg. 2006 aug; 105(2):200-204. also been reported and are common after intracranial schwannoma resection17 but rare for extracranial schwannomas. rapidly forming hematoma in a neck surgical wound is a dreadful complication and should merit immediate intervention. tracheostomy may be needed if the airway is compromised. post surgery atelectasis of the lung is usually the main cause of pneumonia and aggressive chest physiotherapy should be instituted both pre and post operation. pneumonia may also occur as a result of aspiration secondary to vocal cord palsy possibly due to direct trauma to vagal trunk, traction injury or even compression from hematoma. because initial laryngeal functions were noted to be normal after the tumour resection in this case, the subsequent wound hematoma could have compressed on the preserved vagal trunk and precipitated aspiration pneumonia. in conclusion, a patient presenting with solitary mass in the neck should raise the alarm of possible nerve sheath tumour and in the setting of parapharyngeal space involvement, the possibility of arising from cranial nerves, brachial plexus, cervical sympathetic chains or major peripheral nerves. every effort should be made to preserve the nerve of origin and the patient should be counseled preoperatively on the risk of morbidity especially in the elderly group. intervention was needed in this case in view of the rapid enlargement of the cervical swelling that could signify malignant transformation or anticipated compressive symptoms. surgical extirpation is still the treatment of choice for nerve sheath tumours and tumour recurrence is uncommon. nonetheless, in view of the possible surgical morbidities, close follow up and aggressive rehabilitation should be instituted following surgical treatment. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations philippine journal of otolaryngology-head and neck surgery 45 abstract acute laryngeal trauma is a great challenge for the otoloaryngologist. early recognition, accurate evaluation and proper treatment may be crucial to immediate survival and long-term function. objective: to describe an endoscopically-guided open reduction and adaptation plate fixation of an acute laryngeal fracture secondary to vehicular accident. methods: a. study design: surgical innovation/ case report b. setting: tertiary hospital in metro manila results: post-operative follow-up showed good vocal fold function and arytenoid position, with no food regurgitation, signs of aspiration or penetration on fiberoptic endoscopic evaluation of swallowing conclusion: endoscopic guidance allows higher magnification minimizing iatrogenic mucosal damage during manipulation. keywords: laryngeal trauma, endoscopic technique, rigid fixation, fracture external laryngeal trauma is a relatively uncommon injury estimated at approximately 1 in every 30,000 emergency room visits1. however, laryngeal injury can result in serious airway problems and impaired voice production if not diagnosed and managed properly, and the consequences of mistreatment are severe. historically, the surgical repair of laryngeal fractures involved simple wire fixation of fragments with autologous cartilage grafts for large defects. internal stents were used to preserve the proper three-dimensional shape of the airway when extraluminal repair could not ensure immediate restoration of a stable laryngeal framework. although these techniques suffice to align fracture fragments, they do not always restore the functional architecture of the larynx2. with improved image resolution and quality of stroboscopy, videolaryngoscopy became a routine part of the examination of individuals with voice disorders3. however, its use was mainly for pre-operative assessment and post-operative follow-up. a medline search engine using mesh database with the keywords larynx, trauma, and fracture failed to find descriptions of endoscopic-guided management of laryngeal trauma. we describe the management of a case of laryngeal trauma under endoscopic guidance. case report a 29-year-old male fell from a moving motorcycle, hitting the anterior part of his neck on a concrete curb. a tracheotomy was performed at a nearby hospital due to subsequent loss of voice and difficulty of breathing and he was transferred to the st. luke’s medical center emergency open reduction and fixation in acute laryngeal trauma under endoscopic guidance jaren r. cabudol, md1, joel a. romualdez, md1, eutrapio s. guevara, jr., md1,2 1department of otolaryngology head and neck surgery st. luke’s medical center 2 department of otorhinolarynogology college of medicine – philippine general hospital university of the philippines manila correspondence: jaren r. cabudol, md department of otolaryngology head and neck surgery st. luke’s medical center 279 e. rodriquez ave, quezon city 1102 philippines telefax (632) 727 5543 e-mail: nerj56@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. presented at the surgical innovation contest (1st place) philippine society of otolaryngology head and neck surgery 49th annual convention, westin philippine plaza hotel, manila, december 1, 2005. philipp j otolaryngol head neck surg 2006; 21 (1,2): 47-50 c philippine society of otolaryngology – head and neck surgery, inc. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations 46 philippine journal of otolaryngology-head and neck surgery room where a skin abrasion (fig. 1) and subcutaneous emphysema were noted over the anterior neck. a neck ct scan (figs. 2 & 3) showed diffuse subcutaneous/soft tissue emphysema involving the parapharyngeal, carotid, retropharyngeal, submandibular, supraclavicular and posterior cervical spaces, and soft tissue fullness in the region of the larynx. the cricoid cartilage was splayed laterally with a possible posterior fracture. the arytenoid cartilages were slightly asymmetrical and the proximal trachea was slightly narrowed. flexible endoscopy showed diffuse laryngeal edema, cricoarytenoid subluxation, right , and anterior commissure prolapse. (figs. 4 & 5) under general anesthesia, the patient was positioned supine with neck slightly extended. a transnasal flexible laryngoscope was positioned to visualize the vocal folds and provide continuous videocam monitoring throughout the procedure (figs. 6 & 7). after preparing and draping, a 6-cm horizontal skin incision at the midinferior margin of the thyroid cartilage was carried through the subcutaneous tissue and platysma. subplatysmal flaps were elevated to the level of the hyoid bone superiorly and caudal edge of the cricoid cartilage inferiorly. the strap muscles were reflected laterally exposing the thyroid cartilage with healing fractures on both thyroid laminae (fig. 8) causing collapse of the laryngeal framework. further evaluation showed complete bilateral fractures of the anterolateral cricoid cartilage displacing it posteriorly (figs. 9 & 10). no mucosal injury was noted. these were approximated using nylon 3/0 (figs. 11 & 12). the thyroid cartilage laminae fracture was reduced using a fourhole “six-box type” microtitanium plate with a 4mm self-drilling, selftapping screw plating system (fig. 13). obviating the need for drill holes produced a tight screw-tissue interface in the thyroid cartilage. there also being a midline fracture, the plate was bent across the fracture line to conform to the pre-trauma thyroid cartilage curvature under endoscopic guidance. the closed-circuit monitoring system allowed us to maintain the position and size of the glottis and thyroid cartilage throughout stabilization closure in layers over suction drain and an external dressing completed the procedure. post-operative follow-up at 2 weeks showed good vocal fold function and arytenoid position, with no food regurgitation, signs of aspiration or penetration on fiberoptic endoscopic evaluation of swallowing (figs. 14 & 15). fig. 1 fig. 2 fig. 3 fig. 4 fig. 5 fig. 6 fig. 7 silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations philippine journal of otolaryngology-head and neck surgery 47 discussion rarely seen in ent emergency practice, external laryngeal trauma may be caused by vehicular accidents, accidental strangulation, assault, and falls4. laryngeal injuries may be classified as suggested by fuhrman5 (table below). fig. 9 fig. 10 fig. 8. healing fractures on both sides of thyroid cartilage fig. 11 fig. 12 fig. 13 fig. 14 fig. 15 fuhrman, g.m., et al, j. trauma, 1990 laryngotracheal injury classification class i ii iii iv v description of injury minor endolaryngeal trauma without detectable fracture edema, hematoma, minor mucosal disruption without exposed cartilage, nondisplaced fractures noted on computer tomographic scan massive edema, mucosal tears, exposed cartilage, cord immobility a class iii injury with more than two fracture lines or massive trauma to laryngeal mucosa complete laryngotracheal separation laryngeal injuries may be treated medically or surgically depending on initial laryngoscopic and ct scan findings. class i injuries (where the injury will likely resolve without surgical intervention and the airway is stable) can be safely managed with a minimum of 24 hours of close observation, head elevation, voice rest and humidification of inspired air. antibiotics and anti-reflux agents are recommended when laryngeal mucosa is disrupted and systemic steroids are often given to reduce laryngeal edema in class ii injuries1. nasogastric tube feedings should be considered in the presence of significant mucosal lacerations. serial flexible laryngeal examinations should be performed to evaluate the airway and healing prior to discharge1. the timing of surgery is an important determinant of final outcome in preserving voice quality and airway patency. indications for surgery range from establishing an airway to open reduction and internal fixation of laryngoskeletal fractures. surgical exploration is warranted in the presence of large mucosal lacerations, exposed cartilage, multiple or displaced cartilaginous fractures, vocal fold immobility, fractured silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations 48 philippine journal of otolaryngology-head and neck surgery cricoid, disruption of the cricoarytenoid joint, and lacerations involving the free margin of the vocal fold or anterior commissure (class iii-v injuries)1. fractures of the cartilages are reduced and can be stabilized using a variety of materials, including stainless steel wires, nonabsorbable suture, and miniplates6. if the fracture is comminuted, small fragments of cartilage with no intact perichondrium have to be removed to prevent chondritis1. as in this case, steel wires or sutures are not used for median or paramedian fractures of the thyroid cartilage because the 2-point fixation only results in flattening of the thyroid cartilage with subsequent airway problems and voice disorders. applying the principles of references: 1. underbrink m, pou anna. laryngeal trauma. grand rounds presentation, university of texas medical branch, department of otolaryngology. sept2003. available from http://www.utmb. edu/otoref/grnds/laryng-trauma-20030903. 2. thekdi a, carrau rl. fixation techniques in laryngeal trauma. operat tech otolaryngol head neck surg. 2002 dec; 13(4):277-280. 3. hirano m, bless dm. introduction and historical review. in hirano m, bless dm, editors. videostroboscopic examination of the larynx. san diego : singular publishing group; 1993: 120. 4. ikram m, naviwala s. case report: acute management of external laryngeal trauma. ear, nose & throat j. 2000 october; 79(10): 802-804. 5. furhman gm, stieg fh, buerk ca. blunt laryngeal trauma: classification and management protocol. j trauma. 1990; 30(1):87-92. 6. austin jr, stanley rb, cooper ds. stable internal fixation of fractures of the partially mineralized thyroid cartilage. ann otol rhinol laryngol. 1992; 101(1)76-80. adaptation fixation (previously validated in craniomaxillofacial surgery) to laryngeal fractures, the use of miniplates optimizes surgical repair and regeneration of normal laryngeal cartilage2. adaptation miniplates have the advantage of immediate stability of the larynx (less need for endolaryngeal stenting), ability to bridge large gaps (comminuted fractures), easier restoration of the preinjury geometry of the laryngeal framework1 and possible shorter hospital stay. endoscopic-guidance allows higher magnification minimizing iatrogenic mucosal damage during manipulation. disadvantages include additional costs for the patient and the need for the surgeon’s expertise and familiarity with the plating system being used. 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 featured grand rounds relapsing polychondritis is an auto-immune disease that can present with a variety of non-specific symptoms involving the ears, nose, throat, head and neck. although uncommon, we should be aware of this disease entity and should include it as a differential diagnosis in patients who complain of difficulty breathing. it is also prudent that we never forget to look at the larger picture beyond specific symptoms to understand and explain a patient’s condition. case an 18-year-old female was admitted at the pediatric emergency room (per) due to recurrent, non-productive cough associated with occasional difficulty of breathing. one year prior to this admission, the patient complained of on and off cough with no other associated symptoms. there was no improvement with antibiotics she was given at a local clinic and the cough spontaneously resolved only to recur. along with the recurrent cough, she eventually experienced difficulty of breathing and found herself in and out of the hospital, treated for bronchial asthma or pulmonary tuberculosis. due to the symptoms’ recurring and worsening nature, the family consulted at our institution, where she was referred to the orl service for further evaluation. on examination, she exhibited hoarseness, occasional stridor and difficulty of breathing. she also had a characteristic saddle nose deformity. flexible nasolaryngotracheoscopy revealed a smooth extraluminal bulge extending from the area of the subglottis up to the second tracheal ring, at the 4 to 7 o’clock position of the neck. a neck soft tissue lateral (stl) film showed widening of the prevertebral soft tissue spaces with irregular calcifications at the level of c4 to c6 pushing the trachea anteriorly, causing narrowing of the tracheal air column (figure 1). ct scans revealed a homogenous, ill-defined mass, posterolateral to the trachea, pushing the trachea anteriorly (figure 2). a ct-guided aspiration biopsy (ct-gab) was deferred by the radiologist who opined that the biopsy would be technically difficult since the mass was small and adjacent to the vessels. prophylactic tracheostomy and open biopsy were recommended but no consent was given by the family and they opted to go home. four months after, the patient returned to the per with difficulty of breathing. she was also noted to have bilateral auricular perichondritis and ocular redness relapsing polychondritis charina melinda c. elgar-reyes, md patrick joseph a. pardo, md 1department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: charina melinda c. elgar-reyes, md department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax: (632) 525 5444 email: chow_md@yahoo.com reprints will not be available from the author. philipp j otolaryngol head neck surg 2009; 24 (1): 32-34 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 33 philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 featured grand rounds which were described by the mother as usually associated with her episodes of dyspnea. an emergent tracheostomy and suspension laryngoscopy were performed, revealing marked enlargement of the cricoid and arytenoid cartilages. both appeared to be heavily calcified. the thyroid cartilage was thinned out and was laterally splayed. on tracheoscopy, a smooth, mucosal swelling and smooth tracheal rings with concentric narrowing were seen. an open biopsy revealed an extraluminal hard, gritty mass adherent to the thyroid cartilage, posteriorly extending from the thyroid notch to the first tracheal ring. biopsy specimens measuring approximately 1.5 x 1.5 cm aggregate diameter were sent for histopathology which revealed fragments of mature hyaline cartilage and lamellar bone with fragments of fibrocartilaginous tissue of chronic non-specific inflammation. with the history of recurrent cough and dyspnea, saddle-nose deformity, binaural perichondritis, ocular redness/inflammation and histologic finding of cartilage inflammation, an assessment of relapsing polychondritis was made. she was referred to the rheumatology service for further evaluation and started on steroids with note of improvement of her symptoms. discussion relapsing polychondritis is a rare, auto-immune condition. it is characterized by recurrent inflammation leading to destruction of cartilage and other connective tissues. the ear, nose and tracheobronchial cartilage are most commonly affected.1 males and females are affected equally with an average age at diagnosis of 51 years old. only a few cases of relapsing polychondritis have been reported in children.2 it is believed that auto-antibodies to cartilage components specifically to collagen type ii cause inflammatory infiltration and cellular mechanisms involving lysosomal enzyme release and eventually result in the destruction of the cartilage due to the following mechanisms: excessive release of proteolytic enzymes by chondrocytes, down-regulation of collagen synthesis and autoimmune reactions against cartilage intercellular matrix components.3 histopathologic studies reveal cartilage destruction with loss of basophilic staining and islands of lymphocytic infiltration. subsequently, fragmentation of cartilage occurs with replacement by fibrous tissue.4 relapsing polychondritis most often manifests as swelling and erythema of the ear (88%) and arthralgias (81%). repeated auricular inflammation, scarring and retraction may cause the appearance of “cauliflower ears.” ocular inflammation manifests in almost 60% of patients.5,2 relapsing polychondritis may also result in dermatologic, cardiac, renal and neurologic manifestations. respiratory involvement is the most common cause of death.6 chondritis may affect the external nares, nasal septal turbinates, eustachian tubes, epiglottis, larynx, thyroid, cricoid, arytenoid, trachea and bronchi. nasal chondritis involves the distal part of the nasal septum and may lead to a saddle nose deformity. laryngotracheal involvement may initially manifest as recurrent cough. hoarseness, dyspnea, anterior neck pain, stridor and wheezing may also be observed. the obstruction is due to figure 1. neck soft tissue lateral (stl) film showing widening of prevertebral soft tissue spaces with irregular calcifications at the c4 to c6 level. figure 2. ct scan showed homogenous, ill-defined mass, posterolateral to the trachea. 34 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 featured grand rounds edema, vocal cord palsy and fixed subglottic or bronchial stenoses. this may suddenly exacerbate to dynamic airway collapse necessitating the need for tracheostomy.1,5 lifethreatening respiratory involvement is more common in females with a 2.6:1 ratio.4 due to the wide-spectrum of signs and symptoms and their non-specificity, a diagnosis of relapsing polychondritis is often only attained a few years after the first manifestation of the disease and after repeated consults with various specialists. the time from onset of initial symptoms to diagnosis varies from 8 months to 13 years.4 mcadam, et al,7 proposed diagnostic criteria based on the most common clinical features of relapsing polychondritis. this was further modified by damiani and levine8 (see table 1): references 1. prakash ubs. uncommon causes of cough accp evidence-based clinical practice guidelines. chest 2006; 129(1). 2. soto-romero i, fustes-morales aj, de leon-bojorge b, contreras-ruiz j, ruizmaldonado r. relapsing polychondritis: a pediatric case. pediatr dermatol 2002; 19(1): 60-63. 3. sacco o, fregonese b. severe endobronchial obstruction in a girl with relapsing polychondritis: treatment with nd yag laser and endobronchial silicon stent. eur respir j 1997; 10: 494–496. 4. sarodia bd, dasgupta a and mehta ac. management of airway manifestations of relapsing polychondritis: case reports and review of literature. chest 1999;116;16691675. 5. kent pd, michet cj and luthra hs. relapsing polychondritis, curr opin rheumatol 2004; 16(1):56-51 6. alatas f, ozkan r, metintas m, moral h, erginel s, ucgun i. relapsing polychondritis. respirology 2003; 8:99-103. 7. mcadam lp, o’hanlan ma, bluestone r and pearson cm. relapsing polychondritis. prospective study of 23 patients and a review of the literature. medicine 1976; 55:193– 215. 8. damiani jm and levine hl. relapsing polychondritis. laryngoscope 1979; 89: 929– 46. 9. peebo bb, peebo m and frennesson c. relapsing polychondritis: a rare disease with varying symptoms. acta ophthalmol scand 2004; 82: 472–475 10. lee cc and singer aj. respiratory failure due to subglottic stenosis from relapsing polychondritis. table 1. clinical diagnostic criteria for relapsing polychondritis:6 clinical features mcadam, et. al.7 damiani and levine8 the presence of three or more of the following criteria: • recurrent chondritis of both auricles • nonerosive inflammatory polyarthritis • chondritis of nasal cartilages • ocular inflammation (conjunctivitis, keratitis, scleritis/episcleritis and/or uveitis) • chondritis of the respiratory tract involving laryngeal and/or tracheal cartilage • audiovestibular damage (neurosensory hearing loss, tinnitus, and/or vertigo) the presence of one of the following criteria: • three or more of mcadam’s signs (histological confirmation is not necessary) • one or more of mcadam ’s signs with positive histological confirmation by biopsy of the cartilage • involvement of two or more separate anatomical locations with response to steroids and/or dapsone with narrowing or collapse of the airways. bronchoscopy must be done with caution as it may cause dyspnea, airway collapse, hypoxia, asphyxia and death.4 bronchoscopy in this patient revealed an inflamed and edematous epiglottis with progressive concentric narrowing of the tracheal space. a computed tomography (ct) scan can show deformity or circumferential thickening of the cricoid or tracheal cartilage, edema and fibrosis or ossification of the soft tissues.6 the course of relapsing polychondritis may vary from immediate death to a relatively benign and painless course for several years. the prognosis is based on the degree of respiratory and cardiovascular involvement.2 corticosteroids are the mainstay of treatment in relapsing polychondritis. this is due to their antiinflammatory and anti-chondrolytic properties. nonsteroidal anti-inflammatory drugs, dapsone and colchicines may be used for mild cases. immunosuppressive therapy in the form of cyclophosphamide, azathioprine and cyclosporine is used for severe cases.2,5 our patient was initially treated with hydrocortisone 100 mg iv every 12 hours and was later shifted to prednisone 40 mg per day. her disease was sufficiently controlled with this medication. tracheostomy, as was performed in our patient, may be necessary when there is respiratory distress and subglottic involvement. other possible adjuncts to medical therapy include continuous positive airway pressure for symptomatic relief, and metallic stent placement.5,10 our patient presented with five of mcadam’s signs namely: recurrent chondritis of both ears, chondritis of nasal cartilages, chondritis of the laryngotracheal cartilage and ocular inflammation. hence, a diagnosis of relapsing polychondritis was established. there is no specific laboratory exam for relapsing polychondritis. however, normocytic, normochromic anemia, mild leukocytosis, thrombocytosis, hypergammaglobulinemia and elevated esr are often observed.6,9 our patient manifested with normocytic, hypochromic anemia, mild leukocytosis and with thrombocytosis. bronchoscopy is an indispensable tool in establishing the exact site, nature and severity of airway involvement. it may show an inflammation of the tracheobronchial tree philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 case reports philippine journal of otolaryngology-head and neck surgery 27 abstract objective: to describe an intranasal mass initially diagnosed and treated as benign that eventually turned out to be a malignant extramedullary plasmacytoma of the maxillary sinus and to review the literature on its presenting signs and symptoms, diagnosis, management and pathophysiology. methods: design: case report setting: tertiary public hospital patient: one results: a 45-year-old male with persistent nasal obstruction and intermittent epistaxis underwent several biopsies of a mass shown on computed tomography scans as heterogeneously enhancing, expansile, occupying the left maxillary sinus with extension into the left nasal cavity with areas of erosion. immunohistochemical staining was negative for cytokeratin (ck) and leukocyte common antigen (lca). complete excision yielded a final histopathologic interpretation of plasmacytoma. laboratory examinations excluded multiple myeloma. the final diagnosis was extramedullary plasmacytoma and he was treated with post-operative adjuvant radiotherapy. conclusion: plasmacytoma may present in the sinu-nasal region and be part of a systemic disease like multiple myeloma. a high index of suspicion and thorough initial histopathological work-up may help in establishing a definitive diagnosis and providing optimum treatment. key words: plasmacytoma, plasma cell tumor, multiple myeloma, plasma cell myeloma, extramedullary plasmacytoma plasmacytomas represent a localized proliferation of plasma cells. they may be primary or secondary to disseminated multiple myeloma and may arise from osseous (medullary) or nonosseous (extramedullary) sites. primary extramedullary plasmacytomas can be solitary or multiple.1 extramedullary plasmacytomas are localized plasma cell neoplasms that occur within soft tissues. by definition, they cannot occur within bone. they account for 1-2% of all plasma growths and have a predilection for the upper respiratory tract without specific manifestations. extramedullary plasmacytoma in the maxillary sinus jennifer de silva-leonardo, md1 rosario r. ricalde, md1 jose roberto v. claridad, md1, 2, 3, erasmo gonzalo d.v. llanes, md1, 4,5 1department of otorhinolaryngology head and neck surgery quirino memorial medical center 2department of otorhinolaryngology head and neck surgery far eastern university –nicanor reyes memorial foundation medical center 3department of otorhinolaryngology head and neck surgery capitol medical center 4department of otorhinolaryngology college of medicine philippine general hospital university of the philippines manila 5department of otorhinolaryngology head and neck surgery rizal medical center philipp j otolaryngol head neck surg 2009; 24 (2): 27-31 c philippine society of otolaryngology – head and neck surgery, inc. correspondence: jennifer de silva-leonardo, md department of otorhinolaryngology head and neck surgery quirino memorial medical center katipunan road ext., project 4, quezon city 1108 philippines phone: (632) 421 2250 local 117 fax: (632) 421 9289 e-mail address: jendesilvaleonardo@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with an organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at the 10th annual northeast manila ent-hns training consortium research contest (2nd place), veterans memorial medical center, quezon city, philippines february 20, 2009; clinical case report contest, philippine society of otolaryngologyhead and neck surgery mid-year convention, bohol tropics hotel, bohol, philippines april 24, 2009. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 case reports 28 philippine journal of otolaryngology-head and neck surgery approximately 80% involve the paranasal sinuses, pharynx, nasal cavity, gums and oral mucosa.2 extramedullary plasmacytomas in the head and neck are submucosal in 80%.3 they have a lower rate of conversion to disseminated multiple myeloma compared to solitary plasmacytoma of the bone. progression to multiple myeloma may occur in 20-30%. the 10year survival rate is 50-89%.2 case report a 45-year-old male with left sided nasal obstruction of four months’ duration also experienced persistent rhinitis and episodes of epistaxis which resolved spontaneously. there was no history of head trauma, hypertension, mucosal or vascular injury or other systemic diseases. he self-medicated with nasal decongestants without relief. a transnasal punch biopsy performed at another institution was read as inflammatory nasal polyp and he was treated for nasal polyposis and sinusitis with unrecalled antibiotics and steroids, still without relief. by the time he consulted at our institution for a second opinion, the mass had grown and there was a prominent bulge on the patient’s left cheek. a red and smooth mass protruding from the left nasal cavity could also be seen on posterior rhinoscopy. the nasal septum was deviated and examination of the oral cavity showed a palatal bulge on the ipsilateral side (figure 1). a paranasal sinus ct scan with contrast showed a heterogeneouslyenhancing expansile soft tissue mass in the left maxillary sinus with extension into the left nasal cavity, opacification of the left frontal sinus and both ethmoid and left sphenoid sinuses. the posterior and anteromedial wall of the left maxillary sinus and left maxillary alveolus showed irregular areas of erosion. calcific foci were seen at the periphery of the mass with bone fragments from the erosion or dystrophic calcification and the nasal septum was shifted to the right. figures 2 and 3 show the axial and coronal ct scans of the patient with the pertinent findings. a second biopsy of the sinonasal mass through a caldwell-luc approach revealed a thinned-out anterior wall of the left maxillary sinus containing a friable pink meaty mass with rubbery gray areas. histopathologic examination revealed extensive necrosis and inflammation with a focus of atypical cells suspicious for malignancy. a third biopsy through the same gingivobuccal incision yielded a histopath diagnosis of malignant round cell tumor versus acute inflammatory pattern. immunostaining with cytokeratin and leukocyte common antigen were both negative. a denker’s procedure revealed an absent anterior maxillary wall and eroded medial wall but smooth, intact posterior and lateral walls. there was partial erosion of the anteromedial hard palate. the left figure 1. pre-operative photograph showing left palatal bulge figure 2. axial and coronal ct scans with contrast showing a heterogeneously enhancing mass in the left maxillary sinus. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 case reports philippine journal of otolaryngology-head and neck surgery 29 discussion extramedullary plasmacytomas comprise less than 1% of head and neck tumors.4 these are soft tissue plasma cell tumors found in patients with no evidence of bone marrow disease and with no findings on total body skeletal survey. however, bone erosions adjacent to the plasmacytoma may occur. approximately 80% of head and neck extramedullary plasmacytomas arise submucosally, the most common site being the sinonasal region.3 the etiology remains unknown but some occupations exposure to certain chemicals, radiation, viruses and genetic factors have been suggested as etiologic factors.5 our patient is an electrician who claims to have been exposed to unrecalled solvents or chemicals used to clean circuit boards and welding fumes. the average age of patients with plasmacytoma is about 60 with men being 3-4 times more affected than women. it occurs in all races but rates are higher in african americans and lower in the asian population.6 the most common initial signs and symptoms are nasal obstruction and epistaxis as in this case.2,3,7(see table 1) fine needle aspiration is non-diagnostic because of the limited tissue available for special staining and for complete histologic examination. therefore, incisional or excisional biopsy, depending on the size and location of the mass is necessary.3 deep biopsies must be taken as the tumor is submucosal and the mucosa may be thickened as the result of an inflammatory reaction.8 this may explain the initial punch biopsy diagnosis of chronic inflammation in our case. radiographic assessment shows local bone destruction in most patients with nasal cavity or maxillary sinus involvement.9 ct, mri and complete endoscopic examination of the aerodigestive and gastrointestinal tracts are required to determine the exact extent of the tumor and its respectability.8 ct allows improved depiction of the tumor and associated local invasion and bony destruction but remains non-specific.10 on gross examination, the masses are usually polypoid but can be sessile. they tend to appear granulomatous and red although some are yellow-gray, gray or dark brown. they are vascular and bleed easily and profusely.11 because the lesion is not common, the diagnosis is typically made on histologic examination with immunostaining in suspected cases. histologically, plasmacytomas are characterized by a diffuse or sheetlike proliferation of plasma cells with varying degrees of maturity and atypia. the nuclei are oval to round and eccentrically located with a dispersed (“clock-face”) nuclear chromatin pattern and a clear or halo area3 consistent with the microscopic description of the specimen examined from the patient. figure 3. axial and coronal ct scan, bone windows: expansile soft tissue mass in the left maxillary sinus extending into the left nasal cavity with irregular areas of erosion on the posterior and anteromedial wall; nasal septum markedly shifted to the right side. inferior turbinate was absent but the middle turbinate and deviated septum were intact. the mass occupied the entire left maxillary sinus and nasal cavity and was completely excised together with remaining bony fragments. the final histopathology reading was plasmacytoma, cytokeratinnegative, leukocyte common antigen (lca) – negative, hmb45negative, cd 138-positive. figure 4 shows a pictomicrograph of the specimen immunostained with cd 138. one month post-operatively, remission of the palatal bulge was noted. additional lab exams ruled out multiple myeloma and the patient underwent adjuvant radiotherapy and comanagement with the hematology-oncology service. his symptoms have not recurred. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 case reports 30 philippine journal of otolaryngology-head and neck surgery plasmacytomas may be confused histologically with other benign and malignant conditions such as benign reactive plasmacytosis, undifferentiated carcinoma, non-hodgkin’s lymphoma, malignant melanoma or esthesioneuroblastoma. therefore, immunohistochemical staining assists in typing the neoplastic and monoclonal nature of the cells3. cytokeratin, an intermediate filament protein of epithelial cells is present in squamous cell carcinoma. lca is seen in lymphoma and hmb 45 a melanoma associated antigen were all negative in our case except for cd 138. cd 138 or syndecan-1 is a glycoprotein found in simple epithelial, stratified epithelia, mesenchymal cells and lymphocytes. it is a good marker for multiple myeloma and reed-sternberg cell identification. the monoclonal antibody cd138/b-b4 can be used on formalin-fixed, decalcified biopsies to localise normal and neoplastic plasma cells on routine bone marrow sections.12 the reported conversion rate of extramedullary plasmacytoma to multiple myeloma is 15-20% and is associated with poor prognosis.13 in a patient with symptoms of myeloma, standards for diagnosis currently require confirmation of one major and one minor criterion or three minor criteria14 (table 2), ruling it out in our case. based on the documented radiation sensitivity of plasma cell tumors, the accepted treatment is radiotherapy although surgery provides the same results when a lesion can be completely resected. like all carcinomas involving the maxillary sinus, the basic surgical starting point is maxillectomy.11 as in our patient, the latter may also be combined with radiotherapy depending on resectability of the lesion and may provide the best results 7-9,15 complete resection including lymph node dissection of palpable nodes should be attempted for extramedullary plasmacytoma.3 chemotherapy may be considered for patients with refractory disease or relapse.17 the clinical course of extramedullary plasmacytoma is more favorable and has better prognosis than multiple myeloma and solitary plasmacytoma of bone, excluding the multiple organ metastases that occur during the end stage of plasma cell malignancy. long-term follow-up is necessary in order to monitor disease recurrence after surgical excision and post surgical radiotherapy.2 a b figure 4. a. low power b. high power views. cd 138 immunohistochemical stain: note sheets of plasma cells with varying degrees of maturity and atypia table 1. initial signs and symptoms of extramedullary plasmacytoma authors ersoy,sanlier, yigit, halefoglu, ucak and altuntas.2 gross, elishar, maly , sichel3 galieni, cavo, pulsoni, et.al.7 nasal swelling and nasal obstruction soft tissue mass or swelling, or airway obstruction, nasal mass, nasal discharge, epistaxis, facial pain mimicking recurrent sinusitis, diffuse infiltration of neighboring structures such as orbit, hard or soft palate, skin or skull base swelling, headache, nasal discharge, epistaxis, nasal obstruction, sore throat, hoarseness, dysphonia, dysphagia, epigastric pain, hemoptysis signs and symptoms table 2. major and minor criteria in diagnosing multiple myeloma14 major criteria • a biopsy-proven plasmacytoma. • a bone marrow sample showing 30% plasma cells. • elevated monoclonal immunoglobulin levels in the blood or urine • a bone marrow sample showing 10%-30% plasma cells. • minor monoclonal immunoglobulin levels in blood or urine • imaging studies revealing holes in bones due to tumor growth • antibody levels (not produced by the cancer cells) in the blood are abnormally low. minor criteria references 1. soesan m, paccagnella a, chiarion-sileni v, salvagno l, fornasiero a, so zorat p-l, et al. extramedullary plasmacytoma: clinical behaviour and response to treatment. ann oncol. 1992;3:51–57. 2. ersoy o, sanlier t,yigit o, halefoglu am, ucak s and altuntas y, extramedullary plasmacytoma of the maxillary sinus. acta otolaryngol. 2004; 124: 642-644. 3. gross m, elishar r, maly b, sichel jy. maxillary sinus plasmacytoma. imaj. 2004; 6:119-120. 4. kost, km. plasmacytomas of the larynx. j otolaryngol. 1990;19:141-6. 5. salmito l, pinto s, campagnoli eb, leon je, lopes ma, jorge j. maxillary lesion presenting as a first sign of multiple myeloma. med oral patol oral cir bucal. 2007;12: e344-7. 6 . kyle ra, gertz m, witzig t, lust j, lacy m, dispenzieri a, et. al. review of 1027 patients with newly diagnosed multiple myeloma.mayo clin proc. 2003; 78:21-33. 7. galieni p, cavo m, pulsoni a, avivisati g, bigazzi c, neri s, et. al. clinical outcome of extramedullary plasmacytoma. haematologica. 2000; 85:47-51. 8. alexiou c, kau rj, dietzfelbinger h, kremer m, spiess jc, schratzenstaller b, et al. extramedullary plasmacytoma: tumor occurrence and therapeutic concepts. cancer. 1999; 85:2305-14. 9. liebross rh, ha cs, cox jd, weber d, delasalle k, alexanian r et. al. clinical course of solitary extramedullary plasmacytoma. radiother oncol. 1999 sep; 52(3):245-9. 10. bourjat p, kahn jl, braun jj. imaging of the solitary maxilla-mandibular plasmacytoma. radiol. 1999; 80:859-62. 11. thawly s, panje w, batsakis j , lindberg r. comprehensive management of head and neck tumors.2nd ed . pennsylvania : wb saunders 1999 12. wijdene j, dore jm, clement c, vermot-descroches c. cd138. j biol regul homeost agents. 2002; 16:152-5. 13. wanebo h, geller w, gerold f. extramedullary plasmacytoma of the upper respiratory tract recurrence after latency of thirty-six years n y state j med 1966; 66:1110-3 14. bayer-garnier ib, prieto vg, smoller br. detection of clonality with kappa and lambda immunohistochemical analysis in cutaneous plasmacytomas. arch pathol lab med 2004;128:645 8 15. hu k, yahalom j. radiotherapy in the management of plasma cell tumors. oncology (huntingt). 2000;14:101-8,111;discussion 111-2. 16. dimopoulos ma, kiamouris c, moulopoulos la. solitary plasmacytoma of bone and extramedullary plasmacytoma. hematol oncol north am. 1999; 13:1249-57. 17. luh s, lai ys, tsai ch,and tsao t .extramedullary plasmacytoma (emp): report of a case manifested as a mediastinal mass and multiple pulmonary nodules and review of literature. world j surg oncol. 2007; 5: 123. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 case reports philippine journal of otolaryngology-head and neck surgery 31 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 from the viewbox philippine journal of otolaryngology-head and neck surgery 49 this 37 year-old male patient underwent high resolution ct imaging of the face including paranasal sinuses following trauma. computed tomography (ct) has a well-established role in the assessment of the facial bones in the context of trauma, in particular for fractures involving the paranasal sinuses and orbit. high resolution imaging permits isotropic reconstruction in multiple planes. its use in imaging the contents of orbit itself is more select, with both direct clinical examination and even orbital ultrasound used to assess the globe and lens of the eye.1 traumatic dislocation of the lens of the eye may entail the partial or complete translocation of the lens from its normal position within the anterior aspect of the eye.2 the high attenuation lens ‘floats’, within the vitreous of the globe (figures 1, 2 and 3). complete dislocation of the lens of the eye always review the complete study correspondence: dr. ian c. bickle department of radiology ripas hospital bandar seri begawan ba1710 brunei darrusalam tel: (673) 8 612182 fax: (673) 224 2690 email: ian@bickle.co.uk reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (1): 49-50 c philippine society of otolaryngology – head and neck surgery, inc. figure 1. coronal ct of the orbit. the lens of the right eye lies posteriorly within the globe of the eye (arrow) in keeping with a lens dislocation. ian c. bickle, mb bch bao, frcr department of radiology ripas hospital, bandar seri begawan brunei philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 50 philippine journal of otolaryngology-head and neck surgery from the viewbox following trauma to the face the injuries may be multiple and cross sub-speciality boundaries, but one should be alert to all injuries. in reviewing ct images one should be forensic in the review of all the anatomy covered, even it is not related to the original clinical query or not pertinent to one’s own clinical speciality. as an old mentor once told me, ‘before you take the film down, have one last paranoid look.’ learning point: always review the entirety of the imaging performed despite the focus of one’s clinical or speciality interest. references 1. kubal ws. imaging of orbital trauma. radiographics. 2008; 28: 1729-1739 2. hardjasudarma m, rivera e, ganley jp, mcclellan rl. computed tomography of traumatic dislocation of the lens. emerg radiol. 1994; 1: 180-182 figure 2. sagittal ct of the orbit. the lens of the right eye (arrow) is situated posteriorly within the globe of the eye. figure 3. axial ct of the orbits. note the dislocated right lens (horizontal arrow); compare with the normal position of the left lens of the eye (vertical arrow). silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 case reports philippine journal of otolaryngology-head and neck surgery 31 abstract objective: to present a case of a benign orbito-maxillary tumor behaving as an invasive, expansive malignancy. design: case report setting: a tertiary care hospital in metro manila patient: a 4 ½-year-old boy with a seven month history of right orbito-maxillary mass, proptosis and epiphora. result: a series of biopsies were done before a definite diagnosis was made due to inconsistencies in the histopathologic findings, clinical picture, and the radiologic presentation of the case. after diagnosis, appropriate intervention resulted in a dramatic decrease in the size of the mass. at present, the patient is disease-free and asymptomatic. conclusion: histopathologic diagnosis of inflammatory pseudotumor is difficult and differentiating it from malignant tumors is often a concern for otolaryngologists and pathologists. in spite of an initial malignant biopsy result, the combination of clinical signs and symptoms and radiologic findings of an infiltrative mass lesion, should not discount the possibility of a benign entity such as inflammatory pseudotumor for which treatment is conservative. keywords: orbito-maxillary mass, inflammatory pseudotumor, pseudotumor, orbital pseudotumor an orbito-maxillary mass may primarily be an orbital lesion extending into the maxillary sinus or a primary maxillary sinus lesion extending into the adjacent orbit. we present a case of 4 ½-year-old boy with an invasive right orbito-maxillary mass. case report seven months prior to consult, our patient presented with right lower eyelid swelling (figure 1-a and 1-b) accompanied by non-productive cough and watery nasal discharge. there was no history of trauma. maternal and birth history were unremarkable. developmental history was at par with age. past medical history included an allergy to contrast (dye) with a family history of brain cancer (maternal grandmother) and leukemia (paternal uncle). he was brought to an ear, nose and throat (ent) specialist who diagnosed sinusitis and gave unrecalled antibiotics for 2 weeks which did not improve his condition. six months prior, the persistence of the symptoms prompted a consultation with another ent specialist. orbital magnetic resonance imaging (mri) revealed a 3.2 x 2.7 x 2.8 cm mass within the inferior half of the right orbit and the right maxillary sinus with destruction of the orbital floor (figure 2). there was also superior displacement and proptosis of the right globe. he was referred to an ophthalmologist who biopsied the mass via an infraciliary approach. the report revealed “small round cell tumor to consider non-hodgkin’s lymphoma, neuroendocrine tumor “(figure 3) with a note from the pathologist that the specimen had inflammatory pseudotumor of an orbitomaxillary mass masquerading as a malignancymaria cristina c. da silva, md1, joel a. romualdez, md1, norberto v. martinez, md 1,2 1department of otolaryngology head and neck surgery st. luke’s medical center 2 department of otolaryngology head and neck surgery santo tomas university hospital correspondence: maria cristina c. da silva, md department of otolaryngology head and neck surgery st. luke’s medical center 279 e. rodriquez ave, quezon city 1102 philippines telefax: (632) 727 5543 e-mail: peachiemd@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this report. presented at the interesting case contest (2nd place) philippine society of otolaryngology – head and neck surgery midyear convention, puerto princesa city, palawan, april 2005. philipp j otolaryngol head neck surg 2006; 21 (1,2): 31-36 c philippine society of otolaryngology – head and neck surgery, inc. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 case reports 32 philippine journal of otolaryngology-head and neck surgery figure 1-a: right lower eyelid swelling figure 3: small round cell tumor to consider nonhodgkin’s lymphoma, neuroendocrine tumor excessive crushing artifact precluding a definite diagnosis. a repeat biopsy was suggested. a trial of oral prednisone at 0.2 mg/kg/day or 4 mg daily for 1 month apparently decreased the size of the mass. the dose was then tapered to 2 mg once a day then 1 mg daily for 2 weeks each but the mass increased in size again. after 2 months of steroid therapy, an orbital computed tomography (ct) scan revealed a 3.6 x 2.7 x 2.7 cm mass within the right orbit and maxillary sinus (figure 4) slightly larger than previously seen on mri. orbital floor lysis, as well as the superior displacement and proptosis of the right globe, were still evident. the patient was referred to our institution for further management. he presented with a 2 x 2 cm mass over the right lower eyelid and slight proptosis of the right eyeball with unremarkable visual acuity, extraocular muscle (eom) motility, and fundoscopic exam. an incision biopsy via caldwell-luc approach revealed “small round cell tumor, consider olfactory neuroblastoma” (figure 5). special staining was negative for chromogranin and lca (leukocyte common antigen) but nse (neuron-specific enolase) was positive, consistent with olfactory neuroblastoma. a positive nse does not confirm the diagnosis nor does a negative chromogranin and lca rule it out because it is not unusual for this kind of tumor to stain only focally. a repeat biopsy was again recommended by the pathologist. we requested a ct scan of the paranasal sinuses (figure 6), which did not show interval changes from previous ct and mri studies. closer examination of all radiologic studies revealed an unremarkable olfactory cleft with no sign of sinus wall bowing characteristic of an olfactory neuroblastoma. clinically, the mass had not increased in size though 6 months had passed since the first biopsy. doubting the diagnosis of olfactory neuroblastoma for lack of clinical and radiologic corroboration, another biopsy was done. the histopathologic reading of “chronic and acute inflammation negative for malignancy” (figure 7) was not compatible with the bony lysis seen on ct and mri. we decided to debulk the tumor for both diagnostic and therapeutic purposes. the specimen was signed out as “inflammatory pseudotumor, right infraorbital area” (figure 8). the patient was given oral prednisone at 2 mg/kg /day or 40 mg daily for 2 weeks, 32 mg once a day for 2 weeks, 24 mg once a day for 2 weeks and 24 mg daily for 4 weeks. 5 months post-surgery, the patient remained asymptomatic with no sign of recurrence of the mass (figure 9). a repeat ct scan of the paranasal sinus revealed significant regression of the previously noted inferior orbital soft tissue mass (1 x 0.4 cm) (figure 10-a). the proptosis and superior displacement of the right globe was no longer appreciated (figure 10-b). steroid therapy was discontinued and a 6-month review scheduled. figure 1-b: view from the right side r l r figure 2: orbital mri: mass within the inferior half of the right orbit and right maxillary sinus r l silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 case reports philippine journal of otolaryngology-head and neck surgery 33 discussion orbital mass lesions may arise primarily within the orbit, extend from contiguous structures, or be metastatic from a distant primary malignancy. primary orbital masses include congenital, vascular, neural, and mesenchymal tumors. other types of lesions masquerading as true neoplasms include lymphoproliferative disorders, autoimmune diseases, and infectious processes. congenital lesions include dermoid cysts, hamartomas and teratomas. the following table (table 1) shows the most common pediatric tumors which present in the orbital area. an olfactory neuroblastoma was considered in our second biopsy but ct and mri studies of our patient did not support this diagnosis. olfactory neuroblastoma (esthesioneuroblastoma) displays a variety of imaging characteristics and aggressiveness, characterized by bowing of the sinus walls, usually replacing the turbinates, septum, and sinus walls with extension into contiguous areas 12. not only did ct and mri studies of our patient not show any of these findings, the unremarkable olfactory cleft cast more doubt on this diagnosis. the acute and chronic inflammation seen on the third biopsy was possible following initial response to steroids but does not explain the lysis or bone destruction evident in the ct and mri studies. the great discrepancy between malignancy and mere inflammation prompted tumor debulking to obtain a larger specimen and once and for all, put this diagnostic dilemma to rest, finally revealing inflammatory pseudotumor. the first specimen had excessive crushing artifacts. microscopically, small round cells which stained blue were identified. small round inflammatory cells seen clumped or grouped together can make them seem neoplastic. because small round cells are non-specific, special stains are needed (table 2). unfortunately, the excessive crushing of the specimen made this virtually impossible to accomplish. the next biopsy again showed small round blue cells in clusters suggesting a neoplasm. special staining negative for chromogranin and lca but positive for nse supported a neuroendocrine tumor such as olfactory neuroblastoma but was not confirmatory. nse is not a specific marker and needs chromogranin to stain positive for the diagnosis to be consistent with olfactory neuroblastoma. the pathologist could not commit to a diagnosis and suggested another biopsy, which gave a clue to the inflammatory nature of this disease. microscopically, inflammatory cells such as lymphocytes, plasma cells and histiocytes were seen. however, the specimen was signed out only as acute and chronic inflammation because such cells are non-specific findings in any inflammatory process. but these cells also could very well be present at the surface of any malignant tumor. tumor debulking provided a clearer pattern of cellular distribution with inflammatory cells present throughout the whole specimen. the pathological picture of dense fibrous tissue with aggregates of lymphocytes, plasma cells and histiocytes is the hallmark of inflammatory pseudotumor, but this basis is non-specific3. it is precisely the non-specific nature of the lesion which makes diagnosis difficult and limits the diagnostic yield of small biopsies. it was not that the specimens submitted were inadequate; the non-specific nature of the lesion could only be confirmed by getting the specimen in toto – a practice not commonly employed when dealing figure 5: small round cell tumor, consider olfactory neuroblastoma r l figure 6: pns ct: no significant interval changes figure 4: orbital ct: slightly larger mass within the right orbit r l silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 case reports 34 philippine journal of otolaryngology-head and neck surgery figure 9: the patient was asymptomatic 6 months post-surgery table 1. common orbital tumors in the pediatric age group age of presentation 2-5 yrs. old before 5 yrs old 2-5 yrs. old 11-20 and 51-50 older age group disease rhabdomyosarcoma retinoblastoma neuroblastoma (metastatic) olfactory neuroblastoma histiocytosis (chronic form) sex predilection male predominance none male predominance no predilection incidence 4.5/ million 1 in 18,000 10/ million rare rare orbital sign/symptom unilateral proptosis leukokoria or proptosis proptosis proptosis exophthalmos with a suspicious malignant-looking mass in an inaccessible area in the head and neck. inflammatory pseudotumor (ipt) is a rarely occurring lesion with no identifiable local or systemic causes. the lesions mimic expansive, invasive, malignant tumors both clinically and radiologically, hence the term “pseudotumor”. ipt most commonly involves the lung and orbit. it has been reported in nearly every site in the body but is most common in the orbit and rare in the sinuses5. in our case, we believe that the mass was primarily an orbital lesion which extended into the maxillary sinus and not the other way around. the behavior of ipt can be quite unpredictable3. some resolve spontaneously and others respond to corticosteroids. in some cases, tapering steroid doses cause lesions to recur. for lesions not responding to steroids, subtotal excision with or without radiotherapy may be required3. ipt is an idiopathic inflammatory lesion although various stimuli may cause it to develop such as unrecognized organisms, minor trauma, smoking, and chronic irritation by cocaine abuse1. the characteristic feature of ipt lies not in the inciting agent but in its response to a trigger agent. according to williams et al4, the underlying mechanism in the development of ipt is localized derangement in the immune response after a particular initial insult. other authors relate ipt to production of mediators of inflammation which stimulate proliferation of fibroblasts, extravasation of neutrophils and activation of procoagulant activity of the vascular endothelium. it also induces production of acute phase reactants, proteolysis and neurologic disturbances1. the most frequent symptom is swelling and pain although other local symptoms depend on the site of involvement. a very similar case was seen in japan by takashi nakagawa et.al.2 where a 63 year old male presented with left eye lacrimation and exopthalmos. ct and mri studies strongly suggested a malignant tumor of the maxillary sinus. a biopsy was also done which revealed ipt. like our case, this patient did not respond to corticosteroids. because total excision of the mass could not be achieved, debulking was done and there have been no observed further changes in the size of the mass several months after. another study done in new york by pm som et al6 discussed 6 cases of ipt of the maxillary sinus. this study showed that ipt of the maxillary figure 7: chronic and acute inflammation negative for malignancy figure 8: inflammatory pseudotumor silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 case reports philippine journal of otolaryngology-head and neck surgery 35 table 2. immunohistochemical stains lca cytokeratin nse desmin vimentin chromogranin synaptophysin tumors lymphoma epithelial tumors neuroendocrine tumors muscle tumors mesenchymal tumors neuroendocrine tumors neuroendocrine tumors sinus causes bone changes on ct and mri, findings that mimic a malignant tumor. heathcote and safneck3 reported a case of a 5-year-old boy who presented with eyelid swelling and was admitted with a diagnosis of orbital cellulitis. a ct scan performed the day after admission revealed a mass in the lateral orbit. rather than the presumptive diagnosis of rhabdomyosarcoma, a biopsy revealed sclerosing ipt. among the different ancillary procedures, ct scan has proven to be of value in defining the extension of ipt and its response to treatment. in the orbit, the most frequent radiologic characteristics are retrobulbar fatty infiltration, proptosis, eom enlargement and apical fat edema. in extraorbital locations in the head and neck, a mass lesion with sharp enhancement is consistently reported. ipt has an aggressive appearance and there is usually bone involvement like erosion, remodeling or sclerosis. the unifying histologic feature of ipt is the highly variable mixture of bland-looking spindle cells and inflammatory cells1. the liberation of cytotoxic proteins from eosinophil granules may promote fibrosis and may also contribute to the degeneration of the extraocular muscles in ipt. histopathologic diagnosis of ipt is difficult and differential diagnosis from malignant tumors is often a concern for otolaryngologists and pathologists. hence, coordination between these 2 specialties facilitates handling such difficult cases as this. the role of the ent specialist in correlating history, physical examination, ancillary procedures and histopathology in spite of disparities cannot be overemphasized. in spite of an initial malignant biopsy result, the combination of clinical signs and symptoms and radiologic findings of an infiltrative mass lesion, should not discount the possibility of a benign entity such as ipt for which treatment is conservative, and unnecessary and potentially mutilating surgery can be avoided. figure 10-a: regression of the globe soft tissue swelling r l figure 10-b: proptosis of the right was no longer evident r l acknowledgements: we thank dr. anthony calibo for help with statistical analysis, dr. francisco narciso for technical assistance and drs. gretchen navarro-locsin and bernabe singson for their scientific advise. references 1. sofie dv, hermans r, sciot r, crevits i, marchal g. extraorbital inflammatory pseudotumor of the head and neck: ct and mr findings in three patients. am j neuroradiol. 1999;20(6):1133-39. 2. nakagawa t, hatttori k, iwata n, hoshino t, sasaki t. a case of inflammatory pseudotumor in the maxillary sinus mimicking malignancy. practica oto-rhino-laryngologica. 2002;95(4):29. 3. heathcote j, safneck j. sclerosing inflammatory pseudotumor of orbit. proceedings of the united states & canadian academy of pathology annual meeting; 2002 feb 24; chicago , illinois . 4. williams sb. inflammatory pseudotumor of the major salivary glands: clinicopathologic and immunohistochemical analysis of six cases. otolaryngol head neck surg. 1993;109(16):548-51. 5. maldijan ja, norton ki, som pm. inflammatory pseudotumor of the maxillary sinus in a 15-year-old boy. am j neuroradiol. 1994;4(15):784-6. 6. som pm, brandwein ms, maldijan c, reino aj, lawson w. inflammatory psuedotumor of the maxillary sinus: ct and mr findings in six cases. ajr. 1994;163(3):689-92. 7. pickuth d, obrunner k, spielman rp. computed tomography and magnetic resonance imaging features of olfactory neuroblastoma: an analysis of 22 cases. clin otolaryngol. 1999;24(5):457-61. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 28 philippine journal of otolaryngology-head and neck surgery case reports abstract objective: to present our experience with the anterolateral thigh flap in reconstructing a full thickness defect of the buccal mucosa and cheek. methods: design: case report setting: tertiary private hospital patient: one results: a 36-year-old male with a t4an0m0 stage iva buccal carcinoma on the left underwent wide excision, marginal mandibulectomy and modified radical neck dissection with preservation of the spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle. the resultant through-and-through defect of the cheek skin measuring 8 x 6cm and buccal mucosa measuring 6 x 10 cm with a concomitant ¼ upper lip and 1/3 lower lip defect was reconstructed with an anterolateral thigh free flap. the patient recovered uneventfully and underwent adjuvant concurrent chemoradiotherapy 1 month post-operation. at 2 ½ months post-operation, he had no oral incontinence and could resume a normal diet with good speech. conclusion: the anterolateral thigh free flap is an excellent soft-tissue flap for reconstruction of a full thickness defect of the buccal area. key words: surgical flap; carcinoma, squamous cell; oral cancer resection of advanced head and neck malignancies can lead to extensive defects resulting in functional and aesthetic problems. when oncological resection is tailored to the reconstructive options available, margins of resection may be compromised. the introduction of microvascular free tissue transfers has broadened the options in head and neck reconstruction. the anterolateral thigh (alt) flap is a fasciocutaneous flap of the thigh that has not been as popular a choice as the radial forearm flap due to the variable anatomy of the vascular pedicle and the relatively difficult technique of dissection.1 in the philippine setting, there has been no reported case of reconstruction using the alt flap. we present our experience with the anterolateral thigh flap in reconstructing a through and through defect of the buccal mucosa and cheek. anterolateral thigh flap reconstruction of full thickness buccal defect samantha s. castaneda, md1,2,3 daniel m. alonzo, md1 rodney marc h. ramos, md1 1 department of otolaryngology head and neck surgery the medical city 2 department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center 3 department of otolaryngology head and neck surgery rizal medical center correspondence: samantha s. castaneda, md department of otolaryngology head and neck surgery the medical city ortigas avenue, pasig city 1600 phone: (632) 635 6789 loc.6250 to 6251 telefax: (632) 687 3349 email: docsamcastaneda@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. presented at the interesting case contest (3rd place) philippine society of otolaryngology head and neck surgery midyear convention, baguio city, april 2007. philipp j otolaryngol head neck surg 2008; 23 (1): 28-30 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 philippine journal of otolaryngology-head and neck surgery 29 case reports case report a 36-year-old male was admitted for a t4an0m0 stage iva buccal squamous cell carcinoma. physical examination centered on the oral cavity revealing a 5 x 5 centimeter fungating left buccal mucosal mass extending to the cheek and lip (figure 1). computed tomography scans from the zygoma to the clavicle with contrast showed erosion of the left posterior maxillary bone and hemimandible, and enlarged level 1 lymph nodes. figure 1. the tumor involving the cheek, lip and buccal mucosa. figure 2. extent of defect after resection following a multidisciplinary meeting to determine the best possible management, the patient underwent wide excision with frozen section of the margins. the resultant buccal mucosa defect measured 10 x 6 cm. one fourth of the upper lip and 1/3 of the lower lip was excised. the cheek skin defect measured 8 x 6 cm. marginal mandibulectomy from the 3rd molar to the canine (figure 2) and modified radical neck dissection with preservation of the sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve were also performed. figure 3. the alt flap after reconstruction of the defect simultaneous with the neck dissection, a separate team harvested the anterolateral thigh flap after determining the dimension of the defect. a 23 x 9 cm flap was harvested based on a musculocutaneous perforator of the descending branch of the lateral circumflex femoral artery. the anastomosis was performed between the vascular pedicle and the ipsilateral facial artery and vein (figure 3). philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 30 philippine journal of otolaryngology-head and neck surgery case reports the donor site was closed primarily. the entire operation lasted for 10 hours. the patient was extubated the following day, 12 hours after the operation. feeding was through a nasogastric tube for 7 days until mucosal wounds were fully healed. he was discharged on the 9th postoperative day without any complication. two and ½ months post-operation, the patient was on regular diet with good oral competence. he and his family were satisfied with his appearance, although secondary operations to decrease the bulk of the flap have been recommended. asked to rate appearance of the left thigh, his rating was “good.” the patient likewise had no complaints about the function of his left thigh (figure 4). references 1 hunt pm, burkey bb. use of local and regional flaps in modern head and neck reconstruction. curr opin otolaryngol head neck surg.2002; 10:249–255. 2 haddad-tame jl, chavez-abraham c, rodriguez d, reynoso-campo r, bello-santamaria ja and sastre-ortiz n. reconstruction of the aesthetic units of the face with microsurgery: experience in five years. microsurg. 2000;20:211-215. 3 shieh sj, chiu hy, yu jc, pan sc, tsai st and shen cl. free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. plast reconstr surg. 2000; 105(jun):2349-2357. 4 kimata y, uchiyama k, ebihara s, nakatsuka t and harii t. anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. plast reconstr surg. 1998; 102(5):1517-1523. 5 lin dt, coppit gl and burkey bb. use of the anterolateral thigh flap for reconstruction of the head and neck. curr opin otolaryngol head neck surg. 2004; 12:300–304. 6 kimata y, uchiyama k, ebihara s, sakuraba m, iida h, nakatsuka t and harii t. anterolateral thigh flap donor-site complications and morbidity. plastreconstr surg. 2000; 106(3):584-589. figure 4. a. reconstruction 2 ½ months post-operation and adjuvant chemoradiotherapy b. left thigh 2 ½ months post-operation with note of only a linear scar a b by including the lateral femoral cutaneous nerve for repair. the color match is satisfactory for orientals. the donor site can usually be closed primarily with only an inconspicuous curvilinear scar left over the thigh.4,5 it has been used successfully in the reconstruction of the laryngopharynx, oral cavity, oropharynx, external skin and maxilla.1 in our case, we harvested a 23 x 9 cm flap to cover both the intraoral and skin defects. no muscle was harvested since a thin flap was needed. although there was only 1 perforator, it was able to supply the large flap. the neck dissection was done simultaneous with flap harvesting thereby shortening total operating time. the patient’s hospital stay was uneventful and he was discharged in 9 days in spite of undergoing a major operative procedure. donor-site morbidity was minimal. in spite of the large flap taken from the thigh, we were able to close the thigh primarily without any dehiscence or skin necrosis. as muscle harvesting was not required, there was neither loss of function nor loss of sensation. the patient rated the appearance of the thigh as good since only an easily hidden linear scar was evident on the left thigh. the anterolateral thigh free flap is an excellent soft-tissue flap for reconstruction of a full thickness defect of the buccal area. discussion the advent of microvascular surgery has broadened the armamentarium of the reconstructive surgeon while eliminating problems inherent in pedicled flaps. the alt flap, first reported in 1984 by song,5 fits the criteria of an ideal flap because it allows greater tissue yield than other flaps, allowing for folding of the flap. the operation can be carried out by two teams working simultaneously, shortening operative time. the large arterial diameter of the vascular pedicle, accompanied by two veins, facilitates easier microvascular anastomosis. the anterolateral thigh flap has good pliability and can be designed as either a single skin paddle for one layer defect reconstruction or doubleskin paddles for through-and-through defects by one perforator or multiple perforators. it can be harvested in the suprafascial plane if a thin flap is needed while the vastus lateralis and tensor fascia lata can be incorporated if bulk is required. the flap is potentially sensate philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 publication and privacy: science and sorcery? “see my thoughts and feelings fill the paper, seems i’ll never, never really know why when other people talk and chatter, i would rather, rather write a song”1 “publish or perish,” the battlecry of modern academia, may well be perceived by some as a call to bare their deepest and darkest secrets. indeed, “publication” (from the middle english publicacioun, from middle french publication, from latin publication-, publicatio, from publicare, from publicus public)2 literally means “to make public,” confronting the comfortable secrecy and seclusion associated with privacy.3 the distinction between publication and privacy also distinguishes science from sorcery. the scientist-scholar engages in the act or process of publishing observations for all to see, while the sorcerer strives to secure secrets and spells from prying eyes. while scientific observation and magical thinking about natural forces and their control may not always differ much, the manner by which the former are made available to public scrutiny and question, testing and replication, rebuttal or verification, distinguish one brand of “truth” from the other. in this vein, invoking the latter anecdotally or under the guise of authority may smack of mere sorcery. in contemporary terms, interesting cases and trends, personal clinical observations and innovations and such other accumulations of wisdom, can well be kept to oneself, recorded in private, or shared with a small circle of colleagues or trainees. unless these are brought to light and published, they do not join the scholarly stream, and will neither contribute to, nor benefit from true science. instead, they may well perpetuate an internally-consistent, albeit inaccurate or downright false, view of reality. exposing one’s ideas and words to possible rejection or revision by the judges and jury of editors and reviewers, not to mention readers, is no easy task either, but it is only by making ideas public that scientists gain the opportunity to dialogue, build on each other’s contributions and join the documented and ongoing history of their field.4 publication also has other rewards, not the least of which is academic promotion and tenure. we particularly challenge psohns fellows to set the example by publishing and leading the way for our diplomates and residents. it gives me great pleasure to announce that the singapore declaration on equitable access to health information in the western pacific region was adopted during the second joint meeting of the asia pacific association of medical journal editors (apame) and the western pacific region index medicus (wprim) convened by the world health organization on the occasion of the 50th anniversary of the singapore medical journal. it was launched at the international forum on academic medical publishing on november 6, 2009 organized jointly by the singapore medical journal (smj) and national cancer centre singapore (ncc), with the support of the singapore medical association (sma) and asia pacific association of medical journal editors (apame). the declaration is simultaneously reproduced in full as a special announcement in several regional journals. josé florencio f. lapeña, jr. m.a., m.d. editorial 4 philippine journal of otolaryngology-head and neck surgery 1lapeña jf, “i’d rather write a song” [unpublished song] manila; 1979. 2publication. (2009). in merriam-webster online dictionary. retrieved october 20, 2009, from http://www.merriam-webster.com/dictionary/publication. 3privacy. (2009). in merriam-webster online dictionary. retrieved october 20, 2009, from http://www.merriam-webster.com/dictionary/privacy. 4publish, not perish: the art and craft of publishing in scholarly journals. university of colorado 2006. available from http://www.publishnotperish.org accessed 24 april 2008. abstract objective: to describe a new “sail” shaped excision technique for alar lift surgery and present the outcome of this technique through photo documentation. methods: design: surgical innovation; case series setting: tertiary government hospital participants: four patients underwent alar rim lift procedure using “sail” excision technique performed by the senior co-author. the indication for “sail” excision technique was a hanging ala (type iv) based on the classification of alar-columellar discrepancies by gunter et al. the outcomes were described with comparison of pre-operative and post-operative photographs. results: post-operative improvement of the alar-columellar relationship and counter-rotation of the tip, the “gull’s wing in flight” was further enhanced. there were no scar contracture or vestibular stenosis, and scars were aesthetically acceptable. conclusion: alar lift surgery demands an accurate diagnosis and analysis of the alar-columellar discrepancies. in southeast asian noses, unlike caucasian noses, the most common indication for alar surgery are wide and overhanging ala. our proposed technique is an easy and safe method of correcting alar overhang. this procedure with its advantages represents a new, reliable and simple way of achieving predictable results in many rhinoplasty cases. keywords: alar lift, hanging ala, alar-columellar relationship, alar-columellar discrepancies, counterrotation of tip, vestibular stenosis alar lift surgery is an integral part of any rhinoplastic procedure but is often overlooked by surgeons performing rhinoplasties. this alar lift is usually indicated in asian noses which often require re-contouring or re-shaping of the nostril to achieve symmetry and appropriate size and to correct alar overhang.1 it is also used in re-contouring cleft lip noses, equalizing asymmetrical nostrils, enlarging small nostrils, converting round to oval nostrils and correction of alar overhang.1 the alar overhang gives a poor aesthetic relationship of the alar rim with columella as exemplified by the low wings of the “gull’s wing in flight” appearance. overhanging alae are a common feature in southeast asian noses notably of malayan origin. countries included are cambodia, indonesia, malaysia, singapore, thailand, vietnam, myanmar and the philippines. such features are also seen in taiwan, hong-kong and southern china.2 the standard management of an overhanging ala involves a horizontal ellipse incision on the “sail” excision technique: a modified alar lift procedure for southeast asian noses dennis eusebio a. baladiang, md mildred b. olveda, md eduardo c. yap, md department of otorhinolaryngology head and neck surgery ospital ng makati correspondence: dennis eusebio a. baladiang, md department of otorhinolaryngology-head and neck surgery 5th floor ospital ng makati sampaguita st. cor gumamela st. pembo makati city 1218 philippines telefax: 882 6316 loc 309 email: denshomed2000@gmail.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. presented at surgical innovation contest (1st place), philippines society of otolaryngology head and neck surgery 53rd annual convention, edsa shangrila manila, philippines december 2009. philipp j otolaryngol head neck surg 2010; 25 (1): 31-37 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 31 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 surgical innovations and instrumentation 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 surgical innovations and instrumentation the vestibular skin.3 while experienced rhinoplastic surgeons may be able to rely on their aesthetic judgment, we believe that this technique is quite risky and difficult especially for inexperienced surgeons. this technique involves partial excision of the vestibular skin which may lead to over-resection resulting to distortion of the anatomy and disorientation of the surgeon. we introduce a simple yet reliable technique to lift the ala and correct the overhang through a “sail” excision. surgical technique the alar lift can be performed any time during rhinoplasty but it is advised to have it done as the initial step because of the easy manipulation on everting the alar rim starting from marking to incision to suturing. the procedure starts with careful assessment of the alar-columellar relationship and identification of the important landmarks of the “sail”. markings are performed on the vestibular side of the ala with a “sail” shaped or an isosceles triangle (2 sides and a base) (figure 1). the “apex” starts at the peak of the “gull’s wing-inflight” (figure 2). the caudal side is along the alar rim while the cephalic side is along the vestibular groove (figure 3). the groove is located few millimeters inferior-lateral to the caudal-lateral margin of the upper lateral cartilage (figure 4). alternatively, it can also be identified along the demarcation of the hair bearing and non-hair bearing area on the lateral vestibular wall. the base is usually at the area where the nasal sill ends. in cases associated with wide alar base and alar flaring, wherein concomitant alar base and sill excision are required, it will be appropriate to put its markings prior to “sail” incision as to avoid overlapping and properly place the base of the “sail” incision. after all the markings are placed, the vestibular wall is infiltrated with 2% lidocaine hcl and 1:100,000 units of epinephrine assuming that the patient is usually under iv sedation. this step is accomplished using a 10cc syringe with 30 gauge needle. three to five minutes are allowed to elapse for complete analgesia and vasoconstriction. a no.15 blade is used to perform the “sail” incision. the initial incision may be carried out along the base or any of the sides of the “sail” and continued to complete the “sail” excision on whatever preferred side of the triangle (figure 5a). the incision along the cephalic side should parallel the contour of the vestibular groove. the vestibular skin is excised together with a moderate amount of subcutaneous tissue (figure 5b). it is essential not to expose the opposite dermis of the alar skin. the retained subcutaneous tissue will somehow ensure a smooth contour of the alar rim. this step is usually accomplished with minimal bleeding and electrocauterization is seldom necessary. the same procedure should be done on the contralateral ala. needless to say, symmetry in this procedure is essential. the vestibular defect is closed in a single layer of simple interrupted nylon 6.0 suture (figure 6a). due to uneven length of the “sail” excision, figure 1. markings on the vestibular side of ala figure 2. the gull’s wing-in-flight (relationship of nasal ala with the infra-tip lobule). [adapted from paper id. orten ss, hilger pa. facial plastic and reconstructive surgery. new york: thieme; 2002. 2nd ed chap. 31p. 364] figure 3. boundaries of the “sail” incision philippine journal of otolaryngology-head and neck surgery 33 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 surgical innovations and instrumentation vestibular skin approximation starts on both ends of the defect (apex and base) and adjustments are made during closure (figure 6b). it is important not to suture too tightly or leave the sutures more than 5 to 7 days. occasionally, there may be suture indentations but these usually smooth out in time. figure 4. vestibular groove (arrow) figure 5. vestibular skin incision. incision noted at the border of hair bearing and non-hair bearing area (a). excision of vestibular skin with subcutaneous tissue (b) figure 6. closure of nasal vestibular defect. “sail” shape defect after removal of excised vestibular skin (a). schematic illustration showing approximation starting at both ends of the defect (b). the optimum height of the lift can be calculated by the length of the base excised divided into half. therefore, a 4 mm excision at the base can give a 2 mm alar lift (figure 7). the inherent variability on the location of the cephalic incision from the vestibular groove gives the surgeon flexibility to adjust the amount of tissue to be excised. this manner of excision and closure essentially creates a flap from the sidewall of the alar rim towards the vestibular defect, thus creating a new alar rim from the lateral rim skin. lastly, the outcome can be appreciated intraoperatively (figure 8a and b). case series case 1 a 24-year-old male health care provider complained of wide ala and rounded tip, he also requested to have his nose augmented. physical examination showed low dorsum, wide alar base and overhanging ala. the plan was to do augmentation of the dorsum, alar base trimming and alar rim lift. the tip also had to be modified using tip sutures. the 34 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 surgical innovations and instrumentation patient requested for rib cartilage as material for dorsal augmentation. the 7th rib cartilage was harvested and used for the following grafts: dorsal augmentation and columellar strut, shield graft with back stop were used for tip counter-rotation. surgery was done under closed technique. further enhancement procedures performed to improve the figure 7. the optimum lift is approximated by length of base divided by 2. figure 8. . intra-operative alar rim effect. before (a); after (b): alar-columellar relationship were the alar base excision with bunching and alar rim lift via “sail” excision technique (figure 9a-e). figure 9. (case 1) pre-operative photographs show a low dorsum, wide alar base and overhanging ala (a and c); photographs taken immediately post-operative (e) and 1 year after the surgery showed improvement of the alar-columellar relationship, tip projection and counter-rotation look of the tip (b and d). the 7th rib cartilage was used for dorsal augmentation, columellar strut and shield graft. philippine journal of otolaryngology-head and neck surgery 35 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 surgical innovations and instrumentation case 2 a 24-year-old female health care provider complained that her nose was too big and the tip was too rounded. physical examination revealed a short nose, rotated (bulbous) tip, wide ala, overhanging alar rim, low dorsum, retracted columella and premaxilla. since the nose was short and rotated, it was deemed necessary to lengthen the nose with strong structural material. rib cartilage was the appropriate graft to be used. an open approach was done to expose the whole structural framework including the septum. a septoplasty (submucous resection) was performed wherein the quadrangular cartilage was harvested. the rib and septal cartilages were carved into appropriate sizes for the following structural grafts: dorsal augmentation, bilateral extended spreader graft, columellar strut graft, alar strut graft, premaxillary augmentation, shield graft with back stop and onlay perichondrium as camouflage graft. alar base excision with bunching and alar rim lift surgery via “sail” excision technique were further performed to improve the alar-columellar relationship (figure 10a-e). case 3 a 35-year-old female health care provider complained that she had a wide ala and rounded tip. physical examination showed a rounded (bulbous) tip, lower dorsum, wide alar base and overhanging alar rim. the plan was to do dorsal augmentation, tip refinement surgery, septoplasty for cartilage harvest, alar base excision and alar rim overhang correction. the procedure was performed via closed technique. dorsal augmentation was accomplished using two sheets of 3mm expanded polytetrafluoroethylene (e-ptfe), gore-tex® (gore industries, worldwide). septoplasty (submucous resection) for cartilage harvest was used for columellar strut and shield graft, cephalic trim of lower lateral cartilage, domal suturing, interdomal suturing, alar base excision and bunching and alar overhang correction via surgery via “sail” excision technique were done to improve alar-columellar relationship (figure 11a-d). case 4 a 23-year-old male health care provider complained of rounded tip and wide ala. physical examination showed a rounded (bulbous) tip, wide alar base and overhanging alar rim. the plan was to perform correction of the bulbous tip via cephalic trim of lower lateral cartilage, tip suturing, defatting and further enhancement by radix augmentation, alar base excision and alar rim lift. surgical approach was closed technique. nasal septal cartilage was harvested via transfixion incision. tip refinement surgery done was by cephalic trimming of lower lateral cartilage, domal and interdomal suturing technique with columellar strut and shield grafts. radix augmentation accomplished using one sheet of 3mm expanded polytetrafluoroethylene (e-ptfe), gore-tex® (gore industries, worldwide). alar base excision with bunching and alar figure 10. (case 2) pre-operative photographs show short nose, bulbous tip, low dorsum, retracted columella, wide ala and overhanging alar rim (a & c); photographs taken immediately post-operative (e) and 1 year after surgery which demonstrated improvement of the alar-columellar relationship and counter-rotation of tip, the “gull’s wing in flight” was further enhanced. the 7th, 8th rib and septal cartilages used for dorsal augmentation, bilateral extended spreader graft, columellar strut graft, alar strut graft, premaxillary augmentation and shield graft. 36 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 surgical innovations and instrumentation several techniques in alar lift surgery have been proposed. mckinney advocated excision of the nasal lining in the cephalic border of the alar cartilage and caudal to the internal nasal valve.5 ellenbogen used the technique of direct excision of the skin for hanging ala.1 millard described the alar margin sculpturing through shaping the thinning in conjunction with alar base excision.6 gunter further described this idea, suggesting a 3-mm horizontal elliptical incision on the vestibular skin will raise the hanging ala up to 2-mm.3 in our opinion, an excision on the nasal lining adjacent to the internal nasal valve without a definite landmark is difficult and may damage the nasal valve area. a direct external excision on the skin especially on heavier tissue of the nose particularly among thick skinned individuals may lead to roughness of the alar rim and possibly noticeable scarring. all our patients presented with features of southeast asian nose of malay race described here as one with low dorsum, rounded (bulbous) tip, wide and overhanging ala sometimes a retracted columella and drooping tip. in this series, our patients underwent several procedures like tip grafting, columellar and alar base surgery as indicated. rhinoplasty in asian malay noses is a very challenging task for it requires not only improvement on the height of the bridge but also requires improvement on the tip and ala. in order to achieve good aesthetic result with asian malay noses, lower cartilage surgery, tip augmentation (cartilage or synthetic), alarplasty, alar base bunching and alar overhang correction must be accomplished. to address problems associated with the tip and ala, the “sail’ technique was applied in all the patients. the advantage of including this technique as a procedure of choice for correction of overhanging ala was the considerable improvement of the alar-columellar relationship. in addition, it also gives a good counter-rotation look of the tip. since all of the incisions were placed in the vestibular skin, an inconspicuous scar was well hidden in the depth of the normal alar rim lining. the limitation of this technique is its role in severely retracted columella wherein a septo-columellar extension graft could be used to achieve the best aesthetic result. the technique we proposed may be somewhat similar to procedures popularized by other rhinoplastic surgeons. bearing in mind the advantages and benefits of performing alar lift surgery, the procedure was further modified by adapting well defined surgical landmarks that serve to guide the extent of vestibular excision as well as to the amount of skin tissue to be removed. finally, potential complications of the sail excision technique include hypertrophic scar at the alar rim (figure 15), vestibular stenosis and scar contracture which can be attributed to unlevelled closure of skin and post-operative infections. these complications have not been observed in this series. alar lift surgery demands an accurate diagnosis and analysis of alarcolumellar discrepancies. in southeast asian noses, unlike caucasian figure 11. (case 3) pre-operative photographs show low dorsum, bulbous tip, wide ala and overhanging alar rim (a & c); photographs taken 1 year after surgery, post-operative views demonstrate desired alar-columellar relationship and counter-rotation of tip (b and d). note the “gull’s wing in flight” appearance of the ala which was further modified. dorsal augmentation was accomplished using 2 sheets of 3mm e-ptfe (goretex) and septal cartilage for various tip grafting. rim lift surgery via “sail” excision technique were further performed to improve the alar-columellar relationship (figure 12a-d). discussion in an ideal alar-columellar relationship, the greatest distance from the long axis of the nostril to either alar rim or columella should be 1-2 mm3 (figure 13). a columella to nostril axis distance of <1 mm or >2 mm indicates a retracted or hanging columella respectively.3 conversely, an ala to nostril axis distance of <1 mm or >2 mm corresponds to hanging or retracted ala respectively.3 it is requisite to understand the alar-columellar relationship for proper assessment and correction of abnormal relationship (figure 14). in addition, on lateral view of the ideal nose, the nostril is oval with the alar rim forming the superior nostril border and the roll of the columella forming the inferior border. the alar rim is cephalad to and parallel to the columella. on front view, it should have the gentle “gull’s wing in flight” appearance.4 philippine journal of otolaryngology-head and neck surgery 37 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 surgical innovations and instrumentation noses, the most common indication for alar surgery are wide and overhanging ala. our proposed technique is an easy and safe method of correcting alar overhang. this procedure, with its advantages, represents a new, reliable and simple way of achieving predictable results in many rhinoplasty cases. figure 12. (case 4) pre-operative photographs show rounded tip, wide alar base, overhanging alar rim (a and c); photographs taken 1 year after operation show improved alar-columellar relationship. cephalic trim of lower lateral cartilage, tip suturing, defatting, radix augmentation (e-ptfe), alar base excision and alar rim lift (b and d) figure 15. formation of hypertrophic scar along the alar rim (arrow) figure 13. ideal alar-columellar relationship, the greatest distance from the long axis of the nostril to either the alar rim or the columella should be 1 to 2 mm, or ab = bc = 1 to 2 mm [adapted from gunter jp: classification and correction of alar-columellar discrepancies in rhinoplasty. plast. reconstr. surg., 97: 3, 1996] references 1. ellenbogen r, blome dw. alar rim raising. plast reconstr surg. 1992 jul;90(1):28-37 2. yap ec. components in asian malay rhinoplasty. 4th annual rhinoplasty course ospital ng makati 2006 (unpublished lecture); 2006 jun 3. gunter jp, rohrich rj, friedman m. classification and correction of alar-columellar discrepancies in rhinoplasty. plast reconstr surg. 1996 mar;97:643-48 4. paper id, orten ss, hilger pa. facial plastic and reconstructive surgery. new york: thieme; 2002. 2nd ed chap. 31p. 364 5. mckinney p. stalnecker ml. the hanging ala. plast reconstr surg. 1984 mar;73(3):427-30 6. millard r. alar margin sculpturing. plast reconstr surg. 1967 mar;40(4);337-42 figure 14. classification of alar-columellar discrepancies [adapted from gunter jp. classification and correction of alar-columellar discrepancies in rhinoplasty. plast. reconstr. surg., 97: 3, 1996] philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 under the microscope philippine journal of otolaryngology-head and neck surgery 41 malignant glandular neoplasms of the sinonasal tract originate either from the respiratory epithelium or the underlying mucoserous glands. they present with a confusing array of morphologic features and this is reflected in the nomenclature of these tumors. these tumors are grouped into three main types: salivary gland-type, intestinaltype and non-intestinal type adenocarcinomas.1 salivary gland-type adenocarcinomas of the nasal cavity histologically resemble their analogous lesions in the major and minor salivary glands. adenoid cystic carcinoma is the most common although almost any of those described in the salivary glands can occur in the nasal cavity as well. intestinaltype adenocarcinomas resemble glandular neoplasms that occur in the small and large intestines. the more well-differentiated ones resemble colonic tubular and villous adenomas while those at the other end of the spectrum resemble moderately to poorlydifferentiated colonic adenocarcinomas. others may be composed of goblet cells or resemble colonic mucinous carcinomas. nonintestinal-type adenocarcinomas are the most diverse of the lot and are composed of adenocarcinomas whose morphologies do not easily fit in into the previous two categories. for purposes of prognostication, they are divided into low-grade and high-grade categories based on architecture, nuclear features and mitotic activity. low-grade tumors have uniform cells arranged in compact acini, back to back, confluent glands, cystic spaces and papillae. they maintain tall columnar to cuboidal arrangements without much stratification. cytoplasm is often abundant but variable in appearance – basophilic, granular, mucinous, eosinophilic and also oncocytic. nuclear atypia is mild to moderate with few mitoses. high-grade tumors are mostly solid, show prominent nuclear pleomorphism, nucleoli and mitotic activitiy. signet-ring cells may be seen. necrosis may often be present.2,3,4 we present the case of a 73-year-old female with a destructive left nasal cavity mass. biopsy shows an infiltrative epithelial tumor with a papillary configuration composed of tumor cells draped around vascular cores (figures 1 and 2). high-power view shows cuboidal to polygonal cells that have large, angular and hyperchromatic nuclei without distinct nucleoli. mitoses are difficult to come by. cytoplasm is moderate to abundant and has a dense eosinophilic, somewhat oncocytic quality (figures 3 and 4). mucinsecreting or other intestinal-type cells are not seen. the case was signed out as a lowgrade, papillary, nonintestinal-type adenocarcinoma. unfortunately, the patient was subsequently lost to follow-up. nonintestinal-type sinonasal adenocarcinoma jose m. carnate jr., md department of pathology college of medicine – philippine general hospital university of the philippines manila correspondence: jose m. carnate, jr. md university of the philippines manila college of medicine department of pathology 547 pedro gil st., ermita, manila, 1000 philippines phone (632) 526 4550 fax (632) 400 3638 email: jmcjpath@yahoo.com reprints will not be available from the author. philipp j otolaryngol head neck surg 2009; 24 (2): 41-42 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 42 philippine journal of otolaryngology-head and neck surgery under the microscope references 1. thompson ld. malignant neoplasms of the nasal cavity, paranasal sinuses, and nasopharynx. in: thompson ld, ed. head and neck pathology foundations in diagnostic pathology series. goldblum jr series ed. churchill livingstone elsevier, inc. 2006. 2. barnes l, eveson jw, reichart p, sidransky d. pathology and genetics of head and neck tumors. in who classification of tumors. iarc press, lyon 2005. 3. wenig b. atlas of head and neck pathology, 2nd ed. elsevier, inc. 2008. 4. gnepp dr, ed. diagnostic surgical pathology of the head and neck. wb saunders company, 2001 figure. 2 infiltrating tumor with a papillary configuration and focally with solid areas. vascular channels are prominent (hematoxylin and eosin, 100x). figure. 3 the tumor cells are cuboidal to polygonal, have large, angular and hyperchromatic nuclei, do not have distinct nucleoli and have rare mitoses (hematoxylin and eosin, 400x). figure. 1 infiltrating tumor with a papillary configuration (hematoxylin and eosin, 100x). (hematoxylin and eosin, 100x) (hematoxylin and eosin, 100x) (hematoxylin and eosin, 400x) figure. 4 cytoplasm is moderate to abundant and has a dense eosinophilic, somewhat oncocytic quality (hematoxylin and eosin, 400x). (hematoxylin and eosin, 400x) among patients with intestinaland nonintestinal-type adenocarcinomas, histologic grade affects outcome. welldifferentiated tumors with predominantly papillary and tubular configurations do better (80% 5-year survival) while poorly differentiated ones do poorly (40% 5-year survival). recurrences develop in about 50% and distant metastasis in 15%. overall survival is about 40% with death occurring in approximately three years. treatment is radical surgical resection with postoperative radiotherapy.1 philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 case reports 24 philippine journal of otolaryngology-head and neck surgery abstract objective: to present a unique case of intravascular lymphoma of the inferior turbinate because of its rarity, unusual clinical presentation and difficulty in establishing a diagnosis. design: case report setting: a tertiary hospital patient: a 66-year-old male admitted to the hospital due to intermittent high grade fever of six months duration. result: the patient presented with fever of unknown origin, and exhaustive laboratory, ancillary procedures and biopsies to rule in/out infectious, autoimmune and oncologic causes were performed to arrive at a diagnosis. nasal endoscopy revealed an enlarged, hypertrophied and violaceous right inferior turbinate with watery to mucoid discharge and septal deviation to the right confirmed by ct scans of the paranasal sinuses. functional endoscopic sinus surgery (fess), septoplasty and turbinoplasty with biopsy revealed intravascular lymphoma. chemotherapy was deferred due to the deteriorating medical condition and the patient expired seven months after the initial onset of symptoms. conclusion: patients who present with fever of unknown origin should undergo a thorough otorhinolaryngologic examination to exclude primary ent conditions and ensure proper management. given its rarity and multiplicity of presentation, it is extremely difficult to make a diagnosis of intravascular lymphoma. a high index of suspicion of intravascular lymphoma is necessary so that timely acquisition of tissue biopsy of any lesion involved will make a definite diagnosis. keywords: intravascular lymphoma, fever, fever of unknown origin fever of unknown origin (fuo) is defined as continuous fever of at least three weeks duration with daily temperature elevation above 101ºf or 38°c remaining undiagnosed after one week of intensive study in the hospital. it is also defined as temperature >100ºf persisting for at least three weeks in whom history, physical examination, cbc, urinalysis, chest x-ray fail to indicate a diagnosis. 1 it has always been a challenging task to look for the focus of fever. given a case of fuo the possibility of malignancy, infection and autoimmune & connective tissue diseases must be investigated. this process usually entails extensive laboratory and ancillary procedures before finally reaching the definite diagnosis. intravascular lymphoma of the inferior turbinate: an unusual rhinologic presentation of a rare neoplasm milabelle b. lingan, md francis v. roasa, md department of otorhinolaryngology head & neck surgery university of santo tomas hospital correspondence: milabelle b. lingan, md department of otorhinolaryngology head and neck surgery university of santo tomas hospital españa, manila philippines telefax: (632) 839-2201 e-mail: bhelleymd@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no propriety or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this report. presented at the interesting case contest, philippine society of otolaryngology head and neck surgery midyear convention, baguio city, april 2007. philipp j otolaryngol head neck surg 2007; 22 (1,2): 24-26 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 case reports philippine journal of otolaryngology-head and neck surgery 25 case report our patient presented with a 6-month history of intermittent highgrade fever (temp 39-40c), chills, anorexia and weight loss. he had been admitted previously for the same complaint, when a complete blood count, urinalysis, blood culture, chest x-ray and 2d echo had failed to identify the source of the fever. he was discharged after a week with an impression of fever of unknown origin (fuo), but persistence of fever, accompanied by generalized body weakness and dehydration, led to the present admission. on physical examination, the patient was conscious, coherent and ambulatory. aside from a fever of 38.8oc all other findings were essentially normal. the patient was evaluated by a multidisciplinary team composed of an internist, infectious disease specialist, rheumatologist and nephrologist and eventually a neurologist and an otorhinolaryngologist. serial complete blood counts (cbc) showed anemia with normal differential count. erythrocyte sedimentation rate (esr) was elevated at 70mm/h. prothombin time and activated partial thromboplastin time were normal. ultrasonograms showed normal sized spleen, liver and pancreas, small gallbladder cholesterolosis and bilateral diffuse parenchymal renal disease, with a double upper collecting system on the left. urine cultures, blood aerobic and mycobacterium tuberculosis cultures yielded no growth. a malarial smear was negative. with persistent anemia despite multiple blood transfusions, a bone marrow aspiration biopsy was taken, which showed normocellular marrow. bacterial and fungal culture and sensitivity studies of the aspirate failed to grow any organism. antinuclear antibody, anti-neutrophil cytoplasmic antibody, panca and canca were all negative. the patient developed dyspnea, bipedal edema, electrolyte imbalances and elevated levels of serum creatinine, and subsequent acute renal failure probably secondary to decreased effective circulating volume, controlled with colloid infusions and diuretics. he also experienced nasal congestion more on the right nasal cavity. nasal endoscopy showed enlarged, hypertrophic and violaceous right inferior turbinate with watery to mucoid nasal discharge and septal deviation to the right. ct scans of the paranasal sinuses showed a hypertrophied right turbinate or polyps, right maxillary and ethmoid sinusitis, with obstructed right osteomeatal unit (figures 1a and 1b). antibiotics were started and he subsequently underwent endoscopic sinus surgery (ess), septoplasty and turbinoplasty with biopsy. culture and sensitivity of the nasal discharge showed growth of enterobacter cloacae and staphylococcus aureus. the patient later developed altered sensorium and an erythematous rash over the chest (figure 2). the attending neurologist detected nuchal resistance, right-sided weakness and bilateral babinski reflex which led to an impression of probable cns tumor to consider lymphoma (leptomeningeal or parenchymal). histopathologic diagnosis of nasal lesion was angiotropic or intravascular large cell lymphoma, positive for cd20 (b-cell marker) (figure 3a, 3b and 3c). chemotherapy was offered, but not consented to by relatives due to the deteriorating condition of the patient, who expired seven months after the onset of fever. discussion intravascular lymphoma (ivl) is a rare and aggressive form of extra nodal diffuse b-cell lymphoma. to oncologists, intravascular lymphoma is the “great imitator” because it is very difficult to diagnose.² it can occur in any organ of the body with clinical presentations mimicking other diseases. the absence of malignant lymphoid cells in lymph nodes and reticuloendothelial system is a hallmark of the disease. it is characterized by the presence of large to intermediate size lymphoid cells only in the lumina of blood vessels without obvious tumor mass or leukemia.3 the disease was first reported in the literature in 1959 by pfleger and tappeiner in germany and was described as angioendotheliomatosis proliferans systemasata,4 as the authors then believed that the neoplastic cells were derived from endothelium.2 but in 1980s immunophenotyping demonstrated that the neoplastic cell of origin is the lymphocyte.5 ivl has an estimated incidence of less than one person per million. it has been described in patients ranging from 34-90 years of age, with a median age of 70 years. it occurs equally in women and men.3 pathogenic mechanisms have been proposed for the intravascular localization of ivl that relate to defective adhesion mechanism, in which tumor cells express cd44 antigen, the hermes-3-antibodydefined lymphocytic homing receptor for endothelial cells6,7 but lack cd18 surface glycoprotein, which aids in lymphocyte extravasation.7 despite the large number of intravascular tumor cells, these cells are often not seen in peripheral blood smears.3 the majority of cases can be grouped into a few discrete presentations: fever of unknown origin (fuo), central nervous system involvement and cutaneous involvement.8 beyond these major presentations, there are single case reports of ivl presenting primarily in almost every organ system.2 anemia, elevated lactate dehydrogenase (ldh) and erythrocyte sedimentation rate (esr) are the most common laboratory abnormalities seen in ivl. diagnosis is made through surgical biopsy of a suspected site of involvement.2 however, the absence of any anatomic abnormality like lymphadenopathy often delays the diagnosis. in majority of cases, diagnosis is made only after a routine post mortem tissue examination. the standard treatment of intravascular lymphoma if detected early is chemotherapy, however, relapses are common and the condition is usually terminal. treatment options currently available are irradiation, philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 case reports 26 philippine journal of otolaryngology-head and neck surgery high dose corticosteroids and anthracycline-based chemotherapy. the anti-cd20 monoclonal antibody rituximab is widely used for the treatment of ivl with skin and solid organ manifestation. unfortunately, studies have shown that even with chemotherapy, prognosis is poor with a median survival of approximately five months.9 in summary, intravascular lymphoma is very rare malignant disease of extranodal large b cell variety. difficulty in diagnosis is evident due to the inherent diverse clinical presentations mimicking different diseases. part of a thorough examination should include detailed evaluation of the ears, nose and throat in order to search for the early initial manifestation and subsequent histopathologic evaluation of any anatomic involvement. to our knowledge, this is the first and only reported case of intravascular lymphoma of the inferior turbinate, a rare type of lymphoma presenting in a very unusual manner. references 1. friedman ,h. ed. problem-oriented medical diagnosis. 7th edition. philadelphia: lippincott’s william and wilkins, 2001.p 6-10. 2. zuckerman d, seliem r, hochberg e. intravascular lymphoma: the oncologist’s “great imitator”. the oncologist 2006;11:496-502. 3. pfleger l, tappeiner j. {on the recognition of systematized endotheliomatosis of the cutaneous blood vessels (reticuloendotheliosis?)}. hautarzt 1959;10:359-363.german. 4. ganeshan a, soonawala z, baxter j. intravascular lymphoma: a diagnostic enigma. j r soc med 2002;95:37-38. 5. sheibani k, battifora h, winberg cd, burke, j.s., ben-ezra, j., elinger, g.m .,quigley, n.j., fernandez, b.b. ,morrow, d. and rappaport, h. (1986). further evidence that “malignant angioendotheliomatosis’ is an agiotropic large –cell lymphoma. n engl j med 1986;314:943948. 6. ferry j, harris nl, picker lj, winberg,d.s., rosales, r.k., tapia, j. and richardson, e.p. jr. (1988) intravascular lymphomatosis (malignant angioendotheliomatosis): a b-cell neoplasm expressing surface homing receptors. mod pathol.1988;1:444-452. 7. jalkanen s, aho r, kallejoki m., ekfors, t., nortamo, p., gamberg, c., duijvestjn, a., and kalimo, h.(1989). lymphocyte homing receptors and adhesion molecules in intravascular malignant lymphomatosis. int j cancer.1989;44:777-782. 8. ferreri aj, campo e, seymour jf, willemze r, ilariucci f, ambrosetti a, et.al., intravascular lymphoma: clinical presentation, natural history, management and prognostic factors in a series of 38 cases, with special emphasis on the ‘cutaneous variant’. br j haematology. 2004;127:173-183. 9. satti s, and castillo r. intravascular b-cell lymphoma. community oncology. 2005; 2: 55-60. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 22 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the prevalence of, and describe transglottic cancer with thyroid cartilage invasion as a possible risk for, thyroid gland invasion in a series of patients with laryngeal carcinoma who underwent total laryngectomy with thyroidectomy. methods: design: retrospective case series setting: tertiary government training hospital participants: 61 laryngeal carcinoma patients who underwent total laryngectomy with hemior total thyroidectomy from january 2010 to august 2017. results: out of 61 patients with laryngeal carcinoma, 11 patients had supraglottic, 11 glottic, 2 subglottic and 37 had transglottic involvement. eleven had thyroid cartilage invasion, all of whom had transglottic tumors. of these 11 patients, only 1 had thyroid gland invasion. this was a case of a 78 year-old male patient with poorly differentiated scc stage iva transglottic tumor with thyroid cartilage invasion. conclusion: thyroid gland invasion was uncommon in our sample of laryngeal carcinoma patients who underwent laryngectomy and thyroidectomy. although transglottic involvement with thyroid cartilage invasion may increase the risk of thyroid gland invasion, it could not be confirmed by our series. perhaps thyroidectomy should not be routinely performed on all patients with laryngeal carcinoma who undergo total laryngectomy but more rigorous studies are needed to establish this. keywords: laryngeal carcinoma, transglottic, thyroid cartilage invasion, thyroid gland invasion, thyroidectomy total laryngectomy is the standard of care for operable squamous cell carcinoma (scc) of the larynx.1-2 scc of the larynx can spread to adjacent structures like the trachea, esophagus and thyroid gland.3 invasion of the thyroid gland can be contiguous or non-contiguous via lymphovascular spread.4 the incidence of thyroid gland involvement in laryngo-pharyngeal cancer ranges from 0-23%.5-6 the need for thyroidectomy during total laryngectomy is controversial as thyroid gland invasion is rare and thyroidectomy is associated with long term morbidities.7-8 a meta-analysis by mendelson et al. advised hemithyroidectomy in transglottic tumors, subglottic tumors and tumors thyroid gland invasion in laryngeal carcinomamaria concepcion f. vitamog, md samantha s. castañeda, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. maria concepcion f. vitamog department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 743 6921; (632) 711 9491 local 320 email: entjrrmmc@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or in electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest (3rd place). october 6, 2016. natrapharm, the patriot bldg. parañaque city. philipp j otolaryngol head neck surg 2017; 32 (2): 22-24 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 23 with subglottic extension more than 10 mm.9 other indications for thyroidectomy are palpable nodule,10 t3 and t4 lesion,5,9-13 transglottic growth,9-13 subglottic disease or extension more than 10 mm9-12,14-16 anterior commissure involvement5,12 and thyroid cartilage invasion.11 a local study revealed that extralaryngeal spread, tracheostomal involvement and tracheal extension were associated with thyroid gland invasion.17 however, despite all these studies, thyroidectomy is still routinely done for laryngectomy cases in our institution. the nccn 2017 guideline for laryngeal cancer states that for glottic and supraglottic t3 tumors requiring (amenable) to total laryngectomy can undergo the procedure with ipsilateral thyroidectomy. for patients with glottic and supraglottic t4a tumors, the standard approach is total laryngectomy with thyroidectomy and neck dissection as indicated (depending on node involevement) followed by adjuvant treatment.18 studies in the local setting may change prevailing guidelines about the need for thyroidectomy in laryngectomy. our study aims to determine the prevalence of, and describe transglottic cancer with thyroid cartilage invasion as a possible risk for, thyroid gland invasion in a series of patients with laryngeal carcinoma who underwent total laryngectomy with thyroidectomy. methods with institutional ethical review board approval, we retrieved records of all patients who underwent laryngectomy with thyroidectomy of any type at our institution from january 2010 to august 2017. excluded were incomplete records and those of laryngectomy without histopathologically-documented thyroidectomy. demographics such as age and sex of the patients were obtained. the laryngeal tumor extent, type of thyroidectomy and thyroid gland involvement were recorded based on reported histological analysis of pathological specimens by different pathologists. data were tabulated using ms word for mac 2011 version 14.0.0 (100825) (microsoft corporation, redmond, wa, usa). data were analyzed using epi info 2017 version 7 (centers for disease control and prevention, atlanta, ga, usa). a descriptive analysis was performed using frequency and proportion for each subsite of laryngeal carcinoma that was treated with total laryngectomy with or without thyroid cartilage involvement and with or without thyroid gland invasion and results evaluated in the light of the reviewed literature. results records of 64 patients were initially considered but only 61 met the inclusion criteria. of the 3 records excluded from the study, 2 were incomplete while 1 reported a total laryngectomy without thyroidectomy. of the 61 patients included in the study, 58 (95.1%) were males and 3 (4.9%) were females. their mean age was 62 years (range 48 to 78 years). twenty-seven patients underwent hemithyroidectomy (with isthmusectomy) while 34 had total thyroidectomy. eleven had supraglottic involvement, 11 glottic, 2 subglottic and 37 transglottic. out of the 37 transglottic cases, 11 had histopathologic thyroid cartilage invasion. of these 11 transglottic cancers with thyroid cartilage involvement, only 1 (1.6%) had histopathologically-confirmed thyroid gland invasion. discussion our study had a 1.6% prevalence of thyroid gland invasion among patients who underwent total laryngectomy with thyroidectomy for laryngeal scc. previous studies show prevalences ranging from 1-11%,1,11,14,15,17 supportive of our findings that suggest thyroid gland invasion is uncommon in patients undergoing total laryngectomy for laryngeal scc. given the varied sample sizes and clinical scenarios of these studies, there seems to be no significant geographical difference in the incidence rate of thyroid gland invasion. we were also interested in transglottic involvement with thyroid cartilage invasion as a possible risk for thyroid gland invasion. in our study, the prevalence of thyroid gland invasion increases to 2.7% if we consider only transglottic tumors (or 1 out of 37 patients). the lesion has to invade through thyroid cartilage, cricoid cartilage or cricothyroid membrane to reach the extralaryngeal soft tissue.1 a retrospective study by iype et al. showed 30% increase in thyroid gland invasion among patients with pre-operative findings of thyroid cartilage erosion by ct scan.16 in our study, there were 11 cases with thyroid cartilage invasion confirmed through histopathology, all of which were transglottic tumors. among these, only one had positive thyroid gland invasion, increasing the risk to 9.1% or 1 out of 11. laryngeal cancer is 4 times more common in males and 90% more common in patients more than 40 years old.9 our patient with thyroid gland invasion was a 78 year-old male. it may be conjectured that he might have had ossified thyroid lamina that were more vulnerable to tumor invasion. ossified portions of cartilage are potentially at higher risk for invasion because of vascular channel penetration, whereas intact perichondrium that surrounds avascular unossified cartilage resists tumor encroachment.19 having said that, a meta-analysis by mendelson et al. found that cartilaginous invasion by tumor was not a significant predictor of thyroid gland invasion.9 one drawback of the study is the limited number of cases with concomitant thyroid gland invasion. a multiinstitutional study can be conducted to increase the number of cases. another limitation is that it focused only on the subsite involved and presence of thyroid cartilage philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 24 philippine journal of otolaryngology-head and neck surgery original articles references 1. nayak sp, singh v, dan a, bhownik a, jadhav ts, ashraf m. et al. mechanism of thyroid gland invasion in laryngeal cancer and indications for thyroidectomy. indian j otolaryngol head neck surg. 2013 jul; 65(1): s69-s73. doi: 10.1007/s12070-012-0530-9; pmid:24427619 pmcid: pmc3718952. 2. armstrong w, vokes d, maisel r. malignant tumors of the larynx. in: flint p, haughey b, lund v, niparko j, richardson m, robbins kt et al (editors). cummings otolaryngology head and neck surgery. 5th ed. philadelphia: mosby elsevier. 2010.p. 1482. 3. edge sb, byrd dr, compton cc, fritz ag, greene fl, trotti a. ajcc cancer staging manual 7th edition. chapter 5 larynx. new york: springer; 2010.p. 58. 4. gilbert rw, cullen rj, van nostrand aw, bryce dp, harwood ar. prognostic significance of thyroid gland involvement in laryngeal carcinoma. arch otolaryngology head neck surg. 1986 aug; 112(8):856–859. pmid: 3718691. 5. kim jw, han gs, byun ss, lee dy, cho bh, kim ym. management of thyroid gland invasion in laryngopharyngeal cancer. auris nasus larynx. 2008 jun; 35 (2):209-12 . doi:10.1016/j. anl.2007.07.003; pmid: 17851001. 6. croce a, moretti a, bianchedi m. thyroid gland involvement in cancer of the larynx. acta otorhinolaryngoly ital. 1991 jul-aug;11(4):429-35. pmid: 1792897. 7. sinard rj, tobin ej, mazzaferri el, hodgson se, young dc, kunz al, et al. hypothyroidism after treatment of non-thyroid head and neck cancer. arch otolarygol head neck surg. 2000 may;126(5):652-57. pmid:10807335. 8. ho ac, ho wk, lam pk, yeun ap, wei wi. thyroid dysfunction in laryngectomies – 10 years after treatment. head neck. 2008 mar;30(3):336-40. doi10.1002/hed.20693; pmid: 17636544. 9. mendelson aa, al-khatib ta, julien m, payne rj, black mj, hier mp. thyroid gland management in total laryngectomy: meta-analysis and surgical recommendations. otolaryngol head neck surg 2009 mar; 140(3): 298–305. doi: 10.1016/j.otohns.2008.10.031; pmid: 19248932. 10. biel ma, maisel rh. indications for performing hemithyroidectomy for tumours requiring total laryngectomy. am j surg. 1985 oct; 150:435–439. pmid: 4051106. invasion as possible risk factors for having thyroid gland invasion. other parameters such as size of mass, presence of palpable lymph nodes and involvement of anterior commissure as possible risk factors for having thyroid gland invasion can be included in future studies. the quality and reliability of second-hand data retrieved from patient records add another limitation to our study. for instance, our study design cannot account for variability in qualifications and competence among the different pathology residents and pathologists who evaluated and cut the gross specimens, read the slides and issued final histopathology reports. future, controlled studies may address these issues. despite these considerations, thyroid gland invasion was uncommon in our sample of laryngeal carcinoma patients who underwent laryngectomy and thyroidectomy. although transglottic involvement with thyroid cartilage invasion may increase the risk of thyroid gland invasion, it could not be confirmed by our series. perhaps thyroidectomy should not be routinely performed on all patients with laryngeal carcinoma who undergo total laryngectomy but more rigorous studies are needed to establish this. 11. dadas b, uslu b, cakir b, ozdogan hc, calis ab, turgut s. intraoperative management of the thyroid gland in laryngeal cancer surgery. j otolaryngol. 2001 jun; 30(3):179–183. pmid:11771049. 12. brennan ja, meyers ad, jafek bw. the intraoperative management of the thyroid gland during laryngectomy. laryngoscope. 1991 sep;101(9):929–934. doi:10.1288/00005537-19910900000003; pmid: 1886441. 13. gallegos-hernandez jf, minauro-munoz g, hernandez dm, flores-carranza a, hernandezsanjuan m, resendiz-colosia ja. thyroidectomy associated with laryngectomy in laryngeal cancer treatment. is it routinely necessary? cir. 2005 jan-feb; 73(1):3–6. pmid: 15888262. 14. al-khatib t, mendelson aa, kost k, zeitouni a, black m, payne r, et al. routine thyroidectomy in total laryngectomy: is it really indicated? j otolaryngoly head neck surg. 2009 oct; 38(5):564– 567. pmid: 19769827. 15. kumar r, drinnan m, robinson m, meikle d, stafford f, welch a et al. thyroid gland invasion in total laryngectomy and total laryngopharyngectomy: a systematic review and meta-analysis of the english literature. clin otolaryngol. 2013 oct; 38(5): 372-8. doi: 10.1111/coa.12165; pmid: 23998197. 16. iype em, jagad v, nochikattil sk, varghese bt, sebastian p. thyroid gland involvement in carcinoma of larynx and hypopharynxpredictive factors and prognostic significance. j clin diagn res. 2016 feb; 10(2): xco5-xco7. doi: 10.7860/jcdr/2016/15225.7310; pmid: 27042568 pmcid: pmc4800634. 17. holgado j, grullo p, gloria j, pontejos a. thyroid gland involvement in advanced laryngeal squamous cell carcinoma. acta medica philippina. 2017 jan; 51 (1): p. 11-13. 18. pfister d, spencer s, adelstein d, adkins d, brizel d, burtness b, et al. national comprehensive cancer network clinical practice guidelines in oncology version 1. 2017. [accessed 2017 feb 6]. available from: https://www.nccn.org/. 19. parsons m, stachecki r, wippold f. diagnostic imaging of the larynx. in: flint p, haughey b, robbins k, thomas j, niparko j, lund vj et al (editors). cummings otolaryngology head and neck surgery. 6th ed. philadelphia: saunders. 2015.p. 1592. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles philippine journal of otolaryngology-head and neck surgery 5 abstract background: pure tone audiometry is routinely used to determine conductive and sensorineural hearing status. ossicular discontinuity is usually assessed intra-operatively. if ossicular discontinuity can be predicted by pure tone audiometry, perhaps the operative procedure of choice and prognosis for hearing can also be anticipated. objective: to determine the predictive value of preoperative pure tone audiometry on the presence of gross ossicular discontinuity in chronic otitis media. methods: records of 205 patients, 7 to 75 years of age undergoing their first operation for chronic otitis media were reviewed. preoperative audiograms and operative records for tympanomastoidectomy were evaluated. a total of 162 patients meeting inclusion criteria were included in the study. likelihood ratios for positive and negative ossicular discontinuity for frequency-specific air-bone gap cut-offs were determined. multiple logistic regression analysis for pure tone audiometry and operative findings to predict ossicular discontinuity was performed and a model for predicting ossicular discontinuity using logistic regression obtained. results and conclusion: frequency-specific air bone gap (abg) cut-off values can predict ossicular discontinuity in chronic suppurative otitis media namely: < 20 db abg at 500 hz predicts absence of ossicular discontinuity while > 50 db abg at 500 hz, >30 db abg at 2 khz, and > 50 db abg at 4 khz best predict the presence of ossicular discontinuity in general. in the absence of cholesteatoma, the air bone gaps of <30 db at 500 hz and <20 db at 1 khz decrease probability of ossicular discontinuity from 32.97% to 2.54%. combination of air bone gaps of >50 db at 500 hz, >20 db at 2 khz and >40 db at 4 khz increase the probability of ossicular discontinuity from 32.97% to 85.9%. these findings suggest that ossicular exploration may not be necessary for the former while an evaluation of the ossicular chain may be mandatory for the latter in the setting where cholesteatoma is not present or suspected. presence of cholesteatoma, granulation tissue and size of tympanic membrane perforation are important factors to consider in predicting ossicular discontinuity. keywords: air bone gap; audiometry, pure tone; ossicular discontinuity; otitis media, suppurative; logistic regression; likelihood ratio; predictive value. chronic otitis media is a common ear pathology operated on and a common cause of hearing impairment in the local setting. chronic infection may lead to middle ear structure changes including ossicular discontinuity. surgical intervention usually aims to eradicate disease and restore hearing. restoration of hearing may be attained in well-planned ear surgery. hearing tests (pure tone audiometry, speech testing) and imaging studies (x-rays, high resolution computed tomography scanning) are used to predict serviceable hearing reserve and anatomical integrity, relationship of pure tone audiometry and ossicular discontinuity in chronic suppurative otitis media ryner jose c. carrillo, md1, nathaniel w. yang, md2,3, generoso t. abes, md, mph 2,3 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila 3philippine national ear institute national institutes of health university of the philippines manila correspondence: ryner jose c. carillo, md department of anatomy, college of medicine university of the philippines manila pedro gil st. ermita, manila 1000 phone: (632) 526 4194 sentro head and neck medicine and surgery 414 west east center, 1336 taft ave., ermita, manila 1000 phone: 632) 524 4455 e-mail: ryner_c@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at: 1. the 25th politzer society meeting. seoul, korea, october 2005 (poster). 2. resident’s research forum, reserch information and dissemination office, philippine general hospital, university of the philippines manila november 2005. 3. analytical research contest (2nd place), philippine society of otolaryngology head and neck surgery 49th annual convention, westin philippine plaza hotel, manila, december 1, 2005. philipp j otolaryngol head neck surg 2006; 21 (1,2): 5-10 c philippine society of otolaryngology – head and neck surgery, inc. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles 6 philippine journal of otolaryngology-head and neck surgery respectively. in our setting, pure tone audiometry is a routine preoperative procedure for tympanomastoidectomy while computed tomography is expensive and less widely used. further, ossicular integrity can be assessed by high-resolution tomography, but can only be confirmed intra-operatively1-5. lacking prior information, patient prognosis and surgical management techniques can only be determined during surgery. a previous study of the possible predictive value of audiograms on ossicular status showed that the preoperative hearing tests did not correlate with ossicular discontinuity6. however, studies of ossicular dysfunction must be frequency-specific since the ossicular chain and tympanic membrane have different efficiencies across frequencies7,8. by far, pure tone audiometry is the only routine test to quantitatively assess the hearing capacity of patients with otitis media undergoing surgery9. should this be able to predict ossicular chain status, the conduct and the prognosis of ear surgery may be determined. hypothetical air bone gap distributions can be plotted as shown in figure 1. a normal air bone gap will lie between -10 to 15 db. varying degrees of ossicular chain dysfunction, i.e., ossicular fixation, functional ossicular discontinuity and gross ossicular discontinuity may be represented by varying degrees of conductive hearing loss represented by the air bone gap. being able to determine minimum and maximum cut-off levels that may represent absence or presence of particular ossicular defects will allow a routine audiogram to predict specific defects in the hearing mechanism. like the electrocardiogram predicting particular heart defects through “lead-specific tracings”, a frequency-specific audiogram may perhaps point to particular hearing deficits. correlations between pure tone audiometry and ossicular discontinuity can be modified by the type and degree of tympanic perforation, middle ear polyps, degree and bilaterality of hearing loss. granulation tissue and cholesteatoma may be independent predictors of ossicular discontinuity but may alter results of hearing by direct frequency percent gross ossicular discontinuity 92 / 162 56.8% cholesteatoma 91 / 161 56.2% granulation tissue 85 / 162 52.5% tympanosclerosis 22 / 162 13.6 % attic perforation 21 / 162 13.4% subperiosteal abscess 2 / 161 1.2 % polyp in the middle ear 9 / 162 5.6% table 1. operative findings frequency mean standard air bone gap deviation 500hz 41.17 16.81 1khz 35.77 17.34 2khz 20.56 13.76 4khz 34.17 15.30 table 2. average of frequency specific air bone gaps table 3. likelihood ratios (lr) and changes in pretest to post-test probabilities* likelihood ratio likelihood ratio generated changes in for a positive test for a negative test pretest to post-test probabilities > 10 < 0.1 large and conclusive changes 5-10 0.1-0.2 moderate shifts 2-5 0.2-0.5 small but sometimes important shifts 1-2 0.5-1 rarely important shifts *evidence based medicine working group. the users’ guides to evidence-based medicine11 table 4. air bone gap (abg) cut off values at 500 hz and corresponding likelihood ratios (lr) for absence or presence of gross ossicular discontinuity (od). abg od od lr lr p 500 hz (db) (+) (-) (+) (-) value 0.254 0.435 0.516 0.686 0.761 0.965 0.992 1.070 1.141 1.322 1.443 2.283 1.775 1.522 0.068 0.033 0.006 0.005 0.003 0.299 0.602 0-10 >10-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 2 6 11 15 25 26 5 2 6 8 14 13 18 8 2 1 figure 1. theoretical air bone gap distribution silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles philippine journal of otolaryngology-head and neck surgery 7 conduction of sound. inability to isolate a particular ear for testing may alter the correlative process. hence, patients with masking dilemma, canal obstruction, head trauma, intracranial complications of otitis media were excluded from the study. the air-bone gap degree and pattern should be able to predict an ossicular chain dysfunction. such dysfunction can be in the form of ossicular chain fixation or discontinuity. ossicular discontinuity may be further classified as gross or functional discontinuity. gross discontinuity is the absence of specific ossicular bones or a disruption in the ossicular joints. functional discontinuity is the absence of unified ossicular movement on manipulation despite the presence of gross ossicular chain continuity due to fibrosis or granulation tissue. functional discontinuity and ossicular fixation were not analyzed in this study. this study aims to determine the ability of pure tone audiometry in predicting ossicular discontinuity in chronic suppurative otitis media. materials and methods records of 205 patients, 7 to 75 years of age whose first tympanomastoidectomy was performed by a single surgeon (gta) at the philippine general hospital or manila doctors hospital from june 1987 to july 2004 were reviewed. preoperative audiograms within 12 months of surgery and operative records were analyzed. minimum mastoidectomy had to include an atticotomy with visualization of the incudo-stapedial joint. patients with masking dilemma, obstructed canal lumen less than 3mm, congenital defects or fractures of the temporal bone and ears with otitis media complications were excluded. all patients were evaluated intraoperatively by the same surgeon through direct ossicular chain visualization with an operative microscope, and by palpation of the ossicular chain. incudostapedial joint continuity and pathology (granulation or fibrosis) over the ossicular chain were visualized. the malleus handle and incudostapedial joint were palpated further to assess chain continuity. gross ossicular discontinuity was defined as visualization of a disconnected or absent part of the ossicular chain. other forms of dysfunction (ossicular fixation and functional dysfunction) were not included in this study. other findings including the size and location of tympanic perforation, subperiosteal abscess, tympanosclerosis, cholesteatoma and granulation tissue were tabulated. frequency-specific air bone gap cut off values were associated with presence or absence of ossicular discontinuity with significance determined using likelihood ratios (lr) and chi square test/fisher’s exact test. univariate analysis of independent factors and possible modifiers predicting ossicular discontinuity was performed. the full model variables (ossicular discontinuity (od) associated with cholesteatoma, granulation tissue, foul smelling discharge, aural polyp, size and type of perforation, subperiosteal abscess, tympanosclerosis, bilaterality and type of hearing loss, and frequency-specific air bone gap levels) were subjected to the stepwise backward method for model estimation (wald test) and likelihood ratio tests in order to arrive at a parsimonious table 6. air bone gap (abg) cut off values at 2 khz and corresponding likelihood ratios (lr) for absence or presence of gross ossicular discontinuity (od). abg od od lr lr p 2k (db) (+) (-) (+) (-) value 0.733 0.730 0.835 0.918 0.980 0.991 cnt 1.168 1.674 2.283 3.804 3.817 2.290 cnt 0.112 0.010 0.016 0.048 0.321 0.568 cnt 0-10 >10-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 26 22 20 14 8 1 1 0 27 23 12 6 2 0 0 0 table 5. air bone gap (abg) cut off values at 1 khz and corresponding likelihood ratios (lr) for absence or presence of gross ossicular discontinuity (od). abg od od lr lr p 1 khz (db) (+) (-) (+) (-) value 0.484 0.685 0.566 0.791 0.884 0.940 0.991 1.096 1.126 1.546 1.562 1.902 3.043 2.290 0.085 0.125 0.002 0.032 0.064 0.113 0.568 0-10 >10-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 7 11 11 24 19 12 7 1 11 9 19 12 11 6 2 0 table 7. air bone gap (abg) cut off values at 4 khz and corresponding likelihood ratios (lr) for absence or presence of gross ossicular discontinuity (od). abg od od lr lr p 4khz (db) (+) (-) (+) (-) value 1.014 0.592 0.666 0.774 0.890 0.937 cnt 0.999 1.141 1.446 2.092 2.435 9.925 cnt 0.604 0.072 0.012 0.006 0.043 0.031 cnt 0-10 >10-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 8 6 21 24 17 10 6 0 6 12 22 18 7 5 0 0 table 8. gross ossicular discontinuity (od) and cholesteatoma od od (+) (-) with cholesteatoma no cholesteatoma 62 30 8 61 odds ratio of 15.75, (p< 0.0001) silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles 8 philippine journal of otolaryngology-head and neck surgery 56.8% od 75% od >75% od 36.4% od 20 500 hz 1 khz 2 khz 4 khz frequency 40 60 a b g 20 500 hz 1 khz 2 khz 4 khz frequency 40 60 a b g 32.97% od <14% od 56% od >51% od <19% od table 9. no cholesteatoma group: air bone gap (abg) cut off values at 500 hz and corresponding likelihood ratios (lr) for absence or presence of gross ossicular discontinuity (od). abg od od lr lr p 500 hz (db) (+) (-) (+) (-) value 0.407 0.156 0.313 0.581 0.651 0.982 0.983 1.053 1.228 1.510 1.564 2.588 1.356 2.033 0.351 0.021 0.004 0.026 0.005 0.535 0.553 0-10 >10-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 1 0 3 6 6 12 1 1 5 8 13 9 15 8 2 1 table 10. no cholesteatoma group. air bone gap (abg) cut off values at 1 khz and corresponding likelihood ratios (lr) for absence or presence of gross ossicular discontinuity (od). abg od od lr lr p 1 khz (db) (+) (-) (+) (-) value 0.203 0.339 0.395 0.723 0.806 0.931 1.156 1.277 1.871 1.779 2.287 3.050 0.066 0.031 0.001 0.044 0.051 0.199 0-10 >10-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 1 2 4 9 5 6 3 0 10 8 18 9 8 6 2 0 model. data were encoded using epi info 6.04d (centers for disease control, usa and world health organization), transformed to stata file using stat transfer version 5 (circle systems, inc, usa) and analyzed using intercooled stata version 6 (stata corporation, usa) and ebmcal v1.2 (evidence based medicine calculator). results of the 162 patients included in the study, 92 (56.8%) had gross ossicular discontinuity, 91 (56.2%) and 85 (52.5%) had cholesteatoma and granulation tissue respectively. other operative findings are summarized in table 1. audiometry revealed 112 (69%) had bilateral hearing loss while 115 (71%) had mixed hearing loss. averages of frequency-specific air bone gaps were narrowest at 2 khz and widest at 500hz. (table 2) frequency-specific cut-off values were analyzed for the presence or absence of gross ossicular discontinuity. corresponding p values were taken using either chi square or fisher’s exact test, and respective likelihood ratios for positive or negative results were obtained. significant likelihood ratios (lr) were defined as small, moderate or large results. (table 3) for an air bone gap (abg) <20 db at 500 hz the probability of ossicular discontinuity of 56.8% decreased to 36.4%, predicting absence of gross ossicular discontinuity (od). for an abg > 50 db at 500 hz there were increased chances from 56.8% to 75% of predicting the presence of gross ossicular discontinuity. (table 4) air bone gaps >30 db and > 40 db generated statistically significant but small effects on the chance of having ossicular chain discontinuity. (table 5) air bone gaps > 30 db or >40 db at 2 khz shifted the baseline probability of od from 56.8% to 75% and 83.34%, respectively. (table 6) air bone gaps > 50 db at 4 khz increased the chance of od from 56.8% to 76.2%. increasing air bone gap cut-off values showed progressive increase in likelihood ratios for a positive test. (table 7) combinations of air bone gaps of > 50 db at 500 hz, >30 db at 2 khz and >50 db at 4 khz increased the probability of ossicular discontinuity from a baseline probability of 56.8% to 94.35%. there was no significant predictive value for air bone gap levels on the status of ossicular chain continuity in the cholesteatoma group. cholesteatoma was associated with ossicular discontinuity with an odds ratio of 15.75 (p<0.0001). (table 8) among subjects without cholesteatoma, significant cut-off values figure 2. air bone gap and ossicular discontinuity, with or without cholesteatoma figure 3. no cholesteatoma group: air bone gap and ossicular discontinuity silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles philippine journal of otolaryngology-head and neck surgery 9 were obtained. air bone gaps <30 db at 500 hz decreased the probability of ossicular discontinuity from 32.97% to 7.67% while air bone gaps > 50db at 500 hz increased the probability of ossicular discontinuity from 32.97% to 56%. (table 10) in the absence of cholesteatoma, abg < 20 db at 1 khz decreased probability of ossicular discontinuity from 32.97% to 14.29%. (table 10) in the no cholesteatoma group, abg >20 db at 2 khz increased the probability of ossicular discontinuity from 32.97% to 51.4%. (table 11) in absence of cholesteatoma, abg > 40 db at 4 khz increased the probability of gross ossicular discontinuity from 32.97% to 52%. (table 12) in the no cholesteatoma group, a combination of air bone gaps of <30 db at 500 hz and <20 db at 1 khz decreased probability of ossicular discontinuity from 32.97% to 2.54%. combination of air bone gaps of >50 db at 500 hz, >20 db at 2 khz and >40 db at 4 khz increased probability from 32.97% to 85.9%. air bone gap cut off levels were plotted with frequency and probability of ossicular discontinuity. (figure 2 and figure 3). the baseline chance of ossicular discontinuity in general was 57%. in the absence of cholesteatoma, the chance of ossicular discontinuity was 33%. multiple logistic regression analysis was done using gross ossicular discontinuity as dependent variable. the most parsimonious model consisted of cholesteatoma, granulation, abg at 1 khz and size of perforation as the most important independent variables. the simplest model may be used for predicting ossicular discontinuity and the baseline chance of ossicular chain discontinuity was only applicable in this population. (table 13) 1 probability of od = -------------------------------------------------------------------1 + e (-4.386 + 1.66(cholesteatoma) + 2.07(granulation) +0.032(abg at 1khz) +0.0278(size of perforation)) cholesteatoma (0-absent, 1-present) granulation (0-absent, 1-present) abg at 1 khz (continuous variable, 0-60) size of perforation (continuous variable, 0-100) discussion frequency-specific air-bone gap (abg) cut-off values can predict ossicular discontinuity in chronic suppurative otitis media. generally, abg < 20 db at 500 hz predict absence of ossicular discontinuity while abg > 50 db at 500 hz, >30 db at 2 khz, and > 50 db at 4 khz best predict the presence of ossicular discontinuity in general. pre-operative audiograms best detect the absence or presence of ossicular chain discontinuity in the absence of cholesteatoma. table 11. no cholesteatoma group. air bone gap (abg) cut off values at 2 khz and corresponding likelihood ratios (lr) for absence or presence of gross ossicular discontinuity (od). abg od od lr lr p 2khz (db) (+) (-) (+) (-) value 0.763 0.555 0.850 0.965 0.959 0.959 1.154 2.153 2.372 2.033 6.00 6.00 0.263 0.003 0.082 0.401 0.330 0.330 0-10 >10-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 9 3 11 5 1 0 1 0 24 20 11 4 2 0 0 0 table 13. final model for patients showing important variables after logistic regression analysis: coefficient p value cholesteatoma granulation air bone gap 1 khz size of perforation _constant 1.66 2.07 .032 .028 -4.39 0.016 0.000 0.037 0.048 0.001 table 12. no cholesteatoma group. air bone gap (abg) cut off values at 4 khz and corresponding likelihood ratios (lr) for absence or presence of gross ossicular discontinuity (od). abg od od lr lr p 4khz (db) (+) (-) (+) (-) value 0.813 0.271 0.478 0.732 0.944 1.017 1.238 1.657 2.218 1.627 0.579 0.032 0.008 0.024 0.335 0-10 >10-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 2 0 6 10 8 4 0 0 5 10 19 16 6 5 0 0 silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles 10 philippine journal of otolaryngology-head and neck surgery references: 1. banerjee a,et al. computed tomography in suppurative ear disease: does it influence management? j laryngol otol. 2003 jun;117(6):454-8. 2. fuse t, et al. diagnosis of ossicular chain in the middle ear by high-resolution ct. nippon jibiinkoka gakkai kaiho. 1992 feb;95(2):247-52. 3. jackler, rk, et al. computed tomography in suppurative ear disease: a correlation of surgical and radiographic findings. laryngoscope. 1984 jun;94(6):746-52. 4. leighton se, et al. the role of ct imaging in the management of chronic suppurative otitis media. clin otolaryngol. 1993 feb;18(1):23-9. 5. swartz, j, et al. ossicular erosions in the dry ear: ct diagnosis. radiology. 1987 jun;163(3):763-5. 6. jeng fuh-cheng, et al. relationship of preoperative findings and ossicular discontinuity in chronic otitis media. otology and neurotology. vol. 24, no. 3, 2003. 7. cummings, cw, et al. otolaryngology head and neck surgery. 3rd edition. 1998. 8. ruckenstien, m. comprehensive review of otolaryngology. 2004 9. pso-hns clinical practice guideline on chronic suppurative otitis media, 1986. 10. karja j, et al. destruction of ossicles in chronic otitis media. j laryngol otol. 1976 jun;90(6):50918. 11. roman jaeschke, gordon h. guyatt, david l. sackett, and the evidence based medicine working group. the users’ guides to evidence-based medicine and reproduced with permission from jama. (1994;271(5):389-391) and (1994;271(9):703-707). copyright 1995, american medical association. 12. mcgrew, bm., et al. impact of mastoidectomy on simple tympanic membrane perforation repair. the laryngoscope. 2004; 114: 506-511. 13. sakagami, m. et al. cholesteatoma otitis media with intact ossicular chain. auris nasus larynx. 1999: (26) 147-151. likelihood-ratio analysis showed cut-off values in air-bone gaps at 500 hz, 2 khz and 4 khz are more reliable determinants of ossicular status. in the absence of cholesteatoma, air-bone gaps of <30 db at 500 hz and <20 db at 1 khz decrease the probability of ossicular discontinuity from 32.97% to 2.54%. air-bone gaps of >50 db at 500 hz, >20 db at 2 khz and >40 db at 4 khz increase the probability of ossicular discontinuity from 32.97% to 85.9%. these findings suggest that ossicular exploration may not be necessary for the former while an evaluation of the ossicular chain may be mandatory for the latter in the setting where cholesteatoma is not present or suspected. patterns suggesting an intact ossicular chain dictate a more conservative procedure, e.g., wullstein type i tympanoplasty while air-bone gap levels that suggest discontinuity warrant thorough inspection and possible reconstruction of the ossicular chain. routine mastoidectomy for simple tympanic perforations may be avoided, although it may have its advantages12. the presence of cholesteatoma, granulation tissue and size of tympanic membrane perforation are important factors to consider in predicting ossicular discontinuity. the prevalence of ossicular discontinuity and cholesteatoma in this population was 56.8% and 58.2%, respectively. cholesteatoma presence is an important risk factor for ossicular chain discontinuity (odds ratio of 15.75) and may warrant ossicular exploration with even simple or small tympanic perforations. the poor correlation of audiograms in this study with ossicular chain discontinuity in the presence of cholesteatoma may be due to the latter’s ability to transmit sound. even with an intact ossicular chain, subjects with cholesteatoma merit mandatory ossicular inspection by atticotomy and/or mastoidectomy with posterior tympanotomy, followed by ossiculoplasty as needed. for such cases, the advantage of wullstein type iii tympanoplasty over type i has been cited in previous studies13. although ossicular evaluation is routinely performed intraoperatively, prior knowledge of ossicular chain status gleaned from audiograms may influence the planned surgical technique (simple tympanoplasty, atticotomy with attic wall reconstruction, mastoidectomy with posterior tympanotomy and an ossiculoplasty) and implications of treatment, complementing computed tomography (or, as in our setting, replacing it). averaging results across frequencies may dilute the predictive value of audiometry on ossicular chain dysfunction. frequency-specific airbone gap cut-off values can predict gross ossicular discontinuity and the true magnitude of this relationship can be better established in a prospective study. moreover, varying degrees of ossicular dysfunction may be investigated. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 original articles philippine journal of otolaryngology-head and neck surgery 13 abstract objective: to describe the clinical and demographic profile of patients who underwent pediatric endoscopic sinus surgery (ess) and the indications for which the procedure was performed. methods: design: cross-sectional study setting: tertiary government hospital subjects: using the medical record registry, all patients below 18 years of age who underwent ess under the department of otorhinolaryngology – head and neck surgery of a tertiary government hospital in metro manila between december 31, 1999 and january 1, 2008 were reviewed. the age, sex, clinical presentation indications for doing ess and extent of surgery done were described. the lund mackay grading for nasal polyposis and scoring for sinusitis were also applied and cross-referenced. results: twenty-seven children aged 7 to 17 years underwent ess. the mean age was 12.9 years with most (15 patients) belonging to the adolescent age group (13-17 years). male to female ratio was 1.45:1. the mean interval from onset of symptoms to the first outpatient consultation was 1.5 years; the most common presenting symptoms were nasal obstruction (85.2%) and discharge (59.3%). all of the patients who underwent pediatric ess had chronic rhinosinusitis: either with nasal polyposis (85.2%), an antrochoanal polyp (11.1%) or both (3.7%). the lund mackay grading for nasal polyps and sinusitis scores were cross-referenced: patients with larger, grade iii nasal polyps tended to have more extensive sinus disease than those with grade ii polyps. on their first consultation, the patients tended to present with extensive nasal polyp and sinus disease indicating the need for surgery. all patients with crs and nasal polyposis underwent polypectomy with ethmoidectomy, uncinectomy and maxillary antrostomy, with additional frontal sinusotomy for a 17-year-old male and a 17-year-old female, both with grade 3 polyposis. the three patients who had antrochoanal polyps underwent polypectomy with uncinectomy and maxillary antrostomy. there were no operative complications such as cerebrospinal fluid leak and orbital injury reported. pediatric endoscopic sinus surgery in a tertiary government hospital: patient profile and surgical indications michael joseph c. david, md1 gil m. vicente, md1, 2 antonio h. chua, md1, 3    1 department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center 2 department of otorhinolaryngology  head and neck surgery st. luke’s medical center 3 department of otorhinolaryngology  head and neck surgery university of the east ramon magsaysay  memorial medical center correspondence: michael joseph c. david, md department of ent-hns jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone/fax: (632)743 6921 reprints will not be available from the author. no funding support was received for this study. the authors signed disclosures that they have no proprietary or financial interest with an organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at descriptive research contest, philippine society of otolaryngology head and neck surgery, jade valley restaurant, september 25, 2008 philipp j otolaryngol head neck surg 2009; 24 (1): 13-17 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 original articles 14 philippine journal of otolaryngology-head and neck surgery conclusion: most of the patients who underwent pediatric ess were older children who were brought for consultation with long-standing, extensive nasal polyp and sinus disease or with antrochoanal polyps, necessitating surgical management. patients with larger polyps tended to have more extensive sinus disease. they all underwent conservative surgery, with extent of the procedure limited to the extent of the disease present. efforts to raise public awareness about chronic rhinosinusitis and nasal polyposis in children may result in seeing such cases at an earlier, conservatively treatable stage. key words: pediatric endoscopic sinus surgery, nasal polyposis in  children endoscopic sinus surgery (ess) is a surgical procedure for restoration of physiological function to the drainage pathways of the paranasal sinuses. since gross et  al introduced ess for children in 1989, it has rapidly gained acceptance as the primary surgical procedure for the treatment of chronic rhinosinusitis (crs) and nasal polyposis in pediatric patients.1,2 the reported success rates range from 76% to 97.5% following improvements in surgical techniques and the development of optical equipment and instruments. 3 initial surgical indications for pediatric ess were broad, applying adult ess indications to the pediatric population without evidence-based data.3 early studies of pediatric ess were often retrospective without comparison to a medically treated or non-treated group. a paradigm shift occurred when prospective studies indicated that medical therapy was an effective approach to treatment for crs in the pediatric population.4 a meta-analysis of eight published articles reported positive outcomes for pediatric ess ranging from 77% to 100% with a pooled positive outcome in 88.4% of children.5,6,7 as with adults, ess for children with crs is usually reserved for failure of maximal medical management. the definition of optimal medical management, as well as indications and degree of surgical intervention, however, are less clearly defined in children. clary described a surgical candidate as a child with normal immune function testing who has failed to respond to both maximal medical therapy and adenoidectomy and meets criteria of chronic rhinosinusitis by history and ct findings.8 consensus guidelines list nine indications for ess in children: complete nasal obstruction in cystic fibrosis caused by massive polyposis or closure of the nose by medialization of the lateral nasal wall, antrochoanal polyps, intracranial complications of sinus disease, mucoceles and mucopyoceles, orbital abscesses, traumatic injury to the optic canal, dacrocystorhinitis secondary to sinusitis, fungal sinusitis and some meningoencephaloceles.9 unfortunately, pediatric ess is not simply adult fess in a smaller patient. when surgery is indicated, it usually remains conservative, consisting of a maxillary antrostomy and anterior ethmoidectomy. children pose special operative challenges because of the small anatomy and differences in underlying causes of sinus disease. the conservative ess technique dictates that the extent of the procedure performed is proportional to the extent of the disease present. this limited technique of ess was proven to be an effective treatment modality for severe, medically-refractory crs in children.10 the overall incidence of nasal polyps in children is 0.1%; the prevalence of crs with nasal polyps is likewise 0.1%11. nasal polyps usually are manifested after the age of 12 years, with affected males outnumbering females two to one.11,12 the reported prevalence of surgically amenable sinus and polyp disease in children varies from 1 to 5%.12 this paper aims to determine the clinical and demographic profile of pediatric patients who underwent ess at the jose r. reyes memorial medical center between december 31, 1999 and january 1, 2008. specifically, it aims to describe their clinical presentation, symptom duration, radiographic and endoscopic findings, extent of surgery done and to review the indications and/or disease for which pediatric ess was performed. methods design: cross-sectional study setting: tertiary government hospital subjects: using the medical record registry, the records of all patients below 18 years of age who underwent ess under the department of otorhinolaryngology – head and neck surgery of a tertiary government hospital in metro manila between december 31, 1999 and january 1, 2008 were retrospectively reviewed (appendix  a). the age, sex, geographic distribution, clinical presentation and indications for doing ess were described. radiographic and endoscopic findings were recorded and the lund mackay grading for nasal polyposis and scoring for sinusitis (appendix  b)  were used to classify the endoscopic and radiographic findings and cross-referenced.13,14 results twenty seven (27) children aged 7 to 17 years underwent ess during the 8-year period. the mean age was 12.9 years, with most (15 patients) belonging to the adolescent age group (13-17 years). except for a 7-year-old with nasal polyposis, the four youngest patients (ages 8, 9, 9 and 10) all had antrochoanal polyps. sixteen were male and 11 female, with a 1.45:1 male to female ratio. the mean interval from the onset of symptoms to the first outpatient consultation was 1.5 years. patients with nasal polyposis and crs started to have symptoms at 11.4 years on the average and they were first brought for consultation at 12.9 years. those with antrochoanal polyposis were seen at an philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 original articles philippine journal of otolaryngology-head and neck surgery 15 average age of 9 years, but started to have symptoms around the age of 7.5 years. the most common presenting symptoms were nasal obstruction (23/27 or 85.2%) and nasal discharge (16/27 or 59.3%). seven (25.9%) of the patients had anosmia, postnasal drip and/or palpable intranasal masses (figure 1). all of the patients had crs with nasal polyposis in 23 (85.2%), with an antrochoanal polyp in 3 (11.1%), or with both in 1 patient (figure  2). on nasal endoscopy, 14 (58.3%) of those with nasal polyposis had grade iii polyps and 10 (41.7%) had grade ii polyps by lund mackay grading (figure 3). polyp grading was compared with the lund mackay scores for sinusitis (figure 4). patients with higher grade polyps also had more extensive paranasal sinus disease: those with grade ii polyps had a mean score of 16, while those with grade iii polyps had a mean sinusitis score of 18.6. all patients (24) with crs and nasal polyposis underwent polypectomy with ethmoidectomy, uncinectomy and maxillary antrostomy with additional frontal sinusotomy for a 17-year-old male and a 17-year-old female, both with grade 3 polyposis. the three patients who had antrochoanal polyps underwent polypectomy with uncinectomy and maxillary antrostomy. there were no operative complications such as cerebrospinal fluid leak nor orbital injury reported. discussion nasal polyposis is an inflammatory chronic disease of the upper respiratory tract of unknown etiology although it may be associated with cystic fibrosis. in one recent study, the prevalence of nasal polyps in 211 adult patients with cystic fibrosis was 37%.15 however, cystic fibrosis is an autosomal recessive condition affecting mostly caucasians and it is very uncommon in filipinos. the reported prevalence of surgically amenable sinus and polyp disease in children varies from 1 to 5%12. nasal polyps usually are manifested after the age of 12 years, with affected males outnumbering females two to one.11,12 similarly in this study, pediatric ess was found to be mostly performed on older children with nasal polyposis and crs. our survey had a male to female ratio of 1.45:1. the mean interval from the onset of symptoms to the first outpatient consultation was 1.5 years. the tolerance for months or years of persistent nasal obstruction and discharge may account for the relatively advanced polyp and sinus disease on initial consultation. the children may have been too young to give importance to the disease and related symptoms or unable to express themselves adequately.16 in our setting, socioeconomic constraints also affect access to health care and must be considered with such delays in consultation. all patients with grade ii to iii nasal polyposis had equally extensive sinus disease. according to a study done by hopkins et  figure 1. presenting symptoms reported during the first outpatient consultation figure 2. clinical diagnosis prior to pediatric ess figure 3. lund mackay grading of nasal polyps in patients with nasal polyposis lund mackay score for sinusitis # of cases grade i polyposis grade ii polyposis grade iii polyposis 12 14 16 18 19 20 21 0 0 0 0 0 0 0 2 2 3 2 0 0 0 0 2 2 2 5 2 1 figure 4. correlation of the lund mackay scores for sinusitis and polyp grading philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 original articles 16 philippine journal of otolaryngology-head and neck surgery appendix a. patient demographics operative complications patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 age 14 14 9 15 12 12 16 14 17 8 16 17 12 11 15 10 7 14 14 16 10 15 9 14 10 13 15 sex m f f m f m m f m m m f m m f m m f m f m m f m f f m address valenzuela cavite manila quezon city manila quezon city bulacan quezon prov. quezon city valenzuela valenzuela manila manila bulacan manila valenzuela marikina manila pampanga valenzuela albay quezon prov. quezon city manila manila bulacan cavite diagnosis nasal polyposis nasal polyposis antrochoanal polyp with nasal polyposis nasal polyposis nasal polyposis nasal polyposis nasal polyposis nasal polyposis nasal polyposis antrochoanal polyp nasal polyposis nasal polyposis nasal polyposis nasal polyposis nasal polyposis nasal polyposis nasal polyposis nasal polyposis nasal polyposis nasal polyposis antrochoanal polyp nasal polyposis antrochoanal polyp nasal polyposis nasal polyposis nasal polyposis nasal polyposis polyp grade ii iii iii iii ii ii ii iii iii n/a iii iii iii ii ii ii ii iii iii iii n/a iii n/a ii ii iii iii extent of surgery ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy, frontal sinusotomy uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy, frontal sinusotomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy ethmoidectomy, uncinectomy, maxillary antrostomy none none none none none none none none none none none none none none none none none none none none none none none none none none none al, sinusitis scores increased with increasing grade of polyposis.17 in our patients, lund mackay grading for nasal polyps were directly proportional with sinusitis scores as demonstrated by computed tomography of the paranasal sinuses. patients with larger, grade iii nasal polyps tended to have more extensive sinus disease than those with grade ii polyps. following the conservative ess technique, the extent of surgery for majority of cases was limited to polypectomy, ethmoidectomy, uncinectomy and maxillary antrostomy. frontal sinusotomy was only considered an option for 2 of the older patients, both of which had extensive sinus disease. most of the patients who underwent pediatric ess were older children who were brought for consultation with long-standing, extensive nasal polyp and sinus disease or with antrochoanal polyps, necessitating surgical management. they all underwent conservative surgery, with extent of the procedure limited to the extent of the disease present. efforts to raise public awareness about chronic rhinosinusitis and nasal polyposis in children may result in seeing such cases at an earlier, conservatively treatable stage. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 original articles philippine journal of otolaryngology-head and neck surgery 17 appendix b. excerpt from the jose r. reyes memorial medical center department of otorhinolaryngology head and neck surgery nasal polyposis form department of otorhinolaryngology head and surgery jose r. reyes memorial medical center nasal polyposis form patient _______________ age ___ sex ___ hospital no._____ preoperative diagnosis ________________________________ mackay and lund staging of rhinosinusitis sinus right left maxillary 0 / 1 / 2 0 / 1 / 2 anterior ethmoid 0 / 1 / 2 0 / 1 / 2 posterior ethmoid 0 / 1 / 2 0 / 1 / 2 sphenoid 0 / 1 / 2 0 / 1 / 2 frontal 0 / 1 / 2 0 / 1 / 2 ostiomeatal complex 0 / 1 / 2 0 / 1 / 2 total legend: for the sinuses 0: no opacity for the ostiomeatal complex: 0: no obstruction 1: some opacity 2: obstructed 2: total opacity mackay and lund grading of nasal polyposis nasal endoscopy findings polyp grade no polyps 0 polyps restricted to the middle meatus 1 polyps extending below the middle turbinate 2 massive polyposis 3 reference: mackay is, lund vj. imaging and staging in nasal polyposis: an inflammatory disease and its treatment references 1. gross cw, gurucharri mj, lazar rh, long te. functional endonasal sinus surgery (fess) in the pediatric age group. laryngoscope 1989;99(3):272–275. 2. walner d, markey r, jain v, myer cm. clinical outcome of pediatric endoscopic sinus surgery. am j rhinol 2002;16(3):151–154. 3. watelet j b, annicq b, van cauwenberge p, bachert c. objective outcome after functional endoscopic sinus surgery: prediction factors. laryngoscope 2004;114(6): 1092-1097. 4. ramadan hh. surgical management of chronic sinusitis in children. laryngoscope 2004; 114(12):2103-2109. 5. hebert rl, bent jp. meta-analysis of outcomes of pediatric functional endoscopic sinus surgery. laryngoscope 1998. 108(6):796-799. 6. stankiewicz j. pediatric endoscopic nasal and sinus surgery. otolaryngol head neck surg 1995;113(3):204-210. 7. leaper m, dawes p. five year audit of paediatric sinus surgery: dunedin hospital. austral j otolaryngol 2004;7(1):21-25. 8. clary ra. is there a future for pediatric sinus surgery? an american perspective. int j pediatr otorhinolaryngol 2003; 67(1):s213–s215. 9. clement pa, bluestone bd, gordts ,f, lusk rp, otten fwa, goossens h et al. management of rhinosinusitis in children: consensus meeting. arch otolaryngol head neck surg. 1998;124:31-34. 10. chang p, lee l, huang c, lai c, lee t. functional endoscopic sinus surgery in children using a limited approach. arch otolaryngol head neck surg.2004; 130:1033-1036. 11. settipane ga, chafee fh. nasal polyps in asthma and rhinitis. a review of 6,037 patients. j allergy clin immunol 1977;59(1):17-21. 12. settipane g. epidemiology of nasal polyps. allergy asthma proceedings 1996; 17:231–236. 13. lund vj, kennedy dw. staging for rhinosinusitis. otolaryngol head neck surg 1997; 117(3pt 2): 35-40. 14. lund vj, mackay is: imaging and staging. in nasal polyposis: an inflammatory disease and its treatment. edited by mygind n, lildholdt t. copenhagen: munksgaard; 1997:137–144. 15. gysin c, alothman g, papsin b. sinonasal disease in cystic fibrosis: clinical characteristics, diagnosis, and management. pediatric pulmonology 2000; 30:481–489. 16. ramadan hh. relation of age to outcome after endoscopic sinus surgery in children. arc otolaryngol head neck surg 2003; 129:175-177. 17. hopkins c, browne j, slack r, lund v, brown p. the lund-mackay staging system for chronic rhinosinusitis: how is it used and what does it predict?. otolaryngol head neck surg 2007; 137 (4): 555-561. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 philippine journal of otolaryngology-head and neck surgery 57 primary care evaluation of the nose and paranasal sinuses begins with inspection. the astute clinician will seldom miss the hyperemic nose and open-mouth breathing of nasal congestion, the “long-face” facies, infraorbital dark “shiners” and edema of decreased lymphatic drainage from chronic nasal obstruction, and the transverse nasal crease from repeated performance of the “allergic salute” in allergic rhinitis. tearing may be caused by inferior obstruction of the nasolacrimal duct. widening of the nasal bridge (woake’s syndrome) may suggest massive nasal polyposis2. the patient with acute sinusitis may be in obvious pain and actually avoid jarring movements, and orbital complications of acute sinusitis should be apparent even to the untrained eye. a polished mirror or metal tongue depressor gently held under both nostrils can document patency of both nasal airways by observing the misting pattern even before looking inside the nose. glatzel’s mirror test3 attempts to measure this pattern but mere observation for symmetry establishes expiratory patency. inspiratory obstruction can be assessed by gently pulling the ipsilateral cheek laterally. if it relieves nasal obstruction (positive cottle’s sign4), the source of obstruction is in the nasal valve area and may be surgically correctible. anterior rhinoscopy is best done using coaxial binocular illumination such as provided by a properly focused head mirror and bright light source. alternately, a lumiview™ (welch allyn corporation, new york, usa) or hand-held otoscope with the largest available clean ear speculum can be used. in babies and young children, gently flipping up the nasal tip with a finger facilitates viewing the nasal cavities. adult noses are best viewed by aligning the external (downward-facing) and internal (forward-facing) nares with the aid of a nasal speculum. with the thumb on the pivot and index finger resting on the nasal tip, the prongs should be pressed by the remaining digits against the palm and spread superiorly against compliant alae rather than medially toward the septum. insertion should be restricted to the vestibular area (alae nasi); insinuation beyond the internal nares (limen nasi) is painful, as is closing the speculum before withdrawing (pinching vibrissae). decongestion should be performed in the presence of congested or hypertrophic turbinates and to distinguish the latter from nasal polyps (which do not shrink even with decongestion). commercially available oxymetazoline 0.05% and 0.025% (drixine™) or tetrahydrozoline 0.1% (sinutab ns™) nasal solutions should be gently dropped into each nostril while the head is tilted back and nasal tip upturned. the nozzle should not touch the nose at any time. three to five drops are instilled in one nostril after which the head is turned so that the ipsilateral ear faces down. this position (after proetz)5 facilitates the solution spreading to the lateral wall of the nose while the patient gently sniffs in. the maneuver is then replicated for primary care evaluation of the nose and paranasal sinuses jose florencio f. lapeña jr., ma, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila correspondence: jose florencio f. lapeña jr., ma, md department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 phone (632) 526 4360 fax (632) 525 5444 email: pjohns@psohns.org.ph no funding support was received for this study. the author signed a disclosure that he has no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. 1adapted, with permission, from the manuscript “runny nose, rhinitis and sinusitis” accepted for inclusion in the text book on family medicine, unit 4.2.2.2 ambulatory care: head & neck eent (forthcoming). philipp j otolaryngol head neck surg 2006; 21 (1,2): 59-60 c philippine society of otolaryngology – head and neck surgery, inc. practice pearls silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 practice pearls 58 philippine journal of otolaryngology-head and neck surgery the other nostril. three to five drops solution are then instilled in both nostrils a second time and the patient is asked to lower the forehead between the knees or to assume a knee-chest (mecca) position with forehead on the floor which facilitates spreading solution to the roof of the nose6. adequate decongestion not only facilitates examination of the nasal cavities; it affords relief from obstruction and drainage of retained discharges. performing the proetz and mecca maneuvers also educates the patient in the proper way to continue decongestion at home, provided dosing duration (three to five days) and regimens (twelve hourly for oxymetazoline and eight hourly for tetrahydrozoline) are not exceeded due to the danger of rebound rhinitis. the maneuvers are also useful for nasal saline douches and instilling steroid sprays. palpation of the paranasal sinuses is performed by percussion or by pressing firmly but gently over the most accessible points of maximum tenderness for each sinus: the vertex (sphenoid), supero-medial roofs of the orbital sockets (frontal), nasal bones between medial canthi (ethmoid) and incisive fossa area of cheeks (maxillary). upper jaw teeth (especially canines) may be tender when tapped gently in cases of acute maxillary sinusitis. transillumination with a powerful light source in a darkened room may suggest the presence of fluid or masses in the frontal and maxillary sinuses. normal air-filled frontal and maxillary sinuses should “light up” (transilluminate) with light applied over their respective palpation points. external maxillary transillumination also casts a red glow on the hard palate, and a “red streak” in the lateral recess of the oropharynx may predict sinusitis7. better results are achieved for the maxillary sinus with transoral light against the hard palate on each side. transillumination is positive (normal) for the maxillary sinuses when the cheeks turn red-orange, a red-orange crescent lights up the infraorbital rim, and a red-orange papillary reflex is observed on downward gaze; or when the scalloped margins and inter-sinus septum of the frontal sinuses stand out in relief against a red-orange background. opacification can be produced by fluid, masses or hypoplastic sinuses while air-fluid levels produce a combination of findings. swelling, masses, infraorbital nerve hyposthesia and extraocular muscle motion limitations warrant urgent specialist referral. references: 1 lapeña, jf, isidro lapeña, js. runny nose, rhinitis and sinusitis. in: leopando ze (ed) textbook on family medicine. philippine academy of family physicians. makati city: graphic-line enterprises; 2006 (forthcoming). 2 kellerhals b, uthemann b. woakes’ syndrome: the problems of infantile nasal polyps. int j pediatr otorhinlaryngol. 1979; 1:79-85. 3 lieb cc, mulinos mg. nasograph mirror of glatzel as a measure of nasal patency. arch otolaryngol. 1939; 30: 334-343. 4 cottle mh. the structure and function of nasal vestibule. arch otolaryngol. 1955; 62: 173-181. 5 proetz aw. displacement irrigation of nasal sinuses arch otolaryngol 1926; 4: 1-12. 6 evans kl. diagnosis and management of sinusitis. bmj 1994; 309: 1415-1422. 7 thomas c, aizin v. brief report: a red streak in the lateral recess of the oropharynx predicts acute sinusitis. j gen intern med 2006 sept.; 21(9):986-88. abstract objective: to describe a case of sicca syndrome, review the literature on and discuss the diagnostic criteria for sjögren syndrome. methods: design: case report setting: private clinic patient: one results: a 41-year-old female presenting with throat dryness, dry eyes, bilateral parotid enlargement, vaginal dryness and multiple joint pains previously seen by four specialists over three decades was finally diagnosed with sjögren syndrome. conclusion: sjögren syndrome presents uncommonly. as the presentation and clinical course should be taken as a whole, and no single test can be considered as a gold standard for its diagnosis, the disease entity may actually be under diagnosed, misdiagnosed or frequently present as diagnostic dilemmas. a comprehensive history and physical examination beyond the usual focus of the otorhinolaryngologic evaluation is the key for the astute clinician. our experience may indicate a need for further evaluation of the eu revised criteria for sjögren syndrome classification in the local setting. key words: sicca syndrome, sjogren syndrome, keratoconjunctivitis sicca, stomatitis sicca, xerostomia, dysparenuia intially termed keratoconjuctivitis sicca by the ophthalmologist henrik sjögren in the 1930’s, sicca syndrome currently includes dry eyes, decreased lacrimation, dry mouth and decreased salivation, which can be the result of a variety of underlying causes.1 sicca ranks among the more frequently encountered symptoms in otorhinolaryngology with sjögren syndrome as one of the many systemic conditions that present in the head and neck region. often patients come into the clinic with a variety of non specific complaints, making diagnosis elusive and treatment even more difficult. criteria for diagnosis are evolving, although treatment remains symptomatic. we present the case of a frustrated lady whose condition was undiagnosed by four different physicians over three decades. a 41-year-old female presenting with sicca syndrome laurence ian tan, md1 jose florencio f. lapeña, jr., ma, md1,2 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2department of otorhinolaryngology up college of medicine-philippine general hospital university of the philippines manila correspondence: jose florencio f. lapeña, jr. ma, md department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax: (632) 525 5444 email: lapenajf@upm.edu.ph reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interests with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this report. philipp j otolaryngol head neck surg 2008; 23 (2): 32-34 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports 32 philippine journal of otolaryngology-head and neck surgery case report a 41-year-old female from san pablo city was referred for throat dryness of twenty-six years duration, unrelieved by a thyroidectomy (!) recommended by another physician. on review, she had recurrent bilateral parotid swelling since childhood which had been managed with such home remedies as topical vinegar or gentian violet applications. no consults were made, as her parents dismissed the condition as mumps. five years before consultation, she started to note decreased tears, dry eyes and pain in the tempomandibular area with recurrence of bilateral parotid enlargement. throat dryness also persisted, and was now associated with dysphagia and odynophagia for hard solids. another otorhinolaryngologist considered a parotid tumor and advised a sialogram which she deferred, opting instead for complementary and alternative herbal medications with slight relief of throat dryness. her symptoms persisted until two months prior to consult, when she started to experience non-migratory multiplejoint pains. she consulted another physician who referred her to the senior author. on review, she also admitted chronic vaginal dryness and dyspareniua. she had no headache, dizziness or sensorial changes, no vomiting, epigastric pain, rash, oliguria, uremic fetor or chest pain. she had no history of radiotherapy, jaundice, hepatitis or atopy and denied any chronic use of medication. aside from the thyroidectomy in 1980, she had two caesarian sections in 1984 and 1986; a laparotomy and excision of ruptured ovarian cyst in 1989; and total abdominal hysterectomy and bilateral salpingooophorectomy in 1999. a housewife, she had no exposure to radiation, heavy metals or chemicals and did not use tobacco or ethanol. her family medical history did not include atopic or autoimmune disease, cancer, renal disease or hepatitis. physical examination revealed keratoconjunctivitis sicca, xerostomia with no salivary flow, a fissured tongue with flattened papillae, multiple dental carries, vague enlargement of both parotid glands and a healed transverse cervical incision. the rest of the ear, nose, throat, head and neck findings were unremarkable. schrimer’s test without anesthesia confirmed complete absence of tears (figure 1). with a presumptive diagnosis of sjögren syndrome, she was started on artificial tears (tears naturale™, alcon lab phils san juan, metro manila) and saliva (bioxtra™, bio-x healthcare 5032 les isnes, belgium) and a labial biopsy was recommended. she was also referred to a dentist and to a rheumatologist who requested ana, anti ss-a and anti ss-b tests. relieved to have a diagnosis, she opted not to have these tests done. interestingly, a confirmatory thyroid ultrasonogram revealed normal thyroid despite the previous surgery and thyroid function tests were all normal. discussion sicca syndrome can result from a variety of underlying causes, with connective tissue and autoimmune disorders such as systemic lupus erythematosus (sle), rheumatoid arthritis (ra) and sjögren’s syndrome (ss) among the primary differentials. sle commonly presents with cutaneous lesions—malar rash, discoid rash, and oral ulcers while ra prominently features migratory polyarthritis. rheumatoid factor (rf) is positive in most cases of ra. in addition, more than 50% of patients with high levels of rf in their blood have ss. many patients with ra also have ss. there is sexual predilection for both diseases, with two to three times as many women as men having ra, and 90% of ss cases involving females.1 the diagnosis of sjögren syndrome poses difficulty as no single clinical symptom, sign or lab test can be regarded as confirmatory or the gold standard. 2 none of the proposed diagnostic and classification criteria were widely accepted until 1993, when the european criteria gained comparatively more consensus among textbooks, experts and clinicians.2, 3, 4 the current internationally accepted classification criteria for sjögren syndrome is a revised version of the european criteria proposed by the american-european consensus group in 2002.4 [appendix] our patient met four of the six criteria for diagnosis of primary ss: item i, ocular symptoms (foreign body sensation, eye irritation, redness); item ii, oral symptoms (dry mouth, swollen salivary glands); item iii, a schirmer’s i test, performed without anesthesia (<5mm in 5min) and item v, unstimulated salivary flow (< 1.5ml/15 mins). the presence of any four of the six items is indicative of primary ss as long as either item iv (histopathology) or vi (serology) is positive. unfortunately, both were declined by our patient. the presence of any 3 of the 4 objective criteria items (items iii, iv, v, vi) or the classification tree procedure represent valid alternative methods for classification. our patient only fulfilled 2 of the 4 objective criteria items, iii and v. after having seen four physicians without a diagnosis, would our diagnosis now be futile on the basis of inadequate criteria? a study by zhao5 found the american-european criteria for diagnosis of sjögren syndrome to have a high sensitivity and specificity for primary ss patients in china, but questioned the value of histology (lip biopsy) included in eu-am criteria. they found that even without lower lip minor salivary gland histopathology results, these criteria could reach a sensitivity of 87.2% vs 89.2% with a lip biopsy, which they determined to have no significant difference.5 our patient has fulfilled four of the six criteria allowing a diagnosis of primary sjögren syndrome with 97.4% sensitivity and 89.4% specificity.2 what sensitivity and specificity levels are acceptable to make a diagnosis of primary sjögren syndrome, knowing that the diagnosis entails a 40-fold increase in the risk of developing lymphoma, and that treatment consists in palliation of symptoms? are criteria with neither local data nor local prevalence studies applicable locally? our patient opted not to undergo any further tests despite full education on the increased risk of lymphoma for sjögren syndrome and the possibility of misdiagnosis. positive serologic or histological results will not alter immediate management, and treatment is directed mainly at symptom palliation and early detection of malignancy or life threatening complications. keratoconjunctivitis sicca is usually treated with artificial tears (as given to our patient), steroid and non-steroid eye drops, tear passage occlusion or soft adherent lenses. stomatitis sicca may sometimes be sufficiently relieved by n-acetyl-cysteine, artificial saliva (given to our patient), chewing gum and b-vitamin complex. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports philippine journal of otolaryngology-head and neck surgery 33 references 1. aacc.org [homepage on the internet]. washington dc. american association for clinical chemistry 2001-2006 available from http://www.aacc.org/. 2. vitali c, bombadieri s, jonsson r classification criteria for sjögren’s syndrome: a revised version of the european criteria proposed by the american-european consensus group. ann rheum dis 2002;61, 554–8. 3. vitali c, bombardieri s, moutsopoulos hm, alexander el, carsons se, daniels te, et al. assessment of the european classification criteria for sjögren’s syndrome in a series of clinically defined cases. results of a prospective multicentre study. ann rheum dis 1996; 55, 116–21. 4. zhao y, zheng w, zhou w, zeng x, zhang f, tang f, dong y the evaluation of the international classification criteria (2002) for primary sjögren’s syndrome in chinese patients. aplar j rheum 2005; 8 (3), 184-187. 5. zhang zl, dong y clinical and immunological features of primary sjögren’s syndrome with liver damage: 30 cases of clinical analysis. chin j rheum 1998; 2, 92–6. figure 1. schrimer’s test showing absence of production of tears. appendix i ii iii iv v vi 1. have you had daily, persistent, troublesome dry eyes for more than 3 months? 2. do you have a recurrent sensation of sand or gravel in the eyes 3. do you use tear substitute more than 3 times a day? 1. have you had daily feeling of dry mouth for more than 3 months? 2. have you had a recurrent persistently swollen salivary glands as an adult? 3. do you frequently drink liquids to aid in swallowing dry food? 1. schirmer’s i test, performed without anaesthesia (≤5mm in 5min) 2.rose bengal score or other ocular dye score (≥4 according to van bijsterveld’s scoring system) histopathology: in minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis, evaluated by an expert histopathologist, with a focus score ≥1, defined as a number of lymphocytic foci (which are adjacent to normal-appearing mucous acini and contain more than 50 lymphocytes) per 4 mm2 of glandular tissue1 1. unstimulated whole salivary flow (≤1,5 ml in 15 min) 2. parotid sialography showing the presence of diffuse sialectasias (punctate, cavitary or destructive pattern), without evidence of obstruction in the major ducts 3. salivary scintigraphy showing delayed uptake, reduced concentration and/or delayed excretion of tracer autoantibodies: presence in the serum of the antibodies to ro(ssa) or la(ssb) antigens, or both classification criteria for sjögren’s syndrome (2002)2 primary ss criteria any 4 of the 6 items with either item iv or vi is positive any 3 of the 4 objective criteria classification tree procedure secondary ss criteria the presence of item i or item ii plus any 2 from among items iii, iv, and v criteria for diagnosis of sjögren’s syndrome2 exclusion criteria past head and neck radiation treatment hepatitis c infection acquired immunodeficiency disease (aids) pre-existing lymphoma sarcoidosis graft versus host disease use of anticholinergic drugs (since a time shorter than 4-fold the half life of the drug salivary gland enlargement and extra glandular signs are often of less concern but can be treated by nsaids and corticosteroids. her quality of life has dramatically improved, not so much because of the supportive therapy instituted, but because she now has a name for, and an understanding of her disease. sjögren syndrome presents uncommonly. as the presentation and clinical course should be taken as a whole, and no single test can be considered as a gold standard for its diagnosis, the disease entity may actually be under diagnosed, misdiagnosed or frequently present as diagnostic dilemmas. a comprehensive history and physical examination beyond the usual focus of the otorhinolaryngologic evaluation is the key for the astute clinician. our experience may indicate a need for further evaluation of the eu revised criteria for sjögren syndrome classification in the local setting. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports 34 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 25 abstract objective: to identify risk factors associated with disease recurrence among filipinos with papillary thyroid carcinoma (ptc). methods: design: retrospective cohort study setting: tertiary national university hospital participants: 76 patients diagnosed with papillary thyroid carcinoma, classified as low and low-to-intermediate risk (2015 ata classification) that underwent total thyroidectomy with or without neck dissection from 2010-2014 and were followed up from 10 months to 5 years. log rank and cox regression analyses were used to determine significant risk factors for recurrence. results: 29 (38.15%) had recurrence. on univariate analysis, age, tumor size, multifocality, extrathyroidal extension, presence of lateral neck nodes and rai therapy were statistically associated with recurrence. however, on multivariate analysis, no clinicopathologic factor was statistically associated with recurrence. conclusion: age of >45 years, female sex, tumor size of >2 cm, multifocality, presence of microscopic extrathyroidal extension and lymph node metastasis might contribute to the recurrence of papillary thyroid cancer while post-operative radioactive ablation may have some protective effect. however, this study suggests that other factors must be included in the model to better understand the relationship between these factors and recurrence. keywords: papillary thyroid cancer, thyroid neoplasm, recurrence thyroid cancer was the most frequent head and neck cancer in the philippines in 20121 and continues to rank among the most common reasons for admission at the philippine general hospital-department of otorhinolaryngology (pgh-orl). a review of all thyroid cases admitted at the pgh-orl from january 2006 to december 2010 revealed 415 thyroid malignancies managed, of which 82.9% were papillary thyroid carcinoma (ptc).2 risk factors for recurrent papillary thyroid carcinoma jonel donn leo s. gloria, md, moh alfredo quintin y. pontejos, jr., md precious eunice r. grullo, md, mph department of otorhinolaryngology university of the philippines – philippine general hospital correspondence: dr. alfredo quintin y. pontejos, jr. department of otorhinolaryngology ward 10, philippine general hospital university of the philippines, manila taft avenue, ermita, manila 1000 philippines phone: (632) 554 8400 local 2152 email: docpontejosjr@yahoo.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest presented at the philippine society of otolaryngology head and neck surgery analytical research contest (1st place), november 17, 2016. bella ibarra, quezon avenue, quezon city. philipp j otolaryngol head neck surg 2017; 32 (2): 25-29 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 26 philippine journal of otolaryngology-head and neck surgery original articles the primary treatment of ptc is still surgery (thyroidectomy) and when appropriate, a neck dissection.3,4,5 in our setting, a considerable subset of ptc tends to become more aggressive and recurs even with adequate surgical and medical management. while local and regional recurrences of ptc after surgery have ranged from 5-10%,6 a 2010 study among filipinos with thyroid cancer claimed recurrence rates as high as 25%.7 recurrences may be local (primary site and adjacent structures), regional (cervical lymph nodes) or distant and impact negatively on patients’ quality of life with increased morbidity. the extent of surgery and need for adjuvant treatment depend on several prognostic factors that influence risk stratification of patients in terms of recurrence and survival. several studies have identified clinicopathologic factors predictive of increased risk of recurrence among patients with ptc, including age, sex, tumor size, cervical lymph node metastasis, extrathyroidal invasion, bilaterality/multifocality and post-operative rai therapy.8 -17 in order to determine specific patientand disease-related factors associated with ptc recurrence among our patient population that are essential for developing initial treatment and follow-up schemes and establishing the need for adjuvant treatment in our setting, this study aims to determine factors that are associated with recurrence of ptc among patients admitted at pgh-orl in terms of age during initial surgery, sex, tumor size, multifocality, extrathyroidal extension, lymph node metastasis and post-operative rai therapy. methods with institutional review board approval, this retrospective cohort study reviewed the records of 86 patients diagnosed with papillary thyroid carcinoma that underwent total thyroidectomy with or without neck dissection at the pgh-orl from january 2010 to december 2014 and followed up for at least 10 months. papillary thyroid carcinoma recurrence was defined as the reappearance of ptc after a period of at least 10 months from initial surgery including both local and regional recurrences.7 medical records (including operative records and histopathology results) were reviewed for the following data: age (years) at the time of initial surgery, sex, tumor size, multifocality, extrathyroidal extension, lymph node metastasis, post-operative rai therapy and length of follow-up. considered for inclusion were records of patients with papillary thyroid cancer on histopathologic result and low and lowto-intermediate risk 2015 ata classification. excluded were records of cases with no definite histopathologic result and high-risk 2015 american thyroid association (ata) classification (residual disease, gross extrathyroidal extension, distant metastasis) as these patients had high risk of recurrence.18 data was tabulated using microsoft excel version 2013 (microsoft, chicago, usa) and means and proportions were obtained. univariate analysis was performed using log-rank test. the outcome of interest was recurrence, established by imaging (ultrasonography or computed tomography), thyroglobulin levels, thyroid scintigraphy, or histopathology. variables with p < .25 on univariate analysis were included in the multivariate analysis using cox regression. kaplanmeier curves were obtained. data were analyzed using stata version 13.1 (statacorp, tx, usa). results records of 76 patients (21 males, 55 females) were included in this series. the mean age of the patients was 44 ± 2 years (range 15-77 years). the average tumor size was 3.96 ± 0.29 cm (range 0.3 to 14.5 cm). 29 (38.15%) had recurrences while 47 had no observed recurrence on the cut-off date. the sites of recurrences follows: 3, thyroid bed only; 17, lateral neck (16 unilateral and 1 bilateral); 9, both thyroid bed and lateral neck (6 in the thyroid bed and unilateral neck and 3 in the thyroid bed and bilateral neck). the 10 excluded records were those of 2 patients that had no definite histopathologic result and 8 cases with high risk 2015 ata classification. table 1 summarizes the clinicopathologic profiles of the patients included in the series. with cut-off p < .25, age (p = .01), tumor size (p = .2), multifocality (p = .04), extrathyroidal extension (p = .02), presence of lateral neck nodes (p = .03) and rai therapy (p = .2) were included in multivariate analysis on which no clinicopathologic factor was statistically associated with recurrence. this indicates that other factors affecting recurrence are missing in the model (r2=0.3776). table 2 summarizes the results (p values, hazards ratios and confidence intervals) of both univariate and multivariate logistic regression analyses on the factors studied. in this study, those with age > 45 years old had 1.93 times higher risk of having a recurrence than those </= 45 years old . tumor size of >2 to 4 cm and >4 cm had 59% and 74% increased risk of recurrence compared to tumors <2 cm in size, respectively. the presence of multifocality increased the risk of recurrence by 69%. the risk of recurrence was 1.31 times higher if extrathyroidal extension was present. unilateral neck nodes and bilateral neck nodes increased the risk of recurrence 2.06 times and 1.47 times, respectively. rai therapy decreased the risk of recurrence by 51%. figure 1 shows the kaplan-meier curve analysis for each clinicopathologic factor studied. the estimated 5-year recurrencefree estimate is 32.87%. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 27 table 1. clinicopathologic profile of the patients clinicopathologic factors without recurrence n = 47 with recurrence n = 29 age (years) sex tumor size (cm) multifocality extrathyroidal extension central neck nodes lateral neck nodes rai therapy follow-up time (months) ≤ 45 > 45 male female ≤ 2 > 2 to 4 > 4 absent present absent present absent present absent unilateral bilateral absent present 28 (60%) 19 (40%) 14 (30%) 33 (70%) 17 (36%) 16 (34%) 14 (30%) 32 (68%) 15 (32%) 38 (81%) 9 (19%) 33 (70%) 14 (30%) 32 (68%) 14 (30%) 1 (2%) 20 (43%) 27 (57%) 30 (sd:3) 11 (38%) 18 (62%) 7 (24%) 22 (76%) 7 (24%) 6 (21%) 16 (55%) 12 (41%) 17 (59%) 11 (38%) 18 (62%) 21 (72%) 8 (28%) 14 (48%) 12 (41%) 3 (11%) 19 (66%) 10 (34%) 32 (sd:4) table 2. univariate and multivariate analyses of the factors associated with ptc recurrence clinicopathologic factors univariate analysis p multivariate analysis hr ci p age sex tumor size multifocality extrathyroidal extension central neck nodes lateral neck nodes rai therapy ≤ 45 female > 2 to 4 > 4 present present present unilateral bilateral present .01 .27 .20 .04 .02 .74 .03 .20 1.93 1.59 1.74 1.69 1.31 2.06 1.47 0.49 0.78-4.80 0.49-5.24 0.68-4.48 0.71-4.04 0.56-3.1 0.83-5.1 0.33-6.47 0.21-1.15 .10 .44 .25 .25 .53 .12 .61 .10 note: blacked out cells are not included in the multivariate analysis; cut-off p<0.25 a b c philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 28 philippine journal of otolaryngology-head and neck surgery original articles figure 1. kaplan-meier disease-free estimate curves of clinicopathologic factors for papillary thyroid cancer recurrence. a. age. note that age >45 (dash) has a lower recurrence-free estimate than younger patients b. sex. males (solid line) have a lower recurrence free estimate than females but not statistically significant. c. tumor size. tumor size of 2-4 cm (dash) and more than 4 cm (dotted line) have a lower recurrence free estimate than size less than 2 cm (solid). d. extrathyroidal extension. recurrence free estimate is lower when microscopic extrathyroidal extension is present (dash). e. presence of central neck node. the presence of central neck node metastasis (dash) has a higher recurrence-free estimate compared to its absence but only during the early periods of observation. f. presence of lateral neck node. those without lateral neck node (solid) have a significantly higher recurrence free estimate compared to unilateral (dash) and bilateral (dotted) neck node metastasis. g. postsurgical radio¬active iodine (rai) ablation. the use of post-op rai (dash) has higher recurrencefree estimate compared to cases without post-op rai although not statistically significant. discussion this study suggests that age of >45 years, female sex, tumor size of >2 cm, multifocality, presence of extrathyroidal extension and lymph node metastasis may increase the risk of papillary thyroid recurrence although the associations did not reach statistical significance. postoperative rai ablation may decrease the risk of recurrence although this also did not reach statistical significance. (table 2) these factors are similar to reports in other populations.11,16 the 45-year-old age cut-off by the national comprehensive cancer network clinical practice guidelines in oncology was also shown to be a risk factor for papillary thyroid cancer recurrence among filipi nos in this study.4 in this study, ptc patients with multifocal disease had higher risk of developing recurrence than those with unifocal disease. this echoes the findings of qu et al.19 that increasing number of tumor foci of ptc are associated with a tendency toward more aggressive features, shorter recurrence-free survival and may be a possible indicator of cancer death. the number of tumor foci might also represent the tumor burden in ptc patients,19 consistent with another study by lin et al. where 52.9% of recurrent multicentric ptc patients were diagnosed within the first year of thyroidectomy.20 this study showed that extrathyroidal extension carries an increased risk of developing recurrence. in comparison, arora et al. found a 6.4-fold increased risk d e f g philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 29 references 1. world health organization. globocan 2012: estimated cancer incidence, mortality and prevalence worldwide in 2012. [cited 2014 jan 12]. available from: : http://globocan.iarc.fr/ pages/fact_sheets_cancer.aspx. 2. holgado j, gloria j, pontejos a. epidemiologic study of thyroid lesions treated in the philippine general hospital – department of otorhinolaryngology: a 5-year experience. in press 2012. 3. pontejos a, caparas m, cabungcal a, hardillo j, hernandez j, hernandez m, et al. manual for the management of head and neck malignancies, 2nd edition. 2012, p 59-65. 4. national comprehensive cancer network clinical practice guidelines in oncology, head and neck cancers, version 1.2015. [accessed 2015 jan 13]. available from: http:// oralcancerfoundation.org/wp-content/uploads/2015/09/head-and-neck.pdf. 5. sison cm, obaldo j, matsuo j, uy gm, jaring c. university of the philippines – philippine general hospital revised clinical practice guidelines for the management of well-differentiated thyroid carcinoma of follicular cell origin. journal of the asean federation of endocrine societies. 2012 may; 27(1):49-61. doi: https://doi.org/10.15605/jafes.027.01.08. 6. schlumberger m. papillary thyroid carcinoma. orphanet encyclopedia. 2004. [cited 2014 feb 2]. available from: http://www.orpha.net/data/patho/gb/uk-ptc.pdf. 7. kus l, shah m, eski s, walfish p, freeman j. thyroid cancer outcomes in filipino patients. 2010. [cited 2014 jan 23]. available from: http://archotol.jamanetwork.com. 8. popadich a, levin o, lee jc, smooke-praw s, ro k, fazel m, et al. a multicenter cohort study of total thyroidectomy and routine central lymph node dissection for cn0 papillary thyroid cancer. surgery. 2011 dec;150(6): 1048-57. doi: 10.1016/j.surg.2011.09.003; pmid: 22136820. 9. hartl d, mamelle e, borget i, leboulleux s, mirghani h, schlumberger m. influence of prophylactic neck dissection on rate of retreatment for papillary thyroid carcinoma. world j surg. 2013 aug; 37(8):1951-8. doi: 10.1007/s00268-013-2089-3; pmid: 23677562. 10. zhu j, wang x, zhang x, li p, hou h. clinicopathological features of recurrent papillary thyroid cancer. diagn pathol. 2015 jul 14; 10: 96. doi: 10.1186/s13000-015-0346-5; pmid: 26168921; pmcid: pmc4501206. 11. liu fh, kuo sf, hsueh c, chao tc, lin jd, et al. postoperative recurrence of papillary thyroid carcinoma with lymph node metastasis. j surg oncol. 2015 aug; 112(2): 149-54. doi: 10.1002/ jso.23967; pmid: 26175314; pmcid: pmc5034820. of recurrence and significantly decreased disease-free survival in ptc patients with macroscopic extrathyroidal extension21 and nodal metastasis has been reported to increase the risk of recurrence.19, 21 the use of post-operative rai therapy based on our results is protective with an hr of 0.49. unlike in high risk patients where the evidence for the benefits of rai are strong, the ata 2015 guideline reported that there are conflicting observational data in the use of postop rai among low and low-to intermediate risk patients.18 according to the up-pgh revised clinical practice guidelines for the management of well-differentiated thyroid carcinoma of follicular cell origin in 2012, the use of adjuvant rai treatment in well-differentiated thyroid cancer has been shown to significantly decrease disease recurrence and causespecific mortality.5 our study supports this recommendation. there are several limitations of this study. first is the potential for selection bias in a retrospective study. in this study, it was assumed that all tumors were resected if no residual tumor was indicated in the operative technique or no positive margins were noted on histopathologic result. initial thyroglobulin levels were not available 12. yang j, gong y, yan s, shi q, zhu j, li z, et al. comparison of the clinicopathological behavior of the follicular variant of papillary thyroid carcinoma and classical papillary thyroid carcinoma: a systematic review and meta-analysis. mol clin oncol. 2015 jul;3(4):753-764. doi: 10.3892/ mco.2015.540; pmid: 26171175; pmcid: pmc4487034. 13. rapoport a, curioni oa, amar a, dedivitis ra. review of survival rates 20-years after conservative surgery for papillary thyroid carcinoma. braz j otorhinolaryngol. 2015 jul-aug; 81(4):389-93. doi: 10.1016/j.bjorl.2014.08.020; pmid: 26120098. 14. jin bj, kim mk, ji yb, song cm, park jh, tae k. characteristics and significance of minimal and maximal extrathyroidal extension in papillary thyroid carcinoma. oral oncol. 2015 aug;51(8):759-63. doi: 10.1016/j.oraloncology.2015.05.010; pmid: 26093388. 15. scerrino g, attard a, melfa gi, raspanti c, di giovanni s, attard m, et al. role of prophylactic central neck dissection in cn0-papillary thyroid carcinoma: results from a high-prevalence area. minerva chir. 2016 jun; 159-67. pmid: 26046958. 16. suh yj, kwon h, kim sj, choi jy, lee ke, park yj, et al. factors affecting the locoregional recurrence of conventional papillary thyroid carcinoma after surgery: a retrospective analysis of 3381 patients. ann surg oncol. 2015 oct; 22(11): 3543-9. doi: 10.1245/s10434-015-4448-9; pmid: 25743326. 17. kim hj, sohn sy, jang hw, kim sw, chung jh. multifocality, but not bilaterality, is a predictor of disease recurrence/persistence of papillary thyroid carcinoma. world j surg. 2013 feb;37(2):37684. doi: 10.1007/s00268-012-1835-2; pmid: 23135422. 18. haugen br, alexander ek, bible kc, doherty gm, mandel sj, nikiforov ye. 2015 american thyroid association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the american thyroid association guidelines task force on thyroid nodules and differentiated thyroid cancer. thyroid. 2015. doi: 10.1089/thy.2015.0020. 19.qu n, zhang l, ji q, zhu y, wang z, shen q, et al. number of tumor foci predicts prognosis in papillary thyroid cancer. bmc cancer. 2014; 14:914. [cited 2014 feb 12]. available from: http:// www.biomedcentral.com/content/pdf/1471-2407-14-914.pdf 20. lin jd, chao tc, hsueh c, kuo sf. high recurrent rate of multicentric papillary thyroid carcinoma. ann surg oncol. 2009 sep;16(9):2609–2616. doi: 10.1245/s10434-009-0565-7; pmid: 19533244. 21. arora n, turbendian h, scognamiglio t, wagner p, goldsmith s, zarnegar r, et al. extrathyroidal extension is not all equal: implications of macroscopic versus microscopic extent in papillary thyroid carcinoma. surgery. 2008 dec;144(6):942-7. for all patients. second, the timing of recurrence is relative. for some patients, recurrence was detected due to regular determination of thyroglobulin. for some, imaging was done after a neck mass was noted. in effect, the diagnosis of recurrence might be later than it really is. this could decrease the possible relationship of recurrence to the variables studied. third, the variables measured in this study were limited to age (years) at the time of initial surgery, sex, tumor size, multifocality, microscopic extrathyroidal extension, lymph node metastasis and post-operative rai therapy. other variables that could affect recurrence like molecular mutation status and timeliness of rai therapy were not measured. in conclusion, age of >45 years, female sex, tumor size of >2 cm, multifocality, presence of microscopic extrathyroidal extension and lymph node metastasis might contribute to the recurrence of papillary thyroid cancer while post-operative radioactive ablation may have some protective effect. however, the findings in this study suggest that other factors must be included in the model in order to better understand the relationship between these factors and recurrence. philippine journal of otolaryngology-head and neck surgery 43 philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports abstract objective: to present a case of tongue reconstruction using radial forearm free flap. methods: design: case report setting: tertiary government hospital patient: one results: a 52-year-old female with a t3n2cm0 stage iva right tongue carcinoma underwent tracheotomy, right hemiglossectomy with modified radical neck dissection type iii and extended supraomohyoid neck dissection on the left with radial forearm free flap reconstruction. after 1 month, the radial forearm free flap reconstruction in the tongue had acceptable appearance and good tongue mobility with intelligible speech. the patient did not complain about the appearance and function of the left forearm. conclusion: the radial forearm free flap is a viable reconstructive option for tongue defects especially where a thin, pliable flap is needed. there is acceptable form and functional restoration with minimal donor site morbidity. key words: radial forearm free flap, tongue reconstruction a 52-year-old female consulted due to a right lateral tongue mass that was noted 2 months prior as a 1 x 1cm ulcerative lesion with occasional bleeding and tenderness. the patient was a non-smoker. punch biopsy revealed squamous cell carcinoma, well differentiated and surgery was advised, prompting subsequent admission. on examination there was a 5 x 4 cm right lateral tongue mass involving a portion of the tongue base (figure 1) with no limitation of tongue movement. there were also a 2 x 3 cm slightly fixed level ii lymph node on the right side of the neck and a 1 x 1 cm movable level ib lymph node on the left side of the neck. pre-operative staging was t3n2cm0 stage iva. of the treatment options recommended, the patient chose surgery with post-operative chemoradiotherapy. rodney oliver j. aragon,md1 samantha soriano –castaneda, md1,2,3 joselito f. david, md1,2,3 1 department of otolaryngology head and neck surgery rizal medical center 2 department of otolaryngology head and neck surgery the medical city 3 department of otolaryngology head and neck surgery jose reyes memorial medical center correspondence: rodney oliver j. aragon, md department of otolaryngology head and neck surgery rizal medical center pasig blvd., pasig city 1600 philippines telefax: (632) 671 0424 email: rodneyaragon@hotmail.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interests with any organization that may have direct interest in the subject matter of this manuscript, or in any product used or cited in this report. presented at the interesting case contest (3rd place), philippine society of otolaryngologyhead and neck surgery convention, baguio city april 2007. radial forearm flap for tongue reconstruction philipp j otolaryngol head neck surg 2008; 23 (2): 43-45 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 44 philippine journal of otolaryngology-head and neck surgery case reports the patient underwent hemiglossectomy with a portion of the base of the tongue excised for adequate margins. (figure 2) the neck dissection was done simultaneous with the harvesting of the radial forearm free flap (rfff). a level iia lymph node on the right side of the neck was noted to have extracapsular spread which was adherent to the anterior scalene muscle. the cutaneous portion of the rfff measured 7 x 5cm along with additional 4 x 5cm ofsubcutaneous tissue. (figure 3) the donor site was closed with a split thickness skin graft (stsg). the flap was folded to simulate the tongue shape and part of the flap replaced the floor of the mouth. the harvested subcutaneous tissue was tucked in under the flap to add bulk to the tongue base portion of the flap. (figure 4) the radial artery was anastomosed to the superior thyroid artery while the cephalic vein was anastomosed to the facial vein. the total length of the operation was 11 hours and 5 minutes. the patient was decannulated on the 2nd post-operative day and was started on sterile water on the 6th post-operative day. the nasogastric tube was removed on the 7th post-operative day and she was discharged on the 10th postoperative day. final histopathology revealed tongue scca right, with tumor free margins of resection; metastasis 3 of 32 lymph nodes r (levels 2 and 3); negative tumor involvement, left lymph nodes. concurrent chemo-radiation therapy post-operation was delayed due to financial difficulties. four weeks after the operation, there was note of tumor growth at level ii on the right side of the neck. (figure 5) the rfff was noted to have good color and the patient had good tongue mobility. (figure 6) the patient was on soft diet since she was edentulous. speech was intelligible. the patient did not complain about the appearance or function of the left forearm. the patient subsequently underwent 60 grays of external beam radiation at 2 g per day at standard fractionation for 30 days at 1 month and 20 days post-operation with erratic compliance. she was asked to extend her radiotherapy for 10 more days but this was not completed due to her demise at 3 months and 23 days post-operation. discussion head and neck oncologists are often confronted with the difficult challenge of balancing cancer cure and patient survival with preservation of function, cosmesis and quality of life when recommending the best treatment option for the patient. this is difficult in the management of tongue cancer because the tongue is intimately involved in speech and swallowing. with the introduction of microsurgical free tissue transfer, the range of tissues that can be transferred for reconstruction of oral cavity defects has dramatically increased. the radial forearm free flap (rfff) has emerged as the option of choice among reconstructive surgeons for complex head and neck defects after ablative surgery. ease of harvest with two synchronous operative teams, potential for sensory innervation, the thin and pliable skin and fascia obtained and the pedicle length and caliber of the vessels are among the reasons for the rfff’s popularity.1 meaningful statements about cause and effect relationships between reconstructive techniques and function cannot be made figure 1. lesion on the right lateral aspect of the tongue figure 2. tongue after glossectomy figure 3. radial forearm flap. figure 4. tongue with rfff without accounting for the site and extent of the surgical resection and many other factors related to the tumor and the patient. there is also need for development of standardized procedures for evaluating functional outcome.2 haughey et al classified tongue defects of the tongue as hemiglossectomy, three quarter glossectomy, total oral glossectomy and base of tongue defects. they advocated the longitudinal fold technique for hemiglossectomy defects. a small amount of overcorrection about (30%) is needed to allow for decrease in volume of the flap.3 this is the technique that was used on our patient to allow for closure of the floor of the mouth defect but at the same time simulating normal tongue appearance with a thin flap. this was evident in the acceptable appearance of the reconstructed tongue, good tongue mobility with intelligible speech and good deglutition of the patient. donor site morbidity is another factor that must be considered in the patient about the different reconstruction options. a prospective study on long term functional morbidity of the rfff donor site revealed 32% reduced radial nerve sensation, 14% cold intolerance, 14% restriction of wrist movement and 28% poor aesthetic appearance.4 this was also confirmed by toschka et al who opined that it was of no clinical relevance. in their study, 85.7% of patients displayed optimal functional hand testing values (80-100%), and 88.6% gave a positive subjective assessment (80-100%) of postoperative versus preoperative hand function.2 this was evident in our patient who had slight limitation of wrist movement which did not hamper her everyday activities. the reconstruction is fruitless if there is tumor residual or recurrence. inspite of advances in surgical ablation and reconstruction, the overall survival of patients with advanced head and neck malignancies has not significantly increased. thawley and others list the over-all survival of stage iva tongue carcinoma at only 34%.5 in the national comprehensive cancer network clinical guidelines in oncology, the figure 6. recomstructed tongue using the radial forearm free flap at 4 weeks post-operation. acknowledgement we would like to thank dr. erasmo d.v. llanes who provided general support and served as our scientific adviser. references 1. brown js. t2 tongue: reconstruction of the surgical defect.brown js. t2 tongue: reconstruction of the surgical defect. br j oral maxillofacial surg. 1999;37:194–199. 2. toschka h, feifel h, erli hj, minkenberg r, paar o and riediger d. aesthetic and functional toschka h, feifel h, erli hj, minkenberg r, paar o and riediger d. aesthetic and functional results of harvesting radial forearm flap, especially with regard to hand function. intern j oral maxillofacial surg. 2001; 30: 42–48. 3. skoner jm, bascom da, cohen ji, andersen pe and wax m�. short-term functional donor skoner jm, bascom da, cohen ji, andersen pe and wax m�. short-term functional donor site morbidity after radial forearm fasciocutaneous free flap harvest. laryngoscope. 2003;113(dec):2091–2094. 4. richardson d, fisher se, vaughan ed and brown js. radial forearm flap donor-siterichardson d, fisher se, vaughan ed and brown js. radial forearm flap donor-site complications and morbidity: a prospective study. plast reconstr surg.1997; 99(1):109-115. 5. thawley se, panje wr, batsakis jg and lindberg rd. comprehensive management of head and neck tumors. 1999. 34:691-692 6. national comprehensive cancer network clinical practice guidelines in oncology – head and neck cancers version 2006. figure 5. right side of neck with note of neck node at level ii management for tongue carcinoma in this stage is excision of the primary with comprehensive bilateral neck dissection and concurrent chemoradiotherapy if the nodes have adverse features such as presence of extracapsular spread.6 although this would have been ideal for our case, financial constraints led to delays in adjuvant therapy and limitation to radiotherapy only instead of concurrent chemo-radiotherapy. this may have led to the uncontrolled growth of the regional metastasis and eventual demise of the patient. this is a common plight of patients in the philippines wherein much needed health care is not within the means of most of the population. the limitation of the study is that we presented only a single case of tongue reconstruction. an objective assessment of the functional capability of the reconstruction such as videofluoroscopy or a functional endoscopic evaluation of swallowing is the ideal but was not done due to financial and instrumentation constraints. a study comparing different reconstructive techniques for glossectomy defects matched by patient factors and extent of defect based on a standardized functional outcome measure should be done to fully determine the best reconstructive option for glossectomy defects. the radial forearm free flap is a viable reconstructive option for tongue defects especially where a thin, pliable flap is needed. there is acceptable form and functional restoration with minimal donor site morbidity. philippine journal of otolaryngology-head and neck surgery 45 philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles philippine journal of otolaryngology-head and neck surgery 5 philipp j otolaryngol head neck surg 2008; 23 (2): 5-13 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to determine the competency in end-of-life care of ear, nose, throat – head and neck surgery (ent-hns) consultants and residents using the domains of knowledge, skills and attitudes as measures of competency and to identify opportunities for improvement in end of life care education methods: design: crosssectional survey setting: five tertiary hospitals in metro manila subjects: 52 ent-hns consultants and residents results: the majority of the respondents scored low across the knowledge, attitude and skills domains. majority the respondents (67%) were low in the knowledge domain. more than half of the respondents (58%) demonstrated negative attitudes towards end-of-life care while majority of the respondents (56%) had low skills scores. similarly, more than half (67%) of the respondents showed low over-all competence in end-of-life care. conclusion: the majority of the respondents scored low across all three domains that were used to measure the competency in end of life care. these findings may suggest a need to strengthen the enthns practitioners’ education in end-of-life care. key words: end-of-life care, palliative care, terminal care there are 56 million deaths per year in the world, 85% of which are in developing countries.1 one can assume that each death also affects five other people in terms of informal care-giving and grieving relatives and friendsa very modest estimate, particularly in the developing world. the total number of people therefore, affected each year in the world by end-of-life care is about 300 million people, or about 5% of the world population.1 competency in end-of-life care among ent-hns consultants and residents: a multi-center study arnelle y. quiambao, md flordelina e. pio-gulapan, md department of otolaryngology head and neck surgery far eastern university dr. nicanor reyes medical foundation medical center correspondence: arnelle y. quiambao, md department of otolaryngology head neck surgery feunrmf medical center regalado ave. corner dahlia st. west fairview, quezon city 1118 philippines telefax: (632) 939 0470 e-mail: drayq2002@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at descriptive research contest (1st place) philippine society of otolaryngology head and neck surgery 51st annual convention, sofitel philippine plaza, manila. december 1, 2007. north east manila enthns training consortium annual research contest (3rd place). september 2007. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles 6 philippine journal of otolaryngology-head and neck surgery as dying patients confront complex and unique challenges that threaten their physical, emotional and spiritual integrity, clinicians are recognizing the difficulties that arise when caring for the dying patient and their families. in addition to managing pain and multiple physical sources of distress, excellence in end-of-life care requires competencies in recognizing and treating psychological and physical distress; responding appropriately to intense emotions of patients and their families; understanding patients’ and families’ perspectives on care; recognizing and communicating imminence of death; facilitating difficult decision-making; and managing one’s own sense of discomfort, uncertainty or loss. any effort to understand or improve quality end-of-life care must be sensitive to cultural considerations.1 it is known that attitudes toward end-of-life care are relative to particular cultures, societies and times.2 furthermore, even within the same culture, health care providers and patients may disagree on the principles which are influencing the decision-making process. simply applying western perspectives on end-of-life-care to our country are unrealistic and bound to fail. physician competence in end-of-life care requires skill in communication, decision making and building relationships. physician ability in this area correlates directly with patients feeling satisfied with their medical care and adhering to medical advice.3 it may also enhance physicians’ own experiences of providing care. yet these skills were barely taught to the majority of physicians during their training. over the past years, end-of-life care has become an essential aspect of medical care in many parts of the world. there is a deeper recognition of the need to improve in end-of-life care. however, the issue of death and dying in the context of patient care, requisite knowledge and clinical competence has received little attention in the environment of medical education and residency training. despite this recent interest and the inevitability of death, several studies have documented that end-of-life care is inadequately taught during medical school and residency training,4 even in developed countries like the united states. in 1995, only 26% of residency programs in the united states offered courses on care at the end of life as part of the curriculum, and 15% of programs offered no formal training.5 another report from the institute of medicine (iom) of the national academy of sciences in 1997 identified large gaps in knowledge of care at end of life which demanded attention from biochemical, social science and health service researches. the report, entitled approaching death, clearly indicated health care professionals’ lack of education about endof-life care as a major barrier to improvement of services.6 an ideal vision in end-of-life is one in which people die peacefully and comfortably at home, surrounded by supportive family and friends. however, many individuals die in hospitals in the care of their physicians. health care institutions are now examining ways to improve physician competence in the delivery of end-of-life care. experts have suggested that influencing physician’s knowledge and attitudes concerning endof-life care can influence subsequent skills. furthermore, studies have shown that increasing the knowledge and skills in end-of-life care will enhance the level of competence of physicians in this area.7 (figure 1). objectives general objective: to determine the competency in end-of-life care among ent-hns consultants and residents in five tertiary hospitals in metro manila. specific objectives: figure 1. competency in end-of-life care lies primarily in adequate knowledge and skills as well as positive attitudes towards end-of-life care. 1. to determine the competency in end-of-life care of ent-hns consultants and residents using the following domains: a. knowledge b. skills c. attitude 2. to identify opportunities for improvement in end-of-life care education methodology a crosssectional study was conducted in the departments of enthns in five tertiary hospitals in metro manila, namely: far eastern university – dr. nicanor reyes medical foundation medical center, veterans memorial medical center, manila central university hospital, quirino memorial medical center and armed forces of the philippines medical center. consultants and residents who agreed to participate in the study were included. the required sample size was based on the following computation for social science studies: 1. for previously validated questions (part ii: q1,q2,q3,q4,q5,q7,q8,q9, q10,q12; part iii: q1, q2, q3, q4, q5, q6,q7, q9, q10; part iv:q1a, q1b, q1c, q1d, q1e, q2a, q2b, q2c): total items 27) formula: 1 question item: 1 respondent therefore, 27 respondents 2. for unvalidated questions (part ii: q6, q11, q13; part iii: q8; part iv: q3a, q3b, q3c: total items 7) philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles philippine journal of otolaryngology-head and neck surgery 7 formula: number of items x 3 = number of respondents therefore, 21 respondents hence, the required sample size was forty eight. b. survey instrument: a selfadministered questionnaire was developed based on the three domains (knowledge, attitudes and skills) that can measure the competency in end-of-life care. majority of the questions covering the three domains were obtained from previously-validated questionnaires (wenger, 1998; bui, 2002; stoeckie, 1998; yacht, 2007; ganzini, 2001; appendix 1). the rest of the questions were based on in-depth review of current principles in end-of-life care (von gunten, 2000; ferris, 2000; yacht, 2007; appendix 1). the questionnaire was divided into four sections, as detailed in table 1. questions on knowledge and skills domains covered the following end-of-life care core competencies: 1. advance care planning 2. communicating with the dying patient and the family 3. symptom and pain assessment and management questions on the attitude domain covered the following areas: 1. religion and spirituality 2. beliefs 3. personal comfort with the care of the dying 4. desire 5. motivation the knowledge subscale required the respondent to choose an answer from a 3-point scale ranging from “disagree” to “agree”. each statement was designed to have one ethically-appropriate response grounded in authoritative sources from the clinical ethics literature. scores from each question were added to comprise a knowledge score. the knowledge score was categorized low or high and defined as follows: low: ≤ 31 of score high: > 31 of score for the attitude subscale, respondents answered questions on dual 5point likert scales ranging from “strongly disagree” to “strongly agree”. each statement was assigned as either positive or negative attitude. three of the ten attitudinal items were negative attitudes. scores were added to comprise an attitudinal score. the attitudinal score was categorized as low or high and defined as follows: low: ≤ 33 of score high: > 33 of score for the skills subscale, respondents were given brief clinical scenarios presenting with problems that required a response from a physician. the respondents were required to choose an answer from a 3-point scale ranging from “disagree” to “agree”. scores were added to comprise a skills score. the skills score was categorized as low or high and defined as follows: low: ≤ 23 of score high: > 23 of score a composite competency score for the full sets of questions was calculated by combining the scores for the three subscales. competency score was dichotomized into its mean, categorized as low or high and defined as follows: low: ≤ 88 of score high: > 88 of score c. validation of instrument: a 34-item self-administered questionnaire in english language was pretested among 20 physicians. measures of central tendency (mean), standard deviation, frequencies and percentages were derived for each item. data analysis involved frequency endorsements, interitem correlation, inter-total correlation and cronbach’s coefficient alpha. a cronbach’s alpha of 0.8 is desirable but 0.6 is acceptable. for the pre testing of our questionnaire, the cronbach’s alpha computed was 0.7 (appendix 3). d. data collection and analysis: all data gathered were encoded using microsoft excel (microsoft corporation, redmond, wa, usa) and analyzed using statistical package for the social sciences (spss) version 10.0 for windows software (spss inc., chicago, ill, usa). data collected were treated using descriptive statistics. measures of central tendency (mean), standard deviation, frequencies and percentages were then derived for each item. limitations of the study there are a number of limitations in this study. first, it was limited to five enthns training institutions, hence, the results of the study might not be generalizable to other enthns physicians and specialties. second, the subjects may have different definitions or interpretations of “formal education in end-of-life care” since it was not qualified in the questionnaire. although there was verbal explanation of its meaning during the actual survey, there might still have been some degree of confusion as to its meaning among the subjects. lastly, the subspecialty practice of the consultants surveyed was not specified. this might have resulted in possible bias from the proportion of the consultants who are specifically engaged in oncology practice. definition of terms 1. end-of-life care refers to the medical and psychosocial care given in the advanced or terminal stages of illness. an approach that improves the quality of life of patients and their families facing the problems associated with lifethreatening illnesses, through the prevention and relief of suffering. 2. knowledge defined as the state of cognition or understanding principles applied to end-of-life care. 3. skillsdefined as proficiency or facility that is acquired or developed through training or experience in end-of-life care. 4. attitudesdefined as psychological tendency that is expressed by evaluating a particular entity with some degree of favor or disfavor. 5. competency defined as a state of being qualified to handle end of life care issues; measured by knowledge, skills and attitudes towards end-of-life care. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles 8 philippine journal of otolaryngology-head and neck surgery results a total of 52 ent consultants and residents were included in the study. the mean age was 35.06 +/6.56. the majority of respondents were male, constituting 63 % of the total subjects. a little more than half (52 %), were single while 48 % were married. most of the respondents (90 %) were catholics while the rest were from other religions. consultants comprised 56 % of the subjects while residents constituted 44 %. almost half (44 %) had education in end-of-life care during medical school, while 92 % had personal experiences with the death of a family member or a close friend. most of the respondents, 79 %, had experience in caring for the dying. of these, 29 % had 1 year of clinical experience, 24 % had 2-3 years, and another 24 % had 4-5 years experience while the remaining 22 % had > 5 years of clinical experience in the care of the dying patient (table 3). table 4 (appendix 2 a) shows that majority of respondents (67%) scored low in the knowledge domain, with most of the consultants (62%) and residents (74%) obtaining scores below the mean (< 31). table 5 (appendix 2 b) shows that more than half of the respondents (58%) demonstrated negative attitudes towards end of life care, as shown by their low attitudinal score. a greater number of both consultants (55%) and residents (61%) obtained attitudinal scores below the mean (<33). table 6 (appendix 2 c) shows that more consultants (62%) obtained low scores on skills than residents (48%). however, when combined, majority of the respondents (56%) had low skills scores. the composite competency score of the respondents revealed that the majority (67%) show low competence in end-of-life care. 74% of residents and 62% of the consultants obtained scores below the mean (table 7). discussion the issue of death and dying in the context of patient care, requisite knowledge and clinical competence has become very important. however, it has received limited interest, especially in developing table 1. survey questionnaire section i ii iii iv category number of items sociodemographic variables knowledge about end-of-life care attitudes regarding end-of-life skills on end-of-life care 8 items 13 items 10 items 11 items table 2. descriptives of scores on the different areas of competency in end-of-life care areas knowledge attitude skills over-all highest possible score mean 39 50 33 122 31.03 (26 – 37) 33.65 (25 – 43) 23.54 (17 – 33) 88.23(73 – 112) table 3. demographic characteristics of respondents pro��lespro��les n= 52 age (in years) sex male female m:f= 2:1 civil status single married s:m= 1:1 religion catholic inc protestant others category consultant resident formal training/education none residency medical school self-educated personal experience with death of family member or close friend yes no clinical experience in the care of dying patients yes no years of clinical experience in the care of dying patients 1 2 3 4 mean +/sd = 35.06 +/6.56 33 (63.5) 19 (36.5) 27 (51.9) 25 (48.1) 47 (90.4) 1 (1.9) 2 (3.8) 2 (3.8) 29 (55.8) 23 (44.2) 13 (25.0) 15 (28.8) 23 (44.2) 1 (1.9) 48 (92.3) 4 (7.7) 41 (78.8) 11 (21.2) (n=41) 12 (29.3) 10 (24.4) 10 (24.4) 9 (21.9) total n (%) table 4. distribution of respondents according to category and knowledge scores category consultant resident total knowledge score total high (>31) 11 (38.0%) 6 (26.0%) 17 (32.7%) 29 23 52 low(</=31) 18 (62.0%) 17 (74.0%) 35 (67.3%) table 5. distribution of respondents according to category and attitude scores category consultant resident total attitude score total high (>33) (n=22) 13 (45.0%) 9 (39.0%) 22 (42.3%) 16 (55.0%) 14 (61.0%) 30 (57.7%) low(</=33) (n=30) 18 (62.0%) 17 (74.0%) 35 (67.3%) philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 philippine journal of otolaryngology-head and neck surgery 9 original articles higher skills scores than consultants, still more than half or 56 % of the total respondents obtained low skills scores. this shows that ability to have adequate end of life care skills is developed from a comprehensive knowledge base of end-of-life care core competencies. similarly, majority of the respondents (58 %) had negative attitudes towards end-of-life care, with 55% of consultants and 61% of residents obtaining low attitudinal scores (appendix 2 b). although training and exposure in the care of the terminally-ill was endorsed by more than half of the respondents (52 %), there were contrasting results with regard to the respondents’ motivation to care for dying patients. only 39 % of the respondents found caring for dying patients rewarding or fulfilling. it was of concern also that the same number of respondents (38 %) derived greater satisfaction from caring for patients who are expected to improve than with patients who are likely to die. the ability to give optimum care for the terminallyill can be deduced from the respondents’ scores. over-all competency scores showed that only 33 % of the respondents were shown to be competent in handling end-of-life care issues, with majority of consultants (62 %) and residents (74 %) obtaining low scores on over-all competency. the finding that majority of the enthns practitioners showed low over-all competency in end-of-life care may not come as a surprise for some who would argue that ent specialists encounter death and dying patients less commonly than their colleagues in other disciplines. in the field of ent, end-of-life care situations may not occur regularly, and this may have probable implications in the way ent clinicians view and handle end-of-life care situations. a study by teneza et al found that physicians with more years of clinical experience in the care of dying patients had appropriate practice and positive attitudes in end of life care.11 other factors to be considered are barriers such as lack of access to well-trained palliative care physicians who can serve as leaders in clinical care and education, as well as access to end-of-life care services in the respondents’ hospitals of practice. compounding this problem is the lack of information about good end-of-life care in mainstream textbooks which physicians turn to for information. a study by wu et al in 2006 about end-of-life content in geriatric textbooks concluded that most geriatric textbooks lack good coverage on end-of-life care12. as a result of these different factors, physicians often learn on their own to contend with problems of death. be that as it may, these facts should not negate the need for us to undertake steps towards delivering quality end-of-life care. moreover, this finding should prompt us that the model and concept of end-of-life care should be introduced in our training and practice of ent. indeed, the lack of knowledge related to the end-of-life experience represents a health information deficit. it is remarkable that such a significant element of health care delivery is so poorly understood. it is hoped that the results of this study will encourage our colleagues to take a look into the importance of delivering quality care to our dying patients and their families. in our country where healthcare resources, both public and private, are geared towards prevention of death, we believe that efforts to evaluate and improve patient’s experiences at the end of life must also be addressed. caring for patients at the end of life is one of the greatest challenges table 6. distribution of respondents according to category and skills scores category consultant resident total skills score total high (>23) (n=23) 11 (38.0%) 12 (52.0%) 23 (44.2%) 29 23 52 low(</=23) (n=29) 18 (62.0%) 11 (48.0%) 29 (55.8%) table 7. distribution of respondents according to category and over-all competency score category consultant resident total over-all score total high (>88) 11 (38.0%) 6 (26.0%) 17 (32.7%) 29 23 52 low(</=88) 11 (62.0%) 17 (74.0%) 35 (67.3%) countries like ours. thus, little is known about the status of end-of-life care in the local setting. the problem of quality end-of-life care is the lack of information. it is difficult to know how to improve quality end-oflife care without any understanding of what the current quality is, what determines it, and how improvement can be measured. the results of this survey provide initial information about end-of-life care among enthns consultants and residents in the five training institutions identified. majority of the respondents (67 %) obtained a low score in the knowledge domain. the results were similar for both consultants and residents. this demonstrated their lack of understanding of the different end-of-life care core competencies, such as advance care planning, communicating with dying patients and their families and symptom and pain assessment and management (appendix 2 a). for example, there was confusion with the meaning of the question regarding “do not resuscitate” (d-n-r) orders. ninety two percent of the respondents agreed that it precludes the use of cardio-pulmonary resuscitation. however, 75% said that it only instructs the physician to provide comfort measures. a d-n-r order only directs the physician not to resuscitate a patient, but has no effect on other treatment modalities. the misconception that it has a much broader meaning than intended leads physicians to underuse such orders. many, too, held misconceptions regarding end of life decisionmaking. many agree that decisions on the care of a terminallyill patient are established by the best interest decision made by the family and the physician (78 %) and decisionmaking on the care of the dying patient is based on reliance on a family member’s interpretation of patient’s wishes (60 %). these choices revealed that respondents did not universally recognize that a patient’s preference concerning end-of-life care should be respected, even when the strategy would permit death. the result in the knowledge domain was reflected in the respondents’ score in the skills domain. while more residents obtained philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles 10 philippine journal of otolaryngology-head and neck surgery part ii direction: please read each statement about end of life care carefully. please check or encircle the number that you consider as most appropriate to each statement.10 1. d-n-r (do-not resuscitate) order means withholding cardio pulmonary resuscitation1 2. a d-n-r order instructs the physician to provide comfort measures only1 3. advance directives designates an individual to make decisions for the patients if the patient is unable to do so1 4. decisions on the care of a terminallyill patient is established by the best interest decision made by the family and the physician1 5. decisionmaking on the care of the dying patient is based on reliance on a family member’s interpretation of patient’s wishes1 6. delivering information to patients and their families are carried out in a sensitive but straightforward manner2 7. patients should be encouraged to talk about their impending death3 8. end of life care discussions facilitate physician and family agreements on management4 9. open communication bridges the gap between patient’s perception of his situation and the reality2 10. withholding negative information to a patient will result to a better treatment outcome2 11. an increasing need for more analgesic by a terminally-ill patient reflects the progression of symptoms and underlying disease5 12. it is the role of the physicians to address the psychosocial issues of dying patients3 13. higher doses of narcotics will shorten life or depress respiration in dying patients5 disagree 1 1 1 1 1 1 1 1 1 1 1 1 1 unsure 2 2 2 2 2 2 2 2 2 2 2 2 2 agree 3 3 3 3 3 3 3 3 3 3 3 3 3 part ii direction: please read each statement about end-of-life care carefully. please check or encircle the number that you consider as most appropriate to each statement. most clinicians ever face, yet it can be one of the most appreciated and personallyrewarding experiences. listening to the rich and varied perspectives of our dying patients and their families will help meet his challenge. dying is indeed inevitable, and while there is no way out, there is a way through. our findings may suggest a need to strengthen the enthns practitioners’ education in end-of-life care. greater emphasis should be placed on training in the care of dying patients by providing opportunities for learning such as symposia, didactic lectures or seminars. the improvement in the competency in end-of-life care will translate into better care and improved quality of life of dying patients. appendix 1 good day! we are conducting a survey to determine the competency in end-of-life care among ent-hns consultants and residents. please fill up the questionnaire as completely as you can. this survey is completely voluntary and will take only a few minutes of your time. your identity and answers will be kept confidential. thank you. ayq/fep competency in end-of-life care among enthns consultants and residentsa multicenter study id number: ______ part i demographic profile 1. initials: ______ 2. age (years): ____ 3. gender: q male q female 4. civil status: q single q married q separated q widow/er 5. religion/religious affiliation: q catholic q muslim q inc q protestant q others: ______ 6. category: q consultant q resident 7. formal training/education on care of the dying? q residency q selfeducated q medical school q none 8. personal experience with the death of a family member or a close friend? q yes q no 9. clinical experience in the care of the dying patient/s? q yes q no if yes, for how many years? q 0-1 q 2-3 q 4-5 q >5 questionnaire adapted and revised from: 1. wenger ns, lieberman jr. an assessment of orthopedic surgeons’ knowledge of medical ethics. journal of bone and joint surgery, february 1998; 80, 2: 198-206; proquest medical library. 2. von gunten c., ferris f., emanuel l. ensuring competency in endof-life care. jama, 2000; 284:23. 3. bui e, huggins ma. the knowledge, attitudes and practices of physicians in end-of-life care. university of toronto medical journal, march 2002; 79(2):88-93. 4. stoeckie ml, doorley je, macardle rm. identifying compliance with end-of-life care decision protocols. dimensions of critical care nursing, nov/dec 1998; 17, 6:314-320; proquest medical library. 5. ferris fd, von gunten cf, emanuel ll. ensuring competency in endof-life care: controlling symptoms. bmc palliative care, july 2002 6. yacht, ac, suglia, sf, orlander, jd. evaluating an end-of-life curriculum in a medical residency program. american journal of hospice and palliative medicine. january2007; 23 (6): 439-446. 7. ganzini l, nelson hd, lee ma, kraemer df, schmidt ta, delorit ma. oregon physicians’ attitudes about and experiences with end-of-life care since passage of the oregon death with dignity act. jama, maymay 2001; 285(18):2363-2369.285(18):2363-2369. 8. burge f., mcintyre p., kaukman, d., cummings, i. family medicine residents’ knowledge and attitudes about end-of-life care. journal of palliative care; autumn 2000; 16, 3; proquest medical library. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 philippine journal of otolaryngology-head and neck surgery 11 original articles part iii direction: please read each statement about end-of-life care carefully. please check or encircle the number that you consider as most appropriate to each statement. part ii direction: please read each statement about end of life care carefully. please check or encircle the number that you consider as most appropriate to each statement.10 1.faith plays an important role in the ability of patients to deal with medical illness and dying 6 2. physicianpatient interactions would be strengthened if physicians regularly discuss their patient’s spirituality or religion with them 6 3.physicians should frequently initiate discussions about spiritual /religious matters with their patient during end-of-life care 6 4. treating a dying patient is one of the most unpleasant aspects of being a physician 3 5. if given a choice, i prefer to avoid contact with dying people 8 6. the physician should be comfortable providing lifeprolonging measures if the patient and family request them 3 7. the physician should be comfortable withdrawing lifeprolonging measures if the patient and family request them 3 8. training and exposure in the care of the terminally-ill should be mandatory to all physicians 6 9. it is more satisfying to work with patients who are expected to improve than with patients who are likely to die 6 10. caring for dying patients is rewarding or fulfilling 7 unsure 3 3 3 3 3 3 3 3 3 3 agree 4 4 4 4 4 4 4 4 4 4 strongly agree 5 5 5 5 5 5 5 5 5 5 strongly disagree 1 1 1 1 1 1 1 1 1 1 disagree 2 2 2 2 2 2 2 2 2 2 part iv direction: please read each brief clinical scenarios carefully. please check or encircle the number that you consider as most appropriate to each statement. case 1 a 50-year-old man was severely injured in a boating accident. he was submerged for more than 5 minutes when rescuers arrived. after a successful resuscitation and stabilization, he was taken to the or for treatment of multiple facial injuries. postoperatively, he was managed for anoxic brain damage by the neurology department but the family turns to you for decision. after a week of observation, the patient remains in deep coma and it is clear that he will never recover mental function, although his lungs are improving to the point he might be weaned from the ventilator and all other organ function is good. all members of the man’s family agree that he would never want to live in this state and that he should be allowed to die. what maneuvers are acceptable? 1 part ii direction: please read each statement about end of life care carefully. please check or encircle the number that you consider as most appropriate to each statement.10 a. write a do-not-resuscitate order b. remove the patient from ventilator c. start morphine drip for the purpose of suppressing respiration d. stop total parenteral nutrition e. remove the patient out of the icu disagree 1 1 1 1 1 unsure 2 2 2 2 2 agree 3 3 3 3 3 case 2 one day, you speak with a family that is distraught concerning the condition of their 65-year-old mother who has been in the icu for 4 weeks. an infection developed after an operation for laryngeal carcinoma. the patient became septic, went into atrial fibrillation and suffered a stroke. she is now unresponsive; is being ventilated and is receiving pressors, dialysis and antibiotics. the family explained that they are sad regarding the outcome but have accepted their mother’s fate. they are most upset that she is kept alive because she had made them promise that she would never be kept alive on machines if she could not return to functional state: a conclusion that the neurologists came to with certainty 2 weeks ago. what should be done? 1 a. a psychologist or social worker should be called to help b. the patient should be made comfortable and be allowed to die c. the patient should be transferred to a long-term-care facility disagree 1 1 1 unsure 2 2 2 agree 3 3 3 case 3 mrs. x is a terminal cancer patient who has been complaining of escalating pain for the past 2 weeks. despite receiving opioid analgesics, she is still in pain and is pleading for relief. she appears dyspneic and withdrawn, has poor eye contact and doesn’t say much. what measures are appropriate?1 a. include nonpharmacologic interventions and interdisciplinary plan that include other healthcare professionals in addition to pharmacologic treatment b. refuse request to increase doses of pain medication because she is showing signs of addiction c. sit down and engage her in conversation encouraging her to express her feelings disagree 1 1 1 unsure 2 2 2 agree 3 3 3 philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles 12 philippine journal of otolaryngology-head and neck surgery part ii direction: please read each statement about end of life care carefully. please check or encircle the number that you consider as most appropriate to each statement.10 1. d-n-r ( do-not-resuscitate) order means withholding cardio pulmonary resuscitation 2. a d-n-r order instructs the physician to provide comfort measures only 3. advance directives designates an individual to make decisions for the patients if the patient is unable to do so 4. decisions on the care of a terminallyill patient is established by the best interest decision made by the family and the physician 5. decisionmaking on the care of the dying patient is based on reliance on a family member’s interpretation of patient’s wishes 6. delivering information to patients and their families are carried out in a sensitive but straightforward manner 7. patients should be encouraged to talk about their impending death 8. end of life care discussions facilitate physician and family agreements on management 9. open communication bridges the gap between patient’s perception of his situation and the reality 10. withholding negative information to a patient will result to a better treatment outcome 11. an increasing need for more analgesic by a terminally-ill patient reflects the progression of symptoms and underlying disease 12. it is the role of the physicians to address the psychosocial issues of dying patients 13. higher doses of narcotics will shorten life or depress respiration in dying patients dis-agree 3 (5.8%) 8 (15.4%) 2 (3.8%) 10 (19.2%) 14 (26.9%) 0 4 (7.7%) 1 (1.9%) 1 (1.9%) 38 (73.1%) 12 (23.1%) 3 (5.8%) 15 (28.8%) unsure 1 (1.9%) 5 (9.6%) 14 (26.9%) 2 (3.8%) 7 (13.5%) 2 (3.8%) 4 (7.7%) 5 (9.6%) 3 (5.8%) 6 (11.5%) 14 (26.9%) 5 (9.6%) 16 (30.8%) agree 48 (92.3%) 39 (75.0%) 36 (69.2%) 40 (76.9%) 31 (59.6%) 50 (96.2%) 44 (84.6%) 46 (88.5%) 48 (92.3%) 8 (15.4%) 26 (50.0%) 44 (84.6%) 21 (40.4%) appendix 2 2-a. distribution of respondents according to their responses on the different knowledge questions 2-b. distribution of respondents according to their responses on the different attitude questions part ii direction: please read each statement about end of life care carefully. please check or encircle the number that you consider as most appropriate to each statement.10 1. faith plays an important role in the ability of patients to deal with medical illness and dying 2. physicianpatient interactions would be strengthened if physicians regularly discuss their patient’s spirituality or religion with them. 3. physicians should frequently initiate discussions about spiritual /religious matters with their patient during end of life care 4. treating a dying patient is one of the most unpleasant aspects of being a physician 5. if given a choice, i prefer to avoid contact with dying people 6. the physician should be comfortable providing lifeprolonging measures if the patient and family request them 7. the physician should be comfortable withdrawing lifeprolonging measures if the patient and family request them 8. training and exposure in the care of the terminally-ill should be mandatory to all physicians 9. it is more satisfying to work with patients who are expected to improve than with patients who are likely to die 10. caring for dying patients is rewarding or fulfilling unsure 4 (7.7%) 12 (23.1%) 17 (32.7%) 4 (7.7%) 13 (25.0%) 6 (11.5%) 10 (19.2%) 5 (9.6%) 2 (3.8%) 12 (23.1%) agree 23 (44.2%) 20 (38.5%) 20 (38.5%) 19 (36.5%) 11 (21.2%) 33 (63.5%) 23 (44.2%) 28 (53.8%) 20 (38.5%) 20 (38.5%) strongly agree 21 (40.4%) 11 (21.2%) 3 (5.8%) 7 (13.5%) 4 (7.7%) 7 (13.5%) 3 (5.8%) 13 (25.0%) 13 (25.0%) 5 (9.6%) strongly disagree 0 1 (1.9%) 3 (5.8%) 3 (5.8%) 4 (7.7%) 0 3 (5.8%) 1 (1.9%) 3 (5.8%) 2 (3.8%) disagree 4 (7.7%) 8 (15.4%) 9 (17.3%) 19 (36.5%) 20 (38.5%) 6 (11.5%) 13 (25.0%) 5 (9.6%) 14 (26.9%) 13 (25.0%) 2-c.distribution of respondents according to their responses on the different skills cases a. write a do-not-resuscitate order b. remove the patient from ventilator c. start morphine drip for the purpose of suppressing respiration d. stop total parenteral nutrition e. remove the patient out of the icu disagree 13 (25.0%) 29 (55.8%) 42 (80.8%) 37 (71.2%) 20 (38.5%) unsure 6 (11.5%) 8 (15.4%) 4 (7.7%) 8 (15.4%) 6 (11.5%) agree 33 (63.5%) 15 (28.8%) 6 (11.5%) 7 (13.5%) 26 (50.0%) responses case 1 a. a psychologist or social worker should be called to help b. the patient should be made comfortable and be allowed to die c. the patient should be transferred to a long-term-care facility disagree 8 (15.4%) 9 (17.3%) 12 (23.1%) unsure 3 ( 5.8%) 12 (23.1%) 8 (15.4%) agree 41 (78.8%) 31 (59.6%) 32 (61.5%) case 2 a. include nonpharmacologic interventions and interdisciplinary plan that include other healthcare professionals in addition to pharmacologic treatment b. refuse request to increase doses of pain medication because she is showing signs of addiction c. sit down and engage her in conversation encouraging her to express her feelings disagree 2 (3.8%) 24 (46.2%) 2 (3.8%) unsure 4 (7.7%) 9 (17.3%) 4 (7.7%) agree 46 (88.5%) 19 (36.5%) 46 (88.5%) case 3 appendix 3 reliability analysis the frequency of responses for the 34 items of the questionnaire was tabulated, and none of the questions had > 80% response in one category. all of the items, therefore, could discriminate between extreme responses using the frequency endorsement method. inter-item correlation matrix for each question variable should produce a matrix of positive correlations, ranging from modest values (0.2 – 0.4) to moderate values (0.4 – 0.6). one should consider excluding items with weak correlation (< 0.20) or negative correlations with most of the other items. however, items with good but negative correlations with the other items can be re-coded and maintained in the questionnaire. for the first 13 items in the first domain (part ii: knowledge), 6 items had moderate interitem correlation (q1 with q9, q4 with q5, q6 with q7 and q8, q7 with q8 and q8 with q9) while some had modest interitem correlation (q1 with q3, q3 with q7 and q11, q4 with q7 and q10, q5 with q9, q10 and q13, q6 with q9, q7 with q9, q11and q12, q8 with q12 and q10 with q13). negative correlation was seen on q1 with q2, q4, q6, q11; q2 with q6-9, q11-13; q3 with q4 and q8; q4 with q11, q5 with q11, q6 with q10 and q13, q7 with q10 and q13; q9 with q11 and q13; q10 with q11 and q12; q11 with q12, q12 with q13). philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles philippine journal of otolaryngology-head and neck surgery 13 acknowledgements the authors are grateful to amy m. sullivan, ed.d. of danafaber cancer institute and brigham and women’s hospital, harvard medical school, milagros f. neri, md.and maria dolores t. teneza, md of the department of community and family medicine of feunrmf for their invaluable advice; and ms. ma. grace c. rosales for her assistance with the statistical analysis. references 1. singer pa, bowman kw. quality end of life care: a global perspective. bmc palliative care. 2002 july 25. available from: http://www.biomedcentral.com/1472-684x/1/4. 2. bowman kw. culture, ethics and biodiversity crisis of central africa. advances in applied biodiversity 2001.2:167-174. 3. von gunten cf., ferris fd., emanuel ll. ensuring competency in end of life care. jama. 2000 dec 20; 284 (23): 3051-57. 4. mcphee sj., rabow mw., pantilat sg., markowitz aj., winker ma. finding our wayperspectives on care at the close of life. jama. 2000; 284:2512-2513. 5. hill tp. treating the dying patient: the dying for medical education. arch intern med. 1995; 155: 1265-1269. 6. mccue jd. the naturalness of dying. jama 1995; 273: 10391043. 7. burge, f., mcintyre p., kaufman d., cummings i., frager g., pollett a.: family medicine residents’ knowledge and attitudes about end-of-life care. j palliat care. 2000; 16: 5-12. 8. mackinnon nj, molson jd, douglas may j. physician intervention in the dying process: a causal model of physician attitudes and the subjective likelihood of engaging in active euthanasia, physicianassisted suicide, and withholding treatment to terminallyill patients. electronic journal of sociology. 2003; 7. available from: http//www.sociology.org/content/vol7.1/ mackinnon_etal.html. 9. daaleman tp, vandecreek l. placing religion and spirituality in end of life care. jama. 2000 nov 15; 284: 2514-2517. 10. krings cl. historical perspectives of hospice and palliative care including local and global socio-cultural factors. in: post-graduate course in hospice and palliative care: new trends and directions; 1999 nov 11-13; up manila, philippines. 11. teneza md. assessment of knowledge, attitudes and practices in end of life care among feu dr. nicanor reyes medical foundation resident physicians. in press 2006. 12. wu hy., malik fa., higginson ij. end of life content in geriatric textbook: what is the current situation? bmc palliative care. 2006; 5:5. available from: http://biomedcentral.com/1472684x/5/5. for the second domain on attitudes (part iii), several items showed modest interitem correlation, namely: q1 with q6 and q8, q3 with q8, q4 with q5 and q9; q5 with q10, and q8 with q10. moderate interitem correlation as seen with q2 with q3. negative correlation was seen for some of the items. for the third domain (part iv: skills), a lot of the items had modest interitem correlation: q1a with q1s, q1d and q2a; q1b with q2b, q1c with q3a and q3b; q1d with q1e and q2a; and q1e with q2b. moderate interitem correlation was seen on: q1a with q2b, q1b with q1e and q2a; and q1e with q2a. negative correlation was seen for many of the items. inter-total correlation. if an item belonged to a subscale and tapped into some aspect of the same underlying domain, then it should correlate with the subscale total omitting that item. one should consider excluding from the subscale any item with an item-total correlation of less than 0.2. intertotal correlation for the first domain showed r ≥ 0.2 for q3q9. the rest, including q10, q12 and q13 had r < 0.2. negative correlation was seen for items q1 and q2. intertotal correlation for the second domain showed r ≥ 0.2 for q2, q3, q8 and q10. the rest, including q1, q4, q5, q6, q7 and q9 had r < 0.2. none of the items had negative correlation. intertotal correlation for the third domain showed r ≥ 0.2 for q1a, q1b, q1d-e, q2a-b, q3a. question q1c and q3c had negative correlation. cronbach’s alpha. the internal-consistency coefficient shows the similarity in measurement across items within the subscale. this is an index of inter-item consistency. the subscale should be homogenous and all items should be tapping different aspects of the same domain not the different parts of the different domains. cronbach’s coefficient alpha for the first domain had values > 0.6 for all combinations of not removing any or removing each question. reliability coefficient of the 13 items is alpha 0.7. cronbach’s coefficient alpha for the second domain showed that the combination of all the questions and removal of each of the questions resulted to a scale reliability coefficients of < 0.6, except for q10 (0.6270). values ranged from 0.3438 – 0.6270. reliability coefficient of the 10 items is alpha 0.501. cronbach’s coefficient alpha for the third showed that the combination of all the questions and removal of each of the questions resulted to a scale reliability coefficients of 0.607. after reliability analysis, intertotal correlation for the three domains was r ≥ 0.2 while combination of all the questions and removal of each of the questions resulted to a scale reliability coefficient of 0.7401. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 42 philippine journal of otolaryngology-head and neck surgery featured grand rounds orbital wall fractures result from external impact injuries which cause an abrupt increase in intraorbital pressure.1 patients usually present to the emergency room with periorbital swelling and limited eye movements, with or without changes in vision. relatively common in the philippines, these fractures are frequently caused by violent assault followed by vehicular accidents involving motorcycles.2 among 119 maxillofacial trauma cases seen and treated by the department of otorhinolaryngology of the east avenue medical center from 2008-2009, 42 were diagnosed as cases of orbital fractures with 36% having concomitant involvement of the orbital floor. various techniques in diagnosis and treatment developed in the past 20 years, each having its own strengths and weaknesses. the challenge of choosing which among these methods will best achieve the goals of function and aesthetics always confronts surgeons particularly in a developing country setting. we present a case of bilateral orbital floor fractures with diplopia repaired with conchal auricular cartilage graft in a 22-year-old female. case report a 22-year-old female was immediately brought to our emergency room following a headon collision with an asian utility vehicle while driving a motorcycle without a helmet. she was conscious and coherent with stable vital signs. on examination, contusion hematomas were noted over both periorbital areas. visual acuity was 20/30 od and 20/40 os with bilateral limitations of extraocular muscle movement. bilateral ocular pressures were measured at 14.6 mmhg. craniofacial ct scans revealed linear frontal bone fractures with subdural hemorrhages and pneumocephalus in the frontal area, fractures of the calvarial bones, lateral orbital walls, inferior orbital rims and orbital floors (figure 1). a mannitol drip was started for the hemorrhage. she developed a persistent headache and binocular vertical diplopia with monocular diplopia, os on left gaze accompanied by pain on lateral left duction. visual acuity was 20/25 ou. on the 17th hospital day, she underwent open reduction and internal fixation of multiple facial fractures using titanium plates and screws with reconstruction of both orbital floors using conchal cartilage autografts. the right eye diplopia resolved on the third postoperative day while the diplopia on left lateral downward gaze in the left eye resolved from the ninth postoperative day until the day of discharge. there was complete resolution of diplopia and improvement in visual acuity to 20/20 od and 20/25 os on follow up at one year. dicussion orbital floor fractures are relatively common midfacial injuries encountered in urban areas2 and were first described by smith and regan in 1957.1 since then, many articles have been written about their diagnosis and treatment, including indications and optimal time for surgery as well as optimal surgical methods.1 epidemiological studies reveal that despite different settings, the majority of cases involve the young male population with violent assault as the most prominent etiology accounting for 37.8% of orbital blowout fractures; motor vehicle accidents came in at second with 17.6%.; with the remaining fractures resulting from athletics (14.1%).2 to our orbital floor fracture reconstruction using conchal auricular cartilage graft rubiliza dc. onofre, md rene louie c. gutierrez, md department of otorhinolaryngology head and neck surgery east avenue medical center diliman, quezon city, philippines correspondence: rubiliza dc. onofre, md department of otolaryngology head and neck surgery 6th floor east avenue medical center east avenue, quezon city 1100 philippines phone: (632) 928 0611 loc 324 fax: (632) 435 6988 e-mail: yukito8211@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2010; 25 (2): 42-45 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 featured grand rounds philippine journal of otolaryngology-head and neck surgery 43 are those in which the inferior orbital wall is completely separated from its original position and the periorbital tissue has prolapsed into the maxillary sinus1 (figure 2). these fractures can be also be classified by location: anterior, posterior and anteroposterior1,4 (figure 3). our patient presented with non trapdoor type orbital floor fractures measuring 10 x 4 mm on the right and 10 x 5mm on the left. patients with orbital floor fractures often complain of blurred vision and pain on eye movement. physical examination also elicits diplopia, accompanying limitation of eye movement and enophthalmos on the affected side. these signs and symptoms are due to (1) herniation of orbital contents with concomitant partial atrophy of extraocular muscles and to (2) an increase in the volume of the orbital cavity with possible compression of the optic nerve.4 because of these features, orbital floor fractures are classified as both otorhinolaryngologic and ophthalmologic emergencies that warrant immediate surgical treatment especially if the patient presents with blurred vision.3,5 confirmatory imaging studies help locate and assess the extent of orbital floor injury. these include radiographs and computed tomography of the facial bones. the commonly used radiograph is the chin-to-nose or water’s view. this gives a view of the whole orbital area and may reveal a pathognomonic “tear drop” sign, seen as an elliptical opacity underneath the inferior orbital rim, that represents orbital contents, usually orbital fat, that herniated through the fracture.1,3 however, facial computed tomography is still the most useful imaging tool in assessing orbital floor fractures.1,2,3,4 it is usually requested without contrast using 3 different cuts: coronal, axial and sagittal. coronal cuts reveal discontinuity of the inferior orbital rims with concomitant soft tissue sublaxation; axial cuts present the extent of areas involved while sagittal cuts help locate if the fracture is anterior, posterior or anteroposterior.1,4 a b figure 1 a and b. craniofacial ct scan, coronal sections, revealing fractures of (a) calvarial bones and (b) inferior orbital rims and orbital floors knowledge, local reports have not been published but similarities in profile can be deduced. orbital floor fractures, also known as blowout fractures, imply that the orbital rims have remained intact, whereas one or more walls of the orbit, typically the floor has fractured.3 orbital floor fractures can be classified into pure and impure according to extent of bone involvement (table 1). pure blowout fractures are fractures of the floor not involving the rim while impure blowout fractures have rim extension.3 pure orbital floor fractures are further classified as trapdoor or non-trapdoor. trapdoor fractures are those in which either edge of the inferior orbital wall is attached to its original position, while non-trapdoor fractures table 1. comparison of pure versus impure blowout fractures pure blowout fractures impure blowout fractures fractures involving the orbital floor without extension to the inferior orbital rim can be classified as trapdoor or non-trapdoor fractures involving the orbital floor with extension to the inferior orbital rimtrapdoor fractures* † one edge of the orbital floor is attached to its original position periorbital contents may or may not be prolapsed into the maxillary sinus common among anterior orbital floor fractures non-trapdoor fractures* † orbital floor completely separates from its original position periorbital contents prolapsed into the maxillary sinus common among posterior orbital floor fractures * kwon, jh. kim, jg. moon, jh. cho, jh. clinical analysis of surgical approaches for orbital floor fractures. arch facial plast surg. 2008 jan-feb;10(1):21-24 † jin hr, yeon jy, shin so, choi ys, lee dw. endoscopic versus external repair of orbital blowout fractures. otolaryngol head neck surg 2007 jan; 136(1):38-44 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 44 philippine journal of otolaryngology-head and neck surgery featured grand rounds figure 2. illustration of fracture classification according to attachment of fragments in reference to original position; trapdoor and nontrapdoor fracture figure 3. illustration of fractures classified according to location; anterior and posterior fractures advantages over conventional external repair. these include excellent visualization of the medial and inferior walls of the orbit; easy access to maxillary bone (avoiding or minimizing use of intraocular alloplastic implants); virtual elimination of significantly visible facial scarring and eyelid complications; and performing the procedure under local anesthesia, making intra-operative evaluation of ocular movements and diplopia possible.5,6 a transorbital approach has the advantage of releasing incarcerated orbital tissue, while, in contrast, simply lifting the orbital tissue upward in a transantral approach may aggravate the incarceration1 (table 2). in this patient, the open approach was used because a mid-facial de-gloving was necessary to access other fractures. the repair of orbital floor fractures involves many techniques, and adequate knowledge and skill is needed to perform any of these techniques employing careful judgment and analysis in formulating a plan that will fit the patient’s needs. as a general principle, the orbital complex is reconstructed by aligning its fractured parts with adjacent stabilized or intact structures.10 familiarity with the complex shape of the orbital walls is important in repair. in the case of the orbital floor, it gently concaves inferolaterally, turning convex medially to posteriorly, assuming an s-shape configuration. 1,3 the posterior part of the floor is farthest from the inferior orbital rim with the infraorbital nerve coursing thru it makes it vulnerable and weak to the extensive forces absorbed when applied into the orbital area.1,3,10 this explains why posterior orbital floor fractures occur as non-trapdoor types and are difficult to expose. the orbital contents are positioned accurately and precisely into the orbit making any change in volume affect eye function. it is important to assess eye function first as it may give the examiner an idea of the extent of injury to the orbital floor. indications for repair include diplopia, nonresolving oculocardiac reflex with entrapment (bradycardia, heartblock vomiting, nausea and syncope), fracture involving >50% of the orbital floor, and early enophthalmos or hypoglobus causing facial asymmetry.11 these signs and symptoms elicited during physical examination with documentation of the location of fracture through diagnostic imaging warrant early repair since herniated soft orbital tissue can atrophy within 2-3 weeks post trauma.4 the types of grafts/implants used to span the defects of orbital floor fractures are divided into alloplastic and autogenous implants7 (table 3). autogenous grafts include bone, cartilage, and fascia. alloplastic implants can be divided into nonabsorbable types, such as those made of silicone, polytef, hydroxyapatite, tantalum mesh, or titanium, and absorbable types, including those made of polyglactin or gel film. repair of the orbital floor defect is mandatory if the defect measures at least 50% of the size of the orbital floor bone. the ideal implant must be nonreactive, provide good structural support, be easily positioned, and be readily available.1,2,3,4 in this case the surgeon utilized conchal cartilage grafts. this graft can be used in repairing defects as large as the goal of surgical repair in orbital floor fractures is two-fold: to reposition herniated orbital fat and tissue back in the orbit; and to reconstruct the traumatic defect.4 approaches are via open surgery (subciliary or transconjunctival) or endoscopic (transantral), (table 2). the open transorbital approach is currently regarded as the mainstream method for reduction of blowout fractures of the inferior orbital wall. it is useful for releasing incarcerated soft tissue, as dissecting all soft tissue around the fracture area is necessary.1 post operative complications include ectropion and unsightly scars, but these rarely occur in the hands of experienced surgeons.5 endoscopic repair, usually via a transantral approach, can provide surgeons with several philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 featured grand rounds philippine journal of otolaryngology-head and neck surgery 45 * kwon, jh. kim, jg. moon, jh. cho, jh. clinical analysis of surgical approaches for orbital floor fractures. arch facial plast surg. 2008 jan-feb;10(1):21-24 † jin hr, yeon jy, shin so, choi ys, lee dw. endoscopic versus external repair of orbital blowout fractures. otolaryngol head neck surg 2007 jan; 136(1):38-44 table 2. comparison between open versus endoscopic approaches in the repair of orbital floor fractures approach endoscopic surgery site of surgical incision advantages disadvantages complications transorbital or subcillary useful in releasing incarcerated inferior orbital wall and periorbital contents can provide better visualization of anterior fractures ideal for anterior, trapdoor orbital floor fractures * need for extensive dissection of surrounding soft tissues for proper placement of graft for reconstruction difficulty in identifying and exposing fractures located at the posterior region of the pyramidal shaped-orbit -excessive dissection for good exposure of posterior orbital floor fractures may lead to optic nerve damage can cause injury to posterior orbital tissue or muscle when graft place in a poorly exposed and dissected area ectropion, visible scars open surgery transantral provide excellent visualization of medial and inferior walls of the orbit enabling safe removal of bony fragments use of endoscope minimizes or eliminates visible scars can be performed under local anesthesia making intraoperative assessment of extraocular movements and diplopia possible † easy access to the maxillary bone for possible graft source for reconstruction minimizes use of allosteric grafts provide better exposure of the posterior orbital floor fractures ideal for posterior non-trapdoor orbital floor fractures use of the approach may not fully release incarcerated orbital contents simply lifting of the orbital tissue upward with this approach can aggravate incarceration needs to be combined with transorbital approach for safe implantation of graft material into the inferior orbital floor infection, optic nerve damage * table 3. type of grafts used in recontruction of orbital floor fractures autogenous grafts include bone, cartilage, and fascia advantages : -readily available -cheap disadvantages: easily undergo resorption except for cartilage grafts need for blood supply for nourishment increase morbidity to the patient since harvesting the graft would produce another surgical site divided into non absorbable (silicone, polytef, hydroxyapatite, tantalum mesh, or titanium) and absorbable (polyglactin or gel film) advantages: do not undergo resorption do not need blood supply for nourishment disadvantages: costly can cause infection can extrude from the surgical site alloplastic grafts 2 x 2mm. it advantages over other autogenous grafts include having a shape similar to the orbital floor, ease of harvest, malleability and limited morbidity at the donor site.4 autogenous tissue grafts, i.e. bone or cartilage, are preferred over alloplastic grafts in the repair of isolated orbital fractures similar to this case.10 grafts (especially bone) should be secured to avoid displacement or migration and improve graft survival. complete dissection of the fracture is necessary to identify the intact bone on all sides of the fracture since these will be used for alignment when placing the graft. in the case of an orbital floor fracture, the posterior portion of the intact bone will serve as a guide to internal orbital reconstruction. the graft should be placed in inclined position just behind the inferior orbital rim to reach the intact posterior bone.3,10 placing the graft based on correct anatomic position during reconstruction is of more significance than using globe position as a basis in volume restoration.10 it is a must to perform duction tests following graft placement and compare these to baseline duction tests prior to surgery.9,10 this will help the surgeon distinguish if the stiff duction test is caused by edema from impingement of the musculofibrous ligament system by the graft material.10 acknowledgment the authors would like to thank dr natividad almazan and dr. felix nolasco for their encouragement and support; and the resident doctors of the department of orl-hns for their help in making this paper. references 1. kwon jh, kim jg, moon jh, cho jh. clinical analysis of surgical approaches for orbital floor fractures. arch facial plast surg. 2008 jan-feb;10(1):21-4. 2. shere jl, boole jr, holtel mr, amoroso pj. an analysis of 3599 midfacial and 1141 orbital blowout fractures among 4426 united states army soldiers 1980-2000. otolaryngol head neck surg 2004 feb;130(2):164-70. 3. kellman rm. chapter 26: maxillofacial trauma in cummings cw, flint pw, harker la, haughey bh, richardson ma, robbins kt, schuller de, thomas, jr, eds. cummings otolaryngology head and neck surgery, 4th ed. vol 4. philadelphia (pa): elsevier-mosby, 2005. p. 602-36. 4. castellani a, negrini s, zanetti u. treatment of orbital floor blowout fractures with conchal auricular cartilage graft: a report on 14 cases. j oral maxillofac surg. 2002 dec; 60(12):1413-17. 5. jin hr, yeon jy, shin so, choi ys, lee dw. endoscopic versus external repair of orbital blowout fractures. otolaryngol head neck surg. 2007 jan; 136, 38-44. 6. hinohira y, yumoto e, shimamura i. endoscopic endonasal reduction of blowout fractures of the orbital floor. otolaryngol head neck surg. 2005 nov; 133(5): 741-7. 7. lee hh, alcaraz n, reino a, lawson w. reconstruction of orbital floor fractures with maxillary bone. arch otolaryngol head neck surg. 1998 jan;124(1):56-9. 8. ducic y, veret dj. endoscopic transantral repair of orbital floor fractures. otolaryngol head neck surg. 2009 jun;140(6):849-54. 9. augsburger j, asbury t. chapter 19: ocular and orbital trauma. vaughan and asbury’s general ophthalmology 16th edition. usa: mcgraw-hill co. inc. 2004. p. 371-8. 10. manson pn. chapter 4.5 orbital fractures. prein j. editor. manual of internal fixation in craniofacial skeleton: techniques recommended by ao/asif maxillofacial group. new york: springerverlag 1998. p. 139-46. 11. burnstine ma. clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. ophthalmology 2002 jul; 109(7):1207-10. philippine journal of otolaryngology-head and neck surgery 35 philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 from the viewbox a 34-year-old filipina presents with bilateral progressive hearing loss and tinnitus of three years’ duration. otologic examination reveals normal external auditory canals and tympanic membranes, with good tympanic membrane mobility on pneumatic otoscopy. standard audiometric examination shows a bilateral moderate conductive hearing loss. temporal bone ct imaging reveals the presence of a focal region of bone demineralization involving the dense bone of the otic capsule surrounding the cochlear lumen (figure 1), a finding consistent with a diagnosis of active otospongiosis. the diagnosis was confirmed by visualization of an otosclerotic focus during transcanal middle ear exploration where stapedectomy with placement of a stainless steel stapes prosthesis was performed. demineralization of the otic capsule in otosclerosis (otospongiosis) nathaniel w. yang, md1,2 1department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila 2philippine national ear institute national institutes of health university of the philippines manila correspondence: nathaniel w. yang, md department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax: (632) 525 5444 email: nwyang@gmx.net reprints will not be available from the author. philipp j otolaryngol head neck surg 2009; 24 (1): 35-36 c philippine society of otolaryngology – head and neck surgery, inc. figure 1. the white arrow is pointing to the area of focal demineralization surrounding the cochlea, a finding described as the “halo effect.”1 philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 36 philippine journal of otolaryngology-head and neck surgery from the viewbox otosclerosis is a condition unique to the temporal bone characterized by abnormal resorption and deposition of bone in the otic capsule and ossicles. although it occurs more rarely in asiatic populations compared to europeans, americans of caucasian origin and indians, it must be considered in patients presenting with primarily conductive hearing loss, especially if there is bilateral involvement. ct imaging of the temporal bone may help to differentiate this condition from other causes of conductive hearing loss such as tympanosclerosis and bony epitympanic fixation of the ossicular chain from chronic infection and inflammation of the middle ear. one must be cognizant of the fact that a normal temporal bone ct scan does not rule out a diagnosis of otosclerosis because an inactive, highly sclerotic focus that appears as a uniform hyperdense mass may be difficult to distinguish from the normal compact labyrinth capsule.1 other causes of otic capsule demineralization include osteogenesis imperfecta, paget disease, otosyphilis and camuratiengelmann disease. these may be differentiated by their individually characteristic patterns of bone involvement and evidence of disease in other organ systems.2 figure 2. a normal temporal bone for comparison showing the dense bone surrounding the cochlear lumen references 1. häusler r. advances in stapes surgery. in : jahnke k, editor. middle ear surgery recent advances and future directions. stuttgart: thieme; 2004. p. 96-133. 2. alkadhi h, rissmann d, kollias ss. osteogenesis imperfecta of the temporal bone: ct and mr imaging in van der hoeve-de kleyn syndrome. am j neuroradiol 2004 jun/jul; 25:1106-1109. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 case reports 20 philippine journal of otolaryngology-head and neck surgery abstract objective: to report a rare case of upper airway obstruction from multiple pharyngeal masses due to nasopharyngeal tuberculosis in a 22-year-old male. methods: design: case report setting: tertiary government hospital patient: one result: a 22-year-old filipino male with upper airway obstruction from multiple pharyngeal masses was diagnosed to have nasopharyngeal tuberculosis by histopathology. he improved after six months of anti-tuberculosis medications. conclusion: tuberculosis should not be overlooked in the differential diagnoses of nasopharyngeal masses because of the difference in its management, and swift and adequate cure, compared to other nasopharyngeal pathologies. keywords: tuberculosis, nasopharynx, mycobacteria, hypopharyngeal mass, upper airway obstruction tuberculosis is the sixth leading cause of morbidity and mortality in the philippines, which ranks highest in southeast asia for number of cases per head and ninth in the world for total number of tuberculosis cases.1 almost two thirds of filipinos have tuberculosis, and up to five million people2 are infected yearly in our country making it a major public health concern. nasopharyngeal tuberculosis is a rare type of extrapulmonary tuberculosis comprising only less than 1% of tuberculosis found in the upper respiratory tract.3 the disease may present on endoscopy as a normal nasopharynx or with mucosal irregularity and ulceration, bulging of the pharyngeal wall or as a polypoid mass that may be accompanied by epistaxis, chronic cough, nasal congestion and in some cases, diplopia.4,5 we found no report of nasopharyngeal tuberculosis in the philippine journal of otolaryngology head and neck surgery and philippine journal of internal medicine or in a search of herdin. neither did we find any reports of upper airway obstruction from nasopharyngeal tuberculosis in a pubmed search using the key words “nasopharyngeal tuberculosis” or “upper airway tract tuberculosis”. nasopharyngeal tuberculosis in a patient presenting with upper airway obstruction cristina s. nieves, md rubiliza dc. onofre, md fortuna corazon a. aberin-roldan, md rene louie c. gutierrez, md department of otolaryngology head and neck surgery east avenue medical center philipp j otolaryngol head neck surg 2010; 25 (1): 20-22 c philippine society of otolaryngology – head and neck surgery, inc. correspondence: cristina s. nieves, md department of otolaryngology head and neck surgery 6th floor east avenue medical center east avenue, quezon city 1100 philippines phone: (632) 928-0611 loc 324 fax: 435-6988 email: eamc_enthns@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this report. presented at the interesting case contest (3rd place) philippine society of otolaryngology head and neck surgery convention, bohol tropics hotel, tagbilaran city. april 24, 2009 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 case reports philippine journal of otolaryngology-head and neck surgery 21 we describe an unusual case of a patient with nasopharyngeal tuberculosis presenting with upper airway obstruction. case report a twenty-two-year-old male with a four-year history of gradually enlarging bilateral neck masses, hyponasal speech, progressive dyspnea and dysphagia presented with impending upper airway obstruction. the patient was initially seen with sternal and intercostal retractions, stridor and tachypnea. he denied any epistaxis, ear symptoms or chronic cough, had an eleven-pack-year smoking history and lived with his father who had been previously diagnosed with and inadequately treated for pulmonary tuberculosis. initial endoscopy revealed midline masses bulging from the midline posterior nasopharyngeal and hypopharyngeal walls, approximately 2cm x 1cm and 2cm x 2cm in size, respectively. there were wellcircumscribed, matted, doughy, movable, bilateral level ii and iii cervical lymph nodes measuring 5cm x 4cm x 1cm on the right and 2.7cm x 3.6cm x 1cm on the left. hematology showed only slight anemia with a normal white blood cell count. chest radiographs revealed homogenous opacification of the left upper lung field and fibrous infiltrates in both lower lung fields. computed tomography of the paranasal sinuses and neck showed a retropharyngeal mass, mucosal thickening in the nasopharynx, and multiple cervical lymphadenopathies. (figure 1) progression of dyspnea necessitated a tracheotomy and hypopharyngeal aspiration-biopsy that yielded 14 ml of serosanguinous fluid with resolution of dyspnea and dysphagia. a nasopharyngeal biopsy revealed chronic granulomatous inflammation with caseation necrosis and langhans giant cells compatible with a tuberculous etiology of the nasopharyngeal mass. cytologic examination of the hypopharyngeal aspirate showed chronic inflammation with mild dysplasia. acid fast staining was negative. sputum culture and sensitivity with acid fast staining showed no growth and no acid fast bacilli. purified protein derivative testing was positive with fifteen millimetres skin induration. the nasopharyngeal and hypopharyngeal masses and lymphadenopathies resolved with a six-month regimen of antituberculosis medications consisting of isoniazid, rifampicin, pyrazinamide and ethambutol for two months followed by isoniazid and rifampicin for four months. (figure 2) discussion nasopharyngeal tuberculosis is an uncommon entity and comprises only 0.12% of all tuberculosis.3 other upper respiratory tract sites that may have tuberculous involvement are the tonsils, hypopharynx, tongue, soft palate and the larynx.6 generally, the upper respiratory tract is thought to be resistant to tuberculosis because saliva has an inhibitory effect on tubercle bacilli. the thickness of the protective epithelial covering and antagonism of the striated musculature to bacteria also defend against tuberculosis whose pathophysiology usually requires a disruption of local mucosa leading to implantation from other foci in the body (e.g. inoculation from sputum). this may explain the localization of ulcers in the posterior part of the roof and the posterior wall of the nasopharynx. although difficult to confirm, hematogenous spread from pulmonary tuberculosis is also considered as another means of infection, as is activation of dormant acid fast bacilli figure 1. computed tomography scan of the pharynx. (a) plain axial ct scan showing mucosal thickening of the nasopharynx and (b) a retropharyngeal cystic mass. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 case reports 22 philippine journal of otolaryngology-head and neck surgery in adenoids during childhood.5 the disease may occur as a primary infection, without involvement of any other system, or as a secondary infection, with simultaneous pulmonary involvement as in our case. the most common symptom of nasopharyngeal involvement is cervical lymphadenopathy, comprising about 70%.7 other symptoms include chronic cough, epistaxis, nasal obstruction, tinnitus, hearing loss, otitis media and even cranial nerve involvement like diplopia.5 varying clinical presentations make diagnosis difficult. in our case the patient did present with a nasopharyngeal mass and cervical lymphadenopathy, but he also experienced upper airway obstruction due to a hypopharyngeal mass, probably resulting from retropharyngeal lymph node involvement. the common differential diagnoses include nasopharyngeal carcinoma, wegener’s granulomatous, sarcoidosis, syphilis, leprosy, lymphoma and fungal infection.9 the diagnosis of nasopharyngeal tuberculosis is best done by biopsy to differentiate it from other nasopharyngeal masses. histopathologic findings in tuberculosis usually include granulomatous inflammation composed of epitheloid cells and langhan’s giant cells with or without caseation. demonstration of acid fast bacilli or a positive culture for mycobacterium tuberculosis gives a definite diagnosis, but few specimens demonstrate acid fast bacilli with the majority yielding negative results.10 diagnostic imaging is inaccurate in confirming the diagnosis. the gold standard for the diagnosis of nasopharyngeal tuberculosis remains to be tissue biopsy. treatment for extrapulmonary and pulmonary tuberculosis is the same unless organisms are known and strongly suspected to be resistant to the first line drugs, or if the patient is diagnosed with tuberculous meningitis.2 in our patient, a sixmonth regimen consisting of isoniazid, rifampicin, pyrazinamide and references 1. world health organization. global tuberculosis control: surveillance, planning, financing. geneva: who 2005. [cited 2009 jan 20]; available from http://apps.who. int/globalatlas/predefinedreports/tb/pdf_files/phl.pdf 2. task force on tuberculosis, philippine practice guidelines group in infectious diseases. pulmonary tuberculosis: clinical practice guidelines. ppgg-id philippine society for microbiology and infectious diseases, inc., philippine college of chest physicians and philippine coalition against tuberculosis. 2006 3. rohwedder jj. upper respiratory tract tuberculosis: 16 cases in a general hospital . ann intern med 1974; 80:708-13. 4. king ad, ahuja at, gary mk, van hasselt ca, chan ab. mr imaging features of nasopharyngeal tuberculosis: report of three cases and literature review. am j neuroradiol 2003; 24:279-82. [cited 2009 jan 20]; available from http://www.ajnr.org/ cgi/reprint/24/2/279.pdf 5. sithinamsuwan p, sakulsaengprapha a, chinvarun y. nasopharyngeal tuberculosis: a case report presenting with diplopia. j med assoc thai 2005; 88:1442-6. [cited 2009 jan 20]; available from http://www.mat.or.th/journal/files/vol88_no10_1442.pdf 6. sierra c, fortun j, barros c, melcon e, condes e, cobo j, et al. extra-laryngeal head and neck tuberculosis. clin microbiol infect 2000; 6:644-48. [cited 2009 jan 20]; available from http://www3.interscience.wiley.com/cgi-bin/fulltext/120711198/pdfstart 7. waldron j, van hasselt ca, skinner dw, arnold m: tuberculosis of the nasopharynx: clinicopathological features. clin otolaryngol 1992; 17:57-9. 8. harrison nk, knight rk. tuberculosis of the nasopharynx misdiagnosed as wegener’s granulomatous. thorax 1986; 41:219-20. [cited 2009 jan 20]; available from http:// www.pubmedcentral.nih.gov/picrender.fcgi?artid=460299&blobtype=pdf 9. tas e, sahin e, vural s, turkoz hk, gursel ao. upper respiratory tract tuberculosis: our experience of three cases and review of article: the internet journal of otorhinolaryngology 2007;6:1. [cited 2009 jan 20]; available from http://www.ispub. com/journal/the_internet_journal_of_otorhinolaryngology/volume_6_number_ 1_18/article_printable/upper_respiratory_tract_tuberculosis_our_experience_of_ three_cases_and_review_of_article.html 10.madhuri, chandra mohan, sharma ml. posterior oropharyngeal wall tuberculosis. indian j otolaryngol head and neck surg 2002; 54:152-3. [cited 2009 jan 20]; available from http://medind.nic.in/ibd/t02/i2/ibdt02i2p152o.pdf ethambutol for two months as the initial phase followed by isoniazid and rifampicin for four months as the continuation phase was advocated. the resolution of the nasopharyngeal mass and cervical lymphadenopathies after completion of the anti-tuberculous medications, further confirms our diagnosis of nasopharyngeal tuberculosis. tuberculosis should not be overlooked in the differential diagnoses of nasopharyngeal masses because of the difference in its management, and swift and adequate cure, compared to other nasopharyngeal pathologies. figure 2. hypopharynx after 6 months of anti-tuberculous medications. flexible laryngoscopy of the patient showing resolution of the retropharyngeal mass. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 achievement and ascription: fact or fiction “castles in the clouds, flying by; men will build them till they die; don’t they know it’s all a lie, tumbling castles make them cry; still they try…1” identity is shaped by thoughts, ideas, feelings and emotions; expressed in words, actions and expressions; and recorded for posterity in mentifacts and artifacts. “paper” (or “plastic”) identity, found on various identification cards, electronic databases, resumés and curriculum vitaes, is not necessarily be the same as the “flesh and blood” or real-life identity known best to those with whom face-to-face interaction takes place over long periods of time in various day-to-day situations. status is both achieved and ascribed, and the degree to which one or the other contributes more draws the thin line between the real and apparent. to achieve means “to carry out successfully (accomplish);” “to get or attain as a result of exertion (reach),” or “to attain a desired end or aim (to become successful).”2 to ascribe, on the other hand, comes from the restored spelling of the middle english ascrive, etymologically derives from the old french, ascrivre, “to attribute, inscribe,” and the latin ascribere “to write in, to add to in a writing,” from ad“to” + scribere “to write.”3 to ascribe is to refer to a supposed cause, source, or author, and “suggests an inferring of cause, quality or authorship” as in the case of “forged paintings formerly ascribed to masters.”4 achievement rightfully bestows an earned “headship,” implied in its etymology from the old french, achever “to finish,” from the phrase à chef (venir) “at an end, finished,” the vulgate latin *accapare, from the latin ad caput (venire). literally, both the old french and latin phrases mean “to come to a head,” from the latin caput “head.”5 ascription is flattery at best; but worse when self-generated and perpetuated. are vicarious experiences that become “personal accomplishments,” casual visits and observations that become “further training and fellowships,” comments and editing (even supervisory positions) that metamorphose into “research and co-authorships” any different from the fictitious medals of a dictator? awards beget awards. those who are thus preceded by reputation may loom “larger than life.” do such giants stand on feet of clay? our circles are a microcosm of the nation and world around us. public servants who believe the fictions crafted by themselves and their coutillons continue to claim the right to rule (rather than the obligation to serve). are we dazzled by the dream? what do we aspire for? et tu? the first meeting of the asia pacific association of medical journal editors (apame) was held in seoul, the republic of korea last may 45, 2008 co-hosted by the world health organization western pacific regional office.6 apame’s vision, it was agreed, would be to promote health care through the dissemination of quality health information in the asia pacific region. the association also established the following aims: 1. to upgrade publishing standards of health journals and books, paper-based or electronic; 2. to develop an aggregated indexing system for health articles published in the asia pacific region; and 3. to enhance optimal access to health articles. the development of the western pacific region index medicus (wprim) and the global health library (ghl) are much-needed efforts to ensure the dissemination of and universal access to reliable health information essential to health development. these efforts will level the playing field for authors, editors, peer reviewers, publishers and subscribers in developing countries, elevating loco-regional research and publishing to the global arena. following our continued compliance with established standards, we anticipate inclusion of the philipp j otolaryngol head neck surg in the wprim. through its president gil m. vicente, and the board of trustees, our society blazes new trails to lead us beyond the confines of self-directed concerns toward new horizons of hope for our various publics, present and future. efforts aimed at health-promotion and disease-prevention, side by side with involvement in ecological and environmental concerns may prove to be as, or even more important, than the equally quixotic pursuit of cutting-edge diagnostic and therapeutic advances. what use are these when they are beyond the reach of most? “when the time of our particular sunset comes, our ‘thing,’ our accomplishment, won’t matter a great deal. but the clarity and concern with which we have loved others will speak with vitality of the great gift of life we have been to each other.”7 jose florencio f. lapeña, jr., ma, md editorial 4 philippine journal of otolaryngology-head and neck surgery 1“castles in the clouds” lapeña jf, [unpublished song] manila: 1978. 2available from: http://www.merriam-webster.com/dictionary/achieve 3available from: http://www.etymonline.com/index.php?search=ascribe&searchmode=nl 4available from: http://www.merriam-webster.com/dictionary/ascribe (italics mine) 5available from: http://www.etymonline.com/index.php?search=achieve&searchmode=nl 6available from: http://apame.info/?id=07. 7 “wherever you go” the weston priory monks [narration from the song] ©1972 the benedictine foundation of the state of vermont, inc., weston priory, weston, vt 05161-6400 philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 under the microscope 36 philippine journal of otolaryngology-head and neck surgery this is from a 76-year-old male with a fungating maxillary antral mass that extends into the nasal cavity. jose m. carnate jr., md department of pathology college of medicine philippine general hospital university of the philippines manila correspondence: jose m. carnate jr., md university of the philippines manila college of medicine department of pathology 547 pedro gil st., ermita, manila 1000 phone (632) 526-4550 fax (632) 400-3638 email: jmcjpath@yahoo.com reprints will not be available from the author. sinonasal teratoid carcinosarcoma philipp j otolaryngol head neck surg 2007; 22 (1,2): 36 c philippine society of otolaryngology – head and neck surgery, inc. sinonasal teratoid carcinosarcoma was first described in 1984 and since then 60 cases have been reported. i have had the opportunity to encounter four cases locally, the first one in 1995, another in 2003 and two cases in 2006. there is a male predominance among cases and age has ranged from 18 to 79 years. the usual symptoms reported are epistaxis and nasal obstruction while the most common physical examination finding is that of a nasal cavity mass. a closer look shows a mass at the ethmoid sinus or maxillary antrum with secondary involvement of adjacent sinuses and soft tissue. the tumor is highly malignant rapidly invading adjacent soft tissues and bone and giving rise to regional node and distant metastases. the reported average survival is 1.7 years after diagnosis, with less than 3% surviving beyond three years. radical surgery, radiotherapy and chemotherapy have all been used with limited success. histologic sections show a confusing array of teratomatous, sarcomatous and carcinomatous elements represented here by immature squamous and cartilaginous islands, atypical fibrosarcoma-like spindle cell stroma and infiltrating atypical adenocarcinomatous glands. references: 1. heffner dk, hyams vj. teratocarcinosarcoma (malignant teratoma?) of the nasal cavity and paranasal sinuses. cancer 1984;53:2140-54. 2. fernandez pl, cardesa a, alos l, pinto j, traserra j. sinonasal teratocarcinosarcoma: an unusual neoplasm. pathology res prac. 1995 march; 191(2): 166-71; discussion 172-3. 3. mills se, gaffey mj, frierson hf. atlas of tumor pathology. tumors of the upper aerodigestive trace and ear. 1997. chapter 12: germ cell tumors, pp. 314-316. 4. deveci sali m, deveci guzin. blastomatous tumor with teratoid features of nasal cavity: report of a case and review of literature. pathology international. 2000 january;50(1):71 5. who classification of tumors (lyon, 2005): head and neck tumors, leon barnes, ed. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery case reports abstract objective: to present a case of progressive hemifacial atrophy in a young woman with parryromberg syndrome and the role of autologous fat transfer to improve her aesthetic appearance and lessen facial asymmetry. methods: design: case report setting: tertiary government training hospital patient: one result: a 20-year-old woman consulted because of drooping of the right eyelid and gradual thinning of right cheek muscles since age 16. on examination, the right facial muscles were hypoplastic with prominent facial bony ridges. an mri scan showed atrophy of the right medial pterygoid and masseter. she underwent autologous fat transfer on the right side of the face to augment the cheek, improve cosmetic appearance and lessen facial asymmetry. conclusion: our patient is satisfied and happy with the outcome and cosmetic appearance of her autologous fat transfer and is ready to undergo the same procedure if the need arises in the future. although no definite cure exists for parry-romberg syndrome, our report illustrates the role of autologous fat transfer as an inexpensive, easily harvested and biocompatible material to improve facial asymmetry. the procedure yielded encouraging results although long-term benefits remain uncertain. keywords: parry-romberg syndrome; progressive hemifacial atrophy; autologous transplantation facial asymmetry or hemifacial atrophy may result from a number of craniofacial syndromes, or develop as a result of trauma, pathology, or abnormal growth.1 parry-romberg syndrome is a rare, progressive but self-limiting degenerative disorder characterized by atrophy of the skin, subcutaneous tissue, and occasionally muscles, cartilage and bone, mainly on one half of the face. 2 the exact etiology of this syndrome remains unclear but it may affect personality, psychosocial and aesthetic make up. the usual surgical approaches involve such complicated tissue transfers as a latissimus dorsi free flap.3 however, such procedures require resources that are unavailable and impractical in many lowand middle-income country settings such as ours and it becomes imperative to consider low-cost, minimally invasive alternatives. autologous fat transfer to improve aesthetic appearance in facial asymmetry from parry-romberg syndrome: a case report ma. nina kristine c. sison, md emmanuel tadeus s. cruz, md mark arjan r. fernandez, md department of otorhinolaryngology head and neck surgery quezon city general hospital correspondence: dr. emmanuel tadeus s. cruz department of otorhinolaryngology head and neck surgery quezon city general hospital seminary road, brgy. bahay toro, project 8 quezon city 1135 philippines phone: (632) 8863 0800 local 401 email: orl_hns_qcgh@yahoo.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery interesting case contest (1st place). may 4, 2019. luxe hotel, cagayan de oro city. philipp j otolaryngol head neck surg 2019; 34 (2): 47-51 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery case reports we present a case of progressive hemifacial atrophy in a young woman with parry-romberg syndrome and discuss the role of autologous fat transfer to improve aesthetic appearance and lessen facial asymmetry. case report a 20-year-old woman was admitted due to drooping of the right eyelid. beginning at age 16, she noted gradual drooping of her right eyelid with no other symptoms such as headache or body weakness. two years later, there was progressive thinning of muscles on the right cheek which eventually prompted consultation and subsequent admission. the maternal and family history were unremarkable with no history of previous illness and trauma. ophthalmologic evaluation showed normal visual acuity and pupillary size without diplopia. there was a significant difference in the palpebral apertures at 6mm o.d. and 10mm o.s. and levator function at 7mm o.d. and 14 mm o.s. with intact extraocular muscle function. she was assessed to have ptosis of the right eye and referred to our service. head and neck examination showed right-sided facial and forehead asymmetry from subcutaneous fatty tissue loss and prominent bony ridges on the right forehead, maxillary and mandibular regions. (figure 1) there was slight deviation of the nasal septum to the right. aside from a shallow right nasolabial fold from cheek muscle atrophy and right lip deviation, the oral cavity was normal with no trismus or tongue involvement. her eyebrows and lips were not on the same horizontal plane. however, she could close her eyes against resistance and blow her cheeks symmetrically. there were no sensory deficits on both sides of the face and motor strength on manual muscle testing was intact. no other cranial nerve deficits were observed. cranial magnetic resonance imaging (mri) revealed atrophy of right facial muscles (particularly the medial pterygoid and masseter) and incidental polysinusitis. no hemorrhage, mass or lesion was seen. (figure 2) with an impression of parry-romberg syndrome, the patient was observed for progression of atrophy over three months. there was no significant change in or progression of atrophy noted in baseline and three-month photographs. (figure 3) she consented to autologous fat transfer to augment the cheek. under intravenous (i.v.) sedation using midazolam 5mg/ml, surgical landmarks were outlined on the patient’s face and donor site. (figure 3 a,b) fat graft harvesting was performed with local anesthesia infiltrated in the umbilical area (6 o’clock position) and a blade 11 incision to create the port site. (figure 4a) tumescent solution (1l saline solution with 50cc lidocaine 1% + 1 ampule of epinephrine 1:1,000,000) was infiltrated into the donor site and allowed to set for 30 minutes before a 20-gauge infusion, 4mm cannula was inserted in the port site with manual negative pressure using a large-bore needle attached to 50-ml syringe to harvest fat. after harvesting, the aspirate was left to stand upright for 15 to 20 minutes to allow gravity to separate the liquid and solid portions into an upper oily layer of fatty acids and adipocyte cell mass and a lower mass of packed red blood cells. (figure 4b) excess plasma was drained. a gauge-18 needle was used to make stab incisions in the recipient areas (right cheek and right infraauricular area) and fat was infiltrated with blunt tip 21-gauge cannulas into the subcutaneous layer. (figure 5 a, b) the infiltrated amount per area was estimated based on the unaffected side, with emphasis on smooth convex facial contours to determine whether volume augmentation was sufficient, with over-correction to account for possible resorption. (figure 6) the stab incisions were closed with single interrupted nylon 5-0 sutures. an abdominal binder was maintained for 7 days. the immediate post-operative and comparative preand three-day post-operative photos are shown in figures 7 a-d and 8 a, b. she has remained well with minimal noticeable resorption of the fat graft at 3 months follow-up. (figure 8 c) discussion parry–romberg syndrome (prs) is a rare disorder characterized by atrophy of skin, subcutaneous tissue and sometimes bone on the one side of the face.2 the condition slowly progresses over 2 to 20 years figure 1. preoperative photographs before autologous fat transfer procedure. note the asymmetry in eyes, cheek and lip, a. frontal view; b. worm’s eye view revealing pronounced differences in cheek bulk; c. left lateral view showing the normal side, and d. right lateral view emphasizing bony prominences. photos published in full with permission. a c b d philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery case reports figure 2. mri showing a. normal brain; b. intact orbits and c. atrophy of right facial muscles, particularly the medial pterygoid and masseter (arrows), and incidental polysinusitis. figure 3. surgical landmarks traced a. on the patient’s face (recipient area); and b. the abdomen (donor site). photos published in full with permission. figure 4a. incision using blade 11 in the umbilical area to create a port site. (photo published in full, with permission). and b. the aspirate was left upright for 15 to 20 minutes to allow gravity to separate the upper oily layer of fatty acids and adipocyte cell mass from the lower mass of packed red blood cells. figure 5. a, b. recipient areas (right cheek and right infraauricular area) are infiltrated with fat in the subcutaneous layer using blunt tip cannulas through stab incisions. (photos published in full, with permission). figure 6. distribution of fat injected per region in ml (*-injection site). photos published in full, with permission. before stabilizing. it is typically restricted to one half of the face but occasionally involves the arm, trunk and leg. neurological complications such as trigeminal neuralgia, migraine and seizures may be present2 as well as cranial nerve dysfunction, fixed focal neurologic defects, hemiparesis and cognitive impairment.5 cutaneous manifestations such as skin discoloration (hyperpigmentation or depigmentation) and cicatricial alopecia may be observed as well as mandibular and teeth involvement.2 our patient had no focal neurologic complaint, skin lesions or alopecia. ophthalmologic manifestations linked to prs include enophthalmos, uveitis, retinal vasculitis, ipsilateral and contralateral third nerve paresis, glaucoma and eyelid atrophy.6 eye manifestations of our patient were limited to right ptosis and slight atrophy of the eyelid. parry-romberg syndrome was first reported by parry in 1825 and later described as a syndrome by romberg in 1846.5 although there are many hypotheses for its pathogenesis, the etiology of prs varies and remains unclear. some proposed etiologies include heredity, autoimmune disorders, trauma, hypoor hyperactivity of the sympathetic nervous system, disorders of the trigeminal nerve and infectious diseases from slow viruses such as herpes and lyme disease.2 other associated infectious causes are otitis, dental infections, diphtheria, syphilis, rubella and tuberculosis.2 in our case, hemifacial atrophy appeared spontaneously and developed gradually over four years with no apparent cause or precipitating event. a b a b c a b a b philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery case reports its incidence ranges from 0.3 to 2.5 cases per 100,000 population per year,  most probably less than 3/100,000,  and is more common in women, who represent more than 3 of 4 of the patients.5 two cases of progressive hemifacial atrophy were reported in 1997 in the philippine journal of neurology.7 both involved women with a wide age gap and with different degrees of tissue and areas of involvement. examinations and clinical investigations of both cases revealed no definite etiology.7 parry-romberg syndrome is diagnosed based on clinical manifestations and mri findings. it commonly affects the left side of the face in contrast to our present case which showed involvement of the opposite side.2 in a study of brain mris of patients with parry romberg syndrome, half were unremarkable while the remainder exhibited ipsilateral abnormalities including focal occipital and parietal region atrophy, and ipsilateral parietal and bilateral frontal white matter hyperintensities.8 microhemorrhages, malformations, stenoses, and aneurysms were some of the vascular abnormalities reported in association with the syndrome.8 progressive reduced contractility in the contralateral oculomotor nerve-innervated extraocular muscles was apparent in a parry-romberg syndrome patient presented by tama et al., although there was no evidence of gross central nervous system disease.9 a small subarachnoid lesion of the oculomotor nerve may be detected using higher resolution, heavily t2-weighted technique.9 the mri of the brain in our patient was unremarkable. parry-romberg syndrome deformities may be classified into 3 types based on the severity of soft tissue atrophy and bony involvement: mild, moderate and severe.10 our patient may be classified as moderate, involving large areas of soft tissue atrophy and affecting the nasal ala and upper lip with deviation of the oral commissure and mild bony deficiency.10 no standard treatment algorithm currently exists for prs. topical and systemic corticosteroids, immunomodulators and plasmapheresis have been used with varying levels of success.5 variable responses were demonstrated with antimalarials, antibiotics, vitamin d3 analogues and penicillamine.2 surgery to restore a harmonious and symmetrical facial appearance after progression stabilizes within 2 to 20 years is the prevailing therapy.11 for mild and moderate type of prs, treatment focuses on soft tissue reconstruction (with autologous fat grafts, dermis grafts, dermal-fat flaps), injection of biomaterials (such as silicone or collagen), and free tissue transfers (omentum, rectus abdominis, latissimus dorsi).10 for severe types, microvascular-free flaps and autologous bone augmentation are needed.10 in a case series of 7 patients, a combination of autologous mandibular outer cortex (moc) grafting with fat grafting was done in mild to moderate cases of prs, and computer-assisted techniques was applied to improve surgical outcome with precision and accuracy.12 in clinical practice, autologous fat grafting is preferred and has been successfully performed with less morbidity.13 it has many of the characteristics of an ideal filler (“autologous, completely biocompatible, readily available in sufficient quantities, naturally integrated into host tissues, and removable if necessary”)13 and has numerous applications. human adipose tissue also has the highest percentage of adult stem cells (asc) of any tissue in the body, with as many as 5000 asc per gram of fat compared with 100 to 1000 stem cells per milliliter of bone marrow.14 rehman and colleagues reported that the regenerative potential of autologous adipose tissue was related to the presence figure 7. a-d. the patient’s appearance immediately after the autologous fat transfer procedure; compare with figure 1 a-d. (photos published in full, with permission). figure 8. comparative pre-operative a. 3rd post-operative day b. and 3rd month follow-up c. photos (published in full, with permission). a b c a c b d philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery case reports references 1. srivastava d, singh h, mishra s, sharma p, kapoor p, chandra l. facial asymmetry revisited: part idiagnosis and treatment planning. j oral biol craniofac res. 2018 jan-apr; 8(1): 7–14. doi: 10.1016/j.jobcr.2017.04.010; pmid: 29556456 pmcid: pmc5854562. 2. el-kehdy j, abbas o, rubeiz n. a review of parry romberg. j am acad dermatol. 2012 oct; 67(4):769-84. doi: 10.1016/j.jaad.2012.01.019; pmid: 22405645. 3. wójcicki p, zachara m. surgical treatment of patients with parry-romberg syndrome. ann plast surg. 2011 mar; 66(3): 267-72. doi:10.1097/sap.0b013e3181ea1eb4; pmid: 21263294. 4. hamed sa. comorbid nervous system manifestations and disorders with myasthenia gravis: evidences and possible mechanisms. j neuro. 2012; 3(13):3. doi: 10.3823/327. 5. wong m, phillips cd, hagiwara m, shatzkes dr. parry romberg syndrome: 7 cases and literature review. ajnr am j neuroradiol.  2015 jul; 36(7): 1355-61. doi: 10.3174/ajnr.a4297; pmid: 26066627. 6. bucher f, fricke j, neugebauer a, cursiefen c, heindl lm. ophthalmological manifestations of parry-romberg syndrome. surv ophthalmol. 2016 nov-dec; 61(6): 693-701. doi: 10.1016/ j.survophthal.2016.03.009. pmid: 27045226. 7. tenchavez ps,  chi et, fojas ms, espiritu rb. parryromberg syndrome: revisited. philipp j neurol. 1997; 3: 79-80. 8. moko sb, mistry y, blandin de chalain tm. parry-romberg syndrome: intracranial mri appearances. j cranio-maxillofacial surg. 2003 oct; 31(5): 321–324. pmid: 14563334. 9. tam ek, lonngi m, demer jl. mri findings of contralateral oculomotor nerve palsy in parryromberg syndrome. am j ophthalmol case rep. 2018 feb 2; 10: 81–83. doi: 10.1016/j. ajoc.2018.01.048; pmid: 29780922 pmcid: pmc5956749. 10. ortega vg, sastoque d. new and successful technique for the management of parry-romberg syndrome’s soft tissue atrophy. j craniofac surg. 2015 sep; 26(6): e507510. doi: 10.1097/ scs.0000000000002023; pmid: 26335318. 11. vix j, mathis s, lacoste m, guillevin r, neau j. neurological manifestations in parry–romberg syndrome.  2 case reports. medicine (baltimore). 2015 jul;  94(28): e1147. doi: 10.1097/ md.0000000000001147; pmid: 26181554 pmcid: pmc4617071. 12. qiao j, gui l, fu x, niu f, liu j, chen y, et al. a novel method of mild to moderate parry–romberg syndrome reconstruction: computer-assisted surgery with mandibular outer cortex and fat grafting. j craniofac surg. 2017 mar; 28(2): 359-365. doi: 10.1097/scs.0000000000003293; pmid: 27997449. 13. diepenbrock rm, green jm 3rd. autologous fat transfer for maxillofacial reconstruction. atlas oral maxillofac surg clin north am. 2018 mar; 26(1): 59-68. doi: 10.1016/j.cxom.2017.11.002; pmid: 29362072. 14. aust l, devlin b, foster sj, halvorsen yd, hicok k, du laney t, et al. yield of human adiposederive adult stem cells from liposuction aspirates. cytotherapy. 2004; 6(1): 7-14. doi: 10.1080/14653240310004539; pmid: 14985162. 15. rodby ka, kaptein ye, roring j, jacobs rj, kang v, quinn kp, et al. evaluating autologous lipofilling for parry-romberg syndrome–associated defects: a systematic literature review and case report. cleft palate craniofac j. 2016 may; 53(3): 339–350. doi: 10.1597/14-232; pmid: 26295800. 16. simonacci f, bertozzi n, grieco mp, grignaffini e, raposio e. procedure, applications, and outcomes of autologous fat grafting. ann med surg (lond). 2017 ju 27; 20: 49-60. doi: 10.1016/j. amsu.2017.06.059; pmid: 28702187 pmcid: pmc5491488. 17. jiang t, xie y, zhu m, zhao p, chen z, cheng c, et al. the second fat graft has significantly better outcome than the first fat graft for romberg syndrome: a study of three-dimensional volumetric analysis. j plast reconstr aesthet surg. 2016 dec; 69(12): 1621-1626. doi: 10.1016/j. bjps.2016.06.027. pmid: 27746101. 18. modarressi a. platlet rich plasma (prp) improves fat grafting outcomes. world j plast surg. 2013 jan; 2(1): 6-13. pmid: 25489498 pmcid: pmc4238337. 19. gausas re. technique for combined blepharoplasty and ptosis correction. facial plast surg. 1999; 15(3):193–201. doi: 10.1055/s-2008-1064319; pmid: 11816082. 20. berlin aj, vestal kp. levator aponeurosis surgery: a retrospective review. ophthalmology. 1989 jul; 96(7): 1033–1036. pmid: 2771350. of multipotent mesenchymal stem cells which secrete multiple potentially synergistic proangiogenic growth factors: the adipokines.14 further understanding and the ability to influence production of adipokines may lead to increased graft survival in hypovascular areas.14 to obtain a precise volume of soft-tissue augmentation and good aesthetic outcome, the lipofilling procedure may be repeated over multiple sessions15 as the resorption rate ranges from 30-70% within 1 year.16 a retrospective study of 13 patients with prs twice treated with fat grafts revealed that the second fat graft could produce better cosmetic outcomes and volume retention without any sophisticated procedures.17 additional procedures such as addition of autologous platelet rich plasma (prp) have been proposed to address resorption. platelet rich plasma (prp) is a known natural reservoir of growth factors stimulating tissue repair and regeneration.18 another option to improve our patient’s appearance is correction of ptosis. the degree of ptosis and levator function are usually assessed to determine the appropriate surgical technique. levator function may be classified as excellent (13 to 15 mm), good (8 to 12 mm), fair (5 to 7 mm), and poor (4 or less).19 the patient’s levator function was fair (7 mm on the affected side) based on the classification. in patients with fair levator function, levator aponeurotic advancement is a possible technique that shortens the levator complex and produces excellent results.20 we plan this as a future procedure in our patient. meanwhile, our patient is satisfied and happy with the outcome and cosmetic appearance of her autologous fat transfer and is ready to undergo the same procedure if the need arises in the future. although no definite cure exists for parry-romberg syndrome, our report illustrates the role of autologous fat transfer as an inexpensive, easily harvested and biocompatible material to improve facial asymmetry. the procedure yielded encouraging results, although long-term benefits remain uncertain. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations philippine journal of otolaryngology-head and neck surgery 49 abstract the use of local regional flaps is often the most practical and easy means of reconstruction in the management of head and neck tumors. the temporalis muscle coronoid swing has been used to reconstruct the orbital floor and is described in literature as early as 1983. difficulty is encountered when the medial wall and orbital floor are completely removed and a temporalis muscle-coronoid swing is rendered insufficient for orbital reconstruction. objective: to describe a combination of forehead island flap and temporalis muscle-coronoid swing in orbital reconstruction. design: surgical innovation/ case report. subject: 12-year-old female with recurrent maxillary chondroblastic osteosarcoma one year after chemotherapy. methods: the course of tumor excision and defect reconstruction is described. results: there was no diplopia or other morbidity. there was minimal added operative time for reconstruction with acceptable results. conclusion: local flaps can be combined in order to repair the orbital floor. acceptable function with minimal cosmetic deformity can be achieved with less extensive surgery. keywords: forehead flap, temporalis muscle, coronoid, orbit, reconstructive surgical procedures, maxillectomy local regional flaps are often the most practical and easy means of reconstruction in the management of head and neck tumors. not only are the materials for reconstruction near the surgical field, they also require less operative time and skill to accomplish. advantageous to the design of local flaps are flexibility and viability. flexibility requires that restructuring can be done in order to fulfill the need to restore function or cover the defect. viability is dependent on the blood supply. temporalis muscle-coronoid swing and forehead skin island flap reconstruction of the orbit after maxillectomy ryner jose c. carrillo, md, mariano b. caparas, md department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: ryner jose c. carrillo, md department of anatomy, college of medicine university of the philippines manila pedro gil st. ermita, manila 1000 phone: (632) 526 4194 sentro head and neck medicine and surgery 414 west east center 1336 taft ave., ermita, manila phone: (632) 524 4455 e-mail: ryner_c@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. presented at the surgical innovation contest (2nd place), philippine society of otolaryngology head and neck surgery 49th annual convention, westin philippine plaza hotel, manila, december 1, 2005. philipp j otolaryngol head neck surg 2006; 21 (1,2): 51-53 c philippine society of otolaryngology – head and neck surgery, inc. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations 50 philippine journal of otolaryngology-head and neck surgery fig. 2 the temporalis muscle-coronoid swing for orbital floor reconstruction described as early as 1983 by curioni, et al.1 has been used in our institution for the past ten years. its accompanying advantages and disadvantages were discussed by pryor et al in 20042. recipient site options for the coronoid-temporalis muscle pedicled flap include lamina papyracea, nasal bone, the nasal septum or medial orbital wall. when the medial wall and orbital floor are completely removed, a temporalis muscle-coronoid swing is insufficient for lack of a receiving site. to overcome this problem, we describe a combination forehead island flap and temporalis muscle-coronoid swing in orbital floor reconstruction. description and discussion a 12-year-old female with an enlarging naso-maxillary chondroblastic osteosarcoma over one year period, underwent a single cycle of chemotherapy and was lost to follow up. a year after, she returned with an enlarged facial mass involving bilateral maxillary sinuses, pterygoid plates, nasal cavities, ethmoids and sphenoids. the tumor had invaded the medial wall and floor of the left orbit. (figure 1) a variation of the weber ferguson incision consisting of a lip split, a subciliary incision with a 2-3 cm lateral extension and a vertical incision to cut the forehead flap was performed. (figure 2) tumor was excised through the exposure. the left orbit was preserved, but the medial and inferior orbital wall was resected, together with both maxillae, the nasal bone, and septum. orbital reconstruction was done using a coronoid-temporalis pedicled flap (tcs) anchored to the lateral orbital wall remnant, and an island forehead flap (ff ) sutured to the temporalis muscle. (figure 4) both flaps were supplied by distinct arteries and therefore had increased chances of survival. because of their accessibility, the additional operative time was only 30 minutes. post operatively, there was no diplopia, blurring of vision or foreign body sensation of the eye. the mild epiphora was expected due to surgically absent lacrimal drainage. the combination of forehead and temporalis flaps has previously only been used to fill defects from orbital exenteration, as described by christo in 20023. this technique demonstrates their versatility in orbital reconstruction, restoring function with the ease of application and minimal cost. local flaps can be combined in order to repair the orbital floor fig. 1 silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations philippine journal of otolaryngology-head and neck surgery 51 references: 1. curioni c, toscano p, fioretti c, salerno g. reconstruction of the orbital floor with the musclebone flap (temporal muscle with coronoid process). j maxillofac surg. 1983 dec;11(6):263-8. 2. pryor sg, moore ej, kasperbauer jl, hayden re, strome se. coronoid-temporalis pedicled rotation flap for orbital floor reconstruction of the total maxillectomy defect. laryngoscope. 2004 nov;114(11):2051-5. 3. christo s. temporalis muscle flap and forehead flap for a single stage primary repair of the orbit after exenteration. west afr j med. 2002 jul-sep;21(3):248. 4. birt bd, antonyshyn o, gruss js. the temporalis muscle flap for head and neck reconstruction. j otolaryngol. 1987 jun;16(3):179-84. 5. clauser l, curioni c, spanio s. the use of the temporalis muscle flap in facial and craniofacial reconstructive surgery. a review of 182 cases. j craniomaxillofac surg. 1995 aug;23(4):203-14. 6. holmes s, hutchison i. reconstruction of the orbital floor after its removal for malignancy. br j oral maxillofac surg. 2001 apr;39(2):158-9. 7. lari ar, kanjoor jr, vulvoda m, katchy kc, khan zu. orbital reconstruction following sino-nasal mucormycosis. br j plast surg. 2002 jan;55(1):72-5. following radical maxillectomies. the versatility and ease of the temporalis-coronoid swing and the forehead island flap enable good orbital support after total maxillectomy with orbital preservation. minimal functional and cosmetic deformity can be achieved in the reconstruction of the orbital floor without more extensive surgery, added cost or long operative time. weber ferguson exposure post -excision defect fig. 3 fig.4 philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 passages 42 philippine journal of otolaryngology-head and neck surgery manuel g. lim, md (1930 – 2007) the strong-willed win-win practitioner and bon vivant by joselito c. jamir, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila dr. manuel lim was chairman (1991-1994) during one of the most tumultuous times in the up college of medicine. being part of the administration, he had no other recourse but to follow the dictates of the up administration. the faculty and staff of the department, having decided to side with the dean of the upcm refused to teach during the period. dr. lim, although publicly stating the demands of the up officials, did not impose nor apply any sanctions on any of the “striking” faculty members. such was the resiliency of the man that he was able to maintain the steadfastness and cohesiveness of the department during this tempest. while it can be claimed that it was the late dr. vicente l. santos who conceived the formation of the temporal bone dissection laboratory, it was dr. lim who formalized its structure. the ear institute, initially envisioned during the term of dr. armando chiong, sr., took a more concrete form during his watch. he made representations with then pgh director dr. felipe estrella to allocate to the proposed ear institute the clinical spaces it occupies now. he even made arrangements with dr. suzuki to donate some of the required instruments the the institute might need. but foremost of all, he made representations with then senator francisco tatad to sponsor a bill before the philippine senate for the creation of the philippine national ear institute. this was the same bill that was re-filed in later congresses by senator loren legarda. thus, it can be said that it was dr. lim who took the initial steps towards making the ear institute a reality. his love and zest for life is something that is beyond question. he knew how to live and really made every moment worth living in his heydays. but his love for otology was something beyond compare. his dates with otology could never be broken. wednesdays at 7 am were always reserved for the ear rounds that he religiously conducted until his retirement. thursday mornings would find him at the opd presiding over the ear clinic. such was the perseverance, dedication and commitment of the man, but he was such a smooth operator that only a few of us were aware of the things that he did for his love of otology. fewer still can even recall that it was during his term that the textbook basic otolaryngology became a reality and was finally published. like dr. ejercito, he helped found the philippine board of orl-hns and even served as its secretary for a time. he was a man of delicadeza and was the first member of the board to inhibit himself from its activities when his children margaret and manuel, jr. took the certifying examinations. he also proposed the adoption of a retirement age for members of the board who were hitherto members for life. thus, he was also considered a sort of a maverick by his peers. he had always proven himself capable of going against the popular stance for what he deemed right in serving the long term interests of the department and the specialty. unknown to most of the beneficiaries of his actions, he was the person responsible for the formation and early development of a separate department of orl at st. luke’s medical center. moreso, by sheer force of his personality, he single-handedly won accreditation of its residency training program by the pbohns. in exchange, he had to give up his chairmanship at st. luke’s when the board adopted a policy restricting chairmanship to only one institution. he retired from the department after his term as up-pgh orl chair and was practically unheard of since then. why and what transpired is beyond our knowledge. we may only conjecture that having lived a full life, he may have come full circle and adopted an ascetic life. this was, in a nutshell, dr. manuel g. lim, a hard bargainer who knew how to compromise, resilient and fun-loving, a smooth operator but an effective one at that! philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 conflict of interest in medical publishing exists when a participant’s private interests compete with his or her responsibilities to the scientific community, readers, and society. while conflict of interest is common, it reaches the level of concern when “a reasonable observer might wonder if the individual’s behavior or judgment was motivated by his or her competing interests”.1 having a competing interest does not, in itself, imply wrongdoing. but it can undermine the credibility of research results and damage public trust in medical journals. in recent years, the extent of conflict of interest in medical journal articles has been increasingly recognized. medical journals and the popular media have published numerous examples of competing interests that seemed to have biased published reports.2,3,4 organizations have expressed concern for the effects of conflicts of interest on research,5 publication1,6,7 teaching8 and continuing medical and nursing education.9 the world association of medical editors (wame) is one of the institutions engaged in this discussion. wame was established in 199510,11 to facilitate worldwide cooperation and communication among editors of peer-reviewed journals, improve editorial standards and promote professionalism in medical editing.12 membership in wame is open to all editors of peer-reviewed biomedical journals worldwide; small journals in resource-poor countries are well represented. as of december 2009, wame had 1595 individual members representing 965 journals in 92 countries. wame has broad participation as there are no dues and wame activities are largely carried out through the member list serve and the member password-protected website. in march 2009, wame released an updated policy statement, “conflict of interest in peerreviewed medical journals”.1 it details the issues wame believes journals should address when establishing their own policies for conflict of interest. the editors of this journal thought that the issues were important enough to share with its readers. a summary of the statement is presented in table 1and the full statement1 can be found on wame’s website.12 how does this statement differ from earlier conflict–of-interest statements? first, wame expands the scope of competing interests. other statements have been concerned almost exclusively with conflicts of interest related to financial ties to industry – companies that sell healthcare products. the assumption is that financial incentives are especially powerful and are not readily recognized without special efforts to make them apparent. wame has extended the concept of financial conflict of interest to include the effects of clinical income. for example, physicians who earn their livelihood by reading mammograms or performing colonoscopies may be biased in favor of these technologies. wame has also included non-financial conflicts of interest (or the appearance of one) related to scholarly commitment: “intellectual passion,” (the guest editorial 4 philippine journal of otolaryngology-head and neck surgery conflict of interest in peer-reviewed medical journals: the world association of medical editors (wame) position on a challenging problem correspondence: lorraine e. ferris university of toronto, dalla lana school of public health, 500 university ave, suite 390, toronto, ontario, canada m5g 1v7 email: lorraine.ferris@utoronto.ca. conflict of interest as a wame director, lorraine ferris did not participate in the wame board vote to approve the statement or the vote to endorse the editorial. the authors have no conflicts of interest to declare. “this editorial may appear in other medical and biomedical journals whose editors are members of wame.” © 2010 by wame. lorraine e. ferris1 and robert h. fletcher2 1dalla lana school of public health university of toronto clinical epidemiology unit sunnybrook health sciences centre toronto, ontario, canada chair, wame ethics committee 2harvard medical school, boston ma, u.s.a. chair, wame policy committee philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 guest editorial philippine journal of otolaryngology-head and neck surgery 5 tendency to favor positions that one has already espoused or perhaps even established); personal relationships (the tendency to judge the works of friends/colleagues or competitors/foes differently because of the relationship); political or religious beliefs (the tendency to favor or reject positions because it affirms or challenges one’s political or religious beliefs); and institutional affiliations (the tendency to favor or reject results of research because of one’s institutional affiliations). second, wame did not prescribe a universal standard for when meaningful conflict of interest exists. rather, it defined and recommended elements of conflict of interest policies and encouraged journals to establish their own standards. wame left operational definitions and standards on the basic issues to member journals, recognizing that journals exist in very different contexts across the globe, standards for conflict of interest are evolving, and some journals already have well-established policies and standards. wame does not presume to judge which conflicts require action and what the appropriate action may be, although its policy does offer factors to consider.1 obviously, excessive concern for these and more comprehensive lists of possible competing interests could paralyze the peer review and publication process and is not feasible. editors must make judgments as to the strength of the conflict, but to do so must have uncensored information. similarly, readers need transparency about conflicts, and therefore editors should publish with every article all relevant author disclosures.1 third, wame confirms the seriousness of failure to disclose conflict of interest by indicating that editors have a responsibility for investigating, and if relevant acting, if competing interests surface after a manuscript is submitted or published. the intent is that allegations of failure to declare conflicts of interest must be taken seriously by journals. finally, wame has addressed in a single statement the conflicts of interests threatening all participants in the research and publication continuum, including authors, peer reviewers, and editors. conflicts between editors and journal owners, which might affect both the accuracy of articles and the credibility of journals, have been addressed in another wame policy statement.13 what can be done about conflict of interest in medical journals? conflicts of interest cannot be eliminated altogether but it can be managed so that it has the smallest possible effects on journal content and credibility. the backbone of managing conflicts of interest is full written disclosure; without it, nothing else is possible. currently, authors may not reveal all of their competing interests and even if they do, journals too often do not publish them,14 so there is plenty of room for improvement. even so, disclosure alone is an imperfect remedy; editors still must determine whether a conflict has sufficient potential table 1. summary of key elements for peer reviewed medical journal’s conflict of interest policies element aspects key comments a clear definition the journal uses as to what is conflict of interest and who is captured in the definition. a clear statement of examples of the types of competing interests (and their definitions) the journal says must be declared. should include the following as examples but there could be others: (a) financial ties (b) academic commitments (c) personal relationships (d) political or religious beliefs (e) institutional affiliations clear statements on (a) what is to be declared, when and to whom; (b) format for declaration; (c) a journal’s role in asking additional questions or seeking clarification about disclosures; and, (d) consequences for failing to disclose before or after publication. a clear statement on how conflict of interest will be managed by the journal, including the position that all relevant conflict of interest disclosures (or the declaration of no conflict of interest) will be published with the article and clarity about what conflict of interest situations will result in a manuscript not being considered. 1. definition and scope 2. types of competing interests 3. declaring conflict of interests 4. managing conflict of interests sample definition: conflict of interest exists when a participant in the publication process (author, peer reviewer or editor) has a competing interest that could unduly influence (or be reasonably seen to do so) his or her responsibilities in the publication process (submission of manuscripts, peer review, editorial decisions, and communication between authors, reviewers and editors). there is a need to consider a wide range of competing interests (and a recognition that they can coexist) which the individual assess as to whether they unduly influence (or be reasonably seen to do so) his or her responsibilities in the publication process. examples and definitions of what competing interests should be declared needs to be articulated with journals moving beyond just financial conflict of interest. journals rely on disclosure about the facts because routine monitoring or investigation is not possible. this creates a particular onus on the declarer to report carefully and comprehensively. it also means that journals should ask about conflict of interest in such a way that there will be a high likelihood of reporting relevant conflict of interest. journals use various rules about how they will deal with conflict of interest and conflict of interest disclosures and these need to be made known to all those involved in the publication process. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 guest editorial 6 philippine journal of otolaryngology-head and neck surgery acknowledgement the authors wish to warmly thank the world association of medical editors (wame) officers for their helpful comments on an earlier version of this editorial. many thanks to president margaret winker (usa); past president michael callaham (usa); vice-president john overbeke (netherlands); treasurer tom lang (usa); and secretary farrokh habibzadeh (iran). the wame statement on conflict of interest in peer-reviewed medical journals was approved by the wame board in march 2009. many thanks to the members of the wame ethics committee and to the wame editorial policy committee for their insightful and helpful comments on an earlier version of the statement. warm thanks to the wame board for their input and comments: margaret winker; michael callaham; john overbeke; tom lang; farrokh habibzadeh; adamson muula (malawi) and rob siebers (new zealand). references 1. wame statement on conflict of interest in peer-reviewed medical journals http://www.wame. org/conflict-of-interest-in-peer-reviewed-medical-journals 2. bekelman je, li y & gross cp. scope and impact of financial conflicts of interest in biomedical research: a systematic review. jama 2003; 289(4); 454-65. 3. lexchin j, bero la, djulbegovic b, clark o. pharmaceutical industry sponsorship and research outcome and quality: systematic review. bmj 2003;326(7400);1167-1170. 4. altman lk “for science’s gatekeepers, a credibility gap”. the new york times may 2 2006. http:// www.nytimes.com/2006/05/02/health/02docs.html?scp=58&sq=conflict+of+interest+%26+ medicine&st=nyt 5. institute of medicine “conflict of interest in medical research, education, and practice”. washington, dc: national academies press, 2009 (april) http://www.iom.edu/reports/2009/ conflict-of-interest-in-medical-research-education-and-practice.aspx 6. international committee of medical journal editors (icmje) “uniform requirements for manuscripts submitted to biomedical journals; ethical considerations in the conduct and reporting of research: conflicts of interest http://www.icmje.org/ethical-4conflicts.html 7. international committee of medical journal editors (icmje) “uniform format for disclosure of competing interests in icmje journals. october 2009. http://www.icmje.org/format.pdf 8. american association of medical colleges. “industry funding of medical education: report of an aamc task force”. june 2008. 9. hager m, russell s, & fletcher, sw (eds). “continuing education in the health professions: improving healthcare through lifelong learning. josiah macy j foundation, november 2007. http://www.josiahmacyfoundation.org/documents/pub_conted_inhealthprof.pdf 10. squires bp & fletcher sw “the world association of medical editors (wame): thriving in its first decade” science editor 2005, 28(1); 13-16. 11. launching the world association of medical editors: report of the conference to promote international cooperation among medical journal editors 1995. http://www.wame/org/ bellagio.htm 12. wame website. http://www.wame.org 13. wame policy on the relationship between journal editors-in-chief and owners (formerly titled editorial independence). http://www.wame/org/resources/policies#independence 14. bhargava n, qureshi j, & vakil n “funding source and conflict of interest disclosures by authors and editors in gastroenterology specialty journals”. american j of gastroenterology; 2007; 102(6); 1146-1150. to impair an individual’s objectivity such that the article should not be published. even more work may be needed on reviewers’ and editors competing interests, given their critical role as gatekeepers for the medical literature. no statement will solve the conflict of interest problem, nor will it ever be solved altogether. as understanding of the problem and its management evolves, journals should be given latitude to establish their own standards, matching their policies to the best standards of their discipline and culture. wame believes journals should make these policies readily accessible to everyone. all of us—editors, authors, reviewers, and readers--should be paying more attention to conflict of interest than we have been. we hope this statement serves that purpose. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 practice pearls philippine journal of otolaryngology-head and neck surgery 41 obstructive sleep apnea (osa) in children is one of the most common problems encountered by the otolaryngologist. it was described frequently in adults but was not clearly defined as of true medical significance in children until 19761. since then, rapid advances in technology and increasing recognition have propelled pediatric sleep apnea into both fame and notoriety. snoring is the hallmark of sleep disordered breathing. it occurs in up to 27% of schoolaged children 2-10 and peaks at 2-8 years. this is coincident with the peak in size and degree of immunologic activity of the tonsils 11. the reported prevalence of sleep apnea in this age group is 2-3 % 10, 12. snoring again increases in children 15 years and above with nearly half the males and a third of the females snoring habitually13. characteristics of pubertal children with osa closely mimic adult patterns and are usually addressed as such. airway collapse in osa is dictated by many factors. anatomic obstruction caused by adenotonsillar hypertrophy is the most readily recognizable etiology. certain craniofacial characteristics also result in a smaller airway. moreover, functional pharyngeal muscle tone varies in response to sleep state, pressure-flow airway mechanics and respiratory drive to determine the cross sectional area of the upper airway14. in children with primary snoring, narrowing occurs at the level of the soft palate. in those with osa, collapse is at the level of the tonsils and adenoids 12. interestingly several researches have failed to demonstrate significant correlation between adenotonsillar size and osa14-18. this discrepancy is now being attributed primarily but not solely to the increased incidence of childhood obesity. upper airway, neck, chest and abdominal fat deposition give rise to upper airway narrowing, increased mass loading, decreased chest and diaphragmatic excursions14. these result in an obstructive as well as restrictive pattern of respiratory compromise. although obese children may have concomitant adenotonsillar hypertrophy, addressing this exclusively rarely leads to resolution of osa. the consequences of untreated childhood osa encompass a broad range of morbidities including behavioral disturbances and learning deficits, cardiovascular disease, metabolic disturbances, somatic growth compromise, decreased quality of life and psychiatric illness14. mouth breathing is a clinical presentation worthy of special mention. it has been known that adenoid hypertrophy resulting in chronic mouth breathing leads to “adenoid facies.” this is characterized by an incompetent lip seal, narrow upper dental arch, increased anterior face height, steep mandibular plane angle, and a retrognathic mandible 19-20. craniofacial development progresses rapidly and retains its plasticity until early puberty (12 or 13 years). thereafter, growth slows down as the adult face begins to set21. if mouth breathing is left agnes n. tirona-remulla, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila correspondence: agnes n. tirona-remulla, md department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 phone: (632) 526 4360 fax: (632) 525 5444 email: atremulla95@yahoo.com.ph reprints will not be available from the author. no funding support was received for this study. the author signed a disclosure that she has no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. pediatric obstructive sleep apnea and adenotonsillectomy philipp j otolaryngol head neck surg 2008; 23 (1): 41-43 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 practice pearls 42 philippine journal of otolaryngology-head and neck surgery untreated by this age the probability that the child will eventually develop adult-pattern osa is greater. fortunately, not all children develop these complications. environmental exposure and genetic susceptibility certainly play a role in making a child more vulnerable to the effects of osa. on the other hand, some of these morbidities may not be completely reversible despite treatment14, 22. therefore, timely and appropriate management of osa is crucial in ensuring conditions for optimal development. tonsillectomy and adenoidectomy remain the primary mode of treatment for childhood osa. fear of rheumatic fever and its complications traditionally prompted immediate removal of the tonsils and adenoids. in 1978, osa was not documented as an indication for tonsillectomy. an increasing trend was demonstrated such that in 1986 19% of cases were due to osa22. by 2003, upper airway obstruction was the reason for surgery in 96% of tonsillectomies performed in children less than 36 months over a period of 2 years in a tertiary center23. a meta-analysis of 14 studies reporting polysomnographic outcomes of tonsillectomy and adenoidectomy showed a summary success rate of 82.9%24. significant improvement in quality of life based on validated questionnaires measuring sleep disturbance, physical symptoms, emotional symptoms, hyperactivity and daytime functioning without supporting polysomnographic results have also been reported25-30. however, this still leaves a number of children with residual disease. readily identifiable risk factors for surgical failure are untreated nasal obstruction, maxillomandibular deficiency, obesity and a high respiratory index 14,31,32. further treatment using medications, additional surgery or positive airway pressure therapy is usually necessary for this group of patients. the first 24 hours after surgery is probably the most critical time for developing complications. patients have deeper sleep due to chronic poor sleep quality and sedation or may be placed in supine position37. osa as an operative diagnosis automatically increases the risk of the patient. other factors are low weight, obesity especially those with associated co-morbidities (hypertension, asthma and type ii diabetes), age less than 3 years and those with severe pulmonary hypertension33-37. identified problems are supraglottic obstruction, breath holding, desaturation on induction and emergence37. in children less than 6 years 6.4% experienced morbidities which were primarily respiratory. more than half of these children (57.7%) had desaturations necessitating use of an artificial airway via nasopharyngeal airway or endotracheal intubation and 18% had significant chest findings on radiograph particularly atelectasis, infiltrates and pulmonary edema36. children less than 3 years old have nearly a 2-fold increased risk for respiratory complications36. risk-assessment prior to surgery is essential in achieving a safe perioperative outcome. close coordination with other concerned physicians particularly pediatric subspecialists and anesthesiologists is fundamental. the hospital wherein the procedure will be conducted should have provisions for thorough intraand post-operative monitoring. the decision to admit to the icu after surgery is dictated by severity of illness, the presence of co-morbidities and young age. pediatric obstructive sleep apnea is an entity in evolution. heterogenous patient profiles especially in the face of rising obesity, changing syndrome definitions and polysomnographic parameters, innovations in treatment and even legal issues will continue to challenge every otolaryngologist. notwithstanding, otolaryngology should remain in the foreground in treating pediatric osa. despite attendant risks and limitations, pediatric sleep surgery in the hands of the informed otolaryngologist is still the most useful tool in helping children recover from sleep disordered breathing. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 practice pearls philippine journal of otolaryngology-head and neck surgery 43 references 1. guilleminault c, eldridge fl, simmons fb, dement wc. sleep apnea in eight children. pediatrics 1976;58:23-30. 2. o’brien lm, holbrook cr, mervis cb, et al.sleep and neurobehavioral characteristics in 5-7-yearold hyperactive children. pediatrics 2003;111:554–63. 3. urschitz ms, guenther a, eitner s, et al. risk factors and natural history of habitual snoring. chest 2004;126:790–800. 4. ersu r, arman ar, save d, et al. prevalence of snoring and symptoms of sleep-disordered breathing in primary school children in istanbul. chest 2004;126:19–24. 5. kaditis ag, finder j, alexopoulos ei, et al.sleep-disordered breathing in 3,680 greek children. pediatr pulmonol 2004;37:499–509. 6. rosen cl, larkin ek, kirchner hl, et al. prevalence and risk factors for sleep-disordered breathing in 8to 11-year-old children: association with race and prematurity. j pediatr 2003;142:383–9. 7. montgomery-downs he, o’brien lm,holbrook cr, et al. snoring and sleep-disordered breathing in young children: subjective and objective correlates. sleep 2004;27:87–94. 8. montgomery-downs he, gozal d. sleep habits and risk factors for sleep-disordered breathing in infants and young toddlers in louisville, kentucky. sleep med 2006;7(3):211–9. 9. schechter ms. section on pediatric pulmonology,subcommittee on obstructive sleep apnea syndrome. technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. pediatrics 2002;109:e69. 10. ali nj, pitson dj, stradling jr. snoring, sleep disturbance, and behaviour in 4-5 year olds. arch dis child. 1993;68:360-366. 11. marcus cl. sleep-disordered breathing in children. am j respir crit care med 2001;164(1):16– 30. 12. isono s, shimada a, utsugi m, et al. comparison of static mechanical properties of the passive pharynx between normal children and children with sleep-disordered breathing. am j respir crit care med 1998;157:1204–12. 13. ohayon, m at al. snoring and breathing pauses during sleep: telephone interview survey of a united kingdom population sample. bmj 1997;314:860. 14. dayyat e, kheirandish-gozal l, gozal d. childhood obstructive sleep apnea:one or two distinct disease entities? sleep med clin 2. 2007; 433–444. 15. lam yy, chan ey, ng dk, et al. the correlation among obesity, apnea-hypopnea index, and tonsil size in children. chest 2006;130(6):1751–6. 16. fregosi rf, quan sf, kaemingk kl, et al. sleep disordered breathing, pharyngeal size and soft tissue anatomy in children. j appl physiol. 2003;95(5):2030–8. 17. li am, wong e, kew j, et al. use of tonsil size in the evaluation of obstructive sleep apnoea. arch dis child 2002;87(2):156–9. 18. erdamar b, suoglu y, cuhadaroglu c, et al. evaluation of clinical parameters in patients with obstructive sleep apnea and possible correlation with the severity of the disease. eur arch otorhinolaryngol 2001;258(9):492–5. 19. peltomäki t. the effect of mode of breathing on craniofacial growth--revisited. eur j orthod. 2007 oct;29(5):426-9. epub 2007 sep 4. 20. lessa fc, enoki c, feres mf, valera fc, lima wt, matsumoto ma. breathing mode influence in craniofacial development. rev bras otorrinolaringol (engl ed). 2005 mar-apr;71(2):156-60. epub 2005 aug 2. 21. enlow dh, hans mg. essentials of facial growth. new york: w..b.saunders co.1996. 22. rosenfeld rm. green rp. tonsillectomy and adenoidectomy: changing trends. ann otol rhinol laryngol 1990;99:187-91. 23. ross, at, kazahaya, k, tom, lwc. revisiting outpatient tonsillectomy in young children. otolaryngol head neck surg. 2003;128(3):326-331. 24. brietzke se. the effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis. otolaryngol head neck surg. 2006; 134(6): 979-84. 25. constantin e, kermack a, nixon gm, tidmarsh l, ducharme fm, bouillette rt. adenotonsillectomy improves sleep, breathing, and quality of life but not behavior. j pediatr. 2007;150:540-6. 26. montiel a, de diego ji, prim mp, martinez ma, perez, fernandez e, rabanal i. quality of life after surgical treatment of children with obstructive sleep apnea: long term results. int j pediatr otorhinolaryngol. sep 2006;70(9):1575-9. 27. flanary va. long-term effect of adenotonsillectomy on quality of life in pediatric patients. laryngoscope 2003;113:1639-1644. 28. stewart mg, glaze dg, friedman em, smith eo, bautista m. quality of life and sleep study findings after adenotonsillectomy in children with obstructive sleep apnea. arch otolaryngol head neck surg 2005;131:308-314. 29. mitchell rb, kelly j, call e, yao n. quality of life after adenotonsillectomy for obstructive sleep apnea in children. arch otolaryngol head neck surg. 2004;130:190-194. 30. avior g, fishman g, leor a, sivan y, kaysar n, derowe a. the effect of tonsillectomy and adenoidectomy on inattention and impulsivity as measured by the test of variables of attention (tova) in children with obstructive sleep apnea syndrome. otolaryngol head neck surg 2004;131:367-371. 31. shine np. adenotonsillectomy for obstructive sleep apnea in obese children: effects on respiratory parameters and clinical outcome. arch otolaryngol head neck surg 01 oct 2006; 132(10): 1123-7 32. guilleminault c, huang ys, glamann c, li k, chan a adenotonsillectomy and obstructive sleep apnea in children: a prospective survey. otolaryngol head neck surg feb 2007; 136(2): 169-75. 33. sanders jc, king ma, mitchell rb, kelly jp. perioperative complications of adenotonsillectomy in children with obstructive sleep apnea syndrome. anesth analg. 2006; 103(5): 1115-21. 34. carmosino mj, friesen rh, doran a, ivy dd. perioperative complications in children with pulmonary hypertension undergoing noncardiac surgery or cardiac catheterization. anesth analg. 2007; 104(3): 521-7. 35. tait ar, voepel-lewis t, burke c, kostrzewa a, lewis i. incidence and risk factors for perioperative adverse respiratory events in children who are obese. anesthesiology. 2008;108:375-80. 36. statham mm, elluru, rg, buncher r, kalra m. adenotonsillectomy for obstructive sleep apnea syndrome in young children. arch otolaryngol head neck surg 2006;132:476-480. 37. rosenberg j, rasmussen gi, wojdemann kr, et al. ventilatory pattern and associated episodic hypoxaemia in the late postoperative period in the general surgical ward. anaesthesia 1999;54:323–8. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 special announcement philippine journal of otolaryngology-head and neck surgery 5 we, the participants in the joint meeting of the asia pacific association of medical journal editors (apame) and the western pacific region index medicus (wprim) held in singapore from november 4 to 5, 2009: considering that quality scientific and technical health information is essential for health policy makers, healthcare providers and health researchers to develop, improve, and implement efficient and effective healthcare systems and services; that inequitable access to quality health information could result in poor health planning and healthcare delivery which adversely affect the health conditions of the public; that surmounting this inequity requires public private partnerships to facilitate equitable access to both production and consumption of health information for all; that the western pacific region index medicus (wprim), the global health library (ghl), and the asia pacific association of medical journal editors (apame) are important collaborative initiatives which are vital instruments to ensure the global accessibility and dissemination of quality health information in the western pacific region; confirm our commitment to free and universal dissemination and access to quality health information through the wprim and the ghl; our commitment to pursue the goals and objectives of apame by further building networks, convening conferences, and organizing events to educate and empower editors, peer reviewers and authors in generating quality scientific and technical publications; singapore declaration on equitable access to health information in the western pacific region call on member states of the western pacific region, in collaboration with stakeholders from the private sector, to formulate and implement policies that endorse free and equitable access to quality health information; stakeholders from the public and private sectors, national and international organizations, to support wprim and the ghl in order to ensure the free and global accessibility of health research done in the western pacific region; governments, the private sector and other editors’ associations to support apame in implementing various activities, guidelines and practices that would improve the quality of scientific writing and publications in the asia pacific region; commit ourselves to persevere in the pursuit of the wprim and ghl initiatives through apame, by encouraging peer-topeer relationships that will allow editors, editorial staff and librarians to maintain balance, work out ideas and provide mutual support; our organization, apame, to building further networks, convening conferences, and organizing events to educate and empower editors, peer reviewers and authors to achieve and maintain internationally acceptable, but regionally realistic, scholarly standards. november 6, 2009, singapore www.wpro.who.int/apame apame@wpro.who.int (this declaration was launched at the international forum on academic medical publishing held in conjunction with the singapore medical journal golden jubilee conference on november 6, 2009.) this declaration has been concurrently published in the november 2009 issue of the singapore medical journal [singapore med j 2009; 50(11) : 1043]. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles 14 philippine journal of otolaryngology-head and neck surgery abstract objective: to investigate by means of videostoboscopy the characteristics of the neoglottis after total laryngectomy with primary or secondary voice reconstruction using a non-prosthetic tracheoesophageal fistula technique. methods: design: cross-sectional study setting: tertiary public hospital subjects: twenty alaryngeal patients results: videostroboscopy enabled evaluation of the neoglottis in all but two patients with a pectoralis major myocutaneous flap reconstruction of the pharyngoesophageal segment. pooling of saliva was present in the cranial neoglottic opening in all subjects, but obscured visualization in these two. a circular neoglottic shape was most commonly seen. vibration of the neoglottis was noted in 90% of all alaryngeal patients and was associated with a regular mucosal wave. pharyngoesophageal vibration was noted in two thirds of patients. it was associated with a strong mucosal wave, regular vibration and a longer open phase. conclusion: videostroboscopy confirmed that neoglottic vibration accompanies sound production while pharyngoesophageal vibration may reinforce and enhance voice production in alaryngeal patients with non-prosthetic te voice reconstruction. keywords: larynx, total laryngectomy, voice reconstruction, tracheoesophageal (te) fistula speech, alaryngeal voice, alaryngeal speech, videostrobe alaryngeal patients may reacquire their voice through electronic voice resonators, implants, esophageal speech, and tracheoesophageal (te) fistula with and without prosthesis (e.g. blomvideostroboscopic evaluation of neoglottis in alaryngeal patients after tracheoesophageal voice reconstruction without prosthesis jeanne o madrid., m.d.1 celso v. ureta, m.d.1,2 1department of otorhinolaryngology head and neck surgery veterans memorial medical center 2department of otorhinolaryngology head and neck surgery manila central university – filemon d. tanchoco medical foundation (mcu-fdtmf) correspondence: jeanne o. madrid, m.d. department of otorhinolaryngology head and neck surgery veterans memorial medical center north avenue, diliman, quezon city 0870 philippines telephone: (632) 927-6426 local 1359 telefax: (632) 426-9775 e-mail address:enthns_vmmc@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. presented at the descriptive research contest (1st place), philippine society of otolaryngology head and neck surgery, jade valley restaurant, quezon city, september 25, 2008. philipp j otolaryngol head neck surg 2009; 24 (2): 14-18 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles philippine journal of otolaryngology-head and neck surgery 15 singer®, provox®). in the philippine setting, te fistula prostheses are associated with complications of infection and foreign body ingestion and frequent prosthesis replacement is costly and unavailable. hence, non-prosthetic tracheoesophageal (te) fistula speech provides a viable option in relation to voice character, cost, practicability and availability.1 tracheoesophageal fistula speech has been perceived as superior to electrolaryngeal or traditional esophageal speech, even though it is not viewed as comparable to the normal voice. it has been found not to differ significantly from normal speech in intelligibility, rate and inflection, but is less acceptable for fluency, pitch/quality and overall acceptability.2 primary or secondary veterans memorial medical center / manila central university medical foundation celso ureta (vmcu) technique voice reconstruction employs te fistula voice rehabilitation that does not use prosthesis and is a modified amatsu voice reconstruction technique. it utilizes a funnel shaped te fistula that serves as the neoglottis. this has been a standard voice reconstruction technique in our institutions for more than a decade. a series of events occurs during te phonation. to initiate voice production, the patient takes a deep breath, covers the tracheostoma with digital pressure and speaks like a normal person does. tracheostomal occlusion directs pulmonary air through the te fistula into the esophagus. air passing through the te fistula sets off neoglottic vibration and cricopharyngeal muscle constriction and the resultant sound is converted to understandable speech by the intact articulatory structures.3 previous studies on anatomical and morphologic characteristics of the neoglottis have focused on te speech with prosthesis (blomsinger®, provox®) using videofluoroscopy, fiberoptic visualization and videostroboscopy and incorporate further assessment with perceptual evaluation, acoustic analyses and digital high-speed imaging.4 pubmed with philippine index medicus and herdin database searches using “larynx,” “alaryngeal voice,” “alaryngeal speech,” “tracheoesophageal fistula speech,” “videostrobe” mesh terms did not yield a videostroboscopic study on the anatomical and morphologic characteristics of the neoglottis for non-prosthetic tracheoesophageal fistula speech. this paper aims to investigate by means of videostroboscopy the various characteristics of the neoglottis after total laryngectomy with primary or secondary voice reconstruction using a non-prosthetic te fistula or vmcu technique. specifically, it aims to enumerate the videostroboscopic findings and describe the anatomical and morphologic characteristics of the neoglottis; gain insight into the underlying mechanism of voice production; and provide recommendations for videostroboscopic evaluation in these patients. materials and methods informed consent was sought from adult alaryngeal patients who underwent total laryngectomy with primary or secondary vmcu nonprosthetic te voice reconstruction technique between 1997 and 2008. included were patients who underwent total laryngectomy with or without hypopharyngectomy and partial esophagectomy and reconstruction using pectoralis major myocutaneous flap. patients who had active pulmonary tuberculosis or who did not consent to the study were excluded. twenty subjects meeting inclusion criteria consisted of 19 males and one female with age varying from 49 to 78 years (mean, 63 years). five patients had stage iii and 15 had stage iv squamous cell carcinoma of the larynx.5 a total laryngectomy was performed in all 20 patients. in two patients, the pharynx was reconstructed partially with a pectoralis major myocutaneous flap. nineteen patients underwent primary tef reconstruction while one patient underwent secondary tef reconstruction 1.5 years post total laryngectomy. all 20 patients underwent neck dissection and postoperative radiotherapy. in two patients, videostroboscopic examination was performed three weeks shortly after completion of radiotherapy. the rest of the patients were assessed six months or longer post-radiotherapy (table 1). a flexible fiberoptic olympus enf p3 nasopharyngolaryngoscope (olympus-optical, japan) with a kay elemetrics videostroboscopy system model 9100s (kay elemetrics corp., lincoln park, nj usa) was utilized for all patients, following five minutes decongestion and topical anesthesia with intranasal gauze strips soaked in 0.05% oxymetazoline hydrochloride nasal spray (schering plough, east java, indonesia) and 10% lidocaine topical spray (astra zeneca ab, sodertalje, sweden). two patients with strong gag reflexes were given additional topical 10% lidocaine spray per os during the recording examination. a contact microphone was secured to the neck superior to the stoma, utilizing the standard velcro (velcro industries b.v., manchester, nh usa) strap. a single consultant otolaryngologist performed the endoscopy on all patients. transnasal flexible videostroboscopy of the hypopharynx and upper esophagus showing neoglottic activity during quiet breathing and voicing was performed. patients were asked to produce a sustained vowel /a/ and /e/ sound after the cranial opening of the neoglottis was visualized. digital stomal occlusion using the first digit was performed by all patients during phonation. sequences were stored on a computer hard disk and replayed at delayed speeds down to single frame display, using the kay elemetrics philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles 16 philippine journal of otolaryngology-head and neck surgery table 1. profile of alaryngeal patients who underwent tracheoesophageal voice reconstruction without prosthesis included in the videostroboscopic evaluation of neoglottis characteristics mean or proportion (n=20) age 63 years (range 49-78) male 19 (95%) tumor stage (ajcc): stage iii 5 (25%) stage iv 15 (75%) total laryngectomy with neck dissection w/o reconstruction 18 (90%) with pectoralis major myocutaneous flap reconstruction 2 (10%) tracheo-esophageal fistula primary surgery 18 (90%) second stage surgery 2 (10%) time of videostroboscopy evaluation from surgery 3 weeks to 9 years software program (kay elemetrics corp., lincoln park, nj usa). definitions of the variables used for videostroboscopic assessment of the neoglottis were elucidated and modified for non-prosthetic te fistula and the stroboscopic assessment form used for te fistula with prosthesis suggested by hirano and bless6 (appendix 1 a) was modified for use in this study and is found in appendix 1 b. results videostroboscopy enabled evaluation of the neoglottis in all except two patients with a pectoralis major myocutaneous flap reconstruction of the pharyngoesophageal segment. results utilizing the modified hirano and bless assessment form for the videostroboscopic evaluation of the neoglottis without tracheoesophageal prosthesis are listed in table 2. although pooling of saliva was present in the cranial neoglottic opening in all subjects, it obscured visualization in the two patients with pmmf reconstruction. these patients also produced “wet voices,” but they were still comprehensible. in 15/20 patients, there was only little to moderate amount of visible saliva. none of the patients had associated gross aspiration. the average frequency for phonation of sustained vowel /e/ was 91.5 hertz at an average amplitude of 64.5 decibels and an average duration of four seconds. for sustained vowel /a/, the average frequency was 83.5 hertz at an average amplitude of 66.5 decibels and an average duration of 3.5 seconds. the lone female subject exhibited the same fundamental frequency as her male counterparts. table 3 lists the mean frequency, amplitude and duration of neoglottis during sustained vowel /e/ and /a/ phonation. the neoglottis during phonation assumed a circular shape in 8/20 table 2. videostroboscopic evaluation of the neoglottis without tracheoesophageal prosthesis using the modified hirano and bless assessment form variable assessability brightness focus saliva visibility of the origin of the neoglottis shape of the neoglottis presence of neoglottic mucosal wave regularity of neoglottic vibration location of the visible pharyngoesophageal vibration presence of pharyngoesophageal mucosal wave regularity of pharyngoesophageal vibration closure phase judgment good fair moderate poor good fair moderate poor focused slightly unfocused unfocused none a little moderate much obstructing visible not visible circular triangular split side-to-side split anterior-posterior irregular not assessable strong weak absent regular irregular not assessable posterior anterior 2 or 3 walls all walls not assessable strong weak absent regular irregular not assessable open equal closed not assessable standard total laryngectomy phar yngoesophagectomy with pectoralis major flap (pmmf) reconstruction voice reconstruction primary 16 1 16 1 17 9 5 2 1 17 7 3 2 5 15 2 15 2 10 7 15 2 15 2 17 secondary 1 1 1 1 1 1 1 1 1 1 1 1 primary 1 1 1 1 2 1 1 2 2 1 1 1 1 2 1 1 2 2 philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles philippine journal of otolaryngology-head and neck surgery 17 table 3. mean frequency and amplitude of sustained vowel /e/ and /a/ and mean duration of neoglottic vibration on phonation voice characteristics (n=20) mean standard deviation neoglottic frequency (hertz) /e/ /a/ 91.5 hz 83.5 hz 12.6 hz 12.3 hz neoglottic amplitude (decibels) /e/ /a/ 64.5 db 66.5 db 10.7 db 10.7 db neoglottic vibration duration (seconds) /e/ /a/ 4.0 s 3.5 s 1.3 s 1.2 s appendix ia. hirano and bless assessment form of the videostroboscopic evaluation of the neoglottis with tracheoesophageal prosthesis assessability brightness focus saliva visibility of the origin of the neoglottis shape of the neoglottis or vibrating part location of the visible vibration presence of mucosal wave regularity of vibration closure phase variables rating good good focused none visible circular posterior strong regular open phase predominates fair fair slightly unfocused a little not visible triangular anterior weak irregular equal moderate moderate unfocused moderate split side-toside left absent not assessable closed phase predominates poor poor much split anteriorposterior right not assessable obstructing irregular all walls not assessable not assessable (40%) followed by antero-posterior split in 5/20 (25%), triangular in 3/20 (15%) and a side-to-side split in 2/20 (10%). an irregularly shaped neoglottis was not noted. since the neoglottis of two patients reconstructed with pmmf was not visible, its shape could not be assessed. a neoglottic mucosal wave was present in 18/20 (90%) and strongly visible and regular in 16/20 (80%) of the patients. the mucosal wave could not be assessed in the two patients with pmmf reconstruction. transnasal flexible videostroboscopic view of the hypopharynx and upper esophagus showed two bulges in the pharyngoesophageal (pe) segment, which was also noted to vibrate. the vibration involved two to three walls of the pe segment in 11/20 (55%) and involved all walls in 9/20 (45%) of cases. a strong pe mucosal wave was seen in 17/20 (85%), regular pe vibration was observed in 16/20 (80%) and a longer open phase of the pe segment was noted in all 20/20 (100%). in patients wherein the pharynx was reconstructed using a pectoralis major myocutaneous flap, upper pharyngoesophageal vibration was noted in all walls. characteristic wet voice was notably persistent throughout the examination; though less comprehensible, speech was still achieved by non-prosthetic te fistula speech in these patients. discussion requirements for normal phonation are adequate breath support, approximation of vocal folds, favorable vibratory properties, favorable vocal fold shape and control of length and tension.7 in alaryngeal phonation, the neoglottis takes up vocal fold function. the neoglottic mucosa covering muscle, mucosal wave, length and tension change on phonation are similar to those of a normal glottis. this resemblance enables alaryngeal patients to phonate. although the anatomy and morphology of the new voice source (neoglottis) were highly variable, what was consistent in this study was that most patients had a neoglottic vibration and mucosal wave, which could be identified even in patients evaluated shortly after surgery. the consistent findings of neoglottic vibration and mucosal wave in our study confirms previous studies showing the neoglottis as the source of vibration during tracheoesophageal (te) phonation without prosthesis.8 the neoglottis has no uniform anatomical size or shape during phonation.9 its variable shape and length are outcomes of hypopharyngeal and upper esophageal reconstruction.10 wound healing and fibrosis contribute to this occurrence. pharyngeal defects with pmmf reconstruction further complicate the neoglottic appearance. the frequency and amplitude of the non-prosthetic te fistula reinforces findings that the neoglottis functions similarly to true vocal cord. our findings suggest that the non-prosthetic te fistula may be better than te fistulae with prosthesis, as the latter potentially obscure and dampen the neoglottic mucosal wave by mere presence in the fistula. actual comparative studies may elucidate our suggestion. the neoglottis does not have the flexibility and volitional controllability of the glottis and its frequency and amplitude have limited range in vocal pitch compared with normal true vocal cords.9 the human vocal range in terms of frequency is 90-250 hertz for normal male and female voices11 while the average range for both males and the sole female in our study was 83.5-91.5 hertz. pooling of saliva was seen in all neoglottic openings, but was greater philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles 18 philippine journal of otolaryngology-head and neck surgery references 1 ureta cv. primary voice reconstruction in total laryngectomy patients. philippine scientific journal. 2002 jan-dec; 1: 5-6. 2 pindzola rh, cain bh. acceptability ratings of tracheoesophageal speech. laryngoscope. 1988 apr;98(4):394-7. 3 mohri m, yoshifuji m, kinishi m, amatsu m. neoglottic activity in tracheoesophageal phonation. auris nasus larynx. 1994;21(1):53-8. 4 van as cj, op de coul bmr, van den hoogen fja, koopmans–van beinum fj, hilgers fjm. quantitative videofluoroscopy a new evaluation tool for tracheoesophageal voice production. arch otolaryngol head neck surg. 2001;127:161-169. 5 greene fl, page dl, fleming id, fritz af, balch cm, haller dg, morrow m. american joint committee on cancer: ajcc cancer staging manual. new york: springer, 6th ed., 2002. pp 8088. 6 hirano m, bless dm. videostroboscopic evaluation of the larynx. san diego, ca: singular publishing group; 1993. 7 cummings cw, flint pw, haughey bh, robbins kt, thomas jr, hanker la, richardson ma, schuller de.otolaryngology head and neck surgery. 4th ed. volume 3: pennsylvania: elsevier mosby; 2005;p. 1970. 8 saito m, imagawa h, sakakibara k, tayama n, nibu k, amatsu m. high speed digital imaging and electroglottography of tracheoesophageal phonation by amatsu’s method. acta otolaryngol. 2006 may;126(5):521-5. 9 van as cj. tracheoesophageal speech. a multidimensional assessment of voice quality. institute of phonetic sciences, university of amsterdam, proceedings 24 (2001), 189-194. 10 omori k, kojima h, nonomura m, fukushima h. mechanism of tracheoesophageal shunt phonation. arch otolaryngol head neck surg. 1994 jun;120(6):648-52. 11 harries m, morrison m. the role of stroboscopy in the management of a patient with a unilateral vocal fold paralysis. j laryngol otol. 1996; 110(2):141-143. 12 robbins j, christensen j, kempster g. characteristics of speech production after tracheoesophageal puncture: voice onset time and vowel duration. j speech hear res. 1986 dec;29(4):499-504. appendixib. modified hirano and bless assessment form of the videostroboscopic evaluation of the neoglottis without tracheoesophageal prosthesis assessability brightness focus saliva visibility of the origin of the neoglottis shape of the neoglottis or vibrating part location of the visible vibration presence of neoglottic mucosal wave regularity of neoglottic vibration location of the visible pharyngoesophageal vibration presence of pharyngoesophageal mucosal wave regularity of pharyngoesophageal vibration closure phase variables rating good good focused none visible circular posterior strong regular posterior strong regular open phase predominates fair fair slightly unfocused a little not visible triangular anterior weak irregular anterior weak irregular equal moderate moderate unfocused moderate split side-toside left absent not assessable 2 or 3 walls absent not assessable closed phase predominates poor poor much split anteriorposterior right all walls not assessable obstructing irregular all walls not assessable not assessable not assessable in patients with hypopharyngeal reconstruction, resulting in breathy, wet voices and less understandable speech. this may be attributed to a disturbance in the peristaltic and mucosal wave movement of the pharyngoesophageal segment due to pmmf reconstruction of the hypopharynx and esophagus, causing retention and difficult ingestion of saliva.12 vibration in other parts of the cricopharynx further reinforces the vibratory function and enhances voice production.12 of the two bulges seen in the pharyngoesophageal segment, the upper bulge formed by the cricopharyngeal muscle is an ancillary sound source of the nonprosthetic te shunt while the lower bulge corresponds to the upper esophageal muscle sphincter. anteroposterior and undulating regular movements have been observed in the pe segment by other authors.10 videostroboscopic fiberoptic endoscopy confirms that te phonation has two steps, consistent with previous studies.3 first, the preparatory stage of hypopharyngeal closure which forms a small lumen. second, the phonatory stage of the vibration of the neoglottis with a definite configuration maintained by hypopharyngeal muscle contraction. our study confirmed that the neoglottis vibrates to produce sound while the pharygoesophageal segment reinforces vibratory function and enhances voice production in alaryngeal patients with nonprosthetic tracheoesophageal voice reconstruction. neoglottic voice analysis can be measured by videostroboscopy in terms of frequency, amplitude and duration. while the hirano and bless videostroboscopic assessment form was readily adaptable to evaluation of te fistula patients without prosthesis, further studies may be conducted to validate our modification of this instrument, as well as its application in evaluating speech rehabilitation among a larger sample of these patients. philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 philippine journal of otolaryngology-head and neck surgery 51 under the microscope abstract a case of melanotic neuroectodermal tumor of infancy (mneti) is presented. the salient histopathologic features of this unusual neoplasm are discussed including post-chemotherapy morphologic changes. keywords: melanotic neuroectodermal tumor of infancy, retinal anlage tumor, progonoma, neuroectodermal tumors melanotic neuroectodermal tumor of infancy (mneti) is a rare neoplasm of early infancy, arising from neural crest cells, with rapid expansile growth and a high recurrence rate.1 most cases occur in the anterior maxillary alveolus. prognosis is good for the majority of cases. about 250 cases have been reported in the medical literature.2 in the philippines, there is only one reported case of mneti since 1983.3 in this paper, we describe a case of mneti in the left maxillary region, as well as its treatment and a literature review in order to discuss different features of this rare pathology. case report a four-month-old male infant was born full term via primary cesarean section to a 26-yearold gravida 1 para 0 (gipo) mother at a local hospital. pre-natal history was unremarkable. at 19 days of life, the patient was observed to have a gradually enlarging firm mass at the left maxillary area. no other symptoms noted. at two months of life, the mass was excised. gross examination revealed an irregularly shaped tissue measuring 3.8x3x2 cm with a gray to black, fleshy and gritty cut surface. microscopically, the tumor is composed of nests of neoplastic cells, some containing pigment, arranged in an alveolar pattern separated by fibrovascular stroma (figure 1). the tumor cell population is biphasic. it is composed of small, round, neuroblast-like cells with dark nuclei and scanty cytoplasm and flattened to cuboidal epithelioid cells containing melanin-like cytoplasmic pigment (figure 2). these histomorphologic features are consistent with mneti. differential diagnoses considered were non-hodgkin lymphoma, malignant melanoma, rhabdomyosarcoma and ewing sarcoma. however, the biphasic morphology was deemed sufficiently distinct as to rule out these diagnoses on morphologic grounds. a few weeks later, recurrence and rapid growth of the mass were noted. the patient was then referred to the pediatric-oncology section. to confirm the previously issued diagnosis, hmb45 (figure 3), neuron specific enolase (figure 4) and cytokeratin (figure 5) immunohistochemistry were performed, which were all positive in the pigmented epithelioid cells. the synaptophysin showed positivity in the small, neuroblast-like cells (figure 6). ct scan of the head was requested which revealed an expansile hyperdense lytic lesion of the left maxilla which extended to the midline and the left cheek (figure 7). since the mass was unresectable, the patient underwent six cycles of chemotherapy (cyclophosphamide, vincristine and doxorubicin). the patient tolerated the procedure and the mass decreased in size melanotic neuroectodermal tumor of infancy correspondence: a/prof. dr. jose m. carnate jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st., ermita 1000 manila philippines phone (632) 526 4450 fax (632) 400 3638 email: jmcjpath@yahoo.com reprints will not be available from the authors. the authors have no conflict-of-interest issues to disclose. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the case report poster contest (second place), philippine society of pathologists annual convention, dusit hotel, makati city, philippines, april 14, 2011. philipp j otolaryngol head neck surg 2011; 26 (1): 51-54 c philippine society of otolaryngology – head and neck surgery, inc. anjelane m. enriquez, md1 jose m. carnate jr., md2 1department of laboratories philippine general hospital university of the philippines manila 2department of pathology college of medicine university of the philippines manila philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 under the microscope 52 philippine journal of otolaryngology-head and neck surgery by 30 to 40%. one month after treatment, excision of the mass was done showing a 4.5x4x3.5 cm, hard mass with brown black, solid, gritty cut surface (figure 8). microscopic sections of the resected mass showed post-chemotherapy related changes consisting of predominantly melanin-containing epithelioid cells and reduced or disappearance of the neuroblast-like cells (figure 9). facial reconstruction was done. three weeks after the surgery, there was no noted tumor recurrence. discussion mneti (synonyms: retinal anlage tumor, progonoma) clinically presents as a rapidly growing, non-tender, solitary, expansile, partly pigmented mass, typically arising in the maxillary region.1,5 radiographs often reveal a destructive, poorly demarcated radiolucency of the underlying bone with a faint “sunburst” appearance from mild calcification along vessels radiating from the center of the tumor. ct scans reveal a hyperdense mass. microscopic sections usually show biphasic population of cells small, neuroblast-like cells and larger melanin-containing epithelioid cells. immunohistochemistry studies are helpful in differentiating mneti from other “small round cell” tumors common in the head and neck region. in this case, the melanocytic cells are immunoreactive to hmb45, nse and cytokeratin while the neuroblast-like cells are immunoreactive to synaptophysin, confirming the diagnosis of mneti.1 the treatment of choice is complete surgical resection. patients with mneti that are not amenable to surgical management alone may receive other modes of treatment. chemotherapy may serve as an alternative or adjuvant option in the treatment of widely extensive mneti.1 the prognosis is still controversial. many authors consider it good but there are only a few figure 1. neoplastic cells, some containing pigment, arranged in an alveolar pattern separated by fibrovascular stroma (h & e, 40x) (hematoxylin-eosin, 40x) (hematoxylin-eosin, 400x) figure 2. biphasic pattern of cells: small, round, neuroblast-like cells with dark nuclei and scanty cytoplasm and flattened to cuboidal epithelioid cells containing melanin-like cytoplasmic pigment (h & e, 400x) figure 3. melanin-like containing epithelioid tumor cells immunoreactive for hmb45 (400x) cases in the literature. some authors have demonstrated a significant reduction of the neuroblastic-like component with chemotherapy with predominance of melanin-containing epithelioid cells.6 when metastasis develops (up to 7% of cases) it is the “neuroblast-like” component that is regarded as the aggressive part of the neoplasm. although mneti is reported to have a good prognosis, recurrences can occur especially within the first six months, hence, the need for close follow-up post-operatively. close follow-up and early resection of local recurrences minimize complications and thereby avoid loss of local function.4 the rarity of this tumor demands reporting in order to elucidate the real nature of the lesion, as well as its natural outcome. (hmb45, 400x) philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 philippine journal of otolaryngology-head and neck surgery 53 under the microscope figure 4. melanin-like containing epithelioid tumor cells immunoreactive for neuron-specific enolase (400x) figure 5. melanin-like containing epithelioid tumor cells immunoreactive for cytokeratin (400x) figure 6. small, neuroblast-like cells immunoreactive for synaptophysin (400x) figure 7. ct-scan of the head with contrast showing an expansile hyperdense lytic lesion of the left maxilla which extended to the midline and the left cheek (neuron-specific enolase, 400x) (cytokeratin, 400x) (synaptophysin, 400x) philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 under the microscope 54 philippine journal of otolaryngology-head and neck surgery references 1. agarwal p, saxena s, kumar s, gupta r. melanotic neuroectodermal tumor of infancy: presentation of a case affecting the maxilla. j oral maxillofacial pathol. 2010 jan – june; 14(1): 29 – 32. 2. retna kumari n, sreedharan s., balachandran d., melanotic neuroectodermal tumor of infancy: a case report. journal indian society of pedodontics preventive dentistry. 2007 sept; 25(3):148 – 151. 3. pontejos a, lopez j, jurado a. melanotic neuroectodermal tumor of infancy: a case report. philipp j otolaryngol head & neck surgery. 1983: 192 – 194. 4. costa de arau´jo pp, tincani af, paiva vp, loureiro neta is, cardinalle d ia, de cassia pereira d r, brandalise sr. melanotic neuroectodermal tumor of infancy (progonoma)–—clinical, radiological, pathological features and literature review. int j ped otorhinolaryngol extra. 2007 june;2(2):111—115. 5. mosby el, lowe mw, cobb cm, ennis rl. melanotic neuroectodermal tumor of infancy: review of the literature and report of a case. j oral maxillofacial surg. 1992;50:886-894. 6. mello rj, vidal ak, fittipaldi hm jr, montenegro lt, calheiros lm, rocha gi. melanotic neuroectodermal tumor of infancy: clinicopathologic study of a case, with emphasis on the chemotherapeutic effects. int j surg pathol 2000 jul;8(3):247-251 figure 9. post-chemotherapy related changes consisting of predominantly melanin-containing epithelioid cells and disappearance of neuroblast-like cells (h & e, 400x)figure 8. post-chemotherapy excision of the gross specimen (hematoxylin-eosin, 400x) philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 philippine journal of otolaryngology-head and neck surgery 9 original articles philipp j otolaryngol head neck surg 2008; 23 (1): 9-14 c philippine society of otolaryngology – head and neck surgery, inc. abstract the virtual audiometer (va) is a software application that simulates a pure tone audiometer by delivering tones of different frequencies and intensities by air conduction. objectives: to determine correlation between hearing thresholds measured by virtual and pure tone audiometry and degree of agreement in their hearing loss classification. methods: analytic, cross-sectional study set in a philippine tertiary institution. subjects were recruited from the outpatient department in september 2005 and comprised of cooperative, clinically normal and abnormal hearing individuals. thirty-two subjects made 64 total ears tested (n=64), giving 0.90 correlation at 0.05 level of significance (α) (p = 0.05) and 99% power. each subject underwent pure tone and virtual audiometry, the average thresholds calculated, and degree of hearing loss categorized according to classification by the world health organization (who). results were not revealed until both examinations were completed. data were stratified by frequency and compared by pearson’s correlation, while kappa statistics determined degree of agreement between who grades of hearing impairment. results: average age was 40.2 years, with 20-80 year range and 18.5 years standard deviation. nine subjects were male while 23 were female (m:f ratio = 0.39). of 64 ears, 34 were clinically normal and 30 were abnormal. pearson’s correlation demonstrated significant positive correlation between virtual and pure tone thresholds with 99% confidence at 0.05 level of significance. kappa statistics also showed significant degrees of agreement in who grades by both instruments, meaning va will probably categorize hearing loss in the same manner as pure tone audiometry. conclusion: a strong positive correlation exists between hearing thresholds measured by virtual and pure tone audiometry with a significant degree of agreement in hearing loss classification. this supports the possibility of using the virtual audiometer as a clinic-based, air-conduction audiometer for screening and monitoring. when used in conjunction with other examinations, valuable information on over-all integrity of the audiologic system may be ascertained. key words: audiometer, audiometry, air-conduction, hearing test, hearing screening, hearing monitoring the correlation of results between pure tone audiometry and the virtual audiometer: a simulated air-conduction clinic-based audiometer anne elizabeth m. javellana, md ray u. casile, md department of otolaryngology head and neck surgery st. luke’s medical center correspondence: anne elizabeth m. javellana, md department of otolaryngology head and neck surgery st. luke’s medical center 279 e. rodriguez sr. blvd. quezon city 1102 philippines telefax: (632) 727 5543 email: abjavellana@gmail.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product cited in this report. presented at the analytical research contest (2nd place), philippine society of otolaryngology head and neck surgery 50th annual convention, edsa shangri-la hotel, pasig city, philippines, december 2, 2006. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles 10 philippine journal of otolaryngology-head and neck surgery pure tone audiometry is the current gold standard in evaluating auditory sensitivity. regrettably, in developing countries like the philippines, obtaining a pure tone audiogram may be difficult or problematic. there is want for a low-cost, quantitative, clinic-based tool for hearing screening and monitoring. inexpensive tools, such as tuning forks, ballpen-click tests1 and disability questionnaires2 are available; however, these are either qualitative or subjective. in an attempt to answer these needs, the virtual audiometer (va) was developed by one of the authors, r.u. casile, md. it is a software application that simulates and delivers pure tones at different frequencies and intensities using a personal or laptop computer and ordinary earphones in a relatively quiet examination room. this allows the clinician to take quantitative measurements of auditory sensitivity in a clinic-based set-up. pure tone air-conduction thresholds measure the function of the total hearing system. in typical audiometric testing, pure tones in the octave range of 250-8000 hz are presented to the listener by headphones or insert earphones. the hughsonwestlake “ascending method,”3 is used to determine the hearing threshold – the lowest intensity at which a response is obtained three times. from this, the severity of the hearing loss is graded according to the world health organization (who) grades of hearing impairment4, presented in table 1. table 1. world health organization grades of hearing impairment (geneva, 1991)10 grade of impairment corresponding audiometric iso value (average of 500, 1000 and 2000 hz) no impairment slight impairment moderate impairment severe impairment profound impairment including deafness 25 db or better (better ear) 26 – 40 db (better ear) 41 – 60 db (better ear) 61 – 80 db (better ear) 81 db or greater (better ear) this study sought to determine (1) the correlation between the hearing threshold / hearing level (hl) measurements taken by virtual and pure tone audiometry and (2) the degree of agreement between the who grades of hearing impairment categorization of the average thresholds measured by the two examinations. the null hypotheses were: (1) there is no correlation between hearing thresholds measured by virtual and pure tone audiometry; (2) there is no agreement between the who grades of hearing impairment categorization by the two examinations the one-tailed alternate hypotheses were: (1) there is a positive correlation between hearing thresholds measured by virtual and pure tone audiometry; (2) there is a significant degree of agreement between the who grades of hearing impairment categorization by the two examinations. materials and methods the principle of the virtual audiometer software is analogous to a tape recorder that records and collects the different tones of a real audiometer; that is, all frequencies from 500 hz to 4000 hz and the corresponding intensities of each tone from 0 db to 100 db. the pure tone audiometer from which the tones were recorded was a calibrated beltone™ 10c (beltone™, chicago, il, usa). the tones were captured using the built-in sound recorder in microsoft windows™ (microsoft corp., redmond, wa, usa). a software interface that would make the user/tester sound each tone was made using corel™ click and create (now called multimedia® fusion express, clickteam, paris, france). simply stated, the interface retrieves the tone and intensity selected by the examiner as he or she clicks the frequencies and intensities marked on the screen, taking advantage of the speed of retrieval of the computer to sound off the desired tone. this application claims priority from philippine copyright registration number n 2007-19, registered on march 27, 2007. to correlate results of virtual and pure tone audiometry, an analytic, cross-sectional study was set in a tertiary institution in quezon city, philippines in september 2005. assuming that hearing thresholds measured by virtual and pure tone audiometry have a correlation of at least 0.90, a level of significance (α) of 0.05 (p = 0.05) and a power of 99%, the estimated sample size was 24 subjects. the total number of individuals included was 32, with each ear tested separately, giving a total number of 64 tested ears (n=64). from september 5 to 21, 2005, patients seen at the ent va approximates this determination by similarly presenting pure tones and quantifying threshold in terms of intensity. the difference is that the virtual audiometer is meant for clinic use, thereby, making it more accessible to both patients and physicians. the requirements for va examination are minimal. the examiner only needs a computer that runs on windows™ operating system, intra-aural earphones, a relatively quiet room, and knowledge of his or her hearing threshold. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles philippine journal of otolaryngology-head and neck surgery 11 display sound level meter (model number 33-2055, radioshack corp., tx, usa). a pentium 2,23 3mhz laptop computer running on windows 98™ (microsoft corp., redmond, wa, usa) with the display screen facing the examiner was used. the software was loaded directly into the computer (but may be run from the cd copy). intra-aural earphones, such as those from a portable music player, were connected to the speaker output jack of the computer. the authors used a pair of sony™ intra-aural earphones (model mdr-e806, sony corp., tokyo, japan) with a frequency response of 20 hz to 16 khz and an impedance of 16 ohms. this type of headset comes packaged with most sony walkman™ portable music players (sony corp., tokyo, japan). calibration was performed at the onset of each exam. the examiner must have been previously tested by pure tone audiometry, knowing his or her threshold at 1000 hz as the basis of calibration. with one earpiece on either the left or right ear, the examiner cupped hands over both ears to block out any extraneous noise. the signal intensity was matched to the examiner’s threshold, that is, to a point where it was barely audible. this matched the hearing threshold measured by pure tone audiometry, calibrating the software. the earphones were then transferred to the examinee, one earpiece at a time, testing each ear separately. the examinee also cupped his or her hands over both ears to further isolate the signal (alternatively, ear protectors/muffs may be positioned over the earphones). a test frequency was selected and the examiner determined the threshold using the hughson-westlake method. the signal was presented well above the threshold, decreased to a level of inaudibility in 10to 15-db steps, and then increased in “up 5-db, down 10-db steps” until the single hearing level at which a response was obtained three times was reached. the same was done for the remaining test frequencies. the earpiece was transferred to the other ear and the procedure repeated. at the end of each examination, the thresholds of both ears at all four frequencies were plotted in an audiogram. the average thresholds were calculated and the who grade assigned. the procedure was repeated on each examinee. results were correlated at each test frequency. a single subject’s va and pure tone audiometry results were compared to each other, minimizing inter-individual variation. virtual and pure tone measurements were presented side-by-side and stratified according to (1) frequency and (2) who classification. the degree of correlation between va and pure tone threshold measurements at each frequency was analyzed using the pearson outpatient department of the authors’ institution were enlisted in the study. normal volunteers were also recruited from its staff and student population. history and physical examination ascertained whether subjects were clinically normal or abnormal, depending, respectively, on the absence or presence of otologic signs and symptoms (otorrhea, tympanic membrane perforation, impacted cerumen, subjective hearing loss, middle ear effusion, and so on). inclusion of both clinically normal and abnormal subjects would allow measurement of a broader range of hearing levels and a more representative sample. after obtaining informed consent, all subjects underwent both virtual and pure tone audiometry. study subjects had to be (1) cooperative and (2) at least 7 years of age. although conventional audiometry may be performed on children as early as 42-28 months of age3, the instructional set may need to be altered, and social reinforcement remains important. for this reason, small children may not be able to respond appropriately to the tone stimulus and, as such, were excluded. the following subjects were also excluded from the study: (1) uncooperative; (2) physically debilitated or unable to tolerate the procedure; (3) unable to follow or respond appropriately to instructions. primary data on hearing thresholds was collected directly from the subjects. each underwent pure tone and virtual audiometric evaluation of both ears at the frequencies of 500, 1000, 2000 and 4000 hz. the hughson-westlake method was employed for both examinations. results were recorded in an audiogram, the average thresholds calculated, and the degree of hearing loss categorized according to the who classification. these allowed the collection of outcomes that were continuous (i.e., threshold measurements) and categorical (i.e., who classification). the results were not revealed until both examinations had been completed. pure tone audiometry was performed in a soundproof booth with a calibrated audiometer, while virtual audiometry was performed in a quiet room that was not acoustically dampened. this compared the virtual audiometer’s performance to pure tone audiometry in the setting it was meant to be used. the setup follows: testing was done in a relatively quiet environment. the more quiet the room, the better the set-up. any possible noise source was eliminated (doors and windows closed, no outside conversations, towel placed over the computer housing). the authors tested the software in an air-conditioned room with ambient noise level measuring 60-63 db spl using a digital philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles 12 philippine journal of otolaryngology-head and neck surgery product moment correlation, while the degree of agreement between the who classes were analyzed using the kappa statistic. both tests were conducted at 0.05 level of significance. all data were encoded and analyzed using spss (statistical package for the social sciences) v.14 statistical software (spss, inc., chicago, il, usa). results thirty-two subjects were enrolled in the study, giving a total of 64 tested ears (n=64). the average age was 40.2 years, with a 20-80 year range and a standard deviation of 18.5 years. nine subjects were male and 23 were female (m:f ratio = 0.39). of the 64 ears tested, 34 were clinically normal and 30 were clinically abnormal or presented with ear symptoms. a significant positive correlation was found between virtual and pure tone audiometric thresholds on all tested frequencies and the average threshold (figures 1 to 5). pearson’s correlation factors were greater than zero and approximate one, with p values (sig.) <0.01, indicating a direct relationship between the results with at least 99% confidence. in addition, a significant degree of agreement was found between the who grading arrived at by the two examinations. of the 39 subjects found to have normal hearing by va, 28 (71.8%) also had normal hearing by pure tone audiometry, while 11 (28.2%) had mild hearing loss. of the 7 subjects found to have mild hearing loss by va, pure tone audiometry confirmed 4 (57.1%), while 3 (42.9%) actually had moderate hearing loss. of the 12 subjects determined to have moderate hearing loss by va, 9 (75.0%) also had moderate hearing loss by pure tone audiometry, while 3 (25.0%) had severe hearing loss. of the 5 subjects graded as severe by va, pure tone audiometry confirmed 4 (80.0%) and determined 1 (20.0%) to be profound. the single subject graded as profound by va had severe hearing loss by pure tone audiometry. the p values of the kappa statistics for all five who classifications were less than 0.01, meaning a subject determined to have a particular grade of hearing loss by pure tone audiometry would probably be categorized by va in the same manner. the virtual audiometer’s specificity and positive predictive value were both 100%. sensitivity was 69.44%, while negative predictive value was 71.8%. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles philippine journal of otolaryngology-head and neck surgery 13 audiometric thresholds are displayed on an audiogram. data is presented in hearing levels (hl) which are calibrated to referent sound pressures (ansi s3, 6-1969, 1970) that represent the hearing sensitivity of normal, young adults when tested under reasonably quiet test conditions. the pure tone audiometer requires a soundproof booth, regulation headphones, a bone transducer and regular calibration to ensure accurate measurements. the virtual audiometer has several contrasting features. first, it does not have an oscillator. the different tone frequencies were recorded from a pure tone audiometer and stored into a database, then reproduced at different intensities by an authoring software. it is in this sense that this audiometer is “virtual.” it does not produce the pure tones itself, but simulates them. difficulties in reproducing the pure tones were encountered in sound pressure levels above 80 decibels. at this point, the waveforms were clipped and no longer the sine waves of pure tones, but square waves with distortion. below 80db, the tones were accurately simulated. second, since its aim is screening and monitoring, only air conduction is measured. accordingly, bone transducers are not employed. the goal is to keep its requirements simple: a personal computer equipped with windows™ operating system and a sound card, intra-aural earphones and knowledge of one’s own threshold level. the examiner himself calibrates the virtual audiometer. these also seek to minimize the cost of the examination. third, in order to increase accessibility, va was designed to be used in the clinics, not in a sound-insulated room. in spite of these differences, favorable results were still achieved. pearson’s correlation showed a strong positive correlation at all four test frequencies and for the average hearing thresholds. in addition, the kappa statistics also showed a significant degree of agreement across all who classes, strengthening the inference of pearson’s correlation and, consequently, the results of the study. in conclusion, this study established a strong positive correlation between hearing threshold measured by virtual and pure tone audiometry. furthermore, there was a significant degree of agreement in who grading of hearing loss between the two examinations. the results of this study support the possibility of using the virtual audiometer as a clinic-based, air-conduction audiometer for screening and monitoring patients. when used in conjunction with other clinic examinations, valuable information on the discussion pure-tone audiometry is currently the gold standard in evaluating auditory sensitivity.3 pure-tone signals are produced by an oscillator and delivered through air and bone conduction. the american national standards institute (ansi) s3, 20-1973 defines the threshold of audibility as “the minimum effective sound pressure level of an acoustic signal producing an auditory sensation ‘in a specified fraction of the trials.’” often, threshold is defined as the lowest signal intensity at which multiple presentations are detected 50% of the time.3 clinically, philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles 14 philippine journal of otolaryngology-head and neck surgery overall integrity of the subject’s audiologic system may be ascertained. in order to decrease instrumentation errors, the software itself should be fine-tuned to ensure accurate reproduction of pure tones and its calibration may be extended to all test frequencies. in addition, different types of earphones can be tested with the software. an mp3 format of the program is being developed by the authors, making the software more portable by using handy mp3 players. future studies with increased sample size may attain a more representative cross-sectional population, stratifying sampling into all five who classes. statistical analysis may be further stratified according to who classification, thereby allowing more subtle relationships to manifest. acknowledgements we gratefully acknowledge isaac david e. ampil, ii, md, msc, co-director for clinical research, research and biotechnology division, st. luke’s medical center for statistical analysis and content organization. references 1. martinez nv. prevention of deafness program in the philippines. ifhoh [internet]. available from: http://www.ifhoh.org/papers/filipino-2.htm 2. ventry im, weinstein be. the hearing handicap inventory for the elderly: a new tool. ear hear. 1982 3(3):128–134.may–jun. 3. cummings cw, flint pw, harker la, haughey bh, richardson ma, robbins kt, schuller de, thomas jr, editors. cummings otolaryngology-head and neck surgery. 4th ed. vol. 4. philadelphia (pa): mosby, c2005. 3374 p. 4. informal working group on prevention of deafness and hearing impairment. report of the informal working group on prevention of deafness and hearing impairment programme planning. geneva (switzerland): world health organization; 1991 jun. 5. newman cw, sandrigde sa. hearing loss is often undiscovered, but screening is easy. cleve clin j med [internet]. 2004 mar; 71(3): 225-232. available from: www.ccjm.org/pdffiles/ newman304.pdf. 6. yueh b, shapiro n, maclean ch, shekelle pg. screening and management of adult hearing loss in primary care. jama. 2003; 289:1976-1985. 7. cienkowski km. an evaluation of the comparative hearing test. internet j geriatr gerontol [internet]. 2003; 1(1):[about 9 screens]. available from: http://www.ispub.com/ostia/index. php?xmlfilepath=journals/ijgg/vol1n1/hearing.xml 8. stuart a, stenstrom r, tompkins c, vandenhoff s. test-retest variability in audiometric threshold with supraaural and insert earphones among children and adults. audiology. 1991;30(2):82-90. 9. landry ja, green wb. pure-tone audiometric threshold test-retest variability in young and elderly adults. j speech lang pathol audiol [internet]. 1999 jun; 23(2):74-80. available from: http://www.caslpa.ca/pdf/seniors%20articles/puretone_audiometric_thresholdtest_elderly. pdf abstract objectives: to report a case of hemangioma arising from the mandible and its clinical presentation; describe the similarities with which mandibular hemangioma may mimic odontogenic and non-odontogenic lesions; and identify diagnostic and treatment modalities employed in these patients. methods: design: case report setting: tertiary public hospital patient: one results: a 12-year-old male with intractable gum bleeding exacerbated by intraoperative manipulation of a loose first premolar and uncontrolled by left external carotid ligation, underwent segmental mandibulectomy. the resected segment revealed multiple porosities and a hollow blood-filled cavity. histopathology confirmed the diagnosis of cavernous hemangioma. conclusion: though rare, mandibular hemangiomas should be considered in lesions involving the mandible. diagnosis is difficult with an array of lesions that may appear clinically and radiographically similar. the non-specific signs and symptoms of mandibular hemangioma could lead to exsanguinating hemorrhage if not attended to promptly. keywords: cavernous hemangioma, mandible, hemorrhage, external carotid ligation, mandibulectomy cavernous hemangioma of the mandible enrique c. papa ii, md emmanuel s. samson, md francisco a. victoria, md department of otorhinolaryngology head and neck surgery ospital ng maynila medical center correspondence: enrique c. papa ii, md department of otorhinolaryngology-head and neck surgery ospital ng maynila medical center quirino ave. cor. harrison blvd., malate, manila 1004 philippines phone: (632) 524 6061 local 220 email: enriq9tales@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed disclosures that they have no proprietary or financial interest with an organization that may have a direct interest in the subject matter of this manuscript or in any product used or cited in this study. presented at clinical case report contest (2nd place), philippine society of otolaryngologyhead and neck surgery mid-year convention, bohol tropics hotel, bohol, philippines april 24, 2009. philipp j otolaryngol head neck surg 2009; 24 (2): 32-35 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 32 philippine journal of otolaryngology-head and neck surgery case reports while simple gum bleeding is seldom taken seriously, massive, pulsating gingival hemorrhage is often dramatic and may be fatal. precipitated by a simple dental extraction or more violent forms of trauma, control of massive hemorrhage may be troublesome for the clinician, particularly when the underlying cause is unknown or involves multiple unlikely differential diagnoses. we report the case of a benign mandibular lesion that warranted an aggressive approach due to potentially fatal exsanguination. case report a 12-year-old male was referred for intractable left lower gingival bleeding which began over a period of two months. the boy was received biting into an oral pack secured with barton’s bandage and was slightly jaundiced with pale nail beds and hemoglobin of 8mg/dl. he weighed 14 kilograms and had 4 units of packed red blood cells transfused prior to transfer. there was no gross deformity in the area of the left mandible which was not manipulated following the advice of the referring physician not to remove the oral pack as profuse bleeding could ensue from what was likely a hemangioma of the mandible. a similar bleeding episode six years before had been managed with a right mandibulectomy in another hospital. radiographs showed surgical discontinuity of the right mandible and a radiolucency in the left mandible (figure 1). intraoperatively, profuse bleeding squirted from the lingual surface of the mandible adjacent to the first molar following oral pack removal. the first and second premolars were loose. extraction of the first molar caused massive bleeding from the socket, uncontrolled by external carotid artery ligation, necessitating tamponade with antibiotic-impregnated gauze sutured into place and tracheostomy. another 4 units of packed red blood cells plus two units of fresh whole blood had to be transfused. a post-operative panoramic radiograph clearly revealed a 5x3 cm radiolucent area in the body of the left mandible (figure 2) and a segmental mandibulectomy was performed with profuse bleeding that only stopped after final release of the proximal periosteum. the 3 cm. resected segment was hollow with multiple porosities extending to the symphyseal area (figure 3). histopathologic microsections revealed viable bone spicules interspersed with fibrous areas and vessels with wide lumina filled with red blood cells confirming the diagnosis of cavernous hemangioma (figure 4). s s discussion hemangiomas occurring in soft tissues are common and easily diagnosed through clinical data alone. hemangiomas occurring in bones are rare, accounting for only 0.7% of all osseous neoplasms and 10 % of primary benign neoplasms occurring in the skull.1 in the mandible, the tumor has a female: male predominance of 3:1 and occurs most frequently in the portion of the body although condylar tumors have also been cited.2 differential diagnoses included hemangiopericytomas, arterio-venous (av) malformations and aneurysmal bone cysts. hemangiopericytomas usually present with rapid growth and non-painful gingival swelling.3 av malformations have a predilection for age groups in the mixed dentition period and are associated with spontaneous bleeding but typically present with a bruit or evident pulsation.4 aneurysmal bone cysts (abc) also have rapid growth and gingival swelling but involve pain from expansion of the bony cortex. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 case reports philippine journal of otolaryngology-head and neck surgery 33 figure 2. panoramic radiograph showing radiolucency in the body of the mandible (arrow). figure 1. skull ap/l showing discontinuity of the right mandibular body (arrow) and suspicious radiolucency in the left (circle). the non-painful intractable bleeding being the sole symptom presented in the case made its initial diagnosis complicated since it resembles many odontogenic and non-odontogenic tumors. other symptoms that are non-specific but may otherwise narrow the diagnosis include mobility of the adjacent teeth, derangement of occlusion, non-painful bony swelling and pain, when present maybe the only reason for patients to consult. 4 khanna et al reported cases of a clinically-diagnosed ameloblastoma in a 14-year-old male with painless swelling of the right jaw and a 46-year-old male with bleeding gums and a loose lower premolar tooth where resections both revealed cavernous hemangioma.5 mardwah et al. reported an 8-year-old male who underwent dental extraction which progressively led to swelling also due to hemangioma.6 although angiography is the cornerstone for diagnosis of vascular lesions,4 this option was pre-empted by the additional blood loss the added time delay would entail as well as the financial constraints of our indigent patient. this eliminated the option for preoperative embolization as well. other options including radiation and intralesional sclerosing agents have only limited applications in cases of soft tissue involvement since their intraosseous effects remain doubtful.6 radiography, being easily accessible, is an important ancillary tool for evaluation of mandibular lesions. however, radiolucencies seen on plain film and panoramic radiographs suggest a variety of mandibular lesions that may need further ct and mri workups but these were beyond the resources of our patient. the greatest hazard in this case is exsanguinating hemorrhage which may be fatal as reported by lamberg7 or near-fatal as in the case of sadain-urao.8 control of hemorrhage is crucial and restoring hemodynamic stability vital. the cessation of bleeding upon periosteal release and multiple porosities of the mandibular body suggest a peripheral hemangioma which originates in the periosteic vessels that grow into the medullar bone (unlike central hemangiomas that originate in the medullar bone and grow towards the cortical bone).5 as in our case, the most frequent location of hemangioma of the mandible is the molar-premolar region.5 histopathologic study is helpful in confirming the diagnosis. the microscopic picture is that of a proliferating mass of endothelial cells forming a plexiform arrangement of vascular spaces which can either be capillary, cavernous or mixed.6 though rare, mandibular hemangiomas should be considered in lesions involving the mandible. diagnosis is difficult with an philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 34 philippine journal of otolaryngology-head and neck surgery case reports array of lesions that may appear clinically and radiographically similar. the non-specific signs and symptoms of mandibular hemangioma could lead to exsanguinating hemorrhage if no appropriate intervention is performed. figure 3. (top photo) 3 cm resected mandibular segment from parasymphysis to the symphysis, showing a hollow cavity filled with blood and multiple porosities references 1. batsakis jg. tumors of the head and neck. 2nd ed, baltimore: williams and wilkins; 1979. 2. neyaz z, gagodia a, gamanagatti s, mukhopadhyay s. radiographical approach to jaw lesions. singapore med j. 2008 feb; 49(2):165-76. 3. bhutia o, roychudry a. hemangiopericytoma of the mandible. j oral maxillofac pathol 2008;12:26-8 4. menon l; chowhudry r, mohan c. arteriovenous malformation in mandible. mjafi. 2005; 61(3). 5. khanna, p.r. , khanna a.k. , kumarl mohan. hemangioma of the mandible: clinical report. indian j.orl-hns. 2004 apr-jun; 56 (2). 6. mardwah n, agnihotri a, dutta s. central hemangioma: a overview and case report; pediaty. dent. 2006 sep-oct; 28(5): 460-6. 7. lamberg ma, tasanen a, jääskeläinen j. fatality from central hemangioma of the mandible. j oral surg 1979; 37(8):578-84 1979 aug; 37(8):578-84. 8. sadain-urao zk, pontejos aqy. hemangioma of the mandible: an exsanguinating lesion. philipp j otolaryngol head neck surg. 1998. 21-26 9. cummings cw, flint pw, haughey bh, robbins kt, thomas jr, harker la, otorhinolaryngology head and neck surgery 5th ed. elsevier: mosby; 2005. a figure 4. pictomicrograph showing large blood vessels filled with red blood cells interspersed within viable bone spicules. a, low power (hematoxylin-eosin, lpo,100x) b, high power (hematoxylin-eosin, hpo, 400x) b philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 case reports philippine journal of otolaryngology-head and neck surgery 35 philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles philippine journal of otolaryngology-head and neck surgery 5 abstract background: this systematic review aims to strengthen evidence of beneficial effects of intranasal corticosteroids on the medical treatment of adults diagnosed with nasal polyps. objective: (1) to determine efficacy of short-term (2-4 weeks) and long-term (4-12 weeks and > 12 weeks) use of intranasal corticosteroids for reduction of polyp size and rhinitis symptoms. (2) to determine difference in efficacy of a 400 and 800 μg dose. (3) to determine adverse effects of intranasal steroids. study design and selection criteria: meta-analysis of randomized controlled trials on intranasal steroids for nasal polyps. patient-oriented outcomes were reduction of polyp size and overall reduction of rhinitis symptoms. search strategy: comprehensive search of cochrane’s controlled trials registry (cctr) issue 2, 2003, medline 1966 2002, embase 1974 2002, bibliographic review, requests for information from authors and pharmaceutical companies. data collection and analysis: sixteen studies were evaluated for inclusion, and trial quality, validity assessment, and completion of data extraction were done. ordinal data on rhinitis and polyp scores for each study were pooled to generate relative risks. homogeneity was assessed using approximate chi-square tests. preset p value of < 0.10 was deemed significant for heterogeneity. data was analyzed using revman 4.1 (update software, oxford). sensitivity analysis was done for outcomes with significant heterogeneity. results and conclusion: fourteen studies found significant benefit for the use of intranasal steroids in reduction of polyp size with 2 -4 weeks treatment (rr=3.00; 95% ci: 2.39, 3.77). overall rhinitis symptoms decreased significantly (rr=1.64; 95% ci: 1.25, 2.14) with 4-12 weeks treatment, with a tendency for reduction of rhinitis symptoms (rr=1.41; 95% ci:1.05, 1.91) with more than 12 weeks treatment. throat irritation was significantly increased (rr=2.06; 95% ci 1.31, 3.25). there was no difference in overall rhinitis symptoms (rr=0.91; 95% ci: 0.77, 1.07) with 400 μg and 800 μg doses. keywords: polyp, nose, steroids, intranasal steroids, glucocorticosteroid the foremost objective in the treatment of nasal polyps is their disappearance, if not reduction of polyp size1. although surgical therapy continues to play an important role in the intranasal corticosteroids for the medical management of nasal polyps in adults: a meta-analysis natividad a. almazan aguilar, md, m.sc.1,2 1department of otolaryngology head and neck surgery manila central university 2department of otolaryngology head and neck surgery st. luke’s medical center correspondence: natividad a. almazan – aguilar, md, msc department of otolaryngology head and neck surgery st. luke’s medical center 279 e. rodríguez ave., quezon city 1102 philippines telefax (632) 723-1016 reprints will not be available from the author. funding for this study was supported by a grant from the philippine council for health research development (pchrd). the author signed a disclosure that while she had no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript during the course of research, she has performed unrelated research funded by, and is currently a speaker for glaxo smith-kline (consumer division). she is also a speaker for ucb pharma and united american pharmaceuticals at present. this manuscript was adapted from the original thesis submitted to the university of the philippines manila in partial fulfillment of the requirements for the degree master of science in clinical epidemiology, 2004. philipp j otolaryngol head neck surg 2007; 22 (1,2): 5-11 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles 6 philippine journal of otolaryngology-head and neck surgery management of nasal polyps2, there is always the risk of complications and the recurrence rate is about 40 percent 3. in clinical practice, the main concern of patients with nasal polyps is reduction of overall rhinitis symptoms that include nasal obstruction, nasal discharge, sneezing, itchiness and anosmia. the goal of treatment of nasal polyps focuses on control of these symptoms and removal of the polyps without causing complications that will be detrimental to health. over the past decade, there have been improvements in the medical treatment of nasal polyps. a search made by the cochrane ent registry group revealed that 24 of the 45 randomized controlled trials (rcts) showed beneficial results in favor of intranasal corticosteroids. topical nasal steroids such as budesonide, betamethasone and fluticasone have been known since the 1960’s to cause some polyp shrinkage4. glucocorticoids display a favorable therapeutic profile directly preventing polyp formation and growth and reducing local pathology and inflammatory exudates together with bacterial colonization. randomized controlled trials (rcts) on intranasal steroids for nasal polyps looked at a variety of clinical outcomes. studies looking at the same outcome often used different measurement scales. it would be helpful to the clinician if results could be compared across studies. because of the growing demand for medical treatment of nasal polyps, intranasal steroids will continue to be a cornerstone of polyp management. it is the aim of this review to quantify the effect of intranasal corticosteroids in terms of improvement of nasal symptoms and reduction in polyp size. a systematic review on rcts was conducted to determine the favorable dose and duration as well as the occurrence of adverse effects. objectives: this study aimed to determine the efficacy and safety of intranasal corticosteroid therapy and sought to achieve the following specific objectives: 1. to compare short-term (2-4 weeks) intranasal corticosteroid therapy with placebo in the improvement of clinical outcomes, as measured by a. reduction of polyp size; b. reduction of overall rhinitis symptoms (a combination of nasal obstruction, nasal discharge, itchiness and sneezing); and c. peak nasal inspiratory flow (pnif) 2. to compare long-term (4-12 and >12 weeks) intranasal corticosteroid therapy with placebo in the improvement of the clinical outcomes stated above. 3. to compare the frequency of adverse effects between intranasal steroids and placebo. 4. to compare 400 μg versus 800 μg intranasal corticosteroids in the improvement of clinical outcomes stated above. methods identification of trials: the electronic bibliographic database medline/pubmed was searched for all articles in english using the standardized subject terms “nasal polyps,” “intranasal steroids” or “steroids, fluorinated” and “randomized controlled trial” (publication type) from years 1970 to 2002. communication with the uk cochrane center ent research group was done for further comprehensive search of articles especially for non-english titles. the ent specialist registry group searched the following: (1) cochrane central register of controlled trials (central), (2) medline, (3) embase (the reed-elsevier excerpta medica database) (4) cumulative index to nursing and allied health professionals (cinahl), (5) allied and complementary medicine (amed), (6) meta register of clinical trials (mrct), and (7) latin american caribbean health sciences literature (lilacs). the abstracts retrieved by the cochrane group were not limited to rcts. the bibliographies of candidate rcts were further reviewed to identify more studies. full text articles were requested from drug companies and friends from the united states. study selection: three reviewers independently read the methods section of the candidate articles for meta-analysis and applied the stated criteria for inclusion in this review. disagreements were resolved by discussion until a consensus was reached. the following criteria were used to select the studies for meta-analysis: study design: restricted to randomized, parallel, double blind, placebo-controlled trials on intranasal glucocorticosteroids for nasal polyps. study population: rcts on adults clinically diagnosed to have nasal polyps objectively on anterior rhinoscopy and nasal endoscopy in hospital outpatient clinics or specialty private clinics. individual rcts were excluded if any of the following patient characteristics were present: previous use of steroids, sinusitis, upper respiratory tract infection, presence of structural abnormality of the nose and significant co-morbidities. types of intervention: all types of intranasal corticosteroids (e.g. beclomethasone dipropionate, budesonide, and fluticasone propionate) compared to placebo were included. these variables were included; (1) solvent delivery (aqueous or powder); (2) manner of administration (spray, turbohaler); (3) duration of use -short-term (2-4 weeks) and long-term (4-12 weeks and > 12 weeks); and (4) dosage (400 μg, and 800 μg). the placebo made use of the same method of delivery (isotonic aqueous solution or non-medicated powder), manner of administration, and kind of container. outcome measures: (1) reduction in size of polyp reported as polyp size score; (2) reduction in rhinitis symptoms; and (3) adverse effects such as epistaxis, nasal itchiness and throat irritation. the effects of duration (2 to 4 weeks, 4 to 12 weeks, and > 12 weeks) and dose (400 μg, 800 μg) of treatment on these outcomes were also studied. pnif, an objective measure of nasal obstruction, was also included. quality assessment: three reviewers independently assessed the methodological quality of each candidate rct using the quality assessment tool developed by the philippine cardiovascular research group (appendix a).5 this assessment instrument classified study quality according to selection, performance, detection, and exclusion biases, using a, b, or c ratings where a represents the highest score, b the middle score and c the poorest quality score. factors checked to determine which bias was present included: allocation concealment for selection bias, blinding of patients for performance bias, dropouts for philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles philippine journal of otolaryngology-head and neck surgery 7 exclusion bias, and blinding of examiners for detection bias. the lowest score in any of the four bias groups corresponded to the total score of the assessment. discrepancies in the ratings of the three reviewers were resolved by the rule of majority. data extraction: data for the specified outcomes were extracted independently by three reviewers based on reported summary statistics (means, sd, proportions). data measured at several points were grouped into 2-4 weeks, 4-12 weeks and >12 weeks. all data were entered into revman 4.1 (update software, oxford). all studies reported polyp size using johansen’s6 4-scale classification: 0, no polyps; 1, mild; 2, moderate; and 3, severe. for several rhinitis symptoms, the rcts utilized 3 different classification schemes, as follows: (1) scale of 0 – 3: 0 – none; 1 – mild; 2 – moderate; 3 – severe (2) scale of 0 – 5: 0 – symptoms aggravated; 1–no control of symptoms; 2–minor control of symptoms; 3 – substantial control of symptoms; 4 – total control of symptoms (3) johansen scale of 1-4: 1–absent; 2–a few episodes; 3–many episodes; 4–continuous these ordinal scores were dichotomized into positive or negative reduction. positive reduction was defined as any one scale reduction towards benefit or difference before and after treatment. negative reduction was defined as no reduction or any change in scale towards harm before and after treatment. disagreements in data extraction were resolved by consensus. data analysis study selection: kappa statistic 7 was used to assess the interobserver agreement for study selection. a value of κ ≤ 1.0 was considered agreement beyond chance. meta –analysis proper: where dichotomous outcome measures could be assessed, the treatment effect was calculated as the difference in relative risk before and after treatment. all analyses were performed according to the intention-to-treat method, i.e. including all randomized patients. patients with results of no reduction in polyp size or overall rhinitis symptoms were considered as failures. the software package bdp – beclomethasone dipropionate y= yes, n= no,; a, b, c = classification of study quality no. of age duration of outcome study patients range (yrs) treatment drug/ dose (μg) polyp size rhinitis symptoms adverse effects quality assessment score holmberg,12 1997 55 21-71 2 to 4 weeks fluticasone p aqueous 400 y y y b bdp aqueous 400 lund,13 1998 29 22-72 2 to 4 weeks fluticasone d aqueous 400 y y y b 4 to 12 weeks bdp aqueous 400 tos,14 1998 138 20-82 2 to 4 weeks budesonide aqueous 256 y y y b 4 to 12 weeks budesonide powder 240 lildholdt,15 1997 124 20-81 2 to 4 weeks budesonide powder 400 y y y b budesonide powder 800 karlsson,16 1982 40 23-79 2 to 4 weeks bdp aqueous 400 y n n b mygind,17 1975 35 19-78 2 to 4 weeks bdp aqueous 400 y y n b dingsor,11 1985 41 18-73 2 to 4 weeks flunisolide aqueous 200 y n n b 4 to 12 weeks virolainen,18 1980 40 28-72 2 to 4 weeks bdp aqueous 400 y y y b ≥ 12 weeks chalton,19 1985 30 14-66 2 to 4 weeks betamethasone aqueous 200 y n n b holopainen,20 1982 19 18-62 2 to 4 weeks bdp aqueous 400 y y n c toft,21 1982 42 23-78 2 to 4 weeks bdp powder 400 n n y b bdp aqueous 400 lildholdt,1 1995 120 2 to 4 weeks budesonide aqueous 400 y y n c budesonide aqueous 800 ruhno,22 1990 36 20-68 2 to 4 weeks budesonide aqueous 800 n y y b jankowski,23 2001 161 18-76 2 to 4 weeks budesonide 128 bid y y y b budesonide 256 od budesonide 128 od (all aqueous) pentilla,10 2000 142 22-83 2 to 4 weeks fluticasone p aqueous 400 y y y c 4 to 12 weeks fluticasone p aqueous 800 ≥ 12 weeks johansen,6 1993 91 18-78 2 to 4 weeks budesonide aqueous 400 y y n b philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles 8 philippine journal of otolaryngology-head and neck surgery (revman 4.1) provided by the cochrane collaboration 8 was used. the pooled effect sizes and their corresponding 95% confidence intervals (ci) were reported for each outcome, using the fixed effects model. the studies were grouped according to the size of the polyp using the classification of mackay.9 small polyps were defined as those with a polyp scale score of one and big polyps as those with a polyp scale score of two and three. duration and dose of intranasal steroid use were based on previous studies. 10,5,11 differentiation between the usual dose of 400 μg and a high dose of 800 μg was done because one of the outcome measures was reduction in polyp size. studies utilizing subjects with smaller polyps may show better results with intranasal steroids. test of heterogeneity among studies: homogeneity among studies was tested by the chi-square test, where a p < 0.10 was considered statistically significant. statistical heterogeneity 7 (differences in the reported effects), methodological heterogeneity (differences in study design) and clinical heterogeneity (differences between studies in characteristics of the participants, interventions or outcome measures) 8 were also explored. results description of the studies: the 27 studies were further reviewed by three otolaryngologists/clinical epidemiologists for inclusion or exclusion. only 16 articles were finally included (table 1). the kappa coefficient7 between the two raters was 0.85 (standard error = 0.19), indicating substantial agreement. the studies totalled 1,170 patients (mean age 49 years, range 14 to 83 years) with bilateral nasal polyps, who had one or more previous polypectomies that complied with the inclusion criteria, and from which we were able to obtain sufficient data either directly or after transforming continuous data to dichotomous data based on our preset definition of outcome measures or after corresponding with the first author or the sponsoring drug companies. all 16 studies (table 1) included were done in a multi-center outpatient clinic or specialty private practice (in europe and canada where all the studies occurred, these two settings are fairly equivalent and the seven countries included denmark, sweden, canada, united kingdom, finland, norway, france). the patients in the studies reported a history of nasal obstruction, sneezing, nasal discharge and occasionally anosmia. diagnosis of nasal polyps was made by nasal examination with anterior rhinoscopy and nasal endoscopy, which showed polyps in the nasal cavity. the polyps were then measured using a defined scoring system. 6 all 16 studies compared intranasal steroids with placebo. two studies 14, 21 showed the effect of different formulations (aqueous versus nonaqueous), three studies, 1,10,22 the effect of different doses (400 μg versus 800 μg), and two studies, 12,13the effect of different types of steroids. effect of short-term intranasal corticosteroids reduction in polyp size fourteen1,6,10-20,23 out of 16 included studies compared intranasal steroids to placebo for 2 to 4 weeks duration. intranasal steroids showed a clear effect over placebo on polyp size reduction (rr= 3.00, 95% ci: 2.39, 3.77). there was no significant heterogeneity among the trials (x2 = 19.72, p = 0.10, figure 1). reduction in rhinitis symptoms score of the 16 rcts, 12 reported the effect of steroids administered from 2 to 4 weeks on the overall rhinitis symptoms score. there was significant heterogeneity in the risk of reduction of symptoms (x2=44.08, p <0.01). the pooled risk of rhinitis symptom reduction was rr = 2.56 (95% ci: 2.13, 3.08). pnif pnif, a continuous variable, was measured in 3 trials13,10,20. however, the trials did not report standard deviations or absolute values of test–statistics and p-values, which are required for pooling studies. the mean difference of pnif between the steroid and placebo groups could not be calculated without this information. effect of long-term use (4-12 weeks and >12 weeks) of intranasal corticosteroids reduction of polyp size, 4 to 12 weeks four 10,11,13,14, out of 16 studies showed the effect of intranasal steroids given for 4 to 12 weeks on the reduction of polyp size when combined. there was significant reduction in polyp size that favored steroids over placebo (rr=2.89; 95% ci: 1.99, 4.18). however, a significant heterogeneity across studies was noted (x2 = 11.14, p = 0.01). reduction of overall rhinitis symptoms, 4 -12 weeks the same four studies 10,11,13,14 reported the comparison of intranasal steroids and placebo in terms of the effect on rhinitis symptoms after 4-12 weeks. fixed effect analysis demonstrated that intranasal corticosteroids have a beneficial effect over placebo on reduction in rhinitis symptoms (rr=1.64; 95% ci: 1.25, 2.14). there was no significant heterogeneity (x2= 0.73, p = 0.87, figure 2). reduction of polyp size, >12 weeks no study reported effects of treatment of >12 weeks on polyp size. reduction of overall rhinitis symptoms, >12 weeks two studies10,18,(total n=182) were pooled and showed significant benefit with intranasal steroids versus placebo in reducing rhinitis symptoms when given >12 weeks (rr = 1.41; 95% ci: 1.05, 1.91). tests for heterogeneity showed the studies were homogeneous and comparable (x2 = 0.81, p = 0.44). however, one study 19 had a lower ci value of < 1 showing no statistically significant effect when analyzed singly (fig 3). in summary, the use of intranasal steroids for a longer period of 4-12 weeks and >12 weeks significantly reduced the overall rhinitis symptoms. studies on polyp size reduction for 4-12 weeks were heterogeneous. medication side effects of intranasal steroids the three most common side effects reported in the 16 randomized controlled trials included were found to be epistaxis or bloody discharge, nasal itchiness and throat irritation. epistaxis: seven studies reported epistaxis as an adverse effect of intranasal steroids. the risk of epistaxis with the use of intranasal philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles philippine journal of otolaryngology-head and neck surgery 9 steroids compared to placebo was statistically significant (rr=1.95; 95% ci: 1.37, 2.77). however, this finding is inconclusive because it was noted when pooling the studies heterogeneity (x2 = 18.57, p <0.006). nasal itchiness: when the two studies 18,21 that reported nasal itchiness as an adverse effect were combined (x2 = 0.08, p = 0.77), the results showed that the risk of nasal itchiness did not significantly differ between intranasal steroids and placebo (rr= 1.33; 95% ci: 0.72, 2.45, fig 4). throat irritation: on the other hand, the risk of throat irritation was greater in patients treated with intranasal corticosteroids than those in placebo (rr = 2.06; 95% ci: 1.31, 3.25). the effect size of the two studies13,21 were noted to be homogeneous (x2= 0.05, p= 0.83, fig 5). in summary, the side effect which was significantly greater with the use of intranasal steroids was throat irritation. nasal itchiness was not significantly different from intranasal steroids as compared to placebo. comparison of 400 μg vs. 800 μg dose of intranasal steroids: the two different types of intranasal steroids, budesonide and fluticasone were found to have no difference in drug bioavailability, with terminal plasma half life of three hours. the dose delivered per nasal spray actuation was 64 μg/actuation for budesonide and 50 μg/actuation for fluticasone. the dose of intranasal steroids given is determined by the number of sprays delivered into the nasal cavity and the average dose given at 200 to 400 μg, with a maximum high dose of 800 μg per day. two rcts 12,13 compared budesonide 400 μg and fluticasone 400 μg on its effect in reduction of polyp size and rhinitis symptoms and showed no significant difference. comparison of three studies 1,10,15 showed the following results after fixed effect analysis. reduction of polyp size, dose effect: three studies1,10,15 were pooled comparing the 800 μg and 400 μg dose of intranasal steroids on reduction of polyp size which showed rr=1.14 (95% ci: 0.78, 1.66). a test of heterogeneity showed the studies were not comparable (x2=6.12, p = 0.01) and therefore no conclusions could be made. reduction of rhinitis symptoms, dose effect: three studies11,10,15 were combined to show the effect of dose on rhinitis symptoms with use of intranasal steroids for 2 to 4 weeks duration. two different fig 1. reduction of polyp size score, 2 to 4 weeks fig 2. reduction of rhinitis symptoms, 4 to 12 weeks fig 3. reduction of rhinitis symptoms, morethan 12 weeks fig 4. nasal itchiness fig 5. throat irritation fig 6. reduction of rhinitis symptoms, 400 µg vs. 800µg philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles 10 philippine journal of otolaryngology-head and neck surgery intranasal steroids were represented in the trials, namely budesonide and fluticasone. there was no significant difference between the 400 μg and 800 μg dose of intranasal steroids on reduction of rhinitis symptoms (rr=0.91; 95% ci: 0.77, 1.09). a test of heterogeneity showed the studies were homogeneous and comparable (x2 =1.47, p = 0.48, figure 6). discussion the medical treatment of nasal polyps with intranasal corticosteroids has been studied extensively showing good clinical outcomes. given the large quantity of information on intranasal steroids for nasal polyps, this systematic review sought to quantitatively analyze the effect of intranasal corticosteroids on polyp size and rhinitis symptoms. the review focused on the short-term (2 to 4 weeks) and long-term (4-12 weeks and >12 weeks) use of intranasal steroids to address clinician’s queries on duration of therapy for optimal results. since the use of intranasal steroids for nasal polyps in clinical practice has become common, the adverse effects of epistaxis, nasal itchiness and throat irritation were included in this review. the 400 μg and 800 μg (low versus high) dose of intranasal steroids was also compared to determine if greater benefits obtained with increased dose. a total of 16 rcts were included in this meta-analysis. interpretation of the benefit of treatment: the short-term use of intranasal steroids for 2-4 weeks was significant in the reduction of polyp size, with three times the relative benefit compared to placebo. the anti-inflammatory effect of intranasal steroids immediately showed a response within the first four weeks of treatment for nasal polyps of all sizes. the studies on long-term use of 4-12 weeks were not conclusive with regards effect on polyp size when analyzed together because they were not comparable following a test of heterogeneity. when sensitivity analysis was done, reduction of polyp size was more visible after four weeks of treatment in big compared to small polyps. therefore, reduction of nasal polyp size may be achieved with short-term intranasal steroids in small polyps and long-term use for big polyps. overall rhinitis symptomatology is a summary of the different symptoms of nasal obstruction, rhinorrhea and sneezing. overall rhinitis symptoms were significantly reduced by one and half times compared to placebo in all sizes of polyps only with intranasal steroids given over a long-term duration of 4-12 weeks and >12 weeks. the summary effect on overall rhinitis symptoms for short-term use of 2-4 weeks was not conclusive because of heterogeneity. with sensitivity analysis, the studies with the following characteristics were comparable: small polyp size, date of publication after 1990, non-drug sponsored studies, and sample size < 50. with small polyps, summary effect drastically changed from 2.5 4 times benefit. however, for the rest of the factors, summary effect changed from 2.5 -1.5 times. the reduction in overall rhinitis symptoms was more apparent for small polyps compared to big polyps with 2-4 weeks use of intranasal steroids. positive results for articles published after 1990 may be related to increased awareness of the advantages of intranasal steroids by researchers and clinicians. with these premises, the sensitivity analysis done was just a theoretical exercise to find out with which factors the studies would be comparable. still the final summary effect was that the reduction of overall rhinitis symptomatology was seen only for long-term intranasal steroid use over 4-12 weeks and >12 weeks, and not for short-term use of 2 -4 weeks. the pnif would have been a good objective measure of nasal obstruction. however, the studies could not be pooled for analysis because the standard deviations or variances were not available, leading to the decision to exclude this measure. the summary effect showed that there was no significant difference in the reduction of rhinitis symptoms between 400 μg and 800 μg of intranasal steroids with results showing that effects were not doserelated. reductions in rhinitis symptoms in many patients who use < 400 μg intranasal steroids suggest that dose may not really matter. because of heterogeneity, the comparative effects of 400 and 800 μg doses on polyp size was also not conclusive. adverse effects of treatment: significantly, of the three adverse effects included in this review, only throat irritation was most frequently seen with the use of intranasal steroids as compared to use of placebo. compared to placebo, patients have twice the chance of more symptoms of throat irritation, which may mimic the postnasal drip experienced by patients with rhinitis. in clinical practice, this may be interpreted as postnasal drip or any after-taste from application of the intranasal steroids. two studies that reported nasal itchiness showed that there was no difference between the treatment and the placebo groups. seven studies reported epistaxis but could not be pooled or analyzed because they were positive for heterogeneity. with sensitivity analysis for epistaxis, the studies with the following characteristics were comparable: 1) publications on or earlier than 1990, non-drug company-sponsored studies, small sample size (< 50) and the presence of small polyps. when all of these factors were considered, the studies became homogeneous but there was no significant difference in the frequency of epistaxis between the intranasal steroid and the placebo group. this meta-analysis showed that epistaxis may occur with the use of intranasal steroids or any non-medicated application to the nasal mucosa. in conclusion, this meta-analysis of 16 randomized clinical trials on intranasal steroids for nasal polyps in adults showed that: • there is a significant reduction of polyp size with short-term treatment of intranasal steroids at 2 to 4 weeks (rr = 3.0, 95% ci: 2.39, 3.77). • there is a significant reduction of overall rhinitis symptoms with long-term treatment of intranasal steroids at 4 to 12 weeks (rr =1.64, 95% ci: 1.25, 2.14) and at more than 12 weeks (rr=1.41, 95% ci: 1.05, 1.91). • in two studies, throat irritation was reported more frequently with intranasal steroid use than with placebo (rr=2.06, 95% ci: 1.31, 3.25) • there was no significant difference in nasal itchiness between both the intranasal steroid and placebo groups (rr=1.33, 95% ci: 0.72, 2.45). • there was no significant difference in the use of 400 μg and 800 μg intranasal steroids in the reduction of overall rhinitis symptoms (rr = 0.91, 95% ci: 0.77, 1.09). • the pnif would have been a good objective way to measure nasal obstruction. however, the studies could not be pooled for analysis because of missing information either on the variance, the test-statistic or the p-value. recommendations implications for practice: this meta-analysis documented quantitative evidence to recommend intranasal steroid therapy use for nasal polyps in adults for a short duration of 2-4 weeks to reduce polyp size and 4-12 weeks and >12 weeks to reduce rhinitis symptoms. adverse effects are minimal and should not inhibit the clinician from prescribing intranasal steroids when clinically warranted. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles philippine journal of otolaryngology-head and neck surgery 11 recommendations for research: documentation of new and unusual adverse effects of long-term intranasal steroid administration such as fungal infection is recommended. the benefit of intranasal steroids in children should be looked into to check the reliability of reports of increased recurrence rate of polyps after surgical removal in children. following conclusion of this meta-analysis, the searches were rerun for primary studies up to october 2007 using the same strategies, yielding four studies that have since been published.24, 25, 26, 27 these four studies should be subjected to the same criteria for inclusion in this review in order to compare their findings with ours. acknowledgement: i would like to thank the two reviewers who helped with study selection and data extraction: teresa paz b. grecia pascual, llb, md (medical specialist 1, veterans memorial medical center; assistant professor, de la salle health science institute) and joselito m. acuin, md, msc (past chairman, dept of ent, de la salle health science institute) references 1. lildholdt t, rundcrantz h, lindqvist n. efficacy of topical corticosteroid powder for nasal polyps: a double blind placebo-controlled study of budesonide. clin otolaryngol 1995;20:26-30. 2. chalmers 1983. chalmers tc, celano p, sacks hs, smith h. bias in treatment assignment in controlled clinical trials. n engl j med 1983; 309:1358-61. 3. settipane g, lund v, bernstein j, tos m. nasal polyps: epidemiology, pathogenesis and treatment. oceanside publications inc., providence rhode island 1997. 4. wigand m., hosemann w. microsurgical treatment of recurrent polyposis. rhinology suppl.,8,2530,1989. 5. philippine cardiovascular research group (philippine cardiovascular group quality assessment tool, department of medicine, philippine general hospital. 6. johnasen lv, illum p, kristensen s, winther l, petersen sv, synnerstad b. the effect of budesonide( rhinocort) in the treatment of small and mediun sized nasal polyps. clin otolaryngol 1993;18:524-7. 7. cooper h, hedges l. the handbook of research synthesis. new york :russell sage foundation 1994, 384-98. 8. emerson 1990. emerson jd, burdick e, hoaglin dc, mosteller f, chalmers tc. an empirical study of the possible relation of treatment differences to quality scores in controlled randomized clinical trials. controlled clin trials 1990; 1:339-52. 9. mackay is. topical medical management of allergic conditions of the nose. par 2: intranasal steroids. in: mackay is ed. rhinitis: mechanism and management. london: royal society of medicine services ltd, 1989: 183-98. 10. pentilla m, poulsen p, hollingworth k, holmstrom m. dose-related efficacy and tolerability of fluticasone propionate nasal drops 400 microg once daily and twice daily in the treatment of bilateral nasal polyposis: a placebo-controlled randomized study in adult patients. clin exp allergy 2000 jan;30(1):94-102. 11. dingsor g, kramer j, olsholt r, soderstrom t. flunisolide nasal spray 0.025% in the prophylactic treatment ;of nasal polyposis after polypectomy: a randomized double blind parallel, placebocontrolled study. rhinology 1985;23:49-58. 12. holmberg k, juliusson s, bladder b, smith dl. fluticasone propionate aqueous nasal spray in the treatment of nasal polyposis. ann of allergy asthma & immuno.1997mar;78(3):270-6. 13. lund v, flood j, sykes a, ricards d. effect of fluticasone in severe polyposis. arch otol head and neck surg 1998;124:513-8. 14. tos m. svendstrups f, arndal h. efficacy of an aqueous and a powder formulation of nasal budesonide compared in patients with nasal polyps. am j rhinology suppl 1998;12. 15. lildholdt t, rundcrantz h, bende m, larsen k. glucocorticoid treatment of nasal polyps. the use of topical budesonide poweder, intramuscular betamethasone and surgical treatment. arch head and neck surg;1997(123):595-8. 16. karlsson g, rundcrantz h. a randomized trial of intranasal beclomethasone dipropionate after polypectomy. rhinology 1982; 20:144-8. 17. mygind n, pedersen cb, prytz s, sorensen h. treatment of nasal polyps with intranasal beclomethasone dipropionate aerosol. clin allergy 1975;5. 18. virolainen r, puhakka virolainen. the effect of intranasal beclomethasone dipropioante on the recurrence of nasal polyposis. rhinology 1980;18:9-18. 19. chalton r, mackay i, wilson r, cole p. double blind, placebo controlled trial of bethamethasone nasal drops for nasal polyposis. br med j (clin res ed) 1985;291(6498):788. 20. holopainen e, grahne b, mamberg h, makinen j, lindqvist n. budesonide in the treatment of nasal polyposis. eur l respir dis 1982;63(122):221-8. 21. toft a, wihl ja, toxman j, mygind n. double blind comparison between beclomethasone dipropionate as aerosol and as powder in patients with nasal polyposis. clin allergy 1982;12:391401. 22. ruhno j, anderson b, denburg j et al. a double blind comparison of intranasal budesonide with placebo for nasal polyposis. j allergy clin immunol 1990;86:946-5 23. jankowski r, schrewelius c, bonfils p, saban y, gilain l, prades jm, strunski v. efficacy and tolerability of budesonide aqueous nasal spray treatment in patients with nasal polpys. arch otolaryngol head neck surg 2001apr;127(4):447-52. 24. aukema aa, mulder pg, fokkens wj. treatment of nasal polyposis and chronic rhinosinusitis with fluticasone propionate nasal drops reduces need for sinus surgery. j allergy clin immunol. 2005 may;115(5):1017-23. 25. small cb, hernandez j, reyes a, schenkel e, damiano a, stryszak p, staudinger h, danzig m. efficacy and safety of mometasone furoate nasal spray in nasal polyposis. 3: j allergy clin immunol. 2005 dec;116(6):1275-81. 26. stjärner p, mösges r, jorissen m, passàli d, bellusi l, staudiner h, danzig m. a randomized controlled trial of mometasone furoate nasal spray for the treatment of nasal polyposis. arch otolaryngol head neck surg. 2006 feb; 132(2): 179-85. 27. stjärne p, blomgren k, cayé-thomasen p, salo s, søderstrøm t. the efficacy and safety of oncedaily mometasone furoate nasal spray in nasal polyposis: a randomized, double-blind, placebocontrolled study. acta otolaryngol. 2006 jun;126(6):606-12. 38 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 featured grand rounds primary tumors of the parapharyngeal area are rare and account for 0.5% of all head and neck tumors.1,2 among these, 80% are benign while 20% are malignant.2 next to schwannomas, neurofibromas are the second most commonly encountered primary tumor of nerve sheath origin in the parapharyngeal space but incidence and prevalence rates have not been documented among pediatric patients.3,4 plexiform neurofibromas in particular pose a surgical challenge in pediatric patients. careful preoperative planning, advanced surgical techniques and vigilant postoperative care result in minimal morbidity and resolution of tumor symptomatology.5 although complete surgical resection is ideal for all (especially benign) parapharyngeal tumors,4 the dilemma of complete versus partial resection arises when massive size increases the possibility of neurological dysfunction and cosmetic deformity from damage to adjacent cranial nerves and sympathetic chain fibers.6 we present the management dilemma involving a neurofibroma of the parapharyngeal space in a pediatric patient. case report a 9-year-old female consulted with a 5-year history of a right infraauricular mass with concomitant soft palatal swelling. a tonsillectomy had been previously performed in another institution, with note of the “mass extension at the right posterior tonsillar pillar bulging over the posterior pharyngeal wall.” the histopathologic report was “chronic hypertrophic tonsil; plexiform neurofibroma,” but the patient did not follow up and no further intervention took place until progressive enlargement of the infraauricular and soft palatal swelling prompted this consultation at our institution. on examination, a firm non-tender 6 x 5 x 4 cm tumor in the right parotid region with medial displacement of the right lateral pharyngeal wall and soft palate were noted (figure 1 a,b), together with an open bite deformity and whitish non-foul smelling discharge from the right external auditory canal. no cranial nerve deficits, café au late spots or lisch nodules were noted. contrast computed tomography (figure 2) further revealed the mass extending anteriorly to the right post styloid space, superomedially to the inferior maxillary wall and posteriorly to the prevertebral space. the parotid was displaced laterally and the carotid artery and jugular vein, displaced posteriorly. a wedge biopsy of the soft palate extension revealed neurofibroma. discussion primary tumors of the parapharyngeal space are extremely rare.2 a search of herdin, pubmed and cochrane using the keywords parapharyngeal, neurofibroma and pediatrics, yielded no locally-reported cases among children. neurofibromas ranked second among neuroblastic tumors that occur in the parapharyngeal space.2 plexiform neurofibromas (pns) are typically congenital with approximately 50% occurring in the region of the head, neck, face and larynx.6 the growth pattern has not been fully understood, but they appear to grow in early childhood at variable rates with growth and plateau phases. plexiform neurofibromas tend to be locally invasive and may result in cosmetic parapharyngeal neurofibroma in a pediatric patient rubiliza dc. onofre, md department of otorhinolaryngology head and neck surgery east avenue medical center correspondence: rubiliza dc. onofre, md department of otolaryngology head and neck surgery 6th floor east avenue medical center east avenue, quezon city 1100 philippines phone: (632) 928 0611 loc 324 fax: 435-6988 email: eamc_enthns@yahoo.com, yukito8211@yahoo.com reprints will not be available from the author. philipp j otolaryngol head neck surg 2010; 25 (1): 38-40 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 39 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 featured grand rounds deformities and functional deficits. our patient has a noncutaneous plexiform neurofibroma but did not meet the criteria for the diagnosis of neurofibromatosis i. the ideal treatment for parapharyngeal neurofibromas or schwanommas is surgery,5,7,8 aiming to completely remove tumor with preservation of surrounding nerves and vessels.5 approaches which depend on tumor size and localization include the transparotid (commonly used for deep-lobe parotid and other pre styloid tumors); the transcervical (for post styloid tumors); and combinations of both.7,8,9 a mandibulotomy may be added to increase exposure but poses risk of injury to the inferior alveolar nerve while providing access to the parapharyngeal space. the goal of complete excision without damaging the vagus, trigeminal, brachial plexus and sympathetic nerves or violating the carotid artery and jugular vein that may result in such complications as facial nerve weakness (trigeminal nerve), horner’s syndrome (cervical sympathetic nerve chain), median and ulnar nerve impairment (cervical and brachial nerve plexus), excessive bleeding (carotid artery and jugular vein) is easier said than done.5 further complications of a possible mandibulotomy include inferior alveolar nerve anesthesia, loss of dentition, malocclusion, malunion or nonunion and possible need for a tracheotomy.7 these complications will greatly affect the quality of life and functions of the patient in exchange for removal of a benign tumor that is presently not causing any such problems (except for otitis media figure 1. a anterior view of right infra auricular mass measuring approximately 6 x 5 x 4 cm figure 1 b. close-up intraoral view showing palatal involvement. the right parapharyngeal wall was similarly involved. figure 2. contrast ct scan, axial view at level of the nasopharynx shows mass extending anteriorly to the posterior maxillary wall and pterygoid plate, posteriorly to the prevertebral space and medially to the contralateral nasopharynx, displacing the carotid artery and jugular vein posteriorly acknowledgement the author would like to acknowledge the help, guidance and support of consultant doctors angelo monroy, natividad almazan and felix nolasco and resident doctors of the department of otorhinolaryngology head and neck surgery of the east avenue medical center. references 1. doménech j, monner dieguez a, cisa lluís a, marí roig a, de frías b, jiménez r. schwannoma parafaringeo: a propósito de un caso secondary functional veloplasty: a non-obstructive approach to valopharyngeal insufficiency. rev esp cirug oral y maxilofac 2004;26(1):245-248 2. hughes kv, olsen kd, mccaffrey tv. parapharyngeal space neoplasms, head neck 1995;17(15):124-130 3. kuttesch jf, ater jl. brain tumors in childhood. in: behrman re, kliegman rm, jenson hb, eds. nelson textbook of pediatrics. 17th edition. pennsylvania: elsevier; 2004, p. 1702-1710. 4. luna-ortiz k, navarrete-aleman je, granados-garcia m, herrera-gomez a, primary parapharyngeal space tumors in a mexican cancer center. otolaryngol head neck surg 2005;132(4):587-591. 5. manolidis, s, higuera s, boyd v, hollier lh. single-stage total and near-total resection of massive pediatric head and neck neurofibromas. j craniofac surg. may 2006; 17(3); 506-510 6. wise jb, cryer je, belasco jb, jacobs i, elden e. management of head and neck plexiform neurofibromas in pediatric patients with neurofibromatosis i. arch otolaryngol head neck surg. 2005;131:712-718. 7. olsen kd. tumors and surgery of the parapharyngeal space. laryngoscope 1994; 104: 1-28. 8. shahab r, heliwell t, jones as. how we do it: a series of 114 primary pharyngeal space neoplasms. clinical otolaryngol 2005; 30: 364-367. 9. diaz-ordaz, ea. surgery of the parapharyngeal space. in: lore, jm. medina, je. an atlas of head and neck surgery. 4th edition. pennsylvania: elsevier; 2005, p. 1365-1368 10. baujat b, krastinova-lolov d, blumen m, baglin ac, coquille f, chabolle f. craniofacial plexiform neurofibromatosis: a pilot study. plast reconstr surg april 2006; 117: 1261-1268. 40 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 featured grand rounds possibly related to eustachian tube compression). on the other hand, tumor enlargement may eventually cause greater problems if surgery is not performed now. if the tumor were small, resection would not have been as much a problem.8 chemotherapy has been considered for such large tumors where surgical complications are likely based on findings that desmoid tumors are similar to plexiform neurfibromas. current trials with such agents as combination methotrexate and vinblastine focus on slowing or stopping progression of existing disease.5,6 farnesyl transferase inhibitors are also being considered as alternative chemotherapeutic agents due to high levels of this enzyme found in these tumors.6 other drugs being tested but with limited efficacy are interferon alfa with or without retinoic acid and thalidomide.10 a pilot study on the possible use of radiofequency in the treatment of head and neck neurofibromatosis done among five pediatric patients in early stages of the disease revealed partial diminution and stability of the mass.10 however, further studies are suggested to determine the optimal dose, frequency of sessions and possible complications. we plan to attempt complete excision of the neurofibroma via a combined transparotid-transcervical approach with mandibulotomy and possible reconstruction using titanium plates and screws. post operative mandibular and occlusion rehabilitation is also being considered as the orthognathic structures have already been deformed and malaligned by the mass. the management of huge parapharyngeal tumors is complicated indeed. important factors such as quality of life, age and emotional effects on the patient must be considered as equally important as extirpating the whole tumor itself. we must find the balance between helping remove the burden of an enlarging mass while preserving the good quality of life our patient deserves. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january –june 2008 philippine journal of otolaryngology-head and neck surgery 27 surgical innovations and instrumentation abstract objective: to develop a simple, portable, inexpensive model for otolaryngology trainees to practice on and develop skills required for myringotomy and tympanostomy tube insertion. materials and methods: recycled plastic egg crate, a 3-cc plastic syringe, micropore™ tape and modeling clay were used to create a model to practice myringotomy and tympanostomy tube insertion utilizing tubes fashioned from a recycled 18 guage intravenous catheter. result: the model myringotomy practice set is an inexpensive, simple do-it-yourself device made of locally available, mostly recycled materials. keywords: myringotomy practice set, myringotomy, middle ear ventilation, tympanostomy, tympanostomy tube insertion, instrumentation myringotomy with or without tympanostomy tube insertion is a common ambulatory procedure performed by otorhinolaryngologists. it is usually indicated for otitis media with effusion, and other specific manifestations of eustachian tube dysfunction and middle ear pathology. although the procedure is relatively fast, safe and easy, it still requires appropriate microsurgical skills. unlike temporal bone dissection for learning mastoidectomy, training for myringotomy is difficult if not impossible to do in locally-available cadavers due to hardened and desiccated tissues. models for teaching myringotomy have been developed but are usually expensive and not readily available especially in our local setting. otorhinolaryngology residents are usually introduced to myringotomy by observation followed by practice on actual patients, with all the attendant risks and complications associated with the learning curve. we aimed to develop a simple, portable, inexpensive model for trainees to practice with and develop the skills required for myringotomy and tympanostomy tube insertion without compromising patient safety. the model myringotomy practice set: a do-it-yourself and inexpensive alternative melita jesusa suga tuaño uy, md norberto v. martinez, md department of otorhinolaryngology head and neck surgery university of santo tomas hospital españa, manila correspondence: melita jesusa suga tuaño uy, md department of otorhinolaryngology -head and neck surgery university of santo tomas hospital españa, manila 1001 phone : (632) 731-3001 local 2411 philippines e-mail address: suga_7200@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at the instrument design contest (2nd place) philippine society of otolaryngology head and neck surgery 50th annual convention, edsa shangri-la plaza hotel, mandaluyong city, december 2, 2006. philipp j otolaryngol head neck surg 2007; 22 (1,2): 27-30 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january –june 2008 surgical innovations and instrumentation 28 philippine journal of otolaryngology-head and neck surgery materials for this model are readily available and are inexpensive. materials and methods materials 1. egg crates, plastic 2. modeling clay 3. 3-cc plastic syringe (terumo, japan) for the external auditory canal 4. micropore™ surgical tape (3m™, st. paul, mn, u.s.a.) or paraffin, cellophane or latex gloves for the tympanic membrane 5. rubber bands (to secure the tympanic membrane) 6. intravenous catheter 18 gauge (introcan-w, b.braun laboratories, brazil) for making tympanostomy tubes, or recycled commercially available tympanostomy tubes procedure the syringe was cut into pieces approximately 2.5 cm long, and one end of each piece was beveled at around 40 degrees as shown in figure 1. this beveled syringe would correspond to the external auditory canal. the beveled end of each tube was wrapped with micropore™ tape to simulate a tympanic membrane (figure 2). alternatively, paraffin, cellophane or latex gloves could be used and secured with a rubber band. the rest of the tube could also be wrapped with paper or aluminum foil to darken the simulated external auditory canal. a moderate amount of molding clay was placed in each egg crate (figure 3) and a depression was made to approximate the middle ear cavity, with the orifice the size of the tube. water could be placed in this depression to simulate middle ear fluid. the beveled end of each tube was then sealed in the clay, orienting each in a manner similar to the anatomical orientation of a patient positioned in sitting or supine position for a myringotomy (figure 4). tympanostomy tubes could be made out of gauge 18 iv cannulae cut into 2-mm long tubes with the ends heated to create flanges as previously described1. the model was ready to use for practice myringotomy and tympanostomy tube insertion. suctioning of the fluid could also be practiced (figures 5 to 9). material 1. egg crates, plastic material 2. modeling clay material 3. 3-cc plastic syringe (terumo, japan) for the external auditory canal material 4. micropore™ surgical tape (3m™, st. paul, mn, u.s.a.) or paraffin, cellophane or latex gloves for the tympanic membrane material 5. rubber bands (to secure the tympanic membrane) material 6. intravenous catheter 18 gauge (introcan-w, b.braun laboratories, brazil) for making tympanostomy tubes, or recycled commercially available tympanostomy tubes table 1. cost of production of the model myringotomy practice set grade of impairment corresponding audiometric iso value (average of 500, 1000 and 2000 hz) plastic egg crate 3-cc syringe micropore tape modeling clay intravenous catheter rubber bands and paper total recycled recycled ( php 5.00 if bought) used (php 40.00 if bought) recycled (php 20.00 if bought) recycled (php 36.50 if bought) recycled (php 101.50 if bought) philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january –june 2008 surgical innovations and instrumentation philippine journal of otolaryngology-head and neck surgery 29 figure 1. beveled syringe figure 2. beveled syringe wrapped with micropore figure 3. egg crate with modeling clay figure 4. tube in clay figure 5. tube in crate figure 5. practice myringotomy figure 6a. model tm made out of micropore tape figure 6b. brown colored fluid behind model tm figure 7. myringotomy done on anteroinferior figure 8. suction of fluid philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january –june 2008 surgical innovations and instrumentation 30 philippine journal of otolaryngology-head and neck surgery this paper tried to emulate these dimensions of the external ear by cutting the 3cc syringe to 2.5 cm to approximate the length of the external auditory canal and beveling one end to mimic the tympanic membrane orientation. the 3-cc syringe had a diameter of 9 mm and approximated the dimensions of the tympanic membrane of an adult. the materials used at the beveled end could be interchanged to experience different textures for one practice on. in our experience, micropore™ tape seemed to best mimic the thickness and resistance of the tympanic membrane when punctured. markers could be placed on the micropore™ prior to the myringotomy exercise to indicate the proper orientation of the tympanic membrane and the location of the malleus. after the procedure, trainees could check the accuracy of the incision based on the markers. fluid could be placed in the depression in the modeling clay to practice suctioning fluids from the middle ear. the color and viscosity could be modified using dyes and thickeners to mimic various fluids in middle ear diseases. gentian violet could also be used to practice and simulate administration of local anesthesia. avoidance of the ear canal wall could be practiced by placing dye on the myringotomy knife and making sure the dye was not transferred to the walls. smaller tubes could be used to simulate pediatric ears. our device was very economical as most materials were readily available (or could be purchased at minimal cost) compared with commercially available mannequins and models (table 1) with prices ranging from usd 65.006 to 950.00.7 discussion myringotomy is a common procedure for otorhinolaryngologists. in cooperative teenagers and adults, this can be done under local anesthesia in a clinic setting. in children, general anesthesia is usually required for tympanostomy tube insertion.2 although this is usually a straightforward procedure, difficulties during the process may be encountered. caution must be exercised to avoid traumatizing the anterior canal wall to avoid bleeding and pain. creation of a toolarge myringotomy might cause the tympanostomy tube to fall into the middle ear. additional difficulty is encountered when performing myringotomy on a very small ear canal. these complexities may be avoided or minimized by the experience and skills of the surgeon. trainees are expected to perform such procedures but the lack of materials and expensive cost of commercially available models for teaching myringotomy hamper acquisition of skills before practice on actual patients, potentially compromising patient safety. other models have been developed to meet the need for practicing surgical skills in myringotomy.3,4 some use a mannequin ear to simulate the external ear canal these models either use materials that are not readily available and expensive especially in our setting. our proposed model was basically an inexpensive system made out of readily available materials. one could easily construct his or her own myringotomy practice set by using the aforementioned materials and procedure. the external auditory meatus or canal is composed of the lateral cartilaginous and medial osseous portions. it is approximately 2.5 cm from the conchal cartilage to the tympanic membrane.5 the tympanic membrane is approximately 8 mm wide, 9 to 10 mm high and 0.1 mm thick. its inferior pole is oriented more medially than its superior pole by approximately 40 degrees.5 the model described in figure 9a. myringotomy tube in place figure 9b. placement of myringotomy tube references 1. aguila kp. self-retaining harpoon tympanostomy tube with applicator. philipp j otolaryngol head neck surg. 2007;22(1,2): 27-30. 2 hirsch, b. myringoplasty and tympanoplsty in: myers, e, editor. operative otolaryngology head and neck surgery. volume ii . philadelphia: wb saunders company, 1997. p.1236-1245 3 owa ao and farell rw. simple model for teaching myringotomy and aural ventilation tube insertion. j laryngol otol. 1998 jul 112(7): 642-3 4 pichechero m, poole m., auran m, pichichero fa. teaching mannequin for developing tympanocentesis skills. outcomes management educational workshops, inc. available from http://www.omew.com/research/mannequin.htm 5 ducket l. anatomy of the skul base, temporal bone, external ear, and middle ear, in: cummings, cw, fredrickson jm, harker la, krause cj, schuller de, richardson ma, editors. otolaryngology head and neck surgery, 3rd edition. volume iv. st louis: mosby; 1998. p. 2533-2546 6 the health care net [homepage on the internet]. life-size ear models [cited 2008 june 3]. available from: http://www.thehealthcarenet.com/models_ear_eye_sinus_ teeth.asp#gpi225 7 buyamag, inc. magnetic therapy, acupuncture health products and supplies[homepage on the internet] . ear models [cited 2008 june 3]. available from: http://www.buyamag.com/index.htm philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 42 philippine journal of otolaryngology-head and neck surgery passages fidel p. burgos, md, mha (1959-2009) jose m. acuin md, msc. and pio r. pajarillo, md throughout his relatively brief career, fides received no education other than from the university of the philippines. his, therefore, was a long and unadulterated mentoring by a school which shaped him from primary level to medicine (upcm 1984) to specialty residency (ent-head and neck surgery at up-pgh, 1989) and to masteral degree (masters of hospital administration at up open university, 2006). after successfully passing the diplomate examinations in 1990, fides was invited by dr. dominador almeda to join the far eastern university department of ent-hns as the residency training officer. there he taught residents and students, passing on to them his exceptional skills as a head and neck surgeon. his integrity and devotion to duty earned him the trust and respect of dr. almeda and the other department consultants. fides could have easily trained and practiced abroad with the help of his uncles who were also prominent surgeons. but he chose to stay home. more than that, he chose to settle down and establish his practice in lucena, quezon when he was invited by another ent surgeon, dr. pio pajarillo, at the nañagas eent clinic. his practice rapidly grew, attracting a large following of patients who appreciated his brand of expert and compassionate care. fides never looked back. something about the simplicity and candor of rural folk appealed to him who always spoke plainly and sincerely. there, in lucena, fides poured out all his wondrous skills in treating his patients, seeing them through their illnesses and welcoming them, now made whole again, back to his clinics. there, in lucena, he fell in love with alet, whom he married in 1995 and with whom he had two children, juan gabriel and kyla isabel. but fides proved too big and too gifted to remain a provincial ent doctor, although he would always be the first to tell you that there was nothing more rewarding to him than seeing his patients in his clinic. local physicians took notice of this straight-talking, honest and dependable physician who somehow appeared to understand that hospitals are about people who must be guided and nurtured to become the best they can possibly be. he became a shoulder to those who felt weighed down by their daily grind, an ear to those who needed to simply open up. he had the knack for seeing through people and divining their intentions. he also understood the complexity of hospital systems. he was persuaded by the local physicians to accept the position of medical director for lucena united doctors hospital, but not without first capping a master of hospital administration from the up open university in 2006, graduating cum laude. fides led the lucena united doctors hospital up to the time he died, whipping the organization into shape and instilling discipline among doctors, nurses and the rest of the staff. he carried a big stick. he expected nothing less than the best from his people and gave nothing but the best of himself as an example. he sought out ways for doing the right things better and systematically pruned the inefficiencies that got in the way. he could not be swayed. people who sought to influence his decisions ran smack into a brick wall. he mentored his management staff, seeing them through difficult tasks and building their confidence. he steered the hospital through tangled webs of regulations and corporate issues. all this did not go unnoticed. in december 1, 2008, the pso-hns awarded him a plaque of recognition for being an outstanding administrator in his hospital. fides was different though, once he was with trusted friends, slipping back to his quiet and laid back manner. the quickness of his laughter to the corniest jokes, the way he opened himself up to speak amid contentious talk belied his easy confidence. he knew he did not have to prove anything anymore. the day fides died was like any other. he played badminton but did not come back. those of us who love and miss him will find it hard indeed to understand why he left. did god call him as his sum measure fulfilled and even surpassed all his expectations? was a quick and uneventful bowing out part of the deal for playing well whatever hand god dealt him? we will never know. but for those of us who will find it hard to forget him will probably do well to memorialize him by seizing every swift hour of our lives and throwing ourselves wholly to whatever enterprise we find ourselves in. the way fides did. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 practice pearls philippine journal of otolaryngology-head and neck surgery 43 one of the more important and critical referrals that otolaryngologists can receive from colleagues in internal medicine, family medicine and geriatrics is the assessment of swallowing problems or dysphagia of their patients. the term dysphagia is derived from two greek words which literally mean difficulty in swallowing. swallowing is a complex series of precisely coordinated voluntary and involuntary muscular movements in the mouth, pharynx and esophagus that serves to deliver food from the oral cavity into the stomach. normal swallowing consists of three phases: oral preparatory, pharyngeal and esophageal. one normal swallow of a bolus of food should only take less than one second to reach the esophagus. dysphagia may manifest as difficulty managing secretions, drooling, delayed swallowing, coughing or choking with the swallow, a wet gurgly voice and multiple swallow attempts. the complaint of dysphagia in an elderly patient should not be attributed to normal aging alone but should be considered an alarm symptom that requires immediate definition of the exact cause and initiation of appropriate therapy.1 dysphagia and aspiration pneumonia2,3 dysphagic patients who aspirate have a seven-fold risk for acquiring pneumonia. in patients with an acute stroke, 40-70% have dysphagia. of these, aspiration occurs in 4050%. fifty to 75% of patients with degenerative diseases of the central nervous system (e.g. alzheimer’s disease) also have dysphagia. thus, people older than 75 years old have a six time higher risk of contracting aspiration pneumonia than younger individuals. factors that increase the risk of aspiration pneumonia in dysphagia patients include volume of aspirate, oropharyngeal colonization with pathogens such as staphylococcus aureus, klebsiella sp. or e. coli (due to decreased salivary clearance and poor oral hygiene) and poor nutritional status (that leads to decreased immunity). oropharyngeal dysphagia dysphagia is typically distinguished into two types based on the phase of swallowing affected. dysphagia secondary to a lesion above the esophagus is called orophayrngeal dysphagia. dysphagia involving the upper esophageal sphincter to the stomach is considered esophageal dysphagia. this discussion will concentrate on oropharyngeal the assessment of oropharyngeal dysphagia in adults frederick y. hawson, md, mhped department of otorhinolaryngology head and neck surgery st. luke’s medical center correspondence: frederick y. hawson, md rm. n1004 north tower, cathedral heights bldg. st. luke’s medical center, e. rodriguez ave. quezon city 1102 philippines phone: (632)723-0101 local 5004 reprints will not be available from the author. no funding support was received for this paper. the author signed a disclosure that he has no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this paper. philipp j otolaryngol head neck surg 2009; 24 (2): 43-45 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 practice pearls 44 philippine journal of otolaryngology-head and neck surgery dysphagia. oral dysfunction causes drooling, food spillage, difficulty initiating a swallow, piecemeal swallows and articulation problems. pharyngeal dysfunction gives a sensation of food “getting stuck” immediately upon swallowing, regurgitation into the nose, coughing or choking while eating and vocal problems. difficulty is localized to the cervical region, usually involving liquids. in contrast, patients with esophageal dysphagia usually describe the onset of symptoms several seconds after initiating swallow. difficulty is localized to the suprasternal notch or behind the sternum, usually involving solids.1 oropharyngeal dysphagia is of unique clinical significance. affected patients often have impaired ability to verbalize their discomfort or to cooperate with evaluation and therapy because of their neurological conditions. this dysphagia is usually not only a local problem, but just one aspect of a systemic disease syndrome. diagnosis is a challenge because the problem is usually not obviously visible. management therefore requires a coordinated team approach involving several medical and allied medical professionals. aside from otolaryngologists, neurologists, radiologists, gastroenterologists, oncologists, rehabilitation medicine specialists and speech-language pathologists will have their specific roles.4 oropharyngeal dysphagia can be locally caused by poor dentition, mucosal lesions, problems in salivary production or by a number of neuromuscular disease syndromes. the central nervous system is commonly involved, as with cerebro-vascular accidents (usually in the brainstem), parkinson’s disease, multiple sclerosis, amyotrophic lateral sclerosis and brainstem tumors. the peripheral nervous system can also be involved as with poliomyelitis or myasthenia gravis. local structural lesions may be inflammatory, neoplastic, compressive or post-surgical in nature. there can also be hypertensive or hypotensive motility disorders of the upper esophageal sphincter. 5,6 physical examination a comprehensive physical examination should be part of the initial evaluation of all patients with oropharyngeal dysphagia. examination of the oral cavity, head and neck and supraclavicular region may reveal apparent problems that cause the dysphagia. neurological examination which includes testing of all cranial nerves, especially those involved in swallowing (sensory components of cn v, ix, x and motor components of cn v, vii, x, xi and xii), may also detect disorders with more subtle physical findings of the various neuromuscular syndromes that could cause dysphagia. 7 diagnostic testing classic barium-swallow radiography is the most basic diagnostic test for dysphagia, though more useful for esophageal problems. while esophageal manometry is more useful for esophageal dysphagia, it may also be helpful for patients who have oropharyngeal dysphagia with inconclusive results from other examinations. it is especially useful in cases in which surgical myotomy is being considered. 7 videofluoroscopic evaluation of swallowing (vfes) gives a real-time and detailed analysis of swallowing mechanics from the oral to the esophageal stages, making this the gold standard of swallowing examinations. however, its prohibitive cost and the non-portability make it impractical for several patient settings, most particularly critical patients in intensive care units. fiberoptic endoscopic evaluation of swallowing (fees) is the diagnostic procedure performed mainly by otolaryngologists and will be the discussed in detail here. fiberoptic endoscopic evaluation of swallowing (fees) flexible rhinopharyngoscopy is the preferred technique for examining the pharynx because anatomic structures are visualized without interfering with normal physiology of respiration and phonation.8 fees is an extension technique done to examine swallowing events for both diagnostic and rehabilitative purposes 9 and was first described by susan langmore in 1988.10 fees involves assessment of swallowing function for food and liquid as well as the response to therapeutic interventions. before any food testing, velopharyngeal closure, anatomy of the tongue base and hypopharynx, vocal fold movement, status of pharyngeal musculature and patients’ ability to swallow saliva and secretions are first noted. if the equipment is available, sensory testing by eliciting the laryngeal adductor reflex (lar) using calibrated air pulses delivered to the epithelium innervated by the internal branch of the superior laryngeal nerve should also be performed.11 being an involuntary reflex, this information is important when dealing with patients with impaired cognition.8,11 food samples colored with green food dye (for better visibility) philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 philippine journal of otolaryngology-head and neck surgery 45 practice pearls are typically presented in sequence: pureed food, honey thick liquid, nectar thick liquid, thin liquid, mechanical soft food and regular food. the examiner may also include items from the patient’s current diet. 11 the patient may only swallow when asked to do so. any premature spillage into the hypopharynx should be noted as this is frequently associated with laryngeal penetration. the oropharyngeal stage is not endoscopically visible because the tip of the endoscope will contact the base of the tongue, the epiglottis and the bolus itself when the swallowing reflex starts (swallowing white-out). during this stage, laryngeal penetration of food may be suspected if there are indirect signs like coughing or food in the laryngeal vestibule. after each swallow, it is likewise important to note the amount and location of residual food in the hypopharynx. when the patient talks or moves his head these may also penetrate the larynx. 8,12,13 the most frequent adverse effect reported for fees is discomfort. topical anesthesia in the nose is not usually employed as it may affect the swallowing mechanism. other adverse reactions such as changes in heart rate, epistaxis, laryngospasm and vasovagal response may be risky to the patient but these events are not common. 7,10 because of its ease of use, portability and lower cost, fees is now the first choice method of swallowing investigation in europe. the detection of aspiration of the bolus into the airways (even silent aspiration13) and the presence of bolus residue in the pharynx in fees correlates very well with vfes, the gold standard. 8 based on fees results, the clinician can recommend resumption of oral feeding (with specified food consistencies) or shifting to non-oral options such as the nasogastric tube or percutaneous endoscopic gastrostomy. in either case, he can also recommend the initiation of swallowing rehabilitation therapy if deemed necessary. a medical position statement of the american gastroenterological association enumerates the following steps in the management of oropharyngeal dysphagia, all of which are within the scope of otolaryngologists:4 1. ascertain whether oropharyngeal dysphagia is likely 2. identify structural etiologies of oropharyrngeal dysfunction 3. ascertain the functional integrity of the oropharyrngeal swallow 4. evaluate the risk of aspiration pneumonia references 1. fass r. approach to the patient with dsyphagia. in: uptodate, basow ds (ed), uptodate, waltham, ma, 2009. 2. marik pe, kaplan d. aspiration pneumonia and dysphagia in the elderly. chest 2003: 124: 328-336. 3. perry l, love cp. screening for dysphagia and aspiration in acute stroke: a systematic review. dysphagia 2001; 16: 7-18. 4. aga technical review on management of oropharyngeal dysphagia, gastroenterology 1999; 116: 455-478. 5. castell do, donner mw. evaluation of dysphagia: a careful history is crucial. dysphagia 1987;2:65-71. 6. lembo a. pathogenesis and clinical manifestations of oropharyngeal dysphagia. in: uptodate, basow ds (ed), uptodate, waltham, ma, 2009. 7. lembo a. diagnosis and treatment of orpharyngeal dsyphagia. in: uptodate, basow, ds (ed), uptodate waltham, ma, 2009. 8. nacci a, ursino f, la vela r, matteucci f, mallardi v, fattori b. fiberoptic endoscopic evaluation of swallowing: proposal for informed consent. acta otorhinolaryngol ital. 2008 aug; 28(4): 206-211. 9. leder sb, karas de. fiberoptic endoscopic evaluation of swallowing in the pediatric population. laryngoscope 2000; 110(7): 1132-1136. 10. langmore se, schatz k, olsen n. fiberoptic endoscopic examination of swallowing safety: a new procedure. dysphagia 1988; 2: 216-219. 11. aviv je, kaplan st, thomson je, spitzer j, diamond b, close lg. the safety of flexible endoscopic evaluation of swallowing with sensory testing (feesst): an analysis of 500 consecutive evaluations. dysphagia 2000; 15: 39-44. 12. hafner g, neuhuber a, hirtenfelder s, schmedler b, eckel he. fiberoptic endoscopic evaluation of swallowing in intensive care unit patients. eur arch otorhinolaryngol. 2008; apr; 265: 441-446. 13, leder sb, sasaki ct, burrell mi. fiberoptic evaluation of dysphagia to identify silent aspiration. dysphagia 1998; 13: 19-21. 5. determine if the pattern of dysphagia is amenable to therapy otolaryngologists should be actively involved in the management of critically ill patients via a standardized endoscopy protocol,12 making it routine to perform fees procedures on these patients in order to make the best diagnostic decisions about their dysphagia, preventing aspiration pneumonia and its potentially fatal consequences. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 case reports 36 philippine journal of otolaryngology-head and neck surgery abstract objectives: 1] to describe a case of an embryonal rhabdomyosarcoma presenting as a radiolucent mandibular mass in a 3-year-old child. 2] to review existing literature on the clinical picture and pathophysiology of intraosseous rhabdomyosarcoma. 3] to identify learning points in the diagnosis of intraosseous rhabdomyosarcoma. design: case report. setting: a tertiary referral hospital. patients: one (1) results: a case of a 3-year-old child with a radiolucent mandibular mass is described. the final histopathologic report turned out to be embryonal rhabdomyosarcoma. intraosseous rhabdomyosarcomas are rare occurrences (3.5% in one review), and clinically present in younger age groups, with a non-tender, enlarging, firm-hard mass over a specific area. a review of the available literature on intraosseous rhabdomyosarcomas, and its proposed pathogenesis, is presented. conclusion: a case of a radiolucent mandibular mass in a 3-year-old child is presented. intraosseous rhabdomyosarcomas of the mandible are rare occurrences that pose challenges to the otorhinolaryngologist. taken separately, the presentation, patient characteristics, clinical course, ancillary laboratories and imaging modalities may lead even the most astute otorhinolaryngologist astray. the whole clinical picture should be taken together so that the correct diagnosis will not be missed despite the rare presentation. keywords: embryonal rhabdomyosarcoma, intraosseous rhabdomyosarcoma, mandibular mass tumors of the head and neck can be grouped according to their site of origin, histologic type, or whether they are benign or malignant. appropriate management protocols for these tumors parallel such groupings, favoring medical or surgical, conservative or aggressive approaches, with varying gradations in between. we describe a rare site of occurrence of a common childhood malignancy together with the concomitant difficulties inherent in making decisions in situations with few or no precedents. case report a 3-year-old male from caloocan city was observed by his parents to have a hard, nonpainful, non-movable 1x1cm right mandibular mass four months before admission. there were no other symptoms of fever, cough, colds, trismus, or malocclusion. the mass progressively enlarged to 7x5cms, resulting in gross facial asymmetry with no skin involvement. intra-orally, it extended into the gingivobuccal gutter and floor of the mouth. there embryonal rhabdomyosarcoma of the mandiblerodante a. roldan, md 1, erasmo gonzalo dv llanes, md 2,3, romeo l. villarta md, mph 2,3 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila 3department of otolaryngology head and neck surgery quirino memorial medical center correspondence: rodante a. roldan, md department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 phone: (632) 526 4360 fax: (632) 525 5444 email: dante_roldan@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this report. presented at the interesting case contest (1st place) philippine society of otolaryngology – head and neck surgery midyear convention, puerto princesa city, palawan, april 2005. philipp j otolaryngol head neck surg 2006; 21 (1,2): 37-39 c philippine society of otolaryngology – head and neck surgery, inc. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 case reports philippine journal of otolaryngology-head and neck surgery 37 were no carious teeth, and the overlying dentition was non-mobile and undisplaced. at this time, a 2x3cm firm, irregularly shaped, non-tender, slightly movable mass in the submental area was also noted. a panoramic radiograph revealed a unilocular radiolucent cystic mass, associated with an unerupted tooth and the roots of the first and second premolars on the right, extending from the para-symphyseal area to the second premolar on the right. scalloping of the mandible at the cyst borders was also noted (figure 1). the patient was admitted for an excisional biopsy with the primary impression of an odontogenic tumor. the mass was exposed via a gingival incision through the dental papilla and a mucoperiosteal rhomboid flap. it measured 7.5 x 4.5 x 2 cms, with a thick fibrous capsule. there were no cystic areas, and no evidence of bony erosion (figure 2). en bloc excision with removal of the first and second right mandibular premolars and the embedded unerupted tooth was performed, leaving a thin rim of mandible intact. the firm, nodular submental mass with cream, white, and tan areas was excised transorally superior to the mylohyoid muscle. antibiotic-impregnated gauze was packed into the defect, and removed after six days when the alveolar-mucosal defect was closed under general anesthesia. final histopathologic report was embryonal rhabdomyosarcoma for both mandibular and submental masses. the patient was referred to the pediatric hematology-oncology and the radiation-oncology services for further management. discussion rhabdomyosarcomas are the most common sarcomas in children, accounting for 4-8% of all malignant lesions in those younger than 15 years of age1. of the four principal histologic types (embryonal, alveolar, pleomorphic, and botyroid), embryonal rhabdomyosarcoma is the most common and occurs mainly in children younger than 12 years of age. slightly more boys than girls are affected, with the incidence higher in caucasians than in black or asian children 1, 2. the clinical presentation varies with the anatomic site 1, 2, usually presenting in less than a year as a painless, rapidly growing mass. histologically, rhabdomyosarcomas arise from precursors of striated muscle. appearances vary, ranging from primitive-appearing lesions with virtually no evidence of muscle differentiation, to those containing numerous strap-shaded cells with cross-striations1. genetically, there is loss of heterozygosity at the 11p15.5 locus, and loss of maternal with duplication of paternal-chromosomal material3, 4. they are most commonly seen in the head and neck (38%), urogenital (21%), extremities (18%), trunk (7%), and retroperitoneum (7%)1. in nonparameningeal head and neck sites, primary tumors involve the orbit, pharynx, and soft tissues of the head and neck, in decreasing order of frequency 1. in a 23-year review of 11,250 head and neck cancer cases by gorsky, there were 139 cases (1.24%) of sarcoma; and of these, there were only 16 cases (0.14%) of intra-oral soft tissue sarcoma6. dito and batsakis found only 6 out of 170 cases (3.5%) of rhabdomyosarcoma occurring in figure 1. panoramic radiograph showing unilocular cystic mass. note scalloping of the mandible at cyst borders. figure 2. a clay model showing the tumor in situ. figure 3. gross specimen measuring 7.5 x 4.5 x 2 cm. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 case reports 38 philippine journal of otolaryngology-head and neck surgery the mandible7. a review of 16 cases by bras et al, reported an embryonal rhabdomyosarcoma involving the jaw7. a similar case of an intra-osseous rhabdomyosarcoma of the mandible was reported by loducca et al in sao paulo, brazil5. table 1 shows the similarities and differences between loducca’s patient and ours. both cases belonged in the pre-school age group, exhibited symptoms for less than 1 year, appeared primarily as a bony lesion involving the body of the right hemi-mandible, had similar embryonal type rhabdomyosarcomas, but different radiographic appearances (“moth-eaten” versus unicystic with scalloped borders). how do rhabdomyosarcomas, which by definition arise from striated muscle, occur in bone? the histogenesis of this tumor may support its development in areas in which striated muscle is absent. rhabdomyosarcomas are thought to arise from stores of undifferentiated mesenchyme with the potential for rhabdomyoblastic differentiation. it may also arise from embryonal muscle tissue that was trapped during the early phases of tissue development. the molecular pathways involved in the pathogenesis of rhabdomyosarcoma are still being investigated. preliminary studies suggest that mutations may upset the balance between proliferation and differentiation of primitive mesenchymal tissue in the subverted myogenesis and development of rhabdomyosarcoma5. embryonal rhabdomyosarcoma may also undergo inactivation of one or more tumor suppressor genes as shown by the loss of heterozygosity for multiple closely linked foci at chromosome 11p15.5 3, 4. our experience suggests that not all radiolucent mandibular tumors associated with an unerupted tooth are odontogenic. more aggressive disease may exist despite scalloped tumor borders on radiographs, especially with the presence of nodal involvement. with the paucity of data on a standard or classic radiographic appearance of intraosseous rhabdomyosarcomas, the diagnosis may be missed if the patient and his disease are not considered as a whole. figure 4. gross appearance of the submental mass, 2 adjacent masses, measuring an aggregate diameter of 1.75 x 1.5 x 1 cm. table 1. two cases of intraosseous embryonal rhabdomyosarcoma loducca et al 6-year-old female painful mandibular swelling with a rapid increase in size 1-month gross facial asymmetry with skin swelling, no changes in skin color or temperature painful, firm mass that seemed to be intraosseous, involving the right body of the mandible, measuring ~30mm (+) trismus (-) oral mucosal involvement destruction of the body of the mandible, with irregular limits, and a “moth-eaten” appearance embryonal rhabdomyosarcoma roldan et al 3-year-old male hard, non-painful, nonmovable right mandibular mass 4 months gross facial asymmetry with skin swelling, no changes in skin color or temperature non-painful mass on the right body of the mandible, extending into the gingivobuccal gutter and floor of mouth, measuring ~7x5cms (-) trismus (-) oral mucosal involvement unicystic mass with scalloped borders, extending from the para-symphyseal area to the second premolar on the right embryonal rhabdomyosarcoma patients symptoms duration of symptoms physical examination panoramic radiograph findings final histopath references: 1. thawley se, et al.: dental and jaw tumors. comprehensive management of head and neck tumors. 2nd edition. wb saunders. 1999. usa. 2 arndt ca, crist wm: common musculoskeletal tumors of childhood and adolescence. n engl j med 1999 jul 29; 341(5): 342-52. 3 merlino g, helman lj: rhabdomyosarcoma--working out the pathways. oncogene 1999 sep 20; 18(38): 5340-8. 4 barr fg: molecular genetics and pathogenesis of rhabdomyosarcoma. j pediatr hematol oncol 1997 nov-dec; 19(6): 483-91. 5 loducca sv, et al.: intraosseous rhabdomyosarcoma of the mandible: a case report. int j surg pathol 2003 jan;11(1):57-60. 6 gorsky m, epstein jb: head and neck intra-oral soft tissue sarcomas. oral oncol 1998; 34:292296. 7 sekhar ms, et al.: alveolar rhabdomyosarcoma involving the jaws: a case report. j oral maxillofac surg 2000; 58:1062-1065. 34 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports abstract objective: to report two cases of mucosal melanoma of the sinonasal cavity from india and review the literature emphasizing current important clinical and biologic aspects of this tumor. methods: design: case report setting: tertiary public referral hospital patients: two results: two patients presenting with progressive unilateral nasal obstruction over three to six months, respectively, were diagnosed to have sinonasal mucosal melanoma. the mass involved the nasal cavity and maxillary antrum in both patients. the first patient deferred radiotherapy for four months until pulmonary metastasis became evident, necessitating palliative chemotherapy; the second patient underwent surgical excision and radiotherapy. conclusion: in spite of aggressive therapy, the prognosis for people with mucosal melanoma is extremely poor. surgery remains the mainstay of treatment, although adjuvant radiation therapy has recently had an increasing role in the treatment of mucosal melanoma. a clear understanding of the pathophysiology of this disease may yield more specific immunotherapy and chemotherapy techniques. a multicenter prospective study is required to objectively assess the optimal treatment regimen. keywords: mucosal melanoma, sinonasal cavity worldwide the incidence of melanoma has increased over the past 30 years and continues to do so at an alarming rate, with the number of cases increasing by almost 5% annually.1 although the head and neck accounts for only 9% of total body surface area, as many as 15-25% of all melanomas arise in the head and neck. head and neck melanomas more commonly occur in men (2:1), with a median age at diagnosis of 55 years.2 non-cutaneous melanomas are relatively rare lesions. in the head and neck, the commonest sites for mucosal malignant melanoma are the oral cavity (49%), followed by sinonasal (40%) and pharyngeal (11%) involvement.3 the malignant mucosal melanoma of the nasal cavity and paranasal sinuses is a rare tumor of unknown etiology, unpredictable biologic behavior and poor prognosis.4 we present two such cases and review the literature. sinonasal mucosal melanoma: an enigmahidayat ullah, mbbs, ms 1 mirza qaisar baig, mbbs, md2 1department of ent and 2radiotherapy, brd medical college, gorakhpur, india correspondence: dr hidayat ullah house no 4m, semra no 1 chargawan gorakhpur, uttar pradesh india 273409 drhidayatullah@gmail.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (1): 34-38 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 35 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports case reports case 1 a 32-year-old indian male farmer came to the otolaryngology ward complaining of left nasal obstruction for about three months. gradual in onset, the obstruction progressively became complete about 15 days prior to this visit. he also complained of mucoid, clear rhinorrhoea for the past month that was not blood-tinged. there was no epistaxis, nor associated pain or numbness in the facial region. on anterior rhinoscopy an irregularly-surfaced, polypoidal, non-ulcerated black mass was visible in the left nasal cavity with surrounding secretions (figure 1). the mass was insensitive on palpation and did not bleed on probing. on endoscopy, it appeared to arise from the lateral wall of the nasal cavity, in the region of the middle meatus, with no apparent involvement of the choanae or nasopharynx. there was no apparent neck swelling and no palpable cervical lymph node enlargement. a biopsy was suggestive of a malignant melanoma (figure 2) and computed tomography (ct) showed a mass in the left nasal cavity extending to the maxillary antrum on the left side with no signs of bony or cartilaginous destruction nor other sinus involvement (figure 3). a thorough search for distant metastasis was negative. a course of radiotherapy was advised but the patient only came back after four months with distant metastasis in the lungs. he is currently undergoing palliative chemotherapy. case 2 a 45-year-old male trumpet player, born and residing in india came to the otolaryngology clinic complaining of left nasal obstruction for about six months. the nasal obstruction was gradual in onset and had progressed slowly causing complete obstruction for 60 days, without complaints of epistaxis, rhinorrhoea or pain. on examination, a smooth, dry black mass was visible coming out of the left nasal cavity and expanding the vestibule (figure 4). it was insensitive on palpation and did not bleed on probing. it appeared to be arising from the nasal floor, completely filling the nasal cavity anteriorly, causing widening of the nasal ala. however, the choanae appeared free on posterior rhinoscopy. a biopsy revealed malignant melanoma and the ct scan showed an extensive mass involving maxillary antrum and nasal cavity with no signs of bony or cartilaginous destruction (figure 5). a thorough investigation for distant metastases was negative. the mass was excised by lateral rhinotomy approach and a course of radiotherapy was given. however, the patient died due to systemic metastasis after 15 months. discussion fifteen to twenty five percent of all malignant melanomas occur in the head and neck and of these, 6-8% involve the mucous membranes figure 1. photograph of first patient showing a black polypoidal mass in the left nasal cavity on anterior rhinoscopy. figure 2. histopathologic slide, haematoxylin and eosin stain (h & e) low power view (40 x) showing melanocytes infiltrating nasal mucosa. of the aerodigestive tract.5 in the head and neck, the commonest sites for mucosal malignant melanoma are the oral cavity (49%), followed by sinonasal (40%) and pharyngeal (11%) involvement.1 malignant melanomas of the nasal cavity and the paranasal sinuses are uncommon, accounting for less than 1% of all malignant mucosal melanomas and 2-8% of all malignant neoplasms of the sinonasal tract.5 holdcraft and gallagher6 cited studies of sinonasal melanoma as representing 0.60.7% of all melanomas, 2-9% of melanomas of head and neck and 3.6-4% of all nasal tumors. the incidence of cutaneous malignant melanoma is currently rising (haematoxylin-eosin, 40x). 36 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports remarkably stable over the last several decades.3 most patients are older than 50 years at the time of diagnosis, the mean age of presentation being 60-70 years.6,8 only 10-20% occur in individuals younger than 50 years, as with both our patients. most patients are white but 5-16% are black.6 unlike its cutaneous counterpart, exposure to sunlight is not an etiologic factor for mucosal melanoma. there are however sporadic reports of mucosal malignant melanomas associated with preexisting melanosis or occurring somewhat more frequently in ugandan africans, suggesting possibilities that ectopic melanin production and race may be important factors. calderon-garcideunas et al.9 assessed 256 cases of nasal and paranasal sinus neoplasms, considering the idea that the etiology of these tumors may be related to air pollution in large cities, which could damage nasal respiratory epithelium dna, although epidemiological studies have failed to prove this association. mucosal melanomas of the sinonasal tract are thought to arise from the melanocyte precursors normally present within the mucosa, and occur more often in the nasal cavity than the sinuses, as in the case of both our patients. in a collective review of 407 cases, 73% arose in the nasal cavity, 19% in the sinuses and 8% involved both areas.6,9 the most common site of origin within the nose is the nasal septum, followed by the inferior and middle turbinates. however, it is often difficult, particularly in bulky lesions to determine the exact site of origin.10 when confined to the sinuses, the maxillary sinus is the most commonly involved, followed by the ethmoids. the frontal and sphenoid sinuses are rarely affected.6 figure 3. computed tomography (ct) scan of paranasal sinuses, axial view, shows a mass in the left nasal cavity extending to the maxillary antrum on the left side with no signs of bony or cartilaginous destruction figure 4. photograph of second patient showing a black mass coming out of the left nasal cavity. figure 5. ct scan of paranasal sinuses, coronal view showing an extensive mass involving maxillary antrum and nasal cavity with no signs of bony or cartilaginous destruction. faster than any other cancer and has become an important public health problem. according to rigel,7 the lifetime risk of an individual in the united states to develop cutaneous malignant melanoma was 1:1500 in 1935. by 1980, the risk had increased to 1:250 and by 1991 it was 1:105. in contrast the trend of mucosal melanoma has remained philippine journal of otolaryngology-head and neck surgery 37 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports stammberger et al.11 found involvement of the maxillary sinus in 47%, ethmoidal sinus in 18%, frontal sinus in 14%, nasal cavity in 14% and sphenoid sinus in 7% of all cases. because most of the mucosal melanotic lesions are painless in their early stages, the diagnosis is unfortunately often delayed until symptoms resulting from ulceration, growth and or epstaxis are noted.4 on physical examination, the tumors are sessile or polypoid, pink, white, brown, or black and average 1-4 cm.8 bone destruction may or may not be apparent on radiological imaging. up to 20% have positive cervical lymph node metastasis, especially around the submandibular gland.8 biopsy is confirmatory; immunohistochemistry can be helpful. the traditional histologic staging for cutaneous melanoma (e.g., clark level) cannot be applied to the mucosa because the mucosa lacks histologic landmarks analogous to papillary and reticular dermis. breslow thickness, the single most important histologic prognostic factor in localized cutaneous melanoma, has not been found to be useful in head and neck mucosal melanoma.12–14 mucosal melanoma is one of the great mimickers in pathology. under appropriate conditions it can be mistaken for a variety of tumors. this is especially true in the sinonasal tract where the tumor is rare, often fails to show junctional activities, frequently is amelanotic and occasionally grows in spindle pattern.15 mucosal melanomas of the sinonasal tract resemble their cutaneous counterparts and, as such, are composed of epitheloid or spindle cells arranged in small clusters or sheets. mitoses, pleomorphism, intranuclear inclusions of cytoplasm, necrosis, and lymphatic, vascular, and perineural invasion are additional, although inconsistent features.16 ten to thirty percent of tumors are also amelanotic, requiring special tissue stains (warthin-starry, s-100 protein, hmb-45) and a high index of suspicion for diagnosis.17 the treatment of choice in mucosal melanoma is a combination of surgery and radiation. once considered radio-resistant, radiotherapy is now recognized as an important adjuvant and may even have merit as a primary modality.18.19 owens et al. did a comparable study at the university of texas md anderson cancer center and showed that the addition of radiotherapy decreased the rate of local disease recurrence but did not significantly improve survival.20 a retrospective study conducted by benlyazid et al. found that postoperative radiotherapy improves local control.21 lund et al.17 made a retrospective analysis of 58 individuals diagnosed with nasal mucosa melanoma, followed over a period of 23 years. the patients received surgery alone, surgery with radiotherapy, with or without chemotherapy, radiotherapy or chemotherapy alone. the authors did not see any improvement as far as survival rates are concerned, regardless of the therapeutic method employed, whether single or combined. the 5-year survival rate in head and neck mucosal melanomadiagnosed patients was estimated to be 14% according to a retrospective study carried out by manolidis et al.22the authors reported that the 5-year survival rate mentioned in the literature is 31%, if one considers the primary lesions of the nasal mucosa and it may drop down to zero in cases of primary tumors of the paranasal sinuses. stammberger et al.11 evaluated the possibilities and limitations of endoscopic nasal surgery in the treatment of malignant lesions. in the case of nose and nasal sinuses melanomas, five patients underwent endonasal surgery while two died between five and 14 months after surgery (patients in advanced stage and remote metastasis t4), and the longest survival was 34 months in one patient with local recurrence. a new therapy has been described as yielding benefits in the treatment of nasal mucosa melanomas. seo et al.23 reported three cases of this neoplasm in which hormonal chemotherapy led to a favorable clinical outcome. they used tamoxifen, an anti-estrogen chemotherapeutic agent that competes for the estrogen receptor. although its mechanism of action in mucosal melanomas has not yet been ascertained, the authors believe that this may prove to be one future option in the therapeutic approach to these lesions. immunotherapy in the form of bacillus calmette-guérin vaccine, dendritic cell vaccine or cytokines has been used as adjuvant therapy to treat isolated cases of mucosal melanoma, but with limited success.24,25 gene therapy is another area of active research.26 melanoma arising in the mucous membranes is a rare clinical entity. currently, despite aggressive therapy, the prognosis for people with mucosal melanoma is extremely poor. local treatment failure is a significant problem for most treated patients. local recurrence and distant metastases continue to be responsible for most treatment failures. surgery remains the mainstay of treatment although adjuvant radiation therapy recently had an increasing role in the treatment of mucosal melanoma. a clearer understanding of the biology of this disease process may yield more specific immunotherapy techniques. a prospective study is required to assess objectively the optimal treatment regimen. 38 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports references 1. harris tj, hinchley dm. melanoma of the head and neck in queensland. head neck surg. 1983 jan-feb; 5(3):197-203. 2. thorn m, adami h-o, rinborg u, bergstorm r, krusemo u. the association with anatomic site and survival in mucosal melanoma. an analysis of 2,353 cases from swedish cancer registry. eur j cancer clin oncol 1989 mar; 25(3):483-491. 3. conley jj. melanomas of the mucous membranes of the head and neck. laryngoscope 1989 dec; 99(12):1248-54. 4. huang sf, liao ct, kan cr, chen ih. primary mucosal melanoma of the nasal cavity and paranasal sinuses: 12 years of experience. j otolaryngol 2007apr; 36(2):124-9. 5. spiro jd, soo kc, spiro rh. non squamous cell malignant neoplasms of the nasal cavity and the paranasal sinuses. head neck. 1995 mar-apr; 17(2):114-118. 6. holdcraft j, gallagher jc. malignant melanomas of the nasal and paranasal mucosa. ann otol rhinol laryngol. 1969 feb; 78(1):5-20. 7. rigel ds. epidemiology and prognostic factor in malignant melanoma. ann plas surg. 1992 jan; 28(1):7-8. 8. kingdom tt, kaplan mj. mucosal melanoma of the nasal cavity and the paranasal sinuses. head neck. 1995 may-jun; 17(3):184-189. 9. calderón-garcidueñas l, delgado r, calderón-garcidueñas a, meneses a, ruiz lm, garza j, et al. malignant neoplasms of the nasal cavity: a series of 256 patients in mexico city and monterrey. is air pollution the missing link? otolaryngol head neck surg, 2000 apr; 122(4): 499-508. 10. bizon mj, newman rk. metastatic melanoma of the ethmoid sinus. arch otolaryngol head neck surg. 1986 jun; 112(6):664-7. 11. stammberger h, anderhuber w, walch c, papaefthymiou g. possibilities and limitations of endoscopic management of nasal and paranasal sinus malignancies. acta otorhinolaryngol belg. 1999; 53(3):199-205. 12. prasad ml, patel s, hoshaw-woodard s,escrig m, shah jp, huvos ag, busam kj. prognostic factors for malignant melanoma of the squamous mucosa of the head and neck. am j surg pathol. 2002 jul; 26(7):883–892. 13. prasad ml, busam kj, patel sg, hoshaw-woodard s, shah jp, huvos ag. clinicopathologic differences in malignant melanoma arising in oral squamous and sinonasal respiratory mucosa of the upper aerodigestive tract. arch pathol lab med. 2003 aug; 127(8):997–1002. 14. thompson ldr, wieneke ja, miettinen m. sinonasal tract and nasopharyngeal melanoma: a clinicopathologic study of 115 cases with a proposed staging system. am j surg pathol. 2003 may; 27(5):594–611. 15. nakhleh re, wick mr, rocomora a, swanson pe, dehner lp. morphologic diversities in malignant melanomas. am j clin patho. 1990 jun; 93(6):731-740. 16. chang es, wick mr, swanson pe, dehner lp. metastatic malignant melanoma with “rhabdoid” features. am j clin pathol. 1994 oct; 102(4):426-431. 17. lund vj, howard dj, harding l, wei wi. management options and survival in malignant melanoma of the sinonasal mucosa. laryngoscope. 1999 feb; 109(2):208-11. 18. harwood ar lawson vg. radiation therapy for melanomas of the head and neck. head neck surg 1982 jul-aug; 4(6):468-474. 19. trotti a, peters lj. role of radiotherapy in the primary management of mucosal melanoma of the head and neck. semin surg oncol 1993 may-jun; 9(3):246-250. 20. owens jm, roberts db, myers jn. the role of postoperative adjuvant radiation therapy in the treatment of mucosal melanomas of the head and neck region. arch otolaryngol head neck surg. 2003 aug; 129(8):864-8. 21. benlyazid a, thariat j, temam s, malard o, florescu c, choussy o, makeieff, m, poissonnet g, penel n, righini c, toussaint b, guily j l, vergez s, filleron f. postoperative radiotherapy in head and neck mucosal melanoma : a gettec study. arch otolaryngol head neck surg. 2010 dec;136(12):1219-1225. 22. manolidis s, donald pj. malignant mucosal melanoma of the head and neck: review of the literature and report of 14 patients. cancer. 1997 oct; 80(8):1373-86. 23. seo w, ogasawara h, sakagami m. chemohormonal therapy for malignant melanomas of the nasal and paranasal mucosa. rhinology. 1997 mar; 35(1):19-21. 24. nguyen np, levinson b, dutta s, karlsson u, alfieri a, childress c, sallah s. concurrent interferon-α and radiation for head and neck melanoma. melanoma res 2003 feb; 13(1):67–71. 25. yannelli jr, wroblewski jm. on the road to a tumor cell vaccine: 20 years of cellular immunotherapy. vaccine 2004 nov; 23(1):97–113. 26. liu m, acres b, balloul jm, bizouarne n, paul s, slos p. gene based vaccines and immunotherapeutics. proc natl acad sci usa. 2004 oct; 101:14567–71. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 case reports 18 philippine journal of otolaryngology-head and neck surgery abstract objective: to report a case of fractured tracheotomy tube ingestion in a pediatric patient, discussing the clinical presentation, complications and management of tracheobronchial tree versus upper digestive tract foreign bodies. methods: design: case report setting: tertiary private hospital patient: one result: a 4-year-old male child with unusual hypersensitivity to routine tracheotomy suctioning was discovered to have a fractured tracheotomy tube. emergency radiographs localized the cannula in the abdomen and bronchoscopy was deferred. the foreign body was eventually passed out after four days. conclusion: due diligence in diagnostics prior to bronchoscopy led to the avoidance of an unnecessary and sometimes complicated procedure. in developing countries with poor access to health care, the importance of regular tracheotomy follow-ups and periodic replacement cannot be overemphasized. a search of the english literature using pubmed and ovid search engines with keywords tracheostomy, foreign bodies and pediatrics confirms that this is the first reported accidental ingestion of a fractured tracheotomy tube in a pediatric patient. key words: tracheostomy, complications, foreign bodies, pediatrics tracheotomy is one of the most commonly performed surgical procedures for airway management. among its rarest complications is tracheotomy tube breakage and aspiration of various components into the tracheobroncial tree.1,2 to our knowledge, there are no reports of subsequent ingestion of a fractured tracheostomy tube component in the english literature. we report the first such case in a pediatric patient with a long-standing tracheotomy tube. case report an 8-month-old boy diagnosed with muscular dystrophy underwent tracheotomy for long-term ventilator support. his follow-up visits were few and far between and the originally-inserted shiley® (tyco healthcare group lp in pleasanton, ca) pediatric size fractured tracheostomy tube ingestion in a pediatric patient michie jay d. simtoco, md1 samantha soriano–castaneda, md1,2,3 daniel m. alonzo, md1 maria rina t. reyes-quintos, md, mclinaud1,4 1 department of otolaryngology head and neck surgery the medical city 2department of otolaryngology head and neck surgery rizal medical center 3department of otolaryngology head and neck surgery jose reyes memorial medical center 4department of otorhinolaryngology college of medicine philippine general hospital university of the philippines manila correspondence: michie jay d. simtoco, md department of otolaryngology head and neck surgery the medical city ortigas avenue, pasig city 1600 philippines telefax: (+632) 687 3349 email: mjaymd@gmail.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interests with any organization that may have direct interest in the subject matter of this manuscript, or in any product used or cited in this report. presented at the interesting case contest, philippine society of otolaryngologyhead and neck surgery convention, cagayan de oro city may 2, 2008. philipp j otolaryngol head neck surg 2009; 24 (1): 18-20 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 case reports philippine journal of otolaryngology-head and neck surgery 19 3 tracheostomy tube had never been replaced until we saw him at 4 years of age. a few hours prior, he was noted to be unusually hypersensitive to routine tracheostomy tube suctioning. the mother lifted the tracheostomy tube slightly to adjust it and discovered that the cannula was missing. thinking the broken tube may have been coughed out, a thorough search was conducted in the vicinity, but it was nowhere to be found and he was rushed to the emergency room. no coughing or stridor was observed. on admission, the boy was comfortable with stable vital signs and oxygen saturations of 95%-97%. he was slightly tachypneic with minimal inspiratory stridor, shallow subcostal retractions and wheezing over both lung fields. the outer flange of the tracheostomy tube was in place, but careful lifting confirmed that the cannula was missing. (figures 1 and 2) thinking the fractured cannula could be in the airway, preparations were made for emergency bronchoscopy, including routine chest radiographs. to everyone’s surprise, they revealed the tracheotomy tube cannula in the left upper quadrant of the abdomen (figures 3 and 4). surgery was deferred and the child was observed until the cannula was passed out in the stool six days later. a modified barium swallow after four weeks was normal (figures 5 and 6). in retrospect, the mother recalled that there had been unusual resistance on routine suctioning of the tracheotomy tube beginning one week prior to the incident. discussion tracheostomy is one of the oldest surgical procedures, and over the past decade has become the method of choice in management of patients with an impaired airway.3 despite extra care and meticulous surgical technique, tracheostomy holds a complication rate of 5% to 40%.4 categorized as late onset complications are suprastomal granulation tissue, tracheal stenosis/subglottic stenosis, tracheoesophageal fistula and, as in our case, a fractured tracheotomy tube.5 fractures after prolonged usage longer than recommended may be due to mechanical (suctioning, cleaning, repeated removal) or chemical stress (corrosive cleaning fluids, alkaline figure 1. tracheotomy tube apparently in place (re-enactment) figure 2. fractured tube, flange without cannula figure 3. cannula in left upper quadrant of the abdomen (initial ap view) figure 4. cannula in left upper quadrant of the abdomen (initial lateral view) philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 case reports 20 philippine journal of otolaryngology-head and neck surgery bronchial secretions).1,6 it has also been suggested that chemicals from plastic tubes may leach out causing tissue reactivity.1 death has been reported following fracture of a silver tracheotomy tube attributed to corrosion between the plate and shaft.2 in our case, the prolonged usage for almost four years predisposed to fracture, which may have been initially signaled by the increased resistance on suctioning one week prior to the emergency. previously reported cases of tracheostomy tube fracture in infants and adults all resulted in airway (tracheal or bronchial) foreign bodies.1,2,6,7 choking and acute cough are the most common presenting symptoms and physical findings may range from reduced respiratory sounds, retraction from atelectasis, hyperdistension from obstructive emphysema to no changes at all.8 the classic triad of wheezing, coughing and unilateral reduced respiratory sounds occurs in most cases.9 on the other hand, esophageal foreign bodies may also present with coughing, vomiting, refractory wheeze, respiratory distress and stridor.10,11,12 ingested foreign bodies distal to the esophagus are mostly asymptomatic, 10, 11 but other patients may present with abdominal pain, vomiting, fever, hematochezia or melena.10 the fractured cannula, subcostal retractions and wheezing over both lung fields in our patient suggested aspiration. radiographs should be obtained prior to bronchoscopy even if they may appear normal in up to 50% of airway foreign bodies.13 in our case, they revealed the missing cannula in the abdomen and prevented unnecessary surgery as 90% of foreign bodies distal to the esophagus will pass spontaneously.12 most objects pass within four to six days of ingestion (as in our case), although some may take up to four weeks.10 weekly radiography and instructions to watch for passage of the object in stool are advised.10 the absence of a tracheoesophageal fistula (tef) in our patient corroborated by a normal modified barium swallow after four weeks, leaves us with no other explanation for this unusual case: the patient coughed out the fractured cannula and ingested it. in a developing country with limited access to health care, the importance of tracheotomy tube care and follow up cannot be overemphasized. prolonged tracheotomy tube usage beyond recommended periods become commonplace when socio-economic considerations prevent regular consultations and periodic replacement. we hope our experience prompts increased vigilance and helps prevent similar incidents. figure 5. barium swallow (ap view) entire length of esophagus shows normal distention no intrinsic lesion seen no unusual features noted figure 6. barium swallow (lateral view) -normal motility and mucosal pattern references 1. gana p, takwoingi y. fractured tracheostomy tubes in the tracheobronchial tree of a child. int j pediatr otolaryngol. 2000; 53 (1):45-48. 2. gupta sc. fratured tracheostomy tubes in the tracheobronchial tree: a report of nine cases. j laryngol otol. 1987; 101 (8): 861-867. 3. jackson c. tracheostomy. laryngoscope. 1909;19:285-290 4. waldron j, padgham nd, hurley se. complications of emergency and elective tracheostomy: a retrospective study of 150 consecutive cases. ann r coll surg engl 1990; 72 (4):218-220 5. cummings cw, flint pw, harker la, richardsons ma, schuller de, robbins kt, thomas jr, haughey bh. otolaryngol head neck surg. 2005; 106: 2441-2452 6. kumar ks, das k, dcruz aj. aspiration of a cryptic foreign body (tracheostomy tube flange). indian j pediatr 2004; 71 (12):1145-1146 7. okafor bc. fracture of tracheostomy tubes: pathogenesis and prevention. j laryngol otol. 1983; 97 (8):771-774 8. cataneo aj, cataneo dc, ruiz rl jr. management of tracheobronchial foreign body in children. pediatr surg int 2008; 24 (2): 151-156 9. wiseman ne. the diagnosis of foreign body aspiration in childhood. j pediatr surg 1984; 19 (5) :531-535 10. uyemura mc. foreign body ingestion in children. am fam physician 2005;72 (2) :287292 11. dashan a. management of ingested foreign bodies in children. j okla state med assoc 2001; 94 (6):183-6 12. eisen gm, baron th, dominitz ja, faigel do, goldstein jl, johanson jf, et al. guideline for the management of ingested foreign bodies. gastrointestinal endoscopy 2002; 55 (7) : 802-806 13. lone s, lateef m. foreign body in tracheobronchial tree. jk science. 2004; 6 (2): 77-80 philipp j otolaryngol head neck surg 2010; 25 (2): 6-13 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles 6 philippine journal of otolaryngology-head and neck surgery abstract objective: to compare the postoperative complications (narrowing of the enlarged canal and perichondritis) of a meatoplasty without conchal cartilage removal and more raw skin area (modified meatoplasty) versus a meatoplasty with conchal cartilage removal and less raw skin area (z meatoplasty) including other sequelae (hyperemia, formation of granulation tissue and discharge from the cavity) which may lead to complications in canal wall down post-auricular mastoidectomy. methods: design: concealed, randomized controlled clinical trial setting: tertiary public hospital patients: twenty-one ears of 19 patients with chronic suppurative otitis media (csom) undergoing postauricular open mastoidectomy (radical or modified radical mastoidectomy) between february to july 2009 were randomly assigned to undergo modified meatoplasty (group a: n=11 ) and z meatoplasty (group b:n=10). main outcome measures were postoperative rates of meatoplasty complications and mastoidectomy sequelae that may lead to complications on weeks 1, 2 and 4. results: on the first postoperative week, the z meatoplasty was associated with a higher incidence of hyperemia at the incision site [a: 36.4%, b: 90% (p <0.02)]. the specific complication of perichondritis or other sequelae (discharge from the cavity, granulation tissue) were no different in both types of meatoplasty. on the second postoperative week, the modified meatoplasty was associated with a higher incidence of narrowing of the canal (73% vs 20%) p<0.02; [rr = 3.64 (ci:1.00,13.23)] the only factor associated with this complication was the modified meatoplasty procedure itself [rr = 3.64 (ci: 1.00, 13.23)]. perichondritis and the sequelae of mastoidectomy (discharge from the cavity, granulation tissue) were no different in both types of meatoplasty. conclusion: among csom patients who underwent postauricular open mastoidectomy, the z meatoplasty was associated with a greater risk of hyperemia at the incision site than the modified meatoplasty in the first operative week. compared to the z meatoplasty, the modified meatoplasty was associated with greater risk of narrowing of the canal on the second postoperative week. keywords: meatoplasty, mastoidectomy, complications postoperative wound complications in modified meatoplasty vs zmeatoplasty in canal wall down mastoidectomy at a tertiary hospital: a randomized controlled trial ma. theresa l. gumban, rn, md natividad a. almazan, md, msc department of otorhinolaryngology head and neck surgery east avenue medical center diliman, quezon city, philippines correspondence: ma. theresa l. gumban, md department of otorhinolaryngology head and neck surgery 6th floor east avenue medical center east avenue, quezon city 1100 philippines phone: (632) 928-0611 loc 324 fax: 435-6988 email: eamc_enthns@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the analytical research contest, philippine society of otolaryngology head and neck surgery, glaxo smith kline (gsk) bldg. chino roces ave., makati city, philippines, october 21, 2009. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles philippine journal of otolaryngology-head and neck surgery 7 meatoplasty refers to surgically altering the shape or size of the external opening (meatus) of the external auditory canal. this portion of the ear canal is surrounded by cartilage. therefore meatoplasty is an operation on the skin and cartilage of the lateral one third of the external auditory canal. it is commonly done after performing mastoidectomy, regardless of approach.1 before meatoplasty was developed by stacke (1893) and schwartze (1893) followed by panse, korner, ballance and siebermann, the intentional creation of a postaural fistula after mastoidectomy was often done to facilitate management of the unsafe and diseased ear, such as in cases of sinus thrombosis and brain abscess.2 many papers have been published on different types of meatoplasty, showing the advantage of each in creating a wide meatoplasty necessary for a mastoidectomy, entailing removal of conchal cartilage, suturing it backwards, meatal packing or combinations thereof to facilitate a dry, clean, or easy to clean cavity.3-9 however, there are very few papers that discuss the postoperative complications of meatoplasty. complications of meatoplasty include infection manifested by perichondritis, infected granulation tissue and foul discharge. these may cause narrowing of the external canal and eventual stenosis. in one study, z meatoplasty had a 4% incidence of perichondritis (1 in 24 ears) and 12% incidence of canal stenosis (3 in 24 ears).10 a pubmed search using the terms “meatoplasty, complications” did not reveal any data regarding complications of modified meatoplasty. this paper aimed to compare the postoperative complications between z meatoplasty which entails removal of the conchal cartilage and healing by primary intention and modified meatoplasty which preserves the conchal cartilage and heals by secondary intention for patients with chronic suppurative otitis media undergoing canal wall down mastoidectomy via a postauricular approach. materials and methods nineteen patients (9 males and 12 females aged 15-46 years) diagnosed with chronic suppurative otitis media who underwent postauricular canal down mastoidectomy from february 2009 to july 2009 were included in the study, which was conducted in accord with the helsinki declaration of 1975. fifteen patients were admitted at the out patient department (opd), three patients at the emergency room (er) and one patient was referred from the department of surgery. two of these patients underwent bilateral mastoidectomy making a total of 21 ears to include in the study. patients with congenital or acquired external ear abnormalities were excluded. randomization after approval from the department, separate informed consents for mastoidectomy and inclusion in the study were obtained from the patients or their legal guardians. patients were randomly assigned to undergo meatoplasty with the modified meatoplasty or the z meatoplasty. randomization was performed in blocks of two groups. twenty one pieces of paper numbered 1 to 21 were placed in a bowl and surgeons were asked to draw one piece of paper each to determine the type of meatoplasty to be performed. the trial was concealed with one author holding the list of randomly assigned numbers to either modified meatoplasty or z meatoplasty. this was accomplished using an internet-based research randomizer program (social psychology network, connecticut; usa).11 the authors then informed each surgeon what type of meatoplasty to use. variables the surgeons included in this study had the same level of competency in residency training, but none had performed either modified meatoplasty or z meatoplasty in previous mastoidectomies. learning curves were not accounted for, as a pre-randomization training was not conducted. only one author assessed the variables studied. procedure modified meatoplasty12 a modification of the fisch meatoplasty5 was employed with a 12 o’clock endaural incision without removal of conchal cartilage and allowing healing by secondary intention. the incision is made in the fundus of the external auditory canal at 12 o’clock position, extending radially towards the root of the helix, turning 90 degrees to the direction of the concha, approximately 1.5 to 2cm without overpassing the helix (figure 1). the incision includes the full thickness of the external auditory canal and concha, creating a triangular flap with inferior and lateral base (figure 2). the flap, consisting of skin, soft tissue, cartilage and perichondrium is then rotated in a posterior and inferior direction, then sutured to the digastric muscle using vicryl 3-0 (ethicon, johnson & johnson: somerville, new jersey usa) (figure 3).1 in our study, the authors opted to suture the flap to the soft tissue on the deep surface of the pinna using chromic catgut 3-0 (ethicon, johnson & johnson: somerville, new jersey usa) due to financial constraints. z meatoplasty first described by fagan in 19984 and modified by murray in 200013 for use in endaural approach, tunkel10 in 2006 utilized the z meatoplasty for a postauricular approach mastoidectomy on 24 ears in children with an 87.5% success rate. complications noted in 12.5% (3 ears) were postoperative perichondritis and canal stenosis. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles 8 philippine journal of otolaryngology-head and neck surgery the incision is made along the posterior and inferior conchal borders and along the posterior ear canal meatus (figure 4). a flap of conchal skin just above the perichondrium is elevated posterosuperiorly. a posterior canal flap is also made above the perichondrium, this creates an inferiorly based flap. the conchal and posterior external canal cartilage are excised along with underlying soft tissue (figure 5). the conchal skin flap is then rotated medially and sutured to the deep surface of the pinna using chromic catgut 3-0. the posterior canal flap is rotated laterally and sutured to the edge of the inferior conchal incision using chromic 3-0 (ethicon, johnson & johnson: somerville, new jersey usa) (figure 6).10 chlorhexadine acetate 0.5% tulle gras dressing bp (para-tulle®. cotton craft (pvt.), ltd. lahore, pakistan) or 1% soframycin (framycetin sulfate) lano-paraffin (anhydrous lanolin 9.95%) gauze dressing bp (sofra-tulle®. sanofi-aventis: mumbai, india) gauze dressing was utilized as a mastoid cavity pack based on availability. postoperative evaluation: patients were followed up on the first and second week post surgery. the following parameters were observed by a single author: 1) presence of hyperemia, discharge from the external canal or granulation tissue and 2) narrowing of the meatus and/or perichondritis. statistical analysis: post hoc computation of the estimation of the study sample size was based on the proportion of the variable, narrowing of the external auditory canal. the sample size was sufficient to make an analysis based on the computed 8 ears per group: group a (modified meatoplasty) and group b (z meatoplasty). randomly assigning 21 patients to each group would allow detection of this difference in rate of narrowing of the canal complication rate with 80% power and a 2-tailed significance level of 0.5. no interim analysis was performed. all patients were analyzed in the group to which they were randomly assigned according to the intention-to-treat principle. (appendix) data was encoded and tallied in spss version 10 for windows (ibm; chicago, illinois, usa). descriptive statistics were generated for all variables. for nominal data, frequencies and percentages were computed while mean ± sd were generated for numerical data. comparison of the different variables was performed using the t test, fisher exact test and chi-square test. relative risk (rr) based on confidence intervals was also computed for the variablenarrowing of the external ear canal. each sequela or complication was analyzed in the first, second and fourth week postoperatively. all p values were based on two-tailed figure 1. endaural incision extending to root of helix, turning 90 degrees to concha. adapted from: almario je, lora jg, prieto ja, correa a. modified meatoplasty surgical technique for canal wall down mastoidectomy. grupo médico otológico. 2005. [cited 2009 sep]: [about 3 p.] available from: http:// www.susmedicos.com/ articulos_otologia_modified-meatoplasty.htm figure 2. triangular flap with inferior and lateral base. adapted from: almario je, lora jg, prieto ja, correa a. modified meatoplasty surgical technique for canal wall down mastoidectomy. grupo médico otológico. 2005. [cited 2009 sep]: [about 3 p.] available from: http://www.susmedicos.com/ articulos_ otologia_modified-meatoplasty.htm figure 3. triangular flap, consisting of skin, soft tissue, cartilage and perichondrium rotated in a posterior and inferior direction, sutured to the digastric muscle. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles philippine journal of otolaryngology-head and neck surgery 9 figure 4. incision along posterior and inferior conchal borders and posterior canal meatus. adapted from: tunkel de. the z-meatoplasty for modified radical mastoidectomy in children. arch otolaryngol head neck surg. 2006 dec; 132(1):1319-1322 figure 5. a conchal skin flap elevated superiorly and inferiorly-based posterior canal flap. adapted from: tunkel de. the z-meatoplasty for modified radical mastoidectomy in children. arch otolaryngol head neck surg. 2006 dec; 132(1):1319-1322 figure 6. conchal skin flap rotated medially and posterior canal flap rotated laterally. adapted from: tunkel de. the z-meatoplasty for modified radical mastoidectomy in children. arch otolaryngol head neck surg. 2006 dec; 132(1):1319-1322 test of significance. the proportions of ears free of complications were compared between group a (modified meatoplasty) and group b (z meatoplasty). variables were considered significant at p<0.05. results a total of 21 ears were operated on, 11 had modified meatoplasty and 10 underwent zmeatoplasty. baseline characteristics were similar in the two groups (group a: modified meatoplasty and group b: z meatoplasty (table 1). these include sex, age and type of mastoidectomy. in group a, five (45.5%), were male and six (54.5%) were female and in group b, four (40%) were male and six (60%) were female (p=0.84). the mean ages for group a and b were 30 and 31 years old, respectively (p=1.0). there were two types of open mastoidectomy for both groups, the radical mastoidectomy and modified radical mastoidectomy. radical mastoidectomy was performed on eight ears (72.7%) in group a and four ears (40%) in group b, while modified radical mastoidectomy was performed on three ears (27.3%) in group a and six ears (60%) in group b (p=0.19). for co-morbidities of the disease (table 2), cholesteatoma was present in six (54.5%) and five (50%) in groups a and b, respectively; subperiosteal abscess was present in one (9.1% and 10%) in groups a and b, respectively; temporal lobe abscess was present in two (18.2%) and one (10%) in group a and b, respectively; and meningitis and facial paralysis were each present in one (9.1%) in group a with neither comorbidity present in group b. with regard mastoidectomy sequelae, mastoid cavity discharge (table 3) was not significantly different in groups a and b at all intervals of observation (first, second and fourth week). hyperemia (table 4) was significantly higher in group b (z meatoplasty) during the first week than in group a (modified meatoplasty) [a: 36.4%, b: 90% (p <0.02)]. there was no difference in formation of granulation tissue in groups a and b on the first, second and fourth week of observation (table 5). with regard actual complications of meatoplasty, perichondritis (table 6) was not statistically different in groups a and b at all observation intervals (first, second and fourth week) but external canal narrowing (table 7) was significantly higher in group a, modified meatoplasty with eight ears (72.7%) compared to group b, z meatoplasty with 2 ears (20%) at the second week of observation ( p<0.02) [rr = 3.64 (ci:1.00,13.23)]. discussion although fairly standard, meatoplasty is possibly the most neglected and often the worst performed part of the mastoid operation.3 an adequate meatoplasty more often than not makes up for a less than adequate bony exteriorization.3 the meatoplasty is necessary for the correct exteriorization and selfcleansing property of an open cavity and is made as large as required by the shape of the bony cavity. in a chart review by phelan et al.15 9 out of 37 cases (24%) had an inadequate meatus requiring revision mastoidectomy. similar studies by bercin16 and faramarzi17showed 14 out of 21 patients (66.7%) and 16 out of 53 (30%) respectively, while a study by yang and chiong18 found 10 out of 24 patients (42%) who philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles 10 philippine journal of otolaryngology-head and neck surgery table 1. comparison of the demographic characteristics between the modified meatoplasty and the z meatoplasty variables group a modified meatoplasty (n= 11) age (in years) mean ± sd sex male female type of mastoid surgery modified radical mastoidectomy radical mastoidectomy 30.09 ± 9.85 5 (45.5%) 6 (54.5%) 3 (27.3%) 8 (72.7%) group b: z meatoplasty (n=10) 31.00 ± 10.61 4 (40.0%) 6 (60.0%) 6 (60.0%) 4 (40.0%) p value 0.84 (ns) 1.00 (ns) 0.19 (ns) table 2. distribution of subjects according to comorbidity between the modified meatoplasty and the z meatoplasty comorbidity group a modified meatoplasty (n= 11) cholesteatoma (+) (-) meningitis (+) (-) subperiosteal abscess (+) (-) facial nerve paralysis (+) (-) temporal lobe abscess (+) (-) 6 (54.5%) 5 (45.5%) 1 ( 9.1%) 10 (90.9%) 1 ( 9.1%) 10 (90.9%) 1 ( 9.1%) 10 (90.9%) 2 (18.2%) 9 (81.8%) group b: z meatoplasty (n=10) 5 (50.0%) 5 (50.0%) 0 10 (100%) 1 (10.0%) 9 (90.0%) 0 10 (100%) 1 (10.0%) 9 (90.0%) p value 1.00 (ns) 1.00 (ns) 1.00 (ns) 1.00 (ns) 1.00 (ns) table 3. distribution of subjects according to discharge at different intervals between the modified meatoplasty and the z meatoplasty interval modified (n= 11) 1 week (+) (-) 2 weeks (+) (-) 4 weeks* (+) (-) 8 (72.7%) 3 (27.3%) 8 (72.7%) 3 (27.3%) 6 3 z (n=10) 8 (80.0%) 2 (20.0%) 6 (60.0%) 4 (40.0%) 2 6 p value 1.00 (ns) 0.66 (ns) 0.15 (ns) *p value at 4 weeks with intention to treat making the lost to ff-up neg= 0.18 p value at 4 weeks with intention to treat making the lost to ff-up pos= 0.19 p value at 4 weeks with intention to treat making the lost to ff-up pos/neg= 0.19 had radical mastoidectomy failed due to an inadequate meatus. in our study, third year residents completing their requirements for mastoidectomy procedures including the author who did the assessment were the main surgeons. although the surgeons each had nearly completed half the number of required mastoidectomies in their residency training program at the time of this study, none of them had previously performed either a modified or z meatoplasty nor had pre-randomization training been conducted. these should also be considered in assessing results of our study. while ear discharge that eventually dries up is an expected sequel of mastoidectomy, persistent and foul discharge after mastoidectomy may result from an inadequately drilled mastoid bowl, a high facial ridge and residual infection. although this was not assessed in our study, a common factor was the surgical procedure of radical mastoidectomy (which may also have been reflective of worse ears to begin with compared to those that needed modified radical mastoidectomy only). although the difference between the two groups was not significant, there was a trend of decreasing p value from the first week to the fourth week (p=first week, 1.00; second week, 0.66 and fourth week, 0.15). perhaps with a longer period of observation, the discharge would no longer be present as the cavity re-epithelialized. none of the discharge noted originated from the meatoplasty incision site. an inflammatory response starts with increased blood flow due to vasodilation, causing hyperemia; and increased vascular permeability leads to edema and a cascade of immune responses.19 reactive hyperemia is the transient increase in blood flow following a brief period of ischemia. influx of vasoactive substances in response to prolonged stress further contributes to this. the redness at the edges of the meatoplasty incision may represent the initial phase of revascularization, possibly exacerbated by more skin manipulation as seen on group b. in the first week, the incidence of hyperemia was found to be higher in group b (z meatoplasty) p<0.02. although there was a trend of decreasing hyperemia in the second week (90% to 40%), this was not statistically significant. perichondritis, an infection of the skin and tissue surrounding the cartilage of the outer ear presents with erythema, edema and exquisite tenderness.20 the most common causative organism is p. aeruginosa.21 in our study, perichondritis was found only in group a at the first week (18.2%) and second week (36.4%). interestingly, all of these patients had granulation tissue formation which may indicate a persisting inflammatory response to infection. incising but not removing cartilage and suturing it posteroinferiorly in group a may have increased the chance of exposure to ear discharge from the mastoid cavity contributing to perichondritis. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 philippine journal of otolaryngology-head and neck surgery 11 original articles table 4. distribution of subjects according to hyperemia at different intervals between the modified meatoplasty and the z meatoplasty interval group a: modified meatoplasty (n= 11) 1 week (+) (-) 2 weeks (+) (-) 4 weeks† (+) (-) 4 (36.4%) 7 (63.6%) 5 (45.5%) 6 (54.5%) 2 7 group b: z meatoplasty (n=10) 9 (90.0%) 1 (10.0%) 4 (40.0%) 6 (60.0%) 1 7 p value 0.02 (s) 1.00 (ns) 1.00 (ns) † p value at 4 weeks with intention to treat making the lost to ff-up neg= 1.00 p value at 4 weeks with intention to treat making the lost to ff-up pos= 1.00 p value at 4 weeks with intention to treat making the lost to ff-up pos/neg= 1.00 table 5. distribution of subjects according to granulation at different intervals between the modified meatoplasty and the z meatoplasty interval group a: modified meatoplasty (n= 11) 1 week (+) (-) 2 weeks (+) (-) 4 weeks§ (+) (-) 7 (63.6%) 4 (36.4%) 10 (90.9%) 1 ( 9.1%) 4 5 group b: z meatoplasty (n=10) 6 (60.0%) 4 (40.0%) 7 (70.0%) 3 (30.0%) 2 6 p value 1.00 (ns) 0.31 (ns) 0.61 (ns) § p value at 4 weeks with intention to treat making the lost to ff-up neg= 0.64 p value at 4 weeks with intention to treat making the lost to ff-up pos= 0.67 p value at 4 weeks with intention to treat making the lost to ff-up pos/neg= 0.65 table 6. distribution of subjects according to perichondritis at different intervals between the modified meatoplasty and the z meatoplasty interval group a: modified meatoplasty (n= 11) 1 week (+) (-) 2 weeks (+) (-) 4 weeks‡ (+) (-) 2 (18.2%) 9 (81.8%) 4 (36.4%) 7 (63.6%) 2 9 group b: z meatoplasty (n=10) 0 10 (100%) 0 10 (100%) 0 10 p value 0.48 (ns) 0.09 (ns) 1.00 (ns) ‡ p value at 4 weeks with intention to treat making the lost to ff-up neg= 0.48 p value at 4 weeks with intention to treat making the lost to ff-up pos= 0.64 p value at 4 weeks with intention to treat making the lost to ff-up pos/neg= 0.58 the conchal cartilage is an extremely elastic structure with uniform thickness in its upper two-thirds that gradually increases in thickness towards its inferior aspect.22 it is malleable but is not permanently distorted from its original shape with increasing stress. however, the strain of conchal cartilage is dependent on the abundance of elastic fibers and increases the flexibility of the cartilage in response to stress. simply, conchal cartilage is dependent on the elastic memory or cartilage recoil. narrowing of the meatoplasty was assessed by the capability to visualize the mastoid cavity. if the pinna had to be manipulated to view the cavity, the meatoplasty was considered inadequate. in group a (modified meatoplasty), resection of the skin at the superior edge and pulling of conchal cartilage inferiorly and posteriorly created a wide (albeit, inferoposteriorly-displaced) cavity. the subcutaneous tissue and cartilage adds bulk to the pulled-back concha and this may be the major factor for the 72.7% narrowing of the canal seen during the second week post operation. posterior rotation of the auricle may have been prevented by placing several sutures deep into the soft tissue more superiorly with retraction of the auricle anteriorly.18 suturing to the undersurface of the pinna instead of utilizing the digastric muscle obviated the need for additional sutures. insufficient extension of the incision towards the helical root and further modification of the surgical technique by substituting a weaker, more affordable chromic suture may also have contributed to the narrowing of the canal. in group b (z-meatoplasty), the conchal cartilage, perichondrium and soft tissues were removed and the skin sutured via z-plasty using chromic catgut with little skin tension. the relative risk of narrowing of the external auditory canal was 3.64 higher in group a than in group b on the second week of observation. this was the only variable with significant differences in the two groups on the second week (p<0.02). restoration of vascular integrity is part of the proliferative phase of healing and is termed angiogenesis. angiogenesis occurs as new capillary buds arising from intact vessels adjacent to the wound extend into the wound bed forming a capillary bed. to the naked eye, the capillary loops look like small granules, explaining the termgranulation tissue.23 granulation tissue first appears as pale, pink buds and as it fills with new blood vessels it becomes bright “beefy” red. as it covers the wound, this granulation tissue is very fragile and unable to withstand trauma which may cause bleeding and re-initiate the inflammatory process with laying down of excessive collagen. this results in poor elasticity and a less desirable scar.23 a mature phase eventually ensues whereby the granulation tissue forms a well developed fibrous plug lined by squamous epithelium,24 causing soft tissue stenosis. on the first and second week, both group a (63.6%, 90.9%) and philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles 12 philippine journal of otolaryngology-head and neck surgery group b (60%, 70%) had a high incidence of the development of granulation tissue. although group a had larger raw areas for healing by secondary intention, group b also developed granulation tissue. while this may reflect the normal healing process, it may also result from basically unclean mastoidectomy cavities exposing both groups to infection. whether the use of chlorhexidine tulle gras or soframycin gauze dressing had an effect on granulation tissue formation was not documented in this study either. the goal of surgery is to achieve primary intention healing with minimal edema, no serious discharge or infection without separation of wound edges and with minimal scar formation. in meatoplasty, surgical incisions are allowed to heal by delayed primary intention and the wound is initially left open. wound edges in this case are brought together at about 4-6 days before granulation tissue is visible.25 this method is often used after traumatic injury or “dirty” surgery. because of the presence of infection and excessive trauma or skin loss in mastoidectomy and meatoplasty, the wound edges come together naturally by means of granulation and contraction26 as seen in our cases. the natural healing process dictates that granulation tissues begin to be visible by the first week and as the aural pack is to be removed after one week, the template for the canal outline is also removed. this may explain the outgrowth of granulation tissue in the second week in both groups. group a (modified meatoplasty) had larger raw areas that allowed healing by secondary intention, promoting the outgrowth of more granulation tissue. additional trauma and contaminants brought about by egress of discharge from the mastoid may explain the increased number of ears with higher relative risks of developing narrowing of the canal after modified meatoplasty in group a, 3.64x higher than after z meatoplasty in group b. in the first week, the post operative complication of perichondritis and mastoidectomy sequelae of granulation tissue formation and mastoid cavity discharge showed no significant difference between the two groups. among csom patients who underwent postauricular open mastoidectomy, the z meatoplasty was associated with a greater risk of hyperemia at the incision site than the modified meatoplasty in the first operative week [a: 36.4%, b: 90% (p <0.02)]. compared to the z meatoplasty, the modified meatoplasty was associated with a greater risk of narrowing of the canal on the second postoperative week (73% vs 20%) p<0.02; [rr = 3.64 (ci:1.00,13.23)]. data collection was stopped due to the increasing number of patients who underwent modified meatoplasty having narrowing of the canal based on the intention-to-treat principle and revision surgery table 7. distribution of subjects according to narrowing at different intervals between the modified meatoplasty and the z meatoplasty interval group a: modified meatoplasty (n= 11) 1 week (+) (-) 2 weeks|| (+) (-) 4 weeks¶ (+) (-) 6 (54.5%) 5 (45.5%) 8 (72.7%) 3 (27.3%) 6 3 group b: z meatoplasty (n=10) 2 (20.0%) 8 (80.0%) 2 (20.0%) 8 (80.0%) 2 6 p value 0.18 (ns) 0.02 (s) 0.15 (ns) || at 2 weeks rr (z meatoplasty) 0.28 (0.08 – 1.00) rr (modified meatoplasty ) 3.64 (1.00 – 13.23) ¶ p value at 4 weeks with intention to treat making the lost to ff-up neg= 0.18 p value at 4 weeks with intention to treat making the lost to ff-up pos= 0.19 p value at 4 weeks with intention to treat making the lost to ff-up pos/neg= 0.19 p value at 4 weeks with intention to treat making the lost to ff-up worst/best= 0.02 (s) p value at 4 weeks with intention to treat making the lost to ff-up best/worst= 0.66 was offered to the four patients who had persistence of the narrowing after three months. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles philippine journal of otolaryngology-head and neck surgery 13 acknowledgment special thanks to the first author’s co-residents who performed the surgeries: sherlyn c. ng tsai, md, cristina s. nieves, md and carolynne f. unay, md, who also made the operative procedure illustrations. references 1. myers e, carreria r, eibling d, ferris r, gillman g, golla s. operative otolaryngology. 2nd ed.vol 2. philadelphia: w b saunders; 1997. p.1280. 2. sellars sl. the origins of mastoid surgery. s afr med j. 1974 feb 9; 48(6): 234-242. 3. raut vv, rutka ja. the toronto meatoplasty: enhancing one’s results in canal wall down procedures. laryngoscope. 2002 nov; 112(11): 2093-5 4. fagan p, ajal m. z-meatoplasty of the external auditory canal. laryngoscope. 1998 sep; 108:1421-1422 5. fisch u. tympanoplasty, mastoidectomy and stapedectomy. new york, ny: thieme; 2008. p 39 6. portmann m. “how i do it”—otology and neurotology. a specific issue and its solution. meatoplasty and conchoplasty in cases of open technique. laryngoscope. 1983 apr; 93(4):520-522 7. suskind dl, bigelow cd, knox gw. y-modification of the fisch meatoplasty. otolaryngol head neck surg. 1999 jul; 121 (1):126-7. 8. potsic wp, cotton rt, handler sd. surgical pediatric otolaryngology. new york. thieme medical publishers; 1997. p 54 9. sanna m, sunose h, mancini f. middle ear and mastoid microsurgery. new york thieme medical publishers: 2003. p 279 10. tunkel de. the z-meatoplasty for modified radical mastoidectomy in children. arch otolaryngol head neck surg. 2006 dec; 132(1):1319-1322. 11. research randomizer. connecticut: social psychology network; c1997-2010 [updated 2007; cited aug 26,2009]. available from: http://www.randomizer.org 12. almario je, lora jg, prieto ja, correa a. modified meatoplasty surgical technique for canal wall down mastoidectomy. grupo médico otológico. 2005. [cited 2009 sep]:available from: http://www.susmedicos.com/articulos_otologia_modifiedmeatoplasty.htm 13. murray dp, jassar p, lee msw, veitch dy. z-meatoplasty technique in endaural mastoidectomy. j laryngol otol. 2000; 114:526-527 14. cummings cw, flint pw, harker la, haughey bh, richardson ma, robbins kt, schuller de, thomas, jr, editors. cummings otolaryngology head and neck surgery, 4th ed. vol 4. philadelphia (pa): mosby, c2005. p3082. 15. phelan e, harney m, burns h. intraoperative findings in revision canal wall down mastoidectomy. ir med j. 2008 jan; 101(1):14. 16. bercin s, kutluhan a, bozdemir k, yalciner g, sari n, karamese o. results of revision mastoidectomy. acta otolaryngol. 2009 feb; 129(2): 138-141. 17. faramarzi a, motasaddi-zarandy m, khorsandi mt. intraoperative findings in revision chronic otitis media surgery. arch iran med. 2008 mar;11 (2): 196-199. 18. yang n, chiong c. results of radical mastoidectomy in the philippine general hospital. [monograph on the internet]. advanced science and technology institute (asti); c2009 [cited 2009 sep]. available from: http://202.90.159.173/gsdl/collect/actamedi/ index/assoc/hashdcce.dir/doc.pdf 19. sell s, max e. immunology, immunopathology and immunity. 6th edition, illustrated. new york. asm press; 2001. p 564 20. medline plus online encyclopedia. perichondritis. 2008 sep 8. [cited sep 2009]. available from: http://www.nlm.nih.gov/medlineplus/ency/article/001253.htm. 21. glasscock m, gulya a. glasscock-shambaugh surgery of the ear. chicago. pmph usa; 2003. p 346-347. 22. man-kai tang h. the conchal cartilage effect of its management on the size of the meatoplasty and the outcome of the open mastoidectiomy. thesis. published by university of hong kong. 2001 [cited sep 2009]. available from: http://hub.hku.hk/ handle/123456789/26623 23. sussman c, bates-jensen b. wound care: a collaborative practice manual for health professionals.3rd edition. philadelphia – baltimore. wolters kluwer – lippincott williams & wilkins. 2007; p.21. 24. gottrup f. wound closure techniques. j wound care. 1999; 8(8): 397-400. 25. thomas s. wound management and dressings. london, uk: pharmaceutical press;1990: p. 69-73 26. haberman r. middle ear and mastoid surgery. new york. thieme medical publishers; 2004. p. 189 appendix post hoc computation of the sample size based on proportion of narrowing alone where: n = is the number of subjects needed p1 = 72.7% = 0.727 (estimated proportion of complication in the modified meatoplasty) q1 = 1 – p1 = 1 – 0.727 = 0.273 p2 = 20% = 0.20 (estimated proportion of complication in the z meatoplasty) q2 = 1 – p2 = 1 – 0.20 = 0.80 p = (p1+p2)/2 = (0.727+0.20)/2 = 0.4635 q = 1 – p = 1 – 0.4635 = 0.5365 zα = 95% confidence level = 1.96 zβ= 80% power of the study = 1.28 n = 8/group philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 surgical innovations and instrumentation philippine journal of otolaryngology-head and neck surgery 27 abstract objective: to describe a novel harpoon design for a low cost, self retaining tympanostomy tube with applicator used in a 38-year-old female for otitis media with effusion. methods: a. study design: instrumental innovation/case report b. setting: tertiary hospital in metro manila results: the tympanostomy tube was inserted under endoscopic guidance within 10 seconds, remained in place for two months with relief of symptoms, and spontaneously extruded by the seventh month of follow-up. conclusion: the harpoon-designed tube with applicator provided ease of insertion and good anchorage in the tympanic membrane. maximizing the use of a stylet-needle as both perforator and applicator simplified the tympanostomy and ventilating tube insertion procedures into a single maneuver. key words: middle ear ventilation, tympanostomy tube insertion, grommet insertion, instrumentation the pathogenesis and natural history of middle ear disease were most strikingly altered with the reintroduction of practical, safe and effective middle ear pressure equalization tube (pet) by armstrong in 19541. otitis media with effusion (ome) is a common sequel of acute otitis media (aom). otalgia, aural fullness and hearing loss are the common complaints. oral antibiotics remain the treatment of choice for acute otitis media. over 90% of patients are clinically cured two weeks after the onset of therapy2,3. acute symptomatic failures are observed, in part due to antibiotic resistance, increasing tympanocentesis recommendations for culture purposes in aom4. for persistent effusion, the most commonly used treatment option for most patients is tube insertion5. myringotomy without tube insertion is not commonly recommended because of rapid closure of the tympanic membrane fenestration4. myringotomy with placement of ventilating tubes has become the standard of care for children with ome that has lasted more than three to four months and is unresponsive to conservative treatment6. tympanostomy tubes are highly effective for children and adults with middle ear effusion, with most remaining free of middle ear disease while the tubes remain patent and functional7. prolonged middle ear ventilation of approximately 6 to 12 months provided by most first line pets helps to restore the eustachian tubemiddle ear-mastoid complex to a more normal physiologic state, improving hearing and preventing infection8. because of prohibitive costs and inavailability of commercial tympanostomy tubes, it is common practice in our institution to fabricate myringotomy tubes from 18-gauge intravenous plastic catheters cut into 5 mm segments and heat-flanged over both ends. we describe a novel low-cost, self retaining harpoon tube with applicator that facilitates both tympanostomy and insertion into, as well as anchorage and retention in, the tympanic membrane. self-retaining harpoon tympanostonomy tube with applicator konrad p. aguila, md department of otorhinolaryngology-head & neck surgery jose r. reyes memorial medical center correspondence: konrad p. aguila, md department of otorhinolaryngology head & neck surgery jose r. reyes memorial medical center rizal ave., sta. cruz, manila 1003 philippines telefax: (632) 743-6921 e-mail: kon_eagle@yahoo.com reprints will not be available from the author. no funding support was received for this study. the author signed a disclosure that he has no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product cited in this report. presented at the surgical innovation contest (1st place) philippine society of otolaryngology head & neck surgery annual convention, westin philippine plaza hotel, pasay city, december 1, 2005. philipp j otolaryngol head neck surg 2007; 22 (1,2): 27-30 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 surgical innovations and instrumentation 28 philippine journal of otolaryngology-head and neck surgery to compute for the total cost in the production of one set of the device, the cost of one piece of iv catheter, one piece of tuberculin syringe and ¼ of the total amount in the fabrication of the tube were added giving a sum of php57.25. procedure: a. tympanostomy tube fabrication a 2 x 1cm. piece of aluminum foil was rolled around the intravenous plastic catheter about 1 mm from its tip to serve as guide, with the stylet needle used as stopper. the rim edge was smoothened with a sharp blade (figures 1 & 2). the rolled aluminum foil was slid further away to 2 mm from the catheter tip, and two slits 180o apart were cut into both sides of the catheter, each starting from the edge of the guide aluminum foil and extending 1 mm towards the tip. the stylet prevented each cut from extending to the other side of the catheter (figure 3). the flaps made on each proximal side of the catheter were then elevated and folded, and the distal side of the catheter was cut 5-7 mm from the tip, and the rim was flared over an open flame. alternately, two tongue depressors could be used as template, cutting a groove in both tongue depressors for the catheter to fit between them when placed together, exposing 2-3 mm of the tip to be flared. it could then be secured with a clip and heated over an open flame (figure 4). the procedure was repeated to fashion four tubes (figure 5). b. tympanostomy tube applicator set: a second 18 gauge intravenous plastic catheter was marked alongside the fabricated tympanostomy tube and cut at a point from the tip corresponding to the tube length. the stylet was reinserted into the intravenous catheter, and the cut portion of the intravenous catheter and fabricated tympanostomy tube were reinserted into the stylet (figure 6). after trimming excess portions of the intravenous catheter that could interfere with insertion (figure 7), the assembly was attached to a tuberculin syringe to serve as handle (figure 8) and soaked for 30 minutes in glutharaldehide 2% (glutharex™ 3m, columbia) for sterilization then rinsed with sterile distilled h20. note that the tube’s end was modified into a harpoon-like structure which was incorporated into the tip of an intravenous catheter system to become a self-retaining tympanostomy tube with applicator. using the attached tuberculin syringe as a handle, the metal stylet of the intravenous catheter was designed to puncture the tympanic membrane and facilitate tube insertion in one motion. the arrowfigure 1: aluminum foil used a guide figure 2: smoothened edge figure 3: make a slit 180o apart figure 4: tongue depressors as template in burning one end to make a flare end figure 5: finished product of a tympanostonomy tube figure 6: reinsert the new iv catheter and the fabricated tympanostonomy tube into the stylet table 1. tympanostomy tubes manufactured by medtronic xomed, usa locally distributed by famed company type price per box(5pcs) price per piece sheehy collar button php 5,610 php 1,122 shepard grommet php 3,300 php 660 pediatric php 3,630 php 726 goode t-tube php 6,930 php 1,386 philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 surgical innovations and instrumentation philippine journal of otolaryngology-head and neck surgery 29 head design automatically leaves the tube in place after applicator withdrawal. results with institutional review board approval and informed consent, the device was used on a 38-year-old female with eight months’ aural fullness and hearing loss unrelieved by medications diagnosed to have otitis media with effusion. tympanostomy tube insertion was performed under topical anesthesia using lidocaine 25 mg, prilocaine 25 mg, 5% cream (emla™ astrazeneca) applied for 15 minutes. a 2.7 mm oo rigid scope (model 8670.31 wolf usa) and telecam video system (sl ntsc, karl storz, germany) were used to document the procedure (figures 9&10). the tube was applied within 10 seconds, obtaining clear serous fluid with relief of symptoms. the tube was in place at one week and two months follow-up (figure 11), and spontaneously extruded by the seventh month follow-up. discussion there are many different types of tympanostomy tubes currently in use. they differ in size, shape, materials, coatings and theoretical advantages for the surgeon or patient. commercially available tympanostomy tubes are expensive and burdensome to our financially constrained patients. the cost of a single tympanostomy tube obtained from local suppliers ranges from php 500 to php 1,500 depending on the type & brand (table 1). the fabrication of this device will only cost php 57.25. in our local hospital setting, tympanostomy tubes were improvised using a gauge 18 intravenous catheter. one iv catheter was cut and reduced into four 10 mm long tubes with both ends of the tubes heated to make patent flared rims. the technique of myringotomy and ventilating tube insertion was the same as the standard procedure. the new self retaining tympanostomy tube with applicator is designed to aid the surgeon in performing myringotomy and ventilating tube insertion in a single maneuver. this instrument was inspired by the principle of inserting a catheter intravenously with the aid of a stylet-needle that is subsequently withdrawn to leave the catheter in place. to keep the new tympanostomy tube in place, it is designed like a harpoon which facilitates smooth insertion but is kept automatically in place upon slight retraction with the aid of the hooks located on each side of the tube (figures 12-14). the stylet-needle functions as perforator and applicator eliminating the need for a tympanostomy blade further reducing the expense for the procedure. the attached syringe not only serves as a convenient handle but is also very useful in aspirating discharge for specimen collection, hence, making myringotomy and tympanostomy tube insertion less time consuming. the device can be used under local or general anesthesia. the tympanic membrane can be visualized with or without the use of an aural speculum, under otomicroscopic magnification, or videoendoscopic guidance. during the procedure, care should be given not to injure the external auditory canal or any other part of the tympanic membrane. the plastic iv catheter may be slid gently forward using the middle finger until the posterior flange end touches the tympanic figure 7: remove parts that may interfere with vt insertion figure 8: attach the assembly to a tuberculin syringe to serve as handle figure 9: insertion of the tube figure 10: tympanostomy tube in place figure 11: 2 months follow-up philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 surgical innovations and instrumentation 30 philippine journal of otolaryngology-head and neck surgery membrane. special attention should be given to introduction of the device, inserting the tube until the hooks have penetrated the tympanic membrane and gently retracted until the hooks are secured. avoid pushing the device way beyond the tympanic membrane into the middle ear cavity. such an occurrence is a remote possibility owing to the relatively smaller puncture produced by the needle compared to the larger posterior flange of the device which functions as a stopper, but could potentially happen if extreme force is applied. the device should self-extrude, but removal may be performed with fine serrated end ear microforceps. this modification in the fabrication of a tympanostomy tube from a gauge 18 iv catheter made tube application fast and easy. the harpoon design facilitated tube insertion into the tympanic membrane and helped keep the tube in place. aside from the low cost of material in the production, maximizing the use of stylet-needle, functioning as perforator and applicator eliminated the need for a tympanostomy blade, which simplified the tympanostomy and ventilating tube insertion procedures. although the device was used effectively and safely in one patient, evidence is lacking with regards extrusion rate, risks and complications and further studies of its use on a larger sample size with longer duration of follow-up and comparison with commercially available tympanostomy tubes are suggested. acknowledgement: i would like to express my sincere gratitude to jose a. malanyaon, jr., md for his unselfish contribution in supervising the creation of this paper, and to the residents of the department of orl-hns, jrrmmc for their untiring assistance in the documentation of the tympanostomy tube fabrication and performance of surgical procedure. references: 1. armstrong bw. a new treatment for chronic secretory otitis media. arch otolaryngol 1954; 59:653-654. 2. mccracken gh, jr: treatment of acute otitis media in an era of increasing microbial resistance. pediatr infect dis j 1998; 17:1084-1089; discussion 580. 3. rosenfeld rm, verterees je, carr j, et al.: clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. j pediatr 1994; 124:355-356. 4. pransky sm: surgical strategies for otitis media. j otolaryngol 1998; 27(suppl 2):37-42. 5. rosenfeld rm, post jc; meta-analysis of antibiotics for the treatment of otitis media with effusion. otolaryngol head neck surg 1992; 106:378-386. 6. bower c, waner,m. laser assisted myringotomy. current opinion in otolaryngol head & neck surg 1999 dec; 7(6) : 335. 7. mandel em, rockette he, bluestone cd, paradise jl, nozza, rj. efficacy of myringotomy with and without tympanostomy tubes for chronic otitis media with effusion. arch otolaryngol head neck surg 1989; 115:1217-1224. 8. brodsky l, brookjauser p, chait d, reilly j, duetsch e, cook s, et al. office-based insertion of pressure equalization tubes: the role of laser-assisted tympanic membrane fenestration. laryngoscope, 1999 dec 109(12) 2009-2014. 9. lindstorm r, reuben, b, jacobson k, flanary v, kerschner j. long-term results of armstrong beveled grommet tympanostomy tubes in children. laryngoscope 2004 mar; 114(3): 490-494. figure 12: insertion of the device into the external auditory canal figure 13: insertion of the device through the tympanic membrane figure 14: withdrawal of the device leaving the tube in place materials and methods material manufacturer amount cost (php) intravenous introcan-w, 2 36.50 each catheter 18 b.braun laboratories, gauge, 1.3 x 45 mm brazil tuberculin (1ml) becton, dickinson & co. 1 6.50 each syringe singapore blade no. 11 feather, safety razor co., ltd, japan 1 10.00 each candle liwanag, sevilla candle factory, malabon city, philippines 1 7.00 each tongue depressor union wooden tongue 2 0.50 each depressor manufacturing co. philippines aluminum foil paramount foil manufacturing, u.s.a 2cm x 1cm negligible philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 under the microscope philippine journal of otolaryngology-head and neck surgery 37 we present the case of a 48-year-old lady with a history of episodic hearing loss and tinnitus of several years duration. one month prior to consult, there was note of left occipital pain. no history of dizziness, vertigo or facial nerve palsy was elicited. she was neither a smoker nor an alcoholic beverage drinker. no other co-morbidities were elicited. physical examination revealed a 4-cm diameter left posterior auricular mass which was tender. there was note of a bluish bulge on the left posterior wall of the external auditory canal. the tympanic membrane was intact. the mri revealed a 5-cm diameter, irregular, avidly enhancing mass at the left mastoid bone with permeative bone destruction and indentation of the left cerebellar hemisphere and left superior temporal lobe but without evidence of brain invasion. a biopsy was performed followed by a pre-operative tumor embolization then a sub-total petrosectomy with mastoid obliteration. histologic sections showed an unencapsulated mass with bony invasion composed of cystically dilated glandular structures containing colloid-like material (figure 1) while other areas showed simple and coarse papillae (figure 2). the cells were cuboidal to columnar and had a bland cytomorphology with little nuclear pleomorphism (figure 3). mitoses and necrosis were absent. the general histology had a striking resemblance to either normal thyroid tissue or papillary thyroid carcinoma. a ttf-1 immunohistochemical stain however showed negative nuclear staining (figure 4). we signed out the case as an endolymphatic sac tumor. this tumor has been known in the past by such synonyms as “aggressive papillary middle ear tumor”, “heffner tumor” and “low-grade adenocarcinoma of the middle ear.” it is rare, affects both sexes in roughly equal frequencies and often presents with hearing and vestibular dysfunctions, facial nerve palsy and a mass. it presents radiologically as a multilocular lytic lesion in the petrous area of the temporal bone with bone destruction. because of the histologic resemblance to thyroid tissue, a metastatic thyroid neoplasm is a differential diagnosis. metastases to this area are rare, cases invariably have a known primary focus and otologic symptoms are uncommon. immunohistochemical studies endolymphatic sac tumor jose m. carnate jr., md1 amado o. tandoc, iii, md2 1department of pathology college of medicine – philippine general hospital university of the philippines manila 2dept. of laboratories, philippine general hospital university of the philippines manila correspondence: jose m. carnate, md university of the philippines manila college of medicine department of pathology 547 pedro gil st., ermita, manila 1000 philippines phone (632) 526 4550 fax (632) 400 3638 email: jmcjpath@yahoo.com philipp j otolaryngol head neck surg 2009; 24 (1): 37-38 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 38 philippine journal of otolaryngology-head and neck surgery under the microscope and clinical correlation are helpful in ruling out a metastasis. treatment is primarily surgical. prognosis is generally good but is dependent on the extent of the lesion at presentation. it is locally destructive, has the capacity to damage adjacent nerves and is recurrent if incompletely excised. death may result from a large, destructive lesion in a vital area. to date, there are no reports of metastasis which may make the term “adenocarcinoma” not entirely appropriate. we have limited follow-up information on our present case at this time. references 1. barnes l, eveson jw, reichart p, sidransky d. pathology and genetics of head and neck tumors. in who classification of tumors. iarc press, lyon 2005. 2. thompson ld. head and neck pathology. in foundations in diagnostic pathology series. goldblum jr ed. churchill livingstone elsevier, inc. 2006. 3. wenig b. atlas of head and neck pathology, 2nd ed. elsevier, inc. 2008. 4. gnepp dr, ed. diagnostic surgical pathology of the head and neck. wb saunders company, 2001. figure 1. cystically dilated glandular structures containing colloid-like material 100x, hematoxylin-eosin section figure 2. simple and coarse papillae 100x, hematoxylin-eosin section figure 3. cuboidal to columnar cells with bland cytomorphology, little nuclear pleomorphism and no mitoses or necrosis. note striking resemblance to normal thyroid tissue or papillary thyroid carcinoma. 400x, hematoxylin-eosin section figure 4. ttf-1 immunohistochemical stain with negative nuclear staining 400x, ttf-1 immunohistochemistry philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports philippine journal of otolaryngology-head and neck surgery 27 abstract objectives: to present a rare case of nodular fasciitis presenting as a supra-auricular mass. methods: design: case report setting: private tertiary university hospital patient: one results: a one-year-old boy presented with an initially painless, left supra-auricular mass that rapidly enlarged from < 1 cm to 3 cm (widest diameter) in a two-month period. sarcoma was initially considered over an inflammatory process as the mass was non-responsive to antibiotic therapy. fine-needle aspiration cytology (fnac) and high-resolution computed tomography (hrct) with contrast revealed benign cytologic and radiologic findings making nodular fasciitis the primary impression. the patient eventually underwent complete surgical excision of the left supra-auricular mass. histopathologic findings then showed a stroma rich in collagen and myxoid ground substance and loose array of short s-shaped fascicle cells with scattered lymphocytes, macrophages and red blood cells consistent with nodular fasciitis. conclusion: nodular fasciitis is a rare benign myofibroblastic soft tissue tumor which typically presents as a rapidly progressive nodular lesion in the head and neck region of the young pediatric age group. cytopathologic recognition with fna is a challenge. the gold standard of treatment is still surgical and in most reported cases, curative. more importantly, early clinical recognition and correlation with radiologic and histopathologic appearance is very important to avoid unnecessary work-ups and over-treatment. keywords: nodular fasciitis; pseudosarcomatous fasciits; aggressive fibromatosis, desmoid tumor nodular fasciitis is a benign myofibroblastic proliferation in soft tissue that is frequently misdiagnosed as a sarcoma. it is also known as pseudosarcomatous fasciitis and subcutaneous pseudosarcomatous fibromatosis. most patients are middle aged and the upper extremity is the most common localization. it is rarely diagnosed in childhood but appears in the head and neck region more commonly in children than in adults.1 nodular fasciitis remains a difficult diagnosis, particularly when it occurs in the head and neck as it may mimic other benign conditions and aggressive malignant neoplasms (table 1).2 nodular fasciitis could be rare, under-reported or simply misdiagnosed and not reported at all. a case of nodular fasciitis involving the supraauricular area of a one-year-old male child is presented emphasizing early clinical and pathological recognition to avoid misdiagnosis and over-treatment. nodular fasciitis in a one-year-old male: a diagnostic dilemma adrian f. fernando, md1 antonio h. chua, md1,2 lily l. sia-vargas, md1 1department of otorhinolaryngology head and neck surgery university of the east – ramon magsaysay memorial medical center, inc. quezon city, philippines 2department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center manila, philippines correspondence: adrian f. fernando, md department of otorhinolaryngology – head & neck surgery rm. 463, hospital service bldg., uermmmc, inc., 64 aurora blvd., quezon city, philippines 1113 telephone: +632-7150861 local 257 telefax: +632-7161789 e-mail: ianfernando_md@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the case report poster presentation, philippine society of otolaryngology head and neck surgery mid-year convention, taal vista hotel, tagaytay city, april 22-24, 2010. philipp j otolaryngol head neck surg 2010; 25 (2): 27-31 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 28 philippine journal of otolaryngology-head and neck surgery case reports particularly intracranial. the hrct showed a 2.8 cm well demarcated soft tissue density nodule in the left supra-auricular region with a well delineated fat plane separating the mass from the temporalis muscle and no evident involvement of underlying bone and adjacent soft tissue. the external auditory canal, middle and inner ear structures as well as the tegmen tympani and posterior sinus end plates were normal and the hrct was read as a first branchial cleft cyst vs. soft tissue hemangioma (figure 3). the left supra-auricular mass was excised under general anesthesia and intra-operative findings showed a 2.5 cm well-circumscribed unencapsulated nodular mass at the left supra-auricular area overlying the temporalis muscle and laterally displacing the superior auricle. there was no muscular or other soft tissue infiltration of surrounding structures. the patient was discharged on the third post-operative day. grossly, the mass was 2.3 cm on its widest diameter, nodular, circumscribed and unencapsulated, surrounded by fat tissues. the specimen showed a loose array of short s-shaped fascicle cells accompanied by a small number of scattered lymphocytes, macrophages, and red blood cells indicating an inflammatory process with possible micro-hemorrhages. the stroma was rich in collagen and myxoid ground substance and an accelerated mitotic index with normal mitoses all consistent with nodular fasciitis (figure 4). no recurrence was evident on three follow-up consultations for the past seven months. discussion nodular fasciitis, first described in 1955 by konwaler et al.3 is a benign, reactive proliferation of fibroblasts in the subcutaneous tissues which is commonly associated with the deep fascia. it is also known as pseudosarcomatous fibromatosis because of the marked cellular atypia and mitotic activity that are usually present or proliferative fasciitis when “ganglion-like” cells are present.3,4 it generally presents as a solitary painless, rapidly growing nodule, commonly arising in the upper extremities (flexor surface of the forearm) and the trunk (chest wall and back) of adults and in the head and neck region of infants.1,4 it may also involve vascular and cranial structures with the intravascular type mostly occurring before the age of 30 and the cranial type occurring in infants under 2 years of age.5 there is no sex predilection for nodular fasciitis or intravascular fasciitis, but cranial fasciitis is more frequent in boys.6 the etiology of nodular fasciitis is still unknown though some patients report trauma to the site of the lesion prior to the occurrence of the tumor. one theory on its pathogenesis is due to an unusual proliferation of myofibroblasts triggered by local injury or an inflammatory process.3 the cytomorphology of nodular fasciitis is fairly characteristic, making it possible to recognize these lesions in table 1. differential diagnosis for a rapidly expanding nodular lesion on the head and neck adapted from: rosenberg a. bones, joints and soft tissue tumors. in: cotran r, kumar v, collins t. editors. robbins pathologic basis of disease, 6th ed. philadelphia: w. b. saunders co.1999. p. 1259 – 1267. benign lesions malignant lesions benign fibrous histiocytoma pleomorphic lipoma fibroxanthoma schwannoma neurofibroma proliferative fasciitis / myositis ischaemic fasciitis pleomorphic hyalinizing angiectatic tumor giant cell tumor hemangioma symplasmic glomus tumor nodular fasciitis sarcomas: pleomorphic sarcomas liposarcoma osteosarcoma leiomyosarcoma rhabdomyosarcoma myxofibrosarcoma spindle cell carcinoma spindle cell melanoma spindle cell myoepithelioma or carcinoma table 2. auricular nodular fasciitis: mean size and duration of symptoms by location (source: thompson ld, fanburg-smith jc, wenig bm. nodular fasciitis of the external ear region: a clinicopathologic study of 50 cases. ann diagn pathol. 2001 aug; 5(4):191-198.) anatomic site number ear, not otherwise specified external auditory canal pinna pre-auricular post-auricular total 5 6 2 18 19 50 size (cm) 2.0 1.3 2.3 1.8 2.1 1.9 durations of symptoms prior to recognition (mos.) 2.2. 1.6 4.0 4.4 7.7 5 case report a one-year-old male presented with a two-month history of a rapidly enlarging, painless, left supra-auricular mass. the mass was mobile, non-compressible and tender to deep palpation. there was no history of trauma nor response to analgesic and antibiotic treatment. a month after, the patient was seen at our out-patient clinic with a 3 cm tender and tense nodular transilluminating supraauricular mass, pushing the auricular triangular fossa laterally (figure 1). fine needle aspiration cytology (fnac) of the mass was done to rule out an overlying malignancy, specifically a sarcoma. microscopic examination showed cellular smears with inflammatory cells on a hemorrhagic background (figure 2). with nodular fasciitis as the primary consideration, contrast-enhanced high resolution computed tomography (hrct) was requested to delineate the extent of the mass and rule out possible infiltration and extension to adjacent structures, philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports philippine journal of otolaryngology-head and neck surgery 29 fine needle aspirates with an experienced pathologist. due to lack of clear-cut clinical features, correct clinical diagnosis of nodular fasciitis requires a high index of suspicion and correlation of both fnac and radiologic findings. 7,8 grossly, nodular fasciitis may appear circumscribed or infiltrative but is not encapsulated.9 the cut surface varies from myxoid to fibrous, and occasionally there is central cystic change. microscopically, it is composed of plump but regular spindle-shaped fibroblasts or myofibroblasts lacking nuclear hyperchromasia and pleomorphism. mitotic figures may be abundant, but atypical mitoses are not expected.10 the lesion may be highly cellular, but typically it is at least partly loose appearing and myxoid. in more cellular areas, there is often growth in sor c-shaped fascicles and sometimes a storiform pattern.3 there is normally little collagen with some isolated cases composed of extensive stromal hyalinization. extravasated red blood cells, chronic inflammatory cells and multinucleated osteoclast-like giant cells are other frequently identified features.7 nodular fasciitis typically grows rapidly and has a preoperative duration of not more than 1-2 months while the longest known duration is 26 months.8 soreness or tenderness may be present when the mass is enlarged enough to distend or compress adjacent structures. it usually measures 2 cm or less and almost always is less than 5 cm. hrct imaging of nodular fasciitis typically reveals a smoothly marginated soft-tissue mass that may or may not enhance with contrast material. it figure 1. 1-year old male with a rapidly enlarging nodular left supra-auricular mass of 2 monthsduration. 1.a nodular mass, approximately 2.8-3 cm in widest diameter, non-compressible and mobile under subcutaneous tissue, disfiguring the auricular triangular fossa as it pushes the superior auricular structures postero-laterally. 1.b supra-auricular incision skin marking 1.c intraoperative view after complete excision of mass. note intact temporalis fascia and muscle. 1.d healed incision site, 1 month post excision. figure 2. fine-needle aspiration cytology (fnac) of the supra-auricular nodular lesion 2.a scanning view (40x) showing adequate hypocellular smears 2.b high-power magnification (400x) shows mainly lymphocytes against background of many red blood cells. no atypical cells seen. is also helpful in tumor origin and extension, therefore providing valid diagnostic support for further management and surgery.9 mri features may help delineate the extent of the lesion, but the signal characteristics generally are nonspecific. in our case, the hrct showed a poorly enhancing mass with well demarcated border, intact temporalis fascia and delimited fat pad without bony erosion or soft tissue infiltration making the consideration of a high-grade malignancy least likely. mri was not necessary because the surrounding structures were already delineated with the hrct. however, mri may be necessary in evaluating soft tissue structures in the vascular type of nodular fasciitis.5 with the acute onset and rapid growth of the nodular mass, fnac is necessary to rule out a malignant etiology. fnac of nodular fascitis (fnac, 40x) (fnac, 400x) 30 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports figure 3. axial ct image of a case of cranial fasciitis, initially diagnosed as spindle cell carcinoma (a) and the patient’s axial ct imaging in which sarcoma was initially considered (b). 3.b axial view showing a soft tissue mass with destruction of the inner and outer cranial tables (source: keyserling hf, castillo m, smith jk. cranial fasciitis of childhood. ajnr am j neuroradiol, 2003 aug; 24(7): 1465–1467. reproduced with permission from ajnr available from http://www.4shared.com/document/ nwb2z1yq/fernando.html 3.b axial view of the patient’s temporal bone showing a faintly-enhancing soft tissue density overlying the temporalis muscle with well-demarcated fatty border without evidence of bony extension or erosion. the temporal bone at the petrous apex showed normal middle and inner ear structures. demonstrates features of benign appearing spindle cells, collagen and myxoid materials.3,11 differential diagnosis of a rapidly progressive mass in the patient’s age group would include benign fibrous histiocytoma, pleomorphic lipoma and hemangioma.9 also, aggressive fibromatosis, (hematoxylin-eosin, 40x) (hematoxylin-eosin, 100x) philippine journal of otolaryngology-head and neck surgery 31 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports acknowledgment the authors thank janelyn alexis l. dy, m.d. and janet l. dy, m.d., resident and consultant respectively of the department of pathology of the university of the east ramon magsaysay memorial medical center, inc. for their invaluable help with the pathologic interpretation and analysis of this case. references 1. handa y, asai t, tomita y. nodular fasciitis of the forehead in a pediatric patient. dermatol surg. 2003 aug 29(8):867-868 2. rosenberg a. bones, joints and soft tissue tumors. in: cotran r, kumar v, collins t. editors. robbins pathologic basis of disease, 6th ed. philadelphia: w. b. saunders co.1999. p. 1259 – 1267. 3. konwaler be, keasbey l, kaplan l. subcutaneous pseudosarcomatous fibromatosis (fasciitis). am j clin pathol. 1955 mar; 25(3):241-252. 4. bernstein ke, lattes r. nodular (pseudosarcomatous) fasciitis, a nonrecurrent lesion: clinicopathologic study of 134 cases, cancer. 1982 apr 15; 49(8):1668-1678. 5. koenigsberg ra, faro s, chen x, marlowe f. nodular fasciitis as a vascular neck mass. ajnr am j neuroradiol. 1996 mar; 17(3):567–569. 6. keyserling hf, castillo m, smith jk. cranial fasciitis of childhood. ajnr am j neuroradiol. 2003 aug; 24(7): 1465–1467. 7. mardi k, sharma j, kaur h. nodular fasciitis of the hand a potential diagnostic pitfall in fine needle aspiration cytology. j cytol. 2007 oct dec; 24 (4):197-198. 8. kolo ko, karhousen j, von baer a, land grebek, craciun m, nussle k. radiologic – pathologic conference nodular fascitis, roentgen praxis, 1997 aug; 50(8): 229-232. 9. vyas t, bullock mj, hart rd, trites jr, taylor sm. nodular fasciitis of the zygoma: a case report. can j plast surg. 2008 winter; 16(4): 241-243. 10. cartwright le, steinman hk. rapidly growing, asymptomatic subcutaneous nodules. arch dermatol. 1988 oct; 124(10):1559-1560. 11. stanley mw, skoog l, tani em, horwitz ca. nodular fascitis: spontaneous resolution following diagnosis by fine-needle aspiration. diagn cytopathol. 1993 may; 9(3): 322-324. 12. thompson ld, fanburg-smith jc, wenig bm. nodular fasciitis of the external ear region: a clinicopathologic study of 50 cases. ann diagn pathol. 2001 aug; 5(4):191-198. 13. hüter en, lee ccr, sherry rm, udey mc. spontaneous regression and recurrence in a case of nodular fasciitis. acta derm venereol. 2009 jul; 89(4):438-439. 14. shimizu s, hashimoto h, enjoji m. nodular fasciitis: an analysis of 250 patients. pathology. 1984 apr; 16(2): 161–166. a rare condition marked by the presence of multiple benign slow growing tumors known as desmoid tumors must also be ruled out through detailed history and physical examination. although desmoid tumors are benign, they may appear anywhere causing multiple organ dysfunction.5,6 malignant considerations on the other hand are sarcomas of the pleomorphic type which include osteosarcoma, rhabdosarcoma, leiomyosarcoma and osteoclastoma, all of which have distinct radiologic and pathologic features of invasiveness of surrounding structures.1,6,8 diagnosis of nodular fasciitis is often challenging because it may be confused with various malignant tumors due to its aggressive clinical behavior and histo-cytologic features. clinically, nodular fasciitis presents as a painless, fast-growing mass that commonly occurs in an extremity. however, 20% occur in the head and neck region and 10% of patients recall antecedent trauma (table 2).2,10,11 a 2001 study by thompson, et al.12 of patients diagnosed with auricular nodular fasciitis noted that: most nodular fasciitis are dermal (56%) and subcutaneous (22%) usually measuring 1.9 cm in widest diameter. lesions are usually circumscribed with spindle-shaped to stellate myofibroblasts arranged in a storiform growth pattern, juxtaposed to hypocellular myxoid tissueculture-like areas with extravasation of erythrocytes. also a common histologic finding are dense, keloid-like collagen and giant cells in the absence of atypical forms and does not exhibit stromal invasion, a classic histologic sign of tumor invasiveness. there are few reports of spontaneous regression of nodular fasciitis making a complete excision with minimal inclusion of surrounding subcutaneous tissue the management of choice.13 in some cases where information is necessary to avoid over treatment and resection, immunohistochemical staining may be of value as myofibroblasts are reactive with vimentin, actins, and cd68.8,14 the recurrence rate of nodular fasciitis is low and generally ranges from 0 0.004%.14 local recurrence was noted at 9.3% in 50 cases of nodular fasciitis of the external ear which was attributed to difficulties in obtaining clear surgical margins for the said region.12 there are hardly any locally reported cases on nodular fasciitis which could be due to failed recognition, misdiagnosed surgical excisions or lack of patient follow-up as in the case of medical missions. the location should always be correlated with the other clinical findings as misdiagnosis could lead to a wider surgical resection and higher morbidity.1,6,10 histopathologic recognition with fnac requires familiarization with its vast array of histologic appearances to avoid expensive and unnecessary immunohistochemistry stains as complete surgical excision of the mass already suffices.10,14 indeed, appropriate management of nodular fasciitis requires deeper familiarity with the condition so as to minimize excessive, expensive and unnecessary procedures, and prevent unwanted morbidities. figure 4. gross and histopathologic picture of the supra-auricular nodular lesion after complete excision stained with hematoxylin-eosin. 4.a relatively well-circumscribed, unencapsulated nodular mass measuring 2.8 cm in its widest diameter and subcutaneously located. the cut surface showed a relative amount of fibrous tissue with firm rubbery consistency without muscular or bony tissue. 4.b note the vast array of patterns with some inflammatory cells and an accelerated mitotic index (40x magnification) 4.c note the fibroblasts (arrow) and myofibroblasts arranged in short irregular bundles and usually accompanied by dense reticulin fibrosis (100x magnification). 4.d stroma rich in collagen and/or myxoid ground substance (broken arrow) with fibroblasts uniform and spindle-shaped in appearance (unfilled arrow). extravasated erythrocytes (bold arrow) were also noted with micro-hemorrhages (400x magnification). (hematoxylin-eosin, 400x) philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 from the viewbox 46 philippine journal of otolaryngology-head and neck surgery computed tomography (ct) scan and magnetic resonance imaging (mri) evaluation of the larynx and hypopharynx can be tricky for the untrained eye. we discuss a peculiar pattern of the supraglottic airway at the level of the base of the epiglottis seen on axial ct and mr images, resembling a “black hat” or a “black sombrero.” the level of the base of the epiglottis also corresponds to that of the hyoid bone, where two valuable hypopharyngeal sub-sites are visible the pyriform sinuses and the posterior hypophayngeal wall. a hat has basically two parts, an apical convex crown and a basal horizontal brim. (figure 1.a) correlating the hat’s appearance on axial ct and mr imaging, the hat appears black due to the presence of air at the supraglottic level wherein the crown is positioned anteriorly and the brim positioned posteriorly. (figure 1.b) the black sombrero: a helpful landmark in axial imaging evaluation of the larynx and hypopharynx correspondence: adrian f. fernando, md department of otorhinolaryngology – head & neck surgery rm. 463, hospital service bldg., uermmmc, inc., 64 aurora blvd., quezon city 1113 philippines phone: (632) 7150861 local 257 telefax: (632) 7161789 e-mail: ianfernando_md@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. dr. maglalang developed the original concept and provided the radiographs; drs. lapeña and fernando did the research and developed the manuscript. all three authors revised the manuscript for content and approved the final version. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2010; 25 (2): 46-48 c philippine society of otolaryngology – head and neck surgery, inc. figure 1. the “black sombrero” on axial mr imaging of the supraglottis 1.a. the black hat illustrated with an apical convex crown and a horizontal basal brim. 1.b. axial mri correlation of the black hat at the level of the supraglottis. note that the crown or the epiglottis is located anteriorly while the brim abuts the posterior hypopharyngeal wall. adrian f. fernando, md1 jose florencio f. lapeña, jr., ma, md2,3 gil m. maglalang, jr., md4,5 1department of otorhinolaryngology head and neck surgery university of the east – ramon magsaysay memorial medical center, inc. quezon city, philippines 2department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila 3department of otorhinolaryngology head and neck surgery east avenue medical center diliman, quezon city, philippines 4department of radiology university of the east – ramon magsaysay memorial medical center, inc. quezon city, philippines 5institute of radiology st. luke’s medical center quezon city, philippines philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 philippine journal of otolaryngology-head and neck surgery 47 from the viewbox the top-most convex part of the crown corresponds to the base of the epiglottis. anterior to it is the pre-epiglottic fat plane and the body of the hyoid bone. the crown is also flanked by the paraglottic fat plane on both sides that appears hypodense (dark) on ct and hyperintense (bright) on t1 mri. on the other hand, the posterior-most portion of the hat’s brim abuts the posterior hypopharyngeal wall laterally outlining the pyriform sinuses on each side. the area where the crown joins the brim corresponds to the aryepiglotic folds that are delineated laterally by the medial walls of the pyriform sinuses while its medial aspects correspond to portions of the supraglottis. (figure 2) figure 2. aef, aryepiglottic fold; h, hyoid bone; pe, pre-epiglottic space; pg, paraglottic space; p, pyriform sinuses figure 3. variations in the size and configuration of the hat 3.a with a big crown and a small brim, resembling a “bowler” or “derby hat” 3.b with a tall crown and a floppy brim, resembling a “mexican sombrero” philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 from the viewbox 48 philippine journal of otolaryngology-head and neck surgery the size and configuration of the hat varies and can range from one with a big crown and a small brim (resembling a “bowler” or “derby hat”) to one with a tall crown and a floppy brim (resembling a “mexican sombrero”). (figures 2, 3) infiltrating tumors and inflammatory processes can distort the hat’s usual symmetric configuration which can be useful in determining possible sites of inflammation or infection, tumor origin and spread to hypopharyngeal and supraglottic structures, as the hat’s center represents a potential space at the supraglottic area devoid of any soft tissue structures. (figure 4) in radiology, “the bowler hat sign” and “mexican hat sign” have been used to describe gastrointestinal polyps.1,2,3 the former “is produced by the acute angle of attachment of the polyp to the mucosa” while the latter “consists of two concentric rings and is produced by visualizing a pedunculated polyp head-on.”1 the “mexican hat sign” has also been used to describe osmotic demyelination on mri.4 to our knowledge, these terms have not been applied to the interpretation of supraglottic and hypopharyngeal ct and mri axial images. recognition of the “black sombrero” pattern can be helpful in understanding the anatomic relationship of the supraglottic and hypopharynx structures on axial ct and mr imaging particularly in the evaluation of supraglottic and hypopharyngeal tumor spread. figure 4. axial t1 mr images of the supraglottis 4.a. normal supraglottis and hypopharyngeal imaging 4.b. imaging of the supraglottis shows a large mass infiltrating both the right supraglottic and almost the entire hypopharyngeal spaces; t, tumor references 1. brant we. gastrointestinal tract. in: brant we, helms ca, editors. fundamentals of diagnostic radiology 3rd ed. philadelphia, pa: lippincott williams & wilkins 2007. p 822. 2. levine ms, rubesin se, laufer i, herlinger h. diagnosis of colorectal neoplasms at doublecontrast barium enema examination. radiology 2000 jul; 216(1):11-18. [cited 2010 nov 11] available from http://radiology.rsna.org/content/216/1/11.full.pdf. 3. keller ce,halpert rd, feczko pj, simms sm. radiologic recognition of colonic diverticula simulating polyps. ajr 1984 jul;143(1):93-97. 4. islam o, dillon g. mri in osmotic demyelination: the “mexican hat” sign. the internet journal of radiology [serial on the internet] 2010 [cited 2010 nov 11]; 12(1):[about 3 p.] available from: http://www.ispub.com/journal/the_internet_journal_of_radiology/volume_12_number_1_6/ article/mri-in-osmotic-demyelination-the-mexican-hat-sign.html. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 original articles philippine journal of otolaryngology-head and neck surgery 5 philipp j otolaryngol head neck surg 2009; 24 (1): 5-8 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to compare the therapeutic efficacy of kalachuchi (plumeria acuminata ait.) bark extract ointment (ko) and clotrimazole cream 1% (cc) in the treatment of otomycosis. methods design: randomized double blind controlled trial setting: outpatient otorhinolaryngology clinic of a tertiary government hospital subjects: patients aged 18-years-old and above diagnosed clinically to have otomycosis with a positive potassium hydroxide (koh) smear were randomly assigned to kalachuchi (plumeria acuminata ait.) bark extract ointment or clotrimazole cream 1% in unlabeled containers. selfapplication thrice daily for two weeks followed initial detailed instructions and demonstration. symptoms, physical findings and repeat koh smears were recorded after the first and second weeks of treatment. results: eighteen patients with otomycosis were enrolled in the study. there was one dropout per treatment group with no intention to treat. there were no statistically significant differences between ko and cc, with 75% (n=8) and 87.5% (n=8) cure rates, respectively. one subject in the ko arm reported severe ear pain. conclusion: kalachuchi extract ointment may be a promising topical antifungal agent. multicenter clinical trials to establish its efficacy and safety as an effective alternative in the management of otomycosis should be conducted. key words: otomycosis, kalachuchi, plumeria acuminata ait., clotrimazole, clinical trial, herbal medicine a preliminary study on the efficacy of plumeria acuminata (kalachuchi) bark extract ointment versus clotrimazole cream in the treatment of otomycosis rhoda mae v. boncalon, md marida arend v. arugay, md rachel zita h. ramos, md department of otorhinolaryngology – head & neck surgery western visayas medical center correspondence: rhoda mae v. boncalon, md department of ent-hns western visayas medical center q. abeto st, mandurriao, iloilo city 5000 philippines phone: +639177222407 fax: (6333) 321 1797 email: docboink@yahoo.com reprints will not be available from the author. funding support for this study was received from the research committee of the western visayas medical center. the authors signed a disclosure that they have no proprietary or financial interest in any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at the western visayas medical center 1st interdepartmental residents’ research contest (1st place), wvmc supply building, rooftop, mandurriao, iloilo city, november 26, 2007; analytical research contest (3rd place), philippine society of otolaryngology head and neck surgery, december 1, 2007 at romblon room, sofitel philippine plaza manila, pasay city, december 1, 2007; international research conference (west visayas state university) amigo terrace hotel, iloilo city, february 29, 2008. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 original articles 6 philippine journal of otolaryngology-head and neck surgery otomycosis is one of the common otologic conditions requiring medical consult and therapy. most otomycosis isolates include aspergillus or candida spp.1,2 clinical presentation may include intractable itching of the external auditory canal, otalgia, tinnitus and ear discharge.3,4 physical examination reveals an erythematous canal with black, gray or white fungal elements (figure 1). direct microscopy using 10% koh confirms the diagnosis.5 treatment often requires mechanical cleansing and 1-2 weeks application of topical antifungal agents.6,7 clotrimazole 1% cream is commonly prescribed, providing symptom relief within 2 weeks in 96% of patients.8 other antifungal drops or powder medications (clotrimazole and nystatin) are also effective in many cases.9,10 of the 10 locally available medicinal plants in the priority list of the philippine council for health research and development (pchrd) of the department of science and technology (dost) and plant resource of south east asia (prosea), kalachuchi {plumeria acuminata ait.) has one of the highest activities in assays against candida species. antimycotic properties of kalachuchi (plumeria acuminata ait.) bark extract against aspergillus flavus and aspergillus niger have been shown in in-vitro studies.12 application of this extract in controlled and limited number of subjects may help establish its pharmacotherapeutic potentials. the objective of this study was to compare the therapeutic efficacy of kalachuchi (plumeria acuminata ait.) bark extract ointment (ko) and the standard clotrimazole cream 1% (cc) in the treatment of otomycosis. methods design: randomized double blind controlled trial. the study was reviewed and approved by the ethics committee of the western visayas medical center. setting: outpatient otorhinolaryngology clinic in a tertiary private hospital. subjects: voluntary, informed consent was obtained from 18 patients aged 18 to 70 years with otomycosis defined as presence of itchiness, ear pain, ear discharge, ear fullness or hearing impairment with otoscopic findings of external auditory canal erythema, discharge and fungal elements, testing positive on koh smear were included in the study. ten percent koh smears were performed on swabs taken from the affected ear canal. in cases of bilateral otomycosis, the right ear was chosen for evaluation. exclusion criteria were use of any topical otic medication and/or oral antifungal medication the past 30 days, presence of tympanic membrane perforation, concomitant otitis media, previous surgery on the test ear, history of hypersensitivity to clotrimazole and pregnant or lactating patients. intervention: following thorough mechanical ear cleansing, patients were randomly assigned to the use of unlabeled containers of either clotrimazole cream 1% in group a or kalachuchi (plumeria acuminata ait.) bark extract ointment in group b. details of kalachuchi bark extract preparation followed those previously described12 and are available through corresponding author (figure 2). a voucher specimen of the said kalachuchi was sent to a taxonomist and was positively identified as plumeria acuminata ait. after detailed instructions and demonstration, the topical agent was self-applied 3x a day for two weeks. adverse events were monitored during the two-week treatment period. patients with localized adverse effects such as hypersensitivity reactions, aural tenderness, formation of eczematous lesions and perichondritis were instructed to discontinue the test drug. rescue drugs (antihistamines, analgesics or oral antibiotics) were administered to one such patient until events resolved. patients who developed adverse effects, those with poor compliance to the assigned medication (use of <50% of the test drug) and those who did not wish to continue the treatment were further excluded from the study. figure 1. otoscopy revealing black & white fungal elements figure 2. preparation of kalachuchi (plumeria acuminata ait.) ointment philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 original articles philippine journal of otolaryngology-head and neck surgery 7 outcome measures and statistical analysis: clinical symptoms, physical examination findings and koh smear results were recorded before treatment and at day 7 and day 14 of treatment. comparison between two proportions testing for significant difference was performed using the z-test and chi square test. results eighteen patients diagnosed clinically and microbiologically to have otomycosis were initially enrolled in the study comprising 9 test ears in each treatment group. dropouts included one subject lost to follow up under cc treatment and one subject experiencing severe aural pain and tenderness under ko treatment. sixteen patients with 8 patients in each treatment arm remained for analysis. these were 7 males and 9 females with a mean average age of 44 years. the most common presentation of the patients upon consult was ear fullness (75%) and hearing impairment (75%) followed by itchiness of the affected ear (62.5%). on otoscopic examination, all patients had hyphal elements in the test ear. fifty percent had ear canal erythema and only 34% had ear discharge. there was no significant difference between baseline characteristics of the two groups (table 1). after 7 days of treatment, 37.5% of the subjects using cc and 25% of the subjects using ko reported symptom resolution. after two weeks, both groups had an equal incidence of patients (62.5%) who did not report any residual symptoms (table 2). after one week of therapy, otoscopic examination revealed normal findings in 62.5% and 32.5% of subjects of the cc and ko groups, respectively. there was no statistically significant difference between the two treatment arms after 7 and 14 days of therapy (table 2). it must be noted that in this study, the 62.5% response rate to the standard treatment cc requires a 0% response scenario to ko in order to establish a statistically significant difference. after a week of treatment, only one patient (12.5%) in the ko group had a negative koh smear while 50% of the cc group already showed absence of fungal elements. after two weeks of therapy, 75% and 87.5% had negative koh smear for the ko and cc groups, respectively. the difference, however, was again not statistically significant (table 2). mild stinging of the involved ear canal was a common adverse reaction noted especially in the ko treatment. however, the intensity of the stinging was usually tolerable and was not strong enough to cause discontinuation of the treatment. there was only one patient who developed severe aural tenderness on the third day of treatment using ko, which caused her to discontinue the use of the said medication. other adverse effects were not encountered with either treatment. discussion with its persistence and annoying symptoms, otomycosis can be a challenging and frustrating disease for both patient and otolaryngologist. with the increasing cost of commercially available antifungal agents, finding locally-available alternative herbal treatments can greatly help patients, especially the less affluent. a previous in vitro study of the antifungal activity of four medicinal plants versus clotrimazole in the treatment of otomycosis showed that kalachuchi (plumeria acuminata ait.) bark extract using methylethylketone as solvent at 100% concentration was comparable in efficacy with the standard clotrimazole solution in treating aspergillus flavus and aspergillus niger.12 this in vivo trial conducted to further determine the kalachuchi (plumeria acuminata ait.) bark extract’s benefit as a topical antifungal agent against otomycosis showed no statistical significant difference between kalachuchi (plumeria acuminata ait.) bark extract ointment and clotrimazole cream 1% in terms of cure and complication rate. the cure rate for ko was 75% compared to 87.5% for cc. the results showed no significant difference between the two treatment groups based on chi-square analysis (table 3). the failure rate for both treatment groups was relatively low (12.5% and 25%) for cc and ko, respectively (table 3). this may be due to residual fungal growth in the difficult-to-access antero-inferior recess near the tympanic membrane which may not be reached by topical medications in the form of creams and ointments as well as improper application of the medication. other preparations for kalachuchi extract may need to be explored for ease of application. while this preliminary study may suggest that ko may be as effective as the cc as an antifungal agent for otomycosis, to compare two proportions testing for efficacy of either treatment, a sample size of at least 88 for each treatment group is needed to test for statistically significant difference, accounting for treatment success in each arm and drop out rates. complication rates should also be documented to establish the safety of kalachuchi bark extract compared to standard treatment. a multicenter study is needed to develop kalachuchi extract as an important antifungal agent for otomycosis. table 1. baseline characteristics of patients in the kalachuchi bark extract & clotrimazole treatment groups characteristics total no. of patients frequenc y kalachuchi clotrimazole p-valueno. of patients % no. of patients % signs & symptoms itchiness ear pain ear discharge ear fullness hearing impairment otoscopic findings erythematous eac hyphal elements ear discharge 10 6 4 12 12 8 16 5 62.5% 37.5% 25% 75% 75% 50% 100% 34% 5 3 2 6 6 4 8 3 62.5 37.5 25 75 75 50 100 37.5 5 3 2 6 6 4 8 2 62.5 37.5 25 75 75 50 100 25 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.29 critical values: p-value ≤ 0.05 significant difference p-value > 0.05 no significant difference philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 original articles 8 philippine journal of otolaryngology-head and neck surgery acknowledgement the authors wish to thank dr. jose mari fermin, medical director of western visayas medical center and its research committee for their financial support. mrs. monalisa avanceňa and staff of the western visayas medical center pathology department for their help with microbiologic examinations. dr. gerard penecilla of the west visayas state university microbiology laboratory for his help and guidance during the process of kalachuchi bark extraction and preparation of kalachuchi ointment. prof. isabel blancia for her expertise, time, and service in statistical analysis and the residents of the department of otorhinolaryngology head and neck surgery, western visayas medical center for their support. references 1. geaney gp. tropical otomycosis. j laryngol otol. 1967; 81: 987-97. 2. lakshmipati g, murti rb. otomycosis. j indian med assoc. 1960; 34:439-41. 3. paulose ko, al khalifa s, shenoy p, sharma rk. mycotic infection of the ear (otomycosis): aprospective study. j laryngol otol. 1989; 103:30. 4. than km, naing ks, min m. otomycosis in burma and its treatment. am j trop med hyg. 1980; 29:520. 5. mathur md. otomycosis: a clinicomycologic study. ent j. 2000 ;79:606-9. 6. ballantine j, groves j. scott-brown’s diseases of the ears, nose and throat. boston : butterworths, 4th ed., 93-114. 7. patow ca. fungi as a cause of otitis. j am med assoc. 1995 ; 273 (1):25. 8. ologe fe, nwabuisi c. treatment outcome of otomycosis in ilorin, nigeria. west afr j med. 2002; 21(1):34-36. 9. kwok p, hawke, m. clotrimazole powder in the treatment of otomycosis. j otolaryngol. 1987; 16:398. 10. stern jc, shah mk, lucente fe. in vivo effectiveness of 13 agents in otomycosis and review of the literature. laryngoscope. 1988; 98:1173. 11. penecilla g, magno c, de castro j. et al. production and testing of natural products for antimicrobial and antifungal action. west visayas state university college of arts and sciences research journal. 2001; 2 (1):10-20. 12. villanueva jm, arugay mav, ramos rzh. in vitro antimycotic activity of four medicinal plants versus clotrimazole in the treatment of otomycosis: a preliminary study. philipp j otolaryngol head neck surg 2008; 23(1): 5-8. 13. plumeria acuminata ait. republic of the philippines, department of agriculture, bureau of plant industry. table 2. comparison of the response after 7 days of treatment between kalachuchi bark extract & clotrimazole characteristics 3 2 1 5 5 2 2 5 1 3 7 1 37.5 25 12.5 62.5 62.5 25 25 62.5 12.5 37.5 87.5 12.5 0.29 0.26 0.26 0.16 0.16 0.29 0.50 0.07 0.26 0.16 0.11 signs & symptoms itchiness ear pain ear discharge ear fullness hearing impairment no symptoms otoscopic findings erythematous eac hyphal elements ear discharge normal findings koh smear ( + ) ( ) kalachuchi clotrimazole p-valueno. of patients % after 7 days of treatment after 14 days of treatment 2 1 2 3 3 3 2 2 2 5 4 4 25 12.5 25 37.5 37.5 37.5 25 25 25 62.5 50 50 no. of patients % 2 0 0 2 2 5 0 1 1 7 2 6 25 0 0 25 25 62.5 0 12.5 12.5 87.5 25 75 0.50 0.15 0.50 0.50 0.50 0.50 0.50 0.50 0.52 kalachuchi clotrimazole p-valueno. of patients % 2 1 0 2 2 5 0 1 1 7 1 7 25 12.5 0 25 25 62.5 0 12.5 12.5 87.5 12.5 87.5 no. of patients % critical values: p-value ≤ 0.05 significant difference p-value > 0.05 no significant difference table 3. comparison of the cure rate between the kalachuchi bark extract & clotrimazole treatment treatment % kalachuchi clotrimazole p-value 6 7 0.52 75 87.5 no. of patients % 2 1 25 12.5 no. of patients failurecure critical values: p-value ≤ 0.05 significant difference p-value > 0.05 no significant difference philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 from the viewbox 58 philippine journal of otolaryngology-head and neck surgery unilateral horizontal semicircular canal malformation causing recurrent vertigo a 62-year-old man consulted for recurrent episodes of vertigo lasting from seconds to several minutes. the vertigo was variably described as spinning, lateral swaying and a feeling of being “unsure of his position in space.” these episodes were noted to have begun when the patient was still in his 20’s. standard pure tone audiometry revealed a mild-to-moderate downsloping mixed hearing loss in the left ear. bithermal caloric testing indicated the presence of a significant left-sided peripheral vestibular loss. due to the fact that the vertigo episodes presented relatively early in life, the possibility of a congenital inner ear malformation was considered as a cause for his symptoms. computerized tomographic (ct) imaging of the temporal bone was performed. this clearly showed the left horizontal semicircular canal lacking a central bony island. (figure 1 and 2) the cochlea, superior and posterior semicircular canals, vestibular and cochlear aqueducts and ossicular chain were grossly normal. correspondence: dr. nathaniel w. yang department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax: (632) 525 5444 email: nwyang@gmx.net the author declared that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2017; 32 (2): 58-59 c philippine society of otolaryngology – head and neck surgery, inc. nathaniel w. yang, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila department of otolaryngology head and neck surgery far eastern university nicanor reyes medical foundation institute of medicine creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. computerized tomographic imaging of the temporal bone in the axial view at the level of the horizontal semicircular canal. the arrow points to the left horizontal semicircular canal which lacks a central bony island and has a cystic appearance. in comparison, the right horizontal semicircular canal has the classic “signet ring” appearance. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 philippine journal of otolaryngology-head and neck surgery 59 from the viewbox references johnson j, lalwani ak. sensorineural and conductive hearing loss associated with 1. lateral semicircular canal malformation. laryngoscope 2000 oct;110(10):1673–1679. doi:10.1097/00005537-200010000-00019 pmid: 11037823 casselman jw, delanote j, kuhweide r, van dinther j, de foer b, offeciers ef. congenital 2. malformations of the temporal bone. in: lemmerling m, de foer b, editors. temporal bone imaging. berlin heidelberg: springer-verlag; 2015, pp. 120-154. kim ch, shin je, lee yj, park hj. clinical characteristics of 7 patients with lateral semicircular 3. canal dysplasia. res vestib sci 2012;11(2):64-68. a malformation of the horizontal or lateral semicircular canal is one of the most common inner ear malformations since it is the last vestibular structure to be formed during inner ear embryogenesis. as such, it may occur in isolation or may be associated with other vestibular, cochlear, or middle ear malformations.1,2 although vertigo and dizziness are symptoms to be expected in such a condition, existing data indicates that it may be totally asymptomatic or it may also present as a sensorineural, conductive or mixed type of hearing loss.1,3 radiologic imaging is of prime importance in diagnosing such figure 2. computerized tomographic imaging of the temporal bone in the coronal view showing the horizontal semicircular canals at two different levels. a. is at the level of the ampullated end of the canal, where the canals look similar (white arrows). b. is at the midpoint of the canal where the right side shows a small ovoid lumen separated from the vestibule by bone; whereas the left side shows an enlarged lumen representing the combined vestibule and semicircular canal without any intervening bone (angled white arrows). these images illustrate the difficulty in identifying the abnormality on coronal view as compared to the axial view. conditions especially when auditory and/or vestibular symptoms manifest early in life. this case perfectly illustrates the need for such studies as the patient went undiagnosed for more than forty years! no definitive statements can be gleaned from existing medical literature with respect to treatment. however, in patients with debilitating vestibular symptoms, management with modalities that selectively target the vestibular system, but spare the auditory system, such as vestibular neurectomy and trans-tympanic aminoglycoside therapy appear to be reasonable options. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 46 philippine journal of otolaryngology-head and neck surgery featured grand rounds chronic suppurative otitis media (csom) has a potential for intratemporal complications. gradenigo syndrome, lateral sinus thrombosis and cavernous sinus thrombosis must be considered when patients present with ear discharge, headache, fever and lateral rectus palsy. computed tomography and magnetic resonance imaging are essential in confirming the diagnosis but do not substitute for a good clinical eye in establishing the diagnosis and initiating proper treatment. case a 17-year-old male with an 11-year history of otorrhea on the right ear was admitted because of on-and-off diffuse headache, drowsiness, occasional sensorial changes, high grade fever and vomiting. later in the ward, he complained of double vision; anisocoria and lateral rectus palsy were confirmed by active generation test. associated symptoms included right-sided frontal, orbital and mastoid pain with neck stiffness. otoscopy showed yellowish foul smelling discharge with a pink, smooth mass partially obstructing the external auditory canal. leukocytosis was seen with a count of 32.9 x 103/l. pure tone audiometry revealed moderate conductive hearing loss on the right ear. ct scan with contrast (figure 1) showed lytic erosion of the underpneumatized right mastoid bone and sigmoid sinus plates with slightly asymmetric right internal auditory canal (iac). penicillin g 5 million “iu” every 6 hours and chloramphenicol 1.5 grams iv every 8 hours were given for 3 weeks, but he continued to deteriorate and two units of prbc were transfused. because of his worsening condition, penicillin g was shifted to ceftriaxone 2 grams iv bid while chloramphenicol iv was continued at the same dose. the patient’s headache and fever steadily lessened after 4 weeks but orbital pain and diplopia persisted. on the 50th hospital day, the patient underwent modified radical mastoidectomy, right. intraoperatively, granulation tissue was noted occupying the enlarged mastoid cavity and antrum. a 0.5 cm break at the sigmoid sinus was also occupied by granulation tissue. iv antibiotics were continued 2 weeks postoperatively and after 64 days of hospitalization he was discharged on oral ciprofloxacin 500mg bid for 1 month with steroid/antibiotic otic drops. regular follow-up documented gradual lessening of diplopia, headache and orbital pain. complete resolution of diplopia with normal ophthalmologic findings and a dry mastoidectomy cavity were noted on the fourth month of follow-up. gradenigo syndrome marc reinald g. santiago md natividad a. almazan, md, msc department of otolaryngology head and neck surgery east avenue medical center philipp j otolaryngol head neck surg 2008; 23 (2): 46-48 c philippine society of otolaryngology – head and neck surgery, inc. correspondence: marc reinald g. santiago, md department of otolaryngology head and neck surgery east avenue medical center east avenue, diliman, quezon city, 1100 philippines phone: (632) 928-0611 local 324 email: mgraganza@yahoo.com reprints will not be available from the author. philippine journal of otolaryngology-head and neck surgery 47 philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 featured grand rounds discussion in the philippines, the prevalence of chronic suppurative otitis media (csom) is estimated at 2.5 – 29.5%.1 complications of chronic otitis media can cause grave morbidity and even mortality2 even though the intratemporal and/or intracranial complications of infectious ear disease have become rarer with the advent of broad spectrum antibiotics.3 the spread of infection can occur by osteothrombosis, bone erosion and when present along preformed pathways.2 the triad of gradenigo syndrome includes otorrhea, retroorbital pain and abducens nerve palsy. chole and donald found that the most common presenting symptom in 22 patients from 1976-1995 was otalgia (72%) followed by deep pain, headache and otorrhea (59%). cranial nerve vi paralysis was only present in 18.2% of the cases.4 homer and others reported 3 cases with middle ear infection and 6th nerve palsy without petrositis.5 mri and ct are required to identify the deep seated petrous apex as the site of the inflammatory process.6 while ct scans may demonstrate opacification of the air cells of the petrous apex with cortical bone erosion, mri is very useful for assessing inflammatory soft tissue lesions around the petrous apex.5 both ct and mri are essential to establish opacification of air cells in the petrous apex under suspicion, as opposed to assymetric pneumatization.2 however, acute petrositis cannot always be equated with gradenigo syndrome.7 a study by back and others documented 8 cases of radiologically confirmed apical petrositis that did not manifest the classical syndrome of deep facial pain, otitis media and ipsilateral abducens nerve palsy.8 petrous apicitis is essentially mastoiditis that occurs in the petrous apex.2 because the trigeminal (cn v) or gasserian ganglion lies in meckel’s cave on the antero-superior aspect of the petrous tip, damage or irritation to the ganglion may explain the deep facial pain in some patients with apicitis. the petroclinoid ligament extends from the tip of the petrous apex to the clinoid. below this ligament, the gasserian ganglion (cn v) and abducens nerve (cn vi) travel in the small dorello’s canal. inflammation extending into the canal produces the triad of symptoms recognized by gradenigo9: lateral rectus (cn vi) palsy, retroorbital pain (cn v) and otorrhea. lateral sinus thrombophlebitis (lst) or thrombosis of the lateral sinus usually forms as an extension of a perisinus abscess following mastoid bone erosion from cholesteatona, granulation tissue or coalescence which eventually leads to pressure necrosis and mural thrombus formation.2 classic symptoms of lst include a “picket fence” fever pattern, chills and progressive anemia. symptoms of septic emboli, headache and papilledema may indicate extension to involve the cavernous sinus4 or sudden intracranial hypertension resulting from decreased venous drainage from the skull.2 the diagnostic procedure of choice is mri with mr angiography. the thrombus can be identified by its signal intensity on mri and the flow void in the affected sinus is clearly documented on mr angiography.10 non-contrast ct findings include dense cord sign, dense dural sinuses, diffuse cerebral edema, non hemorrhagic infarct or multifocal haemorrhages.11 papilledema and anisocoria may be symptoms of progression of lateral sinus thrombophlebitis or development of cavernous sinus thrombosis.4 fresh thrombi from the lateral sinus can propagate and extend to the cavernous sinus via the superior and inferior petrosal sinus. cavernous sinus thrombosis (cst) is usually a late complication of an infection of the central face or paranasal sinuses. other causes include bacteremia, trauma and infections of the maxillary teeth or ear, as seen in our patient. cst is generally a fulminant process with high rates of morbidity and mortality. headache is the most common presenting symptom that usually precedes fever, periorbital edema (which may or may not occur) and cranial nerve dysfunction. this intimate relationship of veins, arteries, nerves, meninges, petrous apex and paranasal sinuses account for the characteristic etiology and presentation of cst. the internal carotid artery with its surrounding sympathetic plexus passes through the cavernous sinus. the third, fourth and sixth cranial nerves are attached to the lateral wall of the sinus while the ophthalmic and maxillary divisions of the fifth cranial nerve are embedded in the wall.8 other signs and symptoms include chemosis resulting from occlusion of the ophthalmic veins, lateral gaze palsy (isolated cranial nerve vi), ptosis, mydriasis and eye muscle weakness from cranial nerve iii dysfunction. these are followed by manifestations of increased retrobulbar pressure (such as exophthalmos) and increased intraocular pressure (such as sluggish pupil and decreased visual acuity). systemic signs indicative of sepsis are late findings. the complications of gradenigo syndrome, lateral sinus thrombophlebitis and cavernous sinus thrombosis from chronic suppurative otitis media need immediate diagnosis and aggressive medical treatment with broad spectrum antibiotics against gram positive cocci (staphylococci and streptococci), gram negative bacilli figure 1 non-contrast cranial ct scan showing lytic erosion (arrow) and the underpneumatized right mastoid and sigmoid plates s philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 48 philippine journal of otolaryngology-head and neck surgery featured grand rounds acknowledgement we thank dr jam malanyaon for helping with the grand rounds oral case presentation and the orl-hns residents of the east avenue medical center for their support. references 1. philippine society of otolaryngology head and neck surgery, inc. clinical practice guidelines on chronic suppurative otitis media in adults. pasig city: philippine society of otolaryngology head and neck surgery; 2006, p.13. [9 references] 2. harker la, shelton c. complications of temporal bone infections. in: cummings cw, flint pw, harker la, haughey bh, richardson ma, robbins kt, schuller de, thomas jr, editors. otolaryngology head and neck surgery. 4th edition, vol. 4. philadelphia: elsevier mosby ; 2005. p. 3013-3039. 3. piron k, gordts f, herzeel n. gradenigo syndrome: a case report. bulletin soc. belge ophthalmol. 2003; (290) 43-47. available from: www.ophthalmologia.be/download.php?dof_id=188. 4. chole ra, sudhof hm. chronic otitis media, mastoiditis and petrositis. in: in: cummings cw, flint pw, harker la, haughey bh, richardson ma, robbins kt, schuller de, thomas jr,editors. otolaryngology head and neck surgery 4th edition, vol. 4. philadelphia: mosby; 2005. p.29893012 5. chole ra, donald pj. petrous apicitis, clinical considerations. ann otol rhinol laryngol, 1983 nov-dec; 92 (6 pt1): 544-551. 6. yeung ah. skull base, petrous apex infections. [article on the internet] (updated 2006 june 16;skull base, petrous apex infections. [article on the internet] (updated 2006 june 16;[article on the internet] (updated 2006 june 16; cited 2008 october 29). available from: www.emedicine.com/ent/byname/skull-base-petrousapex-infection.htm. 7. tveteras k, kristensea s, dommerby h. septic cavernous and lateral sinus thrombosis, j laryngol otol 1996; 110:872-874. 8. kamal mk. computed tomography imaging of cerebral venous thrombosis, j pak med assoc, 2006 nov; 56(11) 519-22. available from: http://jpma.org.pk/viewarticle/viewarticle. aspx?articleid=921. 9. back gw. atypical gradenigo’s syndrome complicated by meningitis and sphenoiditis, a casereport. cme bulletin otorhinolaryngology, head and neck surgery, 2000; 4:114-116. available from: http:?//www.rila.co.uk.issues/full/download http://www.rila.co.uk/issues/full/download.http://www.rila.co.uk/issues/full/download. php?file=p.114116.pdf&jid=004&year=2000&volume=4&issue=3. 10. harnsberger rh. handbook of head and neck imaging. 2nd ed. st.louis: mosby;1995. p. 169 – 170. 11. mathaw l, sing s, reyes r, vagnese am. gradenigo’s syndrome: findings on computed tomography and magnetic resonance imaging. j. postgrad med (serial online) 2002 [cited 2008 oct 29]; 48:314. available from: http://www.jpgmonline.com/article.asp. (pseudomonas aeruginosa) and to a lesser extent, anaerobes. these antibiotics should also cross the blood-brain barrier. mastoidectomy is required once the patient is neurologically stable.2 in cases of lateral sinus thrombosis, surgical removal of emboli can be done. however, cummings, syms and colleagues2 report 6 patients operated on without opening and evacuating the lateral sinus clot who all survived, albeit with a longer 49 day average hospital stay. once a highly controversial issue, ligation of the internal jugular vein is seldom needed. in the majority of recent cases, anticoagulation has not been found to be necessary.2 silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles 20 philippine journal of otolaryngology-head and neck surgery abstract objectives: to identify the bacterial pathogens associated with chronic suppurative otitis media and their antimicrobial sensitivity and resistance. study design: cross-sectional survey. setting: the study was carried out from july 2004-july 2005 at the outpatient clinic of a government tertiary hospital. number of subjects: a total of 32 patients (54 ears) with unilateral or bilateral active chronic suppurative otitis media. results: bacterial pathogens of 54 ear discharge samples from csom were studied. among them, 42 (78%) were pure cultures and 9 (16.7%) were mixed, only 3 (5.6%) of the submitted samples had no growth. there were 42 pure isolates, the most common of which was staphylococcus aureus 21 (50%), followed by pseudomonas aeruginosa 14 (33.3%). drug sensitivity pattern of staphylococcus aureus showed that 61.9% were resistant to penicillin while more than 90% were sensitive to aminoglycosides and clindamycin. pseudomonas aeruginosa was resistant to penicillin in 64.3% of cases and ciprofloxacin was active against pseudomonas in 85.7%. conclusion: the most common bacterial pathogens from csom include staphylococcus aureus and pseudomonas aeruginosa. majority of the isolates of staphylococcus aureus were resistant to penicillin. aminoglycosides, macrolides and quinolones were effective against most of the isolates of staphylococcus aureus. keywords: chronic otitis media, perforated tympanic membrane, chronic aural discharge chronic suppurative otitis media (csom), also called chronic active mucosal otitis media, chronic oto-mastoiditis, and chronic tympanomastoiditis, is a chronic inflammation (>6-12 weeks) of the middle ear and mastoid cavity, which presents with recurrent ear discharge or otorrhea through a perforated tympanic membrane1. these perforations may arise traumatically, iatrogenically with tube placement, or after an episode of acute otitis media (aom), which decompresses through a tympanic perforation2. csom is one of the most important causes of preventable hearing loss in the philippines and other developing countries1. previous studies have provided evidence for the resolution of csom using otic drops alone as the first line of treatment4,5. this is because of their good penetration and better availability through the perforation compared to systemic antibiotics. other studies, however, showed an increasing number of treatment failures6. treatment for csom varies considerably based on the chronic suppurative otitis media: bacteriology and drug sensitivity patterns at the quirino memorial medical center (2004-2005): a preliminary study patricia n. ayson, md1, jan eero g. lopez, md1,2, erasmo gonzalo dv llanes, md 1,3 1department of otolaryngology head and neck surgery quirino memorial medical center 2departments of otolaryngology head and neck surgery st luke’s medical center and the medical city 3department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila correspondence: patricia n. ayson, md quirino memorial medical center katipunan ave., project 4, quezon city 1105 philippines phone: (632) 421 2250 local 117/129 fax : (632) 913 4758 email: patty_tlp@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at: 1. north east manila ent consortium research contest (3rd place) september 2005. 2. descriptive research contest (2nd place), philippine society of otolaryngology head and neck surgery 49th annual convention, westin philippine plaza hotel, manila, december 1, 2005. philipp j otolaryngol head neck surg 2006; 21 (1,2): 20-23 c philippine society of otolaryngology – head and neck surgery, inc. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles philippine journal of otolaryngology-head and neck surgery 21 guided by ear fluid culture results. individual data on culture studies could suggest choices for instituting the narrowest spectrum systemic antibiotics applicable in our setting, significantly assuring a most efficient and cost-effective protocol of treatment. however, this may be too expensive for most of our patients, and much of the morbidity of csom comes from treatment failure. recognizing the need for awareness of the current pattern of bacterial pathogens isolated from csom in our setting, the objective of our study is to identify the common bacterial isolates from patients diagnosed with chronic suppurative otitis media at the quirino memorial medical center and to determine the sensitivity and resistance of these bacterial isolates to commonly used antimicrobials. methodology all patients diagnosed with chronic suppurative otitis media (using the world health organization criteria for csom, 2004)1 at the outpatient clinic of the quirino memorial medical center from july 2004 to july 2005 and from whom informed consent was obtained, (signed by the patient or parent/guardian) were considered for inclusion. a total of 32 patients with unilateral or bilateral active csom satisfying the inclusion criteria set before the study (table 1), were assessed at our outpatient clinic. a diagnosis of csom was made using the who definition (2004): 1) a history of chronic purulent ear discharge (>6-12 weeks), and 2) tympanic perforation, verified with otoscopic examination. removal of cerumen and suctioning of ear discharge were done to adequately visualize the character of the discharge, tympanic membrane perforation, and status of the middle ear (polypoid, thickened, eroded). the evaluation and diagnosis was exclusively made by an otorhinolaryngologist before inclusion of the patient. aseptic microsurgical techniques were observed in the collection of specimens. 1) each tympanic membrane was adequately visualized 2) a sterile cotton pledget soaked in povidone-iodine (betadine™) was swabbed 3 times around the external auditory canal (eac) 3) a sterile cotton swab soaked in 70% ethyl alcohol was likewise applied thrice around the eac 4) a sterile, dry micro-cotton swab was applied to the fluid draining from the tympanic membrane (tm) avoiding contact with the eac walls. each specimen bottle was labeled with the patient’s name and ear laterality and submitted for direct culture for aerobes and sensitivity studies at the department of laboratories within 15 minutes of collection. direct culture material was seeded onto sheep blood agar and chocolate agar plates, incubated in the presence of oxygen for 24 hours at 37oc and subjected to automated bacterial identification. isolates yielding pure cultures were further studied for antimicrobial sensitivity and resistance, using drugs chosen from commonlyprescribed medications for patients with csom in our institution. this study was limited to identification of aerobic bacterial isolates from the samples submitted for culture. no studies were done for anaerobes, viruses or fungi. this study adhered to the declaration of helsinki and was approved by the research and ethics committee of the residents training program of our institution. table 1. inclusion and exclusion criteria for selecting patients in the study criteria for selection of patients criteria for exclusion for inclusion in the study patients presenting with chronic ear discharge for more than 6-12 weeks patients with perforated tympanic membrane patients must not have received ototopical or systemic antibiotics (>12wks) prior to the inclusion dates set before the study was started patients with cholesteatoma formation on clinical examination, confirmed by radiologic examination patients with intracranial or extracranial complications of csom (petrositis, facial paralysis, meningitis, abscess) patients with other serious medical conditions such as immunodeficiency states, malignancy or blood dyscrasia patients without any written informed consent table 2. bacteriology of ear discharge samples (n=54) cultures isolated bacterial pathogens total pure mixed no growth total staphylococcus aureus pseudomonas aeruginosa streptococcus viridans proteus mirabilis total : staphylococcus aureus and proteus mirabilis staphylococcus aureus and klebsiella sp. pseudomonas aeruginosa and staph. epidermidis total: 21 14 3 4 42 5 3 1 9 3 54 % 50.0 33.3 7.1 9.5 (77.8%) % 55.6 33.3 11.1 (16/7%) (5.6%) (100%) duration of symptoms, past therapeutic failures, severity of current symptoms and culture and sensitivity profile. patients diagnosed with csom warranting systemic antimicrobial therapy previously needed discharge cultures to determine bacterial profiles for the selection of systemic therapy, until studies identified the common bacterial pathogens serving as bases for the selection of systemic antimicrobials for empiric therapy. however, morbidity from this disease remains significant in our country despite the use of systemic antibiotics to treat the illness and its complications1, with antibiotic resistance becoming a serious and major issue7. according to wintermeyer, et al6, and aslam, et al8, treatment of csom with otic, oral or parenteral drugs should be silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles 22 philippine journal of otolaryngology-head and neck surgery results fifty four specimens were obtained from the 32 patients satisfying our inclusion criteria. on the average, patients were 19-20 years old ± 13-14, ranging from 7 to 41 years old. half of the patients (16/32) were pediatric patients, and half were adults. the proportion of males were larger (59.37% or 19/32) than females (40.62% or 13/32), with a ratio of 1.46:1. fifty one of the 54 samples or 94.4% grew bacterial isolates. forty two of the samples sent for direct culture yielded pure cultures (77.8%), 9 were mixed cultures (16.7%) and 3 samples (5.6%) had no growth (table 2). direct cultures revealed pathogens in 51 (94.4%) of 54 samples. major bacteria isolated from pure cultures were staphylococcus aureus in 50% (21/42), pseudomonas aeruginosa in 33.3% (14/42) streptococcus viridans 7.1% (3/42) and proteus mirabilis 9.5% (4/42). the most common pediatric age-group isolates were staphylococcus aureus (76.19% or 16 /21) and pseudomonas aeroginosa (78.57% or 11/14). most mixed cultures 88.89% (8/9) were isolated from the adult group. combinations included staphylococcus aureus and proteus mirabilis in 55.6% (5/9), staphylococcus aureus and klebsiella spp. in 3 (33.3%) and pseudomonas aeruginosa with staphylococcus epidermidis in 1 (11.1%) (table 3). drug sensitivity patterns for pure cultures (table 4) revealed 61.9% of isolated staphylococcus aureus were resistant to penicillin (13/21), with only 38% sensitive to the drug. pseudomonas aeruginosa (table 5) showed 64.3% resistance to penicillin (all in the pediatric group) while ciprofloxacin was active against 85.7% (12/14) of isolates followed by amikacin (83.3%) and gentamicin (50%). pseudomonas was resistant to macrolides in 77.8%. all isolates of streptococcus viridans and staphylococcus mirabilis tested for penicillin revealed 100% sensitivity to the drug (table 6). discussion the average incidence of chronic suppurative otitis media at the quirino memorial medical center (based on retrospective data reviewed from 2000 to 2003) is 34 cases per year. several surveys among children in metro manila conducted by yabut (1994, in psohns 20049) estimated the prevalence of csom at 2.5-29.4%. the prevalence of csom in various african countries is reported between 2 and 6%, whereas it is below 1%5 in the usa and europe . the estimated yearly incidence of csom in developing countries (including the philippines) is 39.3 according to world health organization (who) data, a prevalence of 4% is representative of asian countries, obviously a lot more than rate patterns in developed countries. there is no gender predilection. although most surveys and studies on csom were done among children, and most developing countries have predominantly young populations in whom csom is most prevalent, csom can affect both pediatric and adult groups, as illustrated in this study. the philippines has been classified by the who as belonging to the high prevalence group (2-4%)2 of csom, and this avoidable burden of disease must be addressed. systemic antimicrobial agents may be necessary for the treatment of csom and the type of antimicrobial and table 4. sensitivity studies for pure cultures (staphylococcus aureus) culture group of antibiotics penicillins pen g ampicillin oxacillin cephalosporins aminoglycosides amikacin gentamicin macrolides chloramphenicol staphylococcus aureus sensitive 8 8 6 18 19 18 % 38.1 38.1 33.3 94.7 90.5 85.7 resistant 13 13 12 1 2 3 % 61.9 61.9 66.7 5.3 9.5 14.3 table 5. sensitivity studies for pure cultures (pseudomonas aeruginosa) culture group of antibiotics penicillins pen g ampicillin oxacillin cephalosporins aminoglycosides amikacin gentamicin macrolides chloramphenicol quinolone (ciprofloxacin) pseudomonas aeruginosa sensitive 5 10 7 2 12 % 35.7 83.3 50.0 22.2 85.7 resistant 9 (all from pediatric group) 2 7 7 2 % 64.3 16.7 50.0 77.8 14.3 table 3. bacteriology of ear discharge specimens according to age group (n=51) age group total % 23.8 21.4 100 25.0 80.0 100 100 33.3 culture pure staphylococcus aureus pseudomonas aeruginosa streptococcus viridans proteus mirabilis staphylococcus aureus and proteus mirabilis staphylococcus aureus andklebsiella spp. pseudomonas aeruginosa and staphylococcus epidermidis no growth adult no. 5 3 3 1 4 3 1 1 % 76.2 78.6 0 75.0 20 0 0 66.7 no. 21 14 3 4 5 3 1 3 % % 38.9 25.9 5.6 7.4 9.3 5.6 1.8 5.6 pediatric no. 16 11 0 3 1 0 0 2 silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles philippine journal of otolaryngology-head and neck surgery 23 route of administration should be selected to suit the specific infecting organism(s). over the years, research on common bacterial pathogens in csom has helped address and control the threat of its complications. local bacteriological studies have been delimited by practical and procedural difficulties in, and inherent costs of obtaining outpatient middle ear discharge cultures. although the type of bacteria isolated in our study (staphylococcus aureus, pseudomonas aeruginosa, proteus species, and polymicrobial isolates3), are similar to those previously reported3,5,8 the higher prevalence of staphyloccoccus aureus, followed by pseudomonas aeruginosa and mixed cultures differs from recent studies3,5,6,7 the individual percentage rates for s. aureus (50%), p. aeruginosa and mixed cultures, also varied from those recently observed by gupta, et al3 and the who where p. aeruginosa predominated in 48-98% of cases. the presence of streptococcus viridans and mixed cultures with klebsiella spp. among the predominant pathogens (aside from s. aureus, p. mirabilis and p. aeruginosa) may generate varied hypotheses regarding the complex relationship between pathogen and host in the middle ear, which cannot be detected by traditional culture techniques. although the small sample size (42 isolates) may restrict the value of our findings, penicillin resistance of s. aureus in 61.9% of the cases and pseudomonas aeruginosa in 64.3%, may suggest increasing penicillin resistance among pathogens that commonly cause csom. penicillinresistant p. aeruginosa are much more common in children, and have become a major cause of therapeutic failure8,10. the increase in rates of penicillin-resistant s. aureus has been a hindrance to empirical treatment, necessitating reassessment of antibacterials of choice, and awakening interest in microbiological monitoring. chronic suppurative otitis media still ranks among the most important causes of preventable hearing loss. morbidity from this disease remains significant in our country despite frequent use of systemic antibiotics to treat the illness and its complications. concern for antimicrobial resistance with the widespread use of systemic antimicrobials is increasing, and it has been recommended that culture table 6. sensitivity studies for pure cultures (streptococcus viridans and stapylococcus mirabilis) group of antibiotics streptococcus viridans staphylococcus mirabilis penicillins pen g ampicillin oxacillin cephalosporins aminoglycosides amikacin gentamicin macrolides chloramphenicol quinolone (ciprofloxacin) s 3 3 3 % 100 100 100 r 0 0 0 s 4 4 4 3 4 4 3 % 100 100 100 75.0 100 100 75.0 r 0 0 0 1 0 0 1 % 25.0 25.0 % culture and sensitivity studies be done before instituting topical, oral or intravenous antibiotics. the bacterial isolates from the ear discharges of csom patients in this study present a pattern similar to studies done internationally (including staphylococcus aureus and pseudomonas aeruginosa as the most common bacterial isolates), but an increasing rate of resistance of these isolates to the antibiotics commonly used to treat the disease was observed. majority of isolates of s. aureus and pseudomonas were resistant to penicillin in more than 50% of cases. macrolides and aminoglycosides were effective against most of the isolates of s. aureus and ciprofloxacin was shown to be active against pseudomonas aeruginosa. these patterns may be useful in instituting the narrowest spectrum systemic antibiotic for csom in our setting. if feasible, future studies may include cultures for anaerobes and fungal microorganisms. references: 1 acuin j; department of child and adolescent health development and team for prevention of blindness and deafness. chronic suppurative otitis media: burden of illness and management options. geneva: world health organization 2004. 2. bluestone cd. epidemiology and pathogenesis of chronic suppurative otitis media: implications for prevention and treatment. int j pediatr otorhinolaryngol 1998; 42:207-223. 3. gupta v, gupta a, sivarajan k. chronic suppurative otitis media: an aerobic microbiological study. indian j otol 1998 jun;4(2):79-82. 4. suzuki k, nishimura t, baba s, et al. topical ofloxacin for chronic suppurative otitis media and acute exacerbation of chronic otitis media: optimum duration of treatment. otol neurotol. 2003 may;24(3):447-52. 5. abes g, espallardo n, tong m et al. a systematic review of the effectiveness of ofloxacin otic solution for the treatment of suppurative otitis media. orl j otorhinolaryngol relat spec. 2003 mar-apr;65(2):106-16. 6. wintermeyer sm, nahata mc. chronic suppurative otitis media. ann pharmacother. 1994 sep;28(9):1089-99. 7. kenna ma, bluestone cd. microbiology of chronic suppurative otitis media in children. pediatr infect dis j. 1986 mar-apr;5(2):223-5. 8. aslam ma, ahmed z, azim r. microbiology and drug sensitivity patterns of chronic suppurative otitis media. j coll physicians surg pak. 2004 aug;14(8):459-61. 9. philippine society of otolaryngology head and neck surgery, task force on clinical practice guideline. consensus report on chronic suppurative otitis media. 2004 (forthcoming). 10. pichichero me. judicious use of antibiotics in pediatric respiratory infections 2000. pediatr infect dis j. 2000 sep;19(9):909-10. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 silver and gold: looking back, looking ahead “where are we headed, oh where have we gone? we’ve come a long way, now let us move on. dreams are for dreaming, wake up and they run; life is for living, come, let us move on1” a quarter of a century ago, dr. angel enriquez en-fleshed for us the opportunity to achieve “immortality in print” at a time when our society was celebrating its silver jubilee. through the years, our journal has allowed us to disseminate ideas, chronicle discoveries, share knowledge and broadcast our dreams and aspirations beyond the confines of our circles. at the same time, our journal has served as a sounding board, monitoring the pulse of our society and the various contexts in which it lives and breathes and has being. the relationship has been and should rightfully be reciprocal: both journal and society react to and influence each other, while being influenced by and impacting the social, cultural, political, economic and environmental forces in the spatio-temporal contexts in which they exist. but existence means not merely “being” but “standing-forth.” while the various editors in chief have reflected their particular zeitgeists, they likewise stood out, leaving their imprints on the sands of time. for the first eight years, angel e. enriquez (1981-1988) nurtured & cared for his “baby” as editor, advertiser, distributor & newsboy all rolled into one. though not surpassed, these efforts were at least equaled by eusebio e. llamas (1989-1990), who was succeeded by alfredo qy pontejos jr (1990). another eight year streak saw untiring efforts to improve the journal and, through it, our society by joselito c. jamir (199198), paving the way for jose m. acuin (1999-2000) to professionalize the journal, aiming for indexing by medline and index medicus by heroically publishing quarterly issues. the past five years saw charlotte m. chiong (2001-2005) at the helm, almost single-handedly performing the herculean task of bringing the journal to where it is today. if there is anything at all to be gleaned from a review of past editorials, it is a humbling, awe-inspiring realization of how each individually made their mark and of how tough an act to follow they collectively are. as we celebrate the silver anniversary of the philippine journal of otolaryngology head and neck surgery in the golden jubilee year of the philippine society of otolaryngology head and neck surgery, let us take the best from the past-from dr. enriquez’ dreams to feature “grand rounds, book reviews, x-ray of the year” to dr. chiong’s aspirations to include a pathology case review section, review articles, proceedings of meetings, conventions and website publication in this “electronic era” of information technology, let us move on to the future with an internationally peer-reviewed publication that will be someday be indexed in medline and index medicus2 and included in the institute for scientific information (isi) master journal list3. to this end, we reiterate our adherence to the uniform requirements for manuscripts submitted to biomedical journals formulated by the international committee of medical journal editors4. we are now available from http://www.psohns.org.ph/pjohns. our new editorial board includes international scholars with impressive publishing records and citation indices. we have an equally august international group of peer reviewers who graciously agreed to help us gratis et amore. this issue features two international source articles. we are especially grateful to friends, alumni and colleagues overseas who choose to publish in our journal rather than in more prestigious, indexed titles. with your support, we trust that the scope and coverage, and quality of editorial work and content of our journal will continue growing in breadth and depth over the next five to eight years. we are thankful to natividad almazan-aguilar, president of the psohns and its board of trustees 2005 for entrusting us with the privilege of serving you through the philipp j otolaryngol head neck surg. we trust that future leaders of our society infuse the journal with the much-needed financial and management support necessary to ensure production quality (layout, printing, graphics, illustrations) and “that services and products of contractors, vendors, and other commercial interests required for proper publication are selected on the basis of merit5”. we invite you to consider your vital role in revitalizing our journal: surely it deserves much more than “second-choice” articles and php100.00 in annual journal fees? through our journal, let us be “informed” of what has “transpired” so that being “inspired,” we can work to “transform” ourselves, our colleagues, our patients, our society and our world for the better. mabuhay tayong lahat! jose florencio f. lapeña, jr., ma, md 1 “moving on” lapeña jf, [unpublished song] manila:1981. 2 journal selection for medline® [fact sheet on the internet] bethesda (md): national library of medicine (us), 1988 [updated 2005 april 04] available from: http://www.nlm.nih.gov/pubs/ factsheets/jsel.html. 3 thomson scientific institute for scientific information (isi) master journal list [database on the internet] available from: http://www.isinet.com/. 4 international committee of medical journal editors. uniform requirements for manuscripts submitted to biomedical journals (n engl j med 1997; 336:309-314) [updated february 2006] available from: http://www.icmje.org/. 5 council of science editors. editorial policy statements approved by the cse board of directors. [printed october 2006] available from: http://www.councilscienceeditors.org/services. editorial 4 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery case reports abstract objective: to present a case of arteriovenous malformation of the mandible in a young postpartum woman and discuss the diagnostic and therapeutic dilemmas involved. methods: design: case report setting: tertiary private teaching hospital participants: one result: a 27-year-old woman with left mandibular swelling two weeks after tooth extraction was diagnosed and managed as a case of arteriovenous malformation. the extent of the lesion prevented surgical intervention and bleeding recurred despite three embolization attempts. ultimately, the left external carotid artery and contralateral dorsal contributory vessel were sacrificed causing necrosis of the anterior tongue and its eventual detachment. three sessions of stereotactic radiosurgery eventually controlled the bleeding with no recurrence to date. conclusion: on her second month following stereotactic radiosurgery, there appeared to be no complete resolution of the avm but there was also no recanalization or regrowth of the lesion. uncertain about whether her arteriovenous malformation will revascularize and how we may be able to help her in the event that it does, the waiting game continues for our patient. keywords: arteriovenous malformations; mandible, abnormalities; vascular malformations arteriovenous malformations (avm) of the mandible account for 1% of facial avm and represent the most severe vascular conditions in the head and neck presenting with pain, loose teeth, gum bleeding, swelling, pulsations and a thrill or bruit.1 symptoms of mandibular vascular malformations may be subtle and related to a preceding dental surgical procedure as previously reported for mandibular hemangiomas.2,3 however, to the best of our knowledge, there are no previous local reports of avm in the mandible. we report a case of avm of the mandible in a young postpartum woman and discuss the diagnostic and therapeutic dilemmas involved. case report a 27-year-old woman presented with painless left mandibular swelling two weeks after extraction of the left second and third mandibular molar due to loose dentition. she narrated that heavy bleeding had been encountered during the tooth extraction but was controlled with no postoperative bleeding episodes. healing of the operative site was unremarkable and completed within 2 weeks. the patient was initially treated with oral antibiotics, but the left mandibular swelling persisted and a faint intermittent throbbing sensation was felt along the left postauricular area. she was then referred to an ear, nose, throat (ent) surgeon for further evaluation and management. arteriovenous malformation of the mandible in a young postpartum woman gabrielle angela g. mercado, md kirt areis e. delovino, md allan b. carpela, md department of otolaryngology head and neck surgery st. luke’s medical center, quezon city correspondence: dr. kirt areis e. delovino department of otolaryngology head and neck surgery st. luke’s medical center 279 e. rodriguez ave., quezon city 1102 philippines phone: (632) 723 0101 fax: (632) 723 1199 (h) email: slmcearnosethroat@yahoo.com the authors declare that this represents original material. that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. reprints will not be available from the author philipp j otolaryngol head neck surg 2019; 34 (1): 52-55 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery case reports a computed tomography (ct ) scan revealed soft tissue attenuation in the medullary portion of the body and ramus of the left side of the mandible causing destruction of the surrounding bone and cortex with irregular areas of lucency. (figure 1) because of the non-painful mandibular swelling after tooth extraction and ct scan findings, the primary consideration was an odontogenic tumor probably an ameloblastoma. a segmental mandibulectomy was recommended but she opted to obtain a second opinion at our institution. on examination, the swelling was only noticeable externally with a very faint area of hyperemic skin overlying the left mandibular body and no facial asymmetry, pain or numbness. she was admitted for biopsy and possible left marginal mandibulectomy. upon incising along the left retromolar trigone to the area of the left lower second molar, profuse bleeding amounting to 500 ml was encountered. hemostasis was done and the procedure was aborted pending further diagnostic work-ups. magnetic resonance angiography (mra) of the oral cavity revealed multiple serpiginous flow void signals seen in the region of the left mandible with cortical erosion and intraosseous involvement as well as involvement of the masseter muscles, masticator and parapharyngeal spaces, with communication with the carotid vessels. (figure 2) a vascular malformation was confirmed by bilateral carotid and facial angiography. (figure 3) the image showed a moderate to high-flow vascular malformation involving the left facial, mandibular and auricular areas with prominent hypertrophied arterial supplies mainly coming from bilateral lingual and facial arteries, the left internal maxillary and pre-auricular arteries, and drained by the corresponding markedly dilated veins in the left side. from the initial admission, our patient was readmitted three more times due to recurrence of oral cavity bleeding despite repeated permanent embolization. the severity of oral cavity bleeding worsened with each admission. the patient experienced episodes of hypovolemic shock, loss of consciousness and seizures. the avm was seen to extend intracranially with recanalizaton of the previously embolized blood vessels arising from the left lingual and left facial arteries with the right facial and right lingual arteries more engorged, with progression in degree of collateral vessel formation. the descending branch of the right internal maxillary artery now contributed to the avm along the left mandible. (figure 4) the patient was being seen by a multispecialty services to discuss the possible options and risks that the patient could encounter. the possibility of performing the mainstay treatment of avm involving embolization and complete excision was not a primary consideration at this point because of the high likelihood of mortality. she was referred to vascular surgery for possible clipping of vessels, radiation oncology for stereotactic radio surgery, endovascular or external beam radiation and interventional oncology for possible reembolization. the chance of complete devascularization of the main a b figure 1. axial ct scans at the level of the mandible a. bone window, b. soft tissue window showing soft tissue attenuation in the medullary portion of the body and ramus of the left side of the mandible causing destruction of the surrounding bone and cortex resulting in irregular areas of lucency (arrows). figure 2. mra of the oral cavity a. coronal view at the level of the parapharyngeal space. b. axial view at the angle of mandible. multiple serpiginous flow void signals are seen in the region of the left mandible with cortical erosion and intraosseous involvement as well as involvement of the masseter muscles, masticator and parapharyngeal spaces and communication with the carotid vessels (arrows). a b branches of the carotid artery was highly considered, but so was the possible compromise of blood supply to the tongue and mandible leading to eventual necrosis. after losing 1.5 liters of blood from the dental sockets within just a few minutes during the third admission, vascular ligation or complete extirpation of the avm was no longer considered an option due to the likelihood of intractable blood loss and necrosis. the most feasible management considered was selective catheterization of the prominent hypertrophied arterial supplies arising from both external carotid arteries and polyvinyl alcohol embolization that resulted in complete devascularization of the said vessels. she was discharged stable, but reported occasional left mandibular pain and progression of skin discoloration along the left mandible with necrosis of the anterior philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery case reports figure 3. serial ct angiogram of carotid arteries, l to r, top to bottom. moderate to high-flow vascular malformation involving the left facial, mandibular and auricular areas with prominent hypertrophied arterial supplies were mainly coming from bilateral lingual and facial arteries (solid arrows), and left internal maxillary (dashed arrows) and pre-auricular arteries (dotted arrows). a d b e c f figure 4. ct angiogram of carotid arteries a. coronal view of the nidus of carotid artery, b. c. and d. sagittal views of the carotid artery. note recanalization of the previously embolized blood vessels arising from the left lingual and left facial arteries with the right facial and right lingual arteries more engorged with progression in degree of collateral vessel formation (solid arrows). the descending branch of the right internal maxillary artery now appears to contribute to the left mandibular arteriovenous malformation (dotted arrows). a b c d third of the tongue. (figure 5a) stereotactic surgery was believed to be the only other option for our patient. on the 49th day, the patient received her first session of stereotactic surgery. on the same day, her necrotic anterior tongue fell off. (figure 5b) she completed stereotactic surgery sessions on the 55th day. monthly follow ups since have shown no significant interval change in degree and extent of the previously dilated and tortuous varices in the left retromandibular region, and no new formation or recanalization of the arteriovenous malformation. (figure 6) although the patient had lost the anterior third of her tongue with resulting dysarthria, her mandible was still intact with no progression of skin changes and she was able to tolerate a pureed diet. until this writing, there has been no recurrence of bleeding and our patient has been undergoing speech and swallowing therapy and vital stimulation. discussion arteriovenous malformations, a subtype of vascular malformations are congenital malformations accounting for 1.5% of all vascular anomalies with 70% involving the cheek, nose, ears and upper lip. exemplified by our patient, more females than males (ratio of 1.5:1) present with avm that commonly involves the cheek.4 these tumors result from errors of vascular morphogenesis that are caused by a disturbance in the late stages of angiogenesis.1 mandibular avm are rare in clinical practice, and are often found by chance when teeth in the area are extracted5 as was the case with our patient. patients are usually pediatric but may not become symptomatic until later in life when they present with facial swelling, pain, otalgia, dental mobility or spontaneous bleeding around the teeth or from the mucosa.6 having a stage 1 avm according to the schobinger classification,7 our patient developed symptoms (including minimal nontender facial swelling and a vague pulsation felt along the cheek) later on in life. according to su et al. avm expand rapidly from an idle state especially after exposure to trauma during pubescence or following the change of estrogenic hormones such as when one is pregnant.5 our patient had recently given birth when she began to notice mandibular skin discoloration. vascular malformations are not known to resolve spontaneously and can be classified further according to hemodynamic criteria into high-flow (avms, arteriovenous fistulae) or low flow (capillary, venous, hemangiomas and lymphatic malformations) lesions.8,9 high-flow vascular malformations are commonly located along the cheek or auricle philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery case reports acknowledgements we thank dr. joel a. romualdez, joanne sebastiana m. de ramos, dr. marcelino s. tuaño and dr. jimmy v. chang for the suggestions and comments regarding the focus and flow of the case report. we also thank our chairs dr. cecilia gretchen navarro-locsin (qc) and dr. william lim (bgc) and residency training officers dr. joseph arañas (qc), and dr. keith aguilera (bgc) for their continued support and encouragement in writing scientific papers. references 1. loureiro cc, falchet pc, gavranich j jr, lobo leandro lf. embolization as the treatment for a life-threatening mandibular arteriovenous malformation. j craniofac surg. 2010 mar;21(2): 380 382. doi: 10.1097/scs.0b013e3181cfa62a; pmid: 20186078. 2. papa ec, samson es, victoria fa. cavernous hemangioma of the mandible. philipp j otolaryngol head neck surg. 2009;24(2):32-35. doi: 10.32412/pjohns.v24i2.685. 3. sadain-urao zk, pontejos aqy. hemangioma of the mandible: an exanguinating lesion. philipp j otolaryngol head neck surg. 1998:21-26. [cited 2019 may 26] available from:  https://pjohns. pso-hns.org/index.php/pjohns/issue/view/73/21. 4. shailaja sr, manika m, manjula m, kumar lv. arteriovenous malformation of the mandible and parotid gland. dentomaxillofac radiol. 2012 oct; 41(7): 609–614. doi: 10.1259/dmfr/47383305; pmid: 22282511 pmcid: pmc3608384. 5. su lx, fan xd, zheng jw, wang ya, qin zp, wang xk, et al. a practical guide for diagnosis and treatment of arteriovenous malformations in the oral and maxillofacial region. chin j dent res. 2014; 17(2):85-9. pmid: 25531015. 6. wang j, huang h. intraoral curettage without presurgical endovascular embolization: a simple but controversial treatment of arteriovenous malformations of the mandible.  int j oral maxillofac surg. 2013 jan; 42(1): 133–136. doi: 10.1016/j.ijom.2012.04.015; pmid: 22608197. 7. mulligan pr, prajapati hj, martin lg, patel th. vascular anomalies: classification, imaging characteristics and implications for interventional radiology treatment approaches. br j radiol. 2014 mar;87(1035):20130392. doi: 10.1259/bjr.20130392 pmid: 24588666. pmcid:pmc4064609 8. ayahao f. feeding and draining vessel ligation with sclerotherapy of high flow arteriovenous malformations in the head and neck. philipp j otolaryngol head neck surg. 2014 jan-jun; 29(1). 37-40. doi:https://doi.org/10.32412/pjohns.v29i1.467. 9. kriwalsky ms, papadimas d, maurer p, brinkmann m, jackowski, j, kunkel m. life-threatening bleeding after tooth extraction due to vascular malformation: a case report and literature review.  oral maxillofac surg.  2014 sep; 18(3): 279-82.  doi: 10.1007/s10006-014-0448-3; pmid: 24756853. 10. perkins j. vascular anomalies of the head and neck. in: flint p, haughey b, lund v, niparko j, robbins t, thomas r, et al., editors. cummings otolaryngology: head and neck surgery 6th edition. philadelphia, pa: saunders elsevier. 2015. p.3078. 11. tarkan o, sürmelioğlu o, tuncer ü, akgül e. face skin necrosis following embolization for arteriovenous malformations: a case report.  oral maxillofac surg. 2010 mar; 14(1):49–52. doi: 10.1007/s10006-009-0180-6; pmid: 19830463. 12. corsten l, bashir q, thornton j, aletich v. treatment of a giant mandibular arteriovenous malformation with percutaneous embolization using histoacrylic glue: a case report. j oral maxillofac surg. 2001 jul; 59(7): 828-832. doi: 10.1053/joms.2001.24311; pmid: 11429753. 13. bouloux gf, perciaccante vj.  massive hemorrhage during oral and maxillofacial surgery: ligation of the external carotid artery or embolization? j oral maxillofac surg. 2009 jul; 67 (7):15471551. doi: 10.1016/j.joms.2009.03.014; pmid: 19531434. as localized pulsatile masses or diffuse areas of increased blood flow.9 there is no single definitive treatment for avm. options include conservative management (transvenous or transarterial embolization, radiotherapy, sclerotherapy, radiotherapy, bone wax packing of bone cavities and curettage), surgical resection and reconstruction or a combination of both.1,6 studies have shown that a single session of superselective intra-arterial embolization is enough to control small high flow vascular malformations of the oral cavity with postprocedural follow up.10,11 small avms including those considered high-flow can be treated by surgical excision and embolization, but this may not apply to large avms such as that in our patient due to the increased risk of exsanguination and incomplete extirpation of the nidus. considering the patient’s petite stature, the margin for blood loss was very low and multiple episodes of oral cavity bleeding almost led to exsanguination. our patient presented with a large high-flow vascular malformations and recurrent profuse bleeding. ligation of the carotid artery and surgical excision was not considered appropriate management as it could not be completely embolized or resected. we resorted to serial embolization, complications of which may include hemorrhage, hematoma formation, infection, dissecting aneurysm, cerebrovascular accident, cranial nerve injury, facial paralysis, skin and mucosal necrosis and ultimately, death.12,13 not only was embolization insufficient, the avm in our patient could not be controlled despite multiple embolization attempts that eventually led to tongue necrosis and autoamputation, permanently affecting her quality of life. the medical team was uncertain about the proper management for our patient. partial and complete embolization of the external carotid artery to control the nidus was attempted but proved to be insufficient. complete surgical resection was not considered an option due to the high risk of exsanguination and extreme facial deformity. there is no definitive management guideline for such a case. had the patient presented with a soft tissue avm, the chances of diagnosis and treatment would have been higher compared to the intraosseous avm which can present as an apparently normal or asymptomatic lesion. our patient has received three sessions of embolization and stereotactic surgery. she has already lost her ability to speak and has impaired feeding and swallowing. on her second month following stereotactic radiosurgery, there appears to be no complete resolution of the avm but there is also no recanalization or regrowth of the lesion. uncertain about whether her arteriovenous malformation will revascularize and how we may be able to help her in the event that it does, the waiting game continues for our patient. ba figure 5. appearance of tongue after complete embolization of the carotid vessels a. necrotic anterior third of the tongue b. auto-amputated anterior third of the tongue. figure 6. ct angiogram of carotid arteries, taken after stereotactic radiosurgery. a. and b. no significant interval change in degree and extent and no new formation or recanalization of the arteriovenous malformation. ba philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles 14 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2008; 23 (2): 14-16 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: this study focuses on evaluating the relationship between physical findings, particularly collar size and body mass index (bmi), and polysomnographic parameters in male patients seen at a sleep disorders laboratory, suspected to have obstructive sleep apnea (osa). methods: design: cross-sectional study setting: academic tertiary private hospital subjects: charts of 149 adult male patients referred for polysomnography between july 1, 2005 and june 30, 2006 were reviewed. height, weight and external neck circumference measurements were obtained. the data from polysomnography results were noted and correlated with the physical measurements. results: the mean collar size for the osa group was 42.03 cm with a mean bmi of 29.14 while the mean collar size for the normal group was 39.05 cm with a mean bmi of 25.36. a significant difference was noted in both the collar size and body mass index (bmi) between the osa group and the normal group (p<0.005). results showed a significant correlation between collar size and bmi. collar size and bmi measurements were also correlated with increasing severity of sleep apnea in the osa group. the ≥40 cm collar size among male adults with symptoms of osa was 80% sensitive and 67% specific with a positive predictive value of 94% in predicting true osa. conclusion: this study suggests that the external neck circumference and the degree of obesity determined through bmi measurement may be important predictors of sleep apnea in adult filipino males suspected to have osa. given the high probability of having true osa in symptomatic male adults with a collar size ≥ 40 cm, outright definitive management may be opted for in these patients, while those with a collar size < 40 cm may need to undergo further confirmatory tests. key words: obstructive sleep apnea, external neck circumference, collar size, body mass index, polysomnography, obesity because of the significantly increased risk of morbidity and mortality, patients with obstructive sleep apnea (osa) must be diagnosed and treated vigorously. clinical evaluations following previous studies consider tonsil size, mallampati score, body mass index (bmi), neck circumference and lateral craniofacial assessment. of these, the bmi has been found to be the most important physical parameter for the prediction of osa.1 collar size as predictor of obstructive sleep apnea lyra valera veloro, md1 michael alexius adea sarte, md1, 2 samantha soriano castañeda, md1,3,4 1 department of otolaryngology head and neck surgery the medical city 2 the center for snoring and sleep disorders the medical city 3 department of otolaryngology head and neck surgery rizal medical center 4 department of otolaryngology head and neck surgery jose reyes memorial medical center correspondence: lyra valera veloro, md department of otolaryngology head and neck surgery po218 2nd floor, hospital podium the medical city ortigas avenue, pasig city 1600 philippines phone: (632) 635 6789 loc 6250 telefax: (632) 687 3349 email: lyraveloro@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. presented at the 22nd annual interdepartmental research contest (1st place, descriptive studies category), the medical city, pasig; december 7, 2006 analytical research contest (1st place), philippine society of otolaryngology – head and neck surgery 51st annual convention, sofitel philippine plaza manila, pasay city, philippines, december 1, 2007. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles philippine journal of otolaryngology-head and neck surgery 15 for a bmi higher than 28 kg/m2 in males and 27 kg/m2 in females, the incidence of osa has been reported at approximately 30%.1 even a 5% to 10% decrease in body weight in some obese individuals with osa can lead to substantial clinical and objective improvement in sleepdisordered breathing.2 although a positive correlation has been found between bmi and severity of osa, bmi does not necessarily predict the presence of osa.1 although neck circumference correlated significantly with bmi in both men and women, the neck circumference measured independently from the bmi is thought to be a very important parameter for the diagnosis of osa. osa is reported to be present in 30% of patients with a neck circumference of 43 cm in males or 38 cm in females in one study.3 others, on the other hand, reported no correlation between increasing neck circumference and severity of osa. currently, polysomnography (psg) is regarded as the most valuable standard and definitive method for establishing the diagnosis of osa. psg continues to be the gold standard for the diagnosis of osa.4 unfortunately, the role of physical findings in the diagnosis of sleep apnea is unclear. this study focuses on evaluating the correlation between physical findings, particularly collar size and bmi, and polysomnographic parameters in patients attending our clinic suspected to have osa. methods design: cross-sectional study setting: academic tertiary private hospital subjects: all charts of adult filipino male patients referred for polysomnography (psg) to the center for snoring and sleep disorders between july 1, 2005 and june 30, 2006 were retrospectively reviewed. included were males 19 years old and above with no craniofacial or neurologic abnormalities and no previous operations in the head and neck region, suspected to have osa based on history (loud snoring, cessation of breathing during sleep, frequent arousals at night, chronic daytime sleepiness or fatigue) and physical examination findings (tonsil size, mallampati scores). height in meters, weight in kilograms and external neck circumference in centimeters (or collar size) taken prior to psg were obtained from patient’s charts as well as records of co-morbidities for sleep apnea: hypertension, stroke, heart disease or adult-onset diabetes. the bmi was obtained by weight in kg divided by the square of height in meters. outcome measure: the results of the psg were noted and correlated with the physical measurements. data and statistical analysis: based on the objectives, statistical analyses included spearman rho correlation for categorical data and chi-square test for association significance. results one hundred forty nine (149) male patients fulfilled the inclusion criteria. of these, 128 were diagnosed with obstructive sleep apnea (osa) by polysomnography while 21 had normal results. the mean age was 45.23 years with a standard deviation of 10.72. the mean collar size for all patients was 41.61 cm and the mean bmi was 28.61. there was no significant difference in age between the group with osa (n=128) and the normal group (n=21). the mean collar size for the osa group was 42.03 cm with a mean bmi of 29.14 while the mean collar size for the normal group was 39.05 cm with a mean bmi of 25.36. a significant difference was noted for both the collar size and body mass index (bmi) between the osa group and the normal group (p<0.005). (table 1) in the osa group, 16 (12.5%) were in the mild category (rdi of 5 to <10) with a mean collar size of 38.4 cm and a mean bmi of 25.96; fortyone (32%) were in the moderate group (rdi of 10 to <30) with a mean collar size of 41.58 cm and mean bmi of 29.39; seventy-one (55.5%) were classified as severe (rdi of >/= 30) with a mean collar size of 43.09 cm and a mean bmi of 29.7. the severity of osa was subsequently classified into normal, mild, and moderate-severe categories as multiple comparison tests showed no significant difference in collar size between those with moderate osa and those with severe osa (table 2). the collar size increased progressively with increasing severity of sleep apnea. likewise, the body mass index (bmi) was related to the severity of sleep apnea and different among the groups mentioned (p<0.005). (table 3) search for a cut-off point collar sizes for the normal group ranged from 33.02 cm to 48 cm. collar sizes for the osa group ranged from 30.37 cm to 48.26 cm. twenty-three percent (23%) of the total patients and 24% of patients diagnosed with osa had a 40-centimeter collar size. only 2-5% of subjects had other collar sizes. on account of the considerable number of the study population clustering in the 40-centimeter collar size, it was selected as the cut-off point and was tested for its predictive value. of the study population, a total of 109 subjects had a collar size ≥ 40 cm, while 40 subjects had a collar size of < 40 cm. for purposes of screening patients with osa as a positive test, the ≥40 cm collar size had a sensitivity, specificity and positive predictive value of 80%, 67% and 94%, respectively. (table 4) discussion osa is currently thought to be caused by a dynamic process with contributions from structural upper airway narrowing and abnormal upper airway neuromotor tone.5 subjective complaints have not yielded enough sensitivity and specificity, prompting attempts to clinically evaluate physical parameters and their relevance to the diagnosis of osa.1 external neck circumference, particularly collar size, has been assessed in several studies with conflicting outcomes.1 our resultsour results may suggest that collar size may be an independent parameter for determining osa. this correlation between sleep apnea and neck circumference may reflect “mass loading,” with the static pharyngeal size modulated by dynamic loading of the airway due to the weight of fatty neck tissue contributing to the pathogenesis of osa.6 statistical analyses suggested a significant difference between the mild and moderate osa groups, but no significant difference between moderate and severe stages. this may support a classification philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles 16 philippine journal of otolaryngology-head and neck surgery consisting of a normal group, a mild osa group and a moderate-severe osa group. collar size and bmi were significantly different among these groups and increased progressively with increasing severity of sleep apnea. the importance of this classification may guide the treatment plan within each category and the management differences between each category. among caucasians, osa is reported to be present in 30% of patients with a neck circumference of 43 cm in males.3 data in the philippine setting is lacking with regards a good collar size cut off point for predicting osa prompting utilization of results from this study as preliminary data to establish associations between collar size and diagnosis of osa locally. forty centimeters was suggested as a cut-off point for predicting osa in filipinos owing to the major percentage of the study population as well as subjects diagnosed with osa falling into this measurement. validation studies in the future may require roc (receiver operating characteristics) analysis for identification of cut-off values with a balanced negative and positive prediction for osa. results have shown that a ≥ 40 cm collar size presents with 94% probability of osa in adult filipino male subjects referred for polysomnography. hence, given the high probability of true osa in symptomatic male adults with a collar size ≥ 40 cm, outright definitive management may be opted for in these patients, while those with a collar size < 40 cm may need to undergo further confirmatory tests. standard criterion studies may validate these results. acknowledgements the authors would like to thank ms. lilian talag and the rest of the staff of the center for snoring and sleep disorders for technical assistance and data collection, ms. diane locayon for statistical analysis and drs. daniel alonzo (department chair) and peter jarin (training officer) for their unwavering support. references 1. erdamar b, suoglu y, cuhadaroglu c, katircioglu s, guven m. evaluation of clinical parameters in patients with obstructive sleep apnea and possible correlation with the severity of the disease. eur arch of otol 2001; 258: 492-495. 2. guce a. obstructive sleep apnea syndrome: a deadly slumber. jmpa vol. 74 nos. 1-4 (july 1998june 1999); vol. 75 nos. 1-4 (july 1999-june 2000). 3. guilleminault c, stoohs r., kim yd. upper airway sleep-disordered breathing women. ann int med. 1995; 122: 493-501. 4. gupta v, reiter e. current practices in obstructive sleep apnea and snoring.current practices in obstructive sleep apnea and snoring. am j otolaryngol. 2004 jan-feb; 25(1): 18-25. 5. greefield m. obstructive sleep apnea syndrome due to adenotonsillar hypertrophy in infants. int j ped otolaryngol. 2003; 67(10): 1055-1060. 6. katz i, stradling j, slutsky as, zamel n and hoffstein v. do patients with obstructive sleep apnea have thick necks? am rev respir dis 1990;141:1228-1231. table 1. demographic and anthropometric parameters for normal and osa subjects total subjects n=149 w/osa n=128 mean 45.49 42.03 29.14 normal n=21 age (yrs) collar (cm) bmi sd 10.35 3.53 4.84 mean 43.67 39.06 25.36 sd 12.96 3.17 5.19 mean diff 1.83 2.98 3.78 p-value 0.545 0.001* 0.004* table 2. severity of osa classified into normal, mild, and moderate-severe w/osa n=128 mean 45.5 42.0 29.1 age collar bmi sd 10.3 3.53 4.84 mild n=16 mean 45.6 38.5 26.0 sd 11.3 3.46 4.23 moderate n=41 mean 45.0 41.6 29.4 sd 10.58 3.28 6.05 severe n=41 mean 45.8 43.1 29.7 sd 10.14 3.13 3.88 multiple comparison test no diff accoss age mild < moderate & severe mild < moderate & severe table 3. collar size and bmi related to severity of osa w/osa mean 45.49 42.03 29.14 age (yrs) collar (cm) bmi sd 10.35 3.53 4.84 mild mean 45.56 38.50 25.97 sd 11.30 3.46 4.23 moderate mean 45.05 41.58 29.39 sd 10.58 3.28 6.05 severe mean 45.73 43.09 29.72 sd 10.14 3.13 3.88 p-value 0.945 0.000* 0.017* *significant difference table 4. sensitivity-specificity analysis of 40-centimeter cut-off point in screening patients for osa 94% 35% 33% 20% 80% 67% 102 out of 109 14 out of 40 7 out of 21 26 out of 128 102 out of 128 14 out of 21 positive predictive value negative predictive value false positive % false negative % sensitivity specificity philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 practice pearls philippine journal of otolaryngology-head and neck surgery 37 nasal saline irrigation is a simple easy-to-do procedure that has been used to treat sinus and nasal conditions for many years. wingrave in his 1902 paper “the nature of discharges & douches” discussed cleansing of the nasal passages as an important method of treating different nasal illnesses in the last part of the 19th century.1 nasal saline irrigation has been used for such sinonasal conditions as atrophic rhinitis, rhinosinusitis and allergic rhinitis, among infants with nasal problems and patients who have undergone endoscopic sinus surgery. past recommendations for use were based on anecdotal evidence such as reports of patients living near the sea, whose symptoms improved with natural seawater irrigation while swimming. the past two decades saw studies undertaken to support what has been in practice for many years. taccariello studied 40 patients suffering from chronic sinusitis with 19 patients receiving traditional alkaline nasal douche and 21 patients receiving sterile sea water spray. results showed that compared to the control group who received no treatment, douching per se improved endoscopic appearance and quality of life scores.2 georgitis compared the use of nasal hyperthermia versus saline irrigation in patients with allergic rhinitis. histamine levels fell with both forms of treatment with greatest declines seen with irrigation. leukotriene c4 levels were significantly reduced by irrigation.3 pediatricians have refrained from using oral and topical decongestants among infants. excessive use of oral decongestants can result in cardiovascular side effects, while excessive use and sufficient absorption of topical decongestants can result in possible complications of cns depression leading to coma and marked reduction in body temperature, especially in infants in whom these drugs should not be used.4 nasal saline irrigation has become a good alternative. another common use follows endoscopic sinus surgery, when the nasal cavity quickly becomes encrusted, and frequent cleaning and saline irrigation are needed for 4-8 weeks until the lining of the nose and sinuses has regenerated.5 nasal saline irrigation moisturizes the nasal cavity and reduces dryness of the nasal mucosa. it has become important in clearing nasal crusts and thick mucous in patients with rhinosinusitis and has been known for its beneficial effect among patients with sinonasal problems. saline solutions can be classified into isotonic or hypertonic, buffered or non-buffered. preparations include powder, spray or mist forms; with and without preservative; and with and without dispenser. the number of available products in the market can make it difficult for the doctor to decide on what product to recommend for his suffering patient, ranging from inexpensive home-made preparations to very expensive imported solutions. different studies will be presented which may help in this choice. isotonic or hypertonic solution the main issue at hand is whether to use an isotonic or hypertonic solution. traissac from the university ent hospital – bordeaux, in a study of 410 patients using isotonic solution, showed the beneficial action on the nasal sinus mucosa in medical disease and after sugery.6 josefino g. hernandez, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila correspondence: josefino g. hernandez, md department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 phone (632) 526-4360 fax (632) 525-5444 reprints will not be available from the author. no funding support was received for this study. the author signed a disclosure that he has a financial association with one pharma, distributors of nasal saline 0.65% and 2.3 % solutions (snif™). nasal saline irrigation for sinonasal disorders philipp j otolaryngol head neck surg 2007; 22 (1,2): 37-39 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 practice pearls 38 philippine journal of otolaryngology-head and neck surgery tomooka (university of california, 2000) in a study of 211 patients using hypertonic saline solution, showed improvement in 23 of the 30 symptoms queried.7 talbot, in 1997, demonstrated among 21 volunteers that 3% hypertonic saline solution decreased mucociliary saccharine transit times more than 0.9% normal saline, 3.1 minutes compared to 0.14 minutes less than baseline.8 this study was corroborated by keojampa in 2004, demonstrating that buffered hypertonic saline improved saccharine clearance time more than buffered normal saline.9 hypertonic saline solution decreases the viscosity of mucus which could have improved saccharine clearance time. however, it has been suggested that the saccharin dissolution method provides a less accurate assessment of mucociliary clearance against tagged insoluble particles, as the saccharin mixes between sol and gel layers of the mucociliary blanket and is not carried solely in the superficial gel layer.8 boek from the university hospital utrecht studied the effect of different saline solutions on the ciliary beat frequency (cbf) of cryopreserved mucosa of the sphenoidal sinus measured by a photoelectric method. results revealed that locke-ringer’s solution (lr) had no effect on the cbf, naci 0.9% had a moderately negative effect, naci 7% solution led to complete ciliostasis within five minutes (reversible after rinsing with lr), and 14.4% hypertonic solution had an irreversible ciliostatic effect. he concluded that lr is an isotonic solution with no effect on ciliary beat frequency.10 therefore, it is probable that this solution is more appropriate than saline for nasal irrigation or antral lavage. this was further supported by the study of min yg published in 2001, wherein isotonic and hypotonic solutions did not decrease ciliary beat frequency, but where ciliostasis was observed within a few minutes in the 3.0% and 7.0% solutions.11 histologic changes showed disruption of nasal epithelial cells in vitro which could have resulted in decrease ciliary beat frequency in hypertonic solutions. buffered or non-buffered solution the effect of ph on the rate of mucociliary clearance of the douching solution was also studied. one group was given hypertonic solution buffered to ph 8 and another group given non-buffered hypertonic solution.12 results showed no difference in mucociliary clearance between solutions buffered to ph 8 and that which is non-buffered.12 in his paper, taccariello noted that alkaline nasal douche improved endoscopic appearance but not the quality of life score, while sea water spray showed improved quality of life but not endoscopic appearance.2 preparations preparations for nasal saline irrigation in the market include powder which can be freshly prepared for use or ready-to-use spray or mist solutions which need preservatives to extend shelf life. common preservatives are benzalkonium chloride, polyethylene glycol and propylene glycol. bezalkonium chloride is an antibacterial preservative which may be potentially toxic to the mucosa. krayenbuhl and seppey (1995) compared application of a saline stream versus drops (passive saline instillation) among 104 patients who underwent intranasal surgeries. stream patients required significantly fewer post-operative recovery days and visits to physicians. the recovery period with saline stream was 18.9 days versus 36.7 days using saline drops.5 nasal saline preparations available in the local market include isotonic drops, isotonic and hypertonic sprays, and isotonic seawater sprays. parsons in 1996 presented a recipe for patients to prepare their own nasal saline solution:8 carefully clean and rinse a 1-quart glass jar. fill the jar with tap water. add 2 to 3 heaping teaspoons of “pickling/canning” salt. add 1 rounded teaspoon of baking soda (pure bicarbonate). stir and shake well before use. store at room temperature. this will result in a 3% saline solution buffered to ph 7.6. if the mixture is too strong and results in a stinging effect in the nose, less salt (1 ½ tsp of salt) can be used. for children, it is best to start with a weaker salt water mixture which can be gradually increased in tonicity. ordinary rock salt is used since iodine in iodized salt can be toxic to the nasal mucosa. a soft plastic catsup container can be used as a dispenser. the nose can be liberally irrigated 2-3 times per day. nasal saline irrigation has been safely used by both children and adults with no documented serious side effects. different studies have shown that both isotonic and hypertonic nasal saline irrigations have beneficial effects in many sinonasal conditions. the exact mechanism by which improvement is effected is unclear.7 hypotheses for why nasal saline irrigation promotes improvement of nasal symptoms include the following: 1. improving mucociliary clearance 2. decreasing mucosal edema 3. decreasing inflammatory mediators 4. mechanically clearing nasal crusts and thick mucous the choice of which nasal saline solution to use depends on the physician and is mainly based on which studies he or she will believe in. whether to recommend a saline solution prepared by the patient at home or saline solutions that are commercially available is really up to the doctor. commercial solutions have the advantage of being sterile. saline prepared at home is cheaper, but sterility may not be guaranteed and the percentage of tonicity may be variable. although several studies have shown that hypertonic saline solutions improve saccharine transit time, other studies have likewise shown that hypertonic saline solutions affect ciliary beat frequency negatively. for philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 practice pearls philippine journal of otolaryngology-head and neck surgery 39 this reason, isotonic saline solutions which do not affect ciliary beat frequency may be more appropriate than hypertonic saline solution for nasal irrigation. however, we cannot discount the mucolytic effect induced by the hyperosmolarity of hypertonic solutions which could have improved saccharine transit time. further studies can be undertaken to finally determine which solution, isotonic or hypertonic, would be better to use as nasal saline irrigation for the different sinonasal disorders. references 1. wingrave w. the nature of discharges and douches. the lancet. 1902 may:1373-1375. 2. taccariello m, parikh a, darby y, scadding g. nasal douching as a valuable adjunct in the management of chronic rhinosinusitis. rhinology 1999; 37:29-32. 3. georgitis gw. nasal hyperthermia and simple irrigation for perennial rhinitis: changes in inflammatory mediators. chest 106:1487, 1994. 4. goodman gilman a, goodman ls, rall tw, murad f. goodman and gilman’s the pharmacological basis of therapies. 7th ed., new york: macmillan publishing co.;1985. 5. papsin b, mctavish a. saline nasal irrigation: its role as an adjunct treatment. canadian family physician 2003; 49:168-173. 6. traissac l, et al. nasal washing with physiomer… 10 years later: 1988-1998. rev laryngol otol rhinol (bord) 1999; 120(2):133-135. 7. tomooka l, murphy c, davidson t. clinical study and literature review of nasal irrigation. laryngoscope 2000 jul; 110(7):1189-1193. 8. talbot ar, herr t, parsons ds. mucociliary clearance and buffered hypertonic saline solution. laryngoscope 1997 april; 107(4):500-503. 9. keojampa bk, nguyen mh, ryan mw. effects of buffered saline solution on nasal mucociliary clearance and nasal airway patency. otolaryngologyhead and neck surgery 2004; 131(5): 679682. 10. boek wm, et al. physiologic and hypertonic saline solutions impair ciliary activity in vitro. laryngoscope 1999 march; 109(3): 396-399. 11. min yg, et al. hypertonic saline decreases ciliary movement in human nasal epithelium in vitro. otolaryngol head neck surg 2001 mar; 124(3):313-316. 12. homer jj, et al. the effect of ph of douching solution on mucociliary clearance. clin otolaryngol 1999; 24:312-315. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 30 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2017; 32 (2): 30-33 c philippine society of otolaryngology – head and neck surgery, inc. an initial overview of management and treatment outcomes for head and neck hemangiomas rodolfo u. fernandez iii, md department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: dr. rodolfo u. fernandez iii department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone (632) 554 8467 email: rufernandez.iii@gmail.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believe that the manuscript represents honest work. the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest, october 6, 2016. natrapharm, the patriot bldg. parañaque city. abstract objectives: to provide an initial overview of the outcomes of different treatment modalities used for hemangiomas. methods: design: case series setting: tertiary national university hospital participants: records of 21 patients diagnosed with head and neck hemangiomas in the philippine general hospital department of otorhinolaryngology from 2009 to 2014 were reviewed. results: majority of the patients were female (61.9%) and in the pediatric age group (57.1%). of the 21 patients, 6 underwent medical management, 13 had surgical management, 1 had both medical and surgical management and 1 opted to observe the lesion. all patients treated with propranolol observed a decrease in the size of the lesion. seven out of the 13 patients had radiofrequency ablation; all had gross residual lesion. six of the 13 underwent excision with complete excision being achieved in 5 of 6 cases. conclusion: treatment response of patients in this series with hemangiomas of the head and neck to propranolol at a dose of 1 to 2 mg/kg/day may reflect international data. outcomes analysis for radiofrequency ablation and surgical excision requires a longer duration of follow-up. keywords: propranolol hydrochloride, prednisone, pulsed radiofrequency treatment, capillary hemangioma, vascular tissue neoplasms hemangiomas are the most common benign vascular tumors in infancy (but may also involve adults) and most commonly affect the head and neck region.1 unlike other vascular tumors, hemangiomas have a characteristic natural course-they rapidly proliferate during infancy and gradually involute over the next few years of life. however, a small proportion of hemangiomas require intervention. indications for intervention include function-threatening hemangiomas (e.g. ocular, ear, nasal tip and genitalia), life-threatening hemangiomas (e.g. airway lesion), disfiguring large hemifacial hemangiomas, ulcerated hemangiomas and those with associated systemic involvement.1 creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 31 systemic corticosteroids (e.g. prednisone at a dose of 2-4 mg/kg/ day) have been used as the first line treatment for hemangiomas for many years but long-term side effects of systemic steroids have been a recurring problem.1 recently, non-selective beta-blockers such as propranolol and timolol have emerged as safer and more promising treatment modalities.1 other treatment options include the use of intralesional triamcinolone, topical steroids such as clobetasol propionate, topical imiquimod and pulse dye laser.1-3 with the failure of medical management, surgical modalities come into play. in the philippine general hospital, hemangiomas are independently managed by different units which include pediatrics, plastic surgery, dermatology and otorhinolaryngology. the objective of this study is to provide an initial overview of the outcomes of different treatment modalities for patients with hemangiomas of the head and neck of the department of otorhinolaryngology from 2009 to 2014. methods with institutional review board approval, this case series purposively identified patients diagnosed with head and neck hemangiomas between january 2009 to december 2014 from outpatient, in patient, and emergency room censuses of the philippine general hospital (pgh) department of otorhinolaryngology, and retrieved their medical records for review. excluded were records of patients with a post-treatment followup of less than 6 months or who were lost to follow-up before or after treatment, those who did not comply with the medical treatment regimen, and those whose records were incomplete or missing. demographic data, location and size of lesion were extracted from the records. for patients treated medically, the following were determined: drug used, method of delivery, dose, duration of treatment, and treatment outcome (complete resolution, no change, decrease or increase in size, change in color). for patients treated surgically, the following were determined: type of surgery and outcome (complete resection, partial resection with gross residual). information was anonymized, recorded and tabulated using microsoft® excel for mac 2015 version 15.13.3 (150815) (microsoft corp., redmond, wa, usa) and descriptive statistics were computed. results out of 41 identified patients from the databases, only 21 fulfilled inclusion and exclusion criteria, 8 males (38.1%) and 13 females (61.9%). the age range was 0.75 to 66 years and a mean age of 18.1 years (sd = 17.2). twelve (57.1%) belonged to the pediatric age group (0 to 17 years) while 9 (42.8%) were adults. six patients underwent medical management, 13 had surgical management, 1 had both medical and table 1. medical management group patient code age/ sex location of lesion size of lesion (cm) drug dose (mg/ kg/ day) duration of treat ment (months) outcome m1 m2 m3 m4 m5 m6 8/m 9 mo s/f 8/f 4/f 6/f 4/f lip buccal lip nasal temporal tongue 1 x 1 x 0.5 8 x 6 x 2 5 x 2 x 1 1 x 1 x 0.5 4.5 x 5 x 1 10 x 8 x 8 oral propranolol oral prednisone oral propranolol oral prednisone intralesional methyl prednisolone oral propranolol oral propranolol oral propranolol 1.25 1 2 1 1.5 q1 month 2 2 1 12 3 6 1.5 3 20 2 6 decrease in size no change decrease in size no change decrease in size decrease in size decrease in size decrease in size surgical management, and 1 patient opted to observe the lesion. all 5 patients who underwent medical management with propranolol doses ranging from 1 to 2 mg/kg/day for at least 2 months were reported to have a decrease in size of their hemangiomas. of the 5, one (m2) was initially treated with oral prednisone (without response) and another (m4) received intralesional methylprednisolone (with decrease in size) prior to propranolol therapy. another patient (m3) who underwent treatment with oral prednisone alone exhibited no change in hemangioma size. (table 1) of the 13 surgical patients, 7 underwent radiofrequency ablation: 4 for lip lesions and one each for the chin, cheek and nasolabial area. two of these patients (s5, s7) had prior surgeries. all 7 had gross residual lesions after the procedure. of the six patients that underwent excision, complete excision was claimed in 5 of 6 cases while 1 case had gross intracranial residual tumor. (table 2) the one patient who underwent both medical and surgical management was a 30-year-old man with a hemangioma in the right buccal area that was surgically excised. due to recurrence, he underwent medical management with nebivolol at a dose of 0.5 mg/kg/day for 24 months. a decrease in size of the lesion was reported after 2 years. the one patient who opted to observe the lesion (a 3-year old female with a right pre-auricular hemangioma) was reported to have spontaneous resolution of her lesion after 4 years. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 32 philippine journal of otolaryngology-head and neck surgery original articles discussion all patients who underwent treatment with oral propranolol in this series were reported to have had a decrease in size in their lesions while those who underwent treatment with oral prednisone had no change in their lesions. the propranolol treatment group had a treatment dose ranging from 1-2 mg/kg/day and a mean duration of 9.3 months (range of 2 to 20 months). the lesion observed in one patient that was reported to spontaneously resolve after 4 years may be explained by the natural history of infantile hemangiomas-a rapid proliferative phase followed by a slower phase of involution.1,4 it is important to note that the majority of infantile hemangiomas undergo spontaneous resolution and that only 10 to 20% of patients require treatment.1 if such is the case, why treat infantile hemangiomas with propranolol to begin with? why not wait for spontaneous resolution (which should happen in most cases) and treat only those that do not resolve? the decision to treat an infantile hemangioma or wait for spontaneous resolution depends on the indication for intervention which includes function-threatening hemangiomas (e.g. ocular, ear, nasal tip and genitalia), life-threatening hemangiomas (e.g. airway lesion), disfiguring large hemifacial hemangiomas and ulcerated hemangiomas.1 it must also be noted that the use of oral propranolol therapy for infantile hemangiomas has contraindications (e.g. sinus bradycardia, bronchial asthma, heart failure) and is associated with several adverse effects (e.g. bradycardia, hypotension, hyperkalemia, hypoglycemia, bronchospasm) therefore, the decision to treat is highly individualized.4 the possible risks and adverse effects should be weighed against the potential benefits of intervention before starting treatment.4 the target dose of propranolol of 1-3 mg/kg/day has been recommended with a mean duration of treatment varying from 6 to 10 months.4 a meta-analysis by marqueling et al. showed that the overall response rate is 98% with a range of 82 to 100%.5 the 2 patients who took prednisone with a dose of 1 mg/kg/day with a mean duration of 2.25 months (range of 1.5 to 3 months) had no response and this may be attributed to an insufficient dose (recommended dose ranges from 2-5 mg/kg/day). for prednisone, the recommended dose is 2-4 mg/kg/ day.6 in a study by benett et al., a dose of 2-4 mg/kg/day resulted in 75% response, >3 mg/kg/day showed 94% response but with greater side effects while a lesser dose of <2 mg/kg/day resulted in poor response and rebound phenomenon in 70% of cases.6 sawa et al. found excellent treatment response to both propranolol and prednisone for infantile hemangiomas, at a median dose of 5 mg/kg/day for prednisone (n = 11) and 2 mg/kg/day for propranolol (n = 7).7 the difference between the two drugs was significantly longer treatment duration for propranolol with a mean duration of 372 days.7 side effects of corticosteroid treatment noted were increase in body-mass index (bmi) and systolic blood pressure.7 propranolol is well documented as an effective treatment modality for infantile hemangiomas.1,4,5,7 its mechanism of action in hemangiomas is related to its beta-2 inhibitory effect which decreases the release of vasodilators such as nitric oxide. vasoconstriction of the feeding capillaries results for the early visible changes in the color of the lesion.1 furthermore, propranolol down-regulates vascular endothelial growth factors and basic fibroblast growth factors, inhibiting the proangiogenic cascade and angiogenesis. this results in apoptosis and regression of hemangiomas.1 table 2. surgical management group patient code age/ sex location of lesion size of lesion (cm) surgery done prior surgery outcome s1 s2 s3 s4 s5 s6 s7 s8 s9 s10 s11 s12 s13 18/f 18/f 66/m 11/f 3/m 4/f 20/m 15/m 20/m 21/m 37/f 26/m 58/f chin cheek nasolabial lip lip lip lip temporal intranasal gingivobuccal intranasal lip and buccal temporal with intracranial extension 5 x 5 x 2 4 x 4 x 0.5 2 x 2.5 x 0.5 3 x 3 x 2.5 1 x 1 x 0.5 2 x 2 x 1 5 x 4 x 1 10 x 8 x 7 5 x 5 x 3 2.5 x 2.5 x 2 1 x 1 x 1 6 x 5 x 4 10 x 8 x 5 rf ablation rf ablation rf ablation rf ablation rf ablation rf ablation rf ablation excision excision via lateral rhinotomy excision endoscopic excision excision with deltopectoral flap reconstruction wide excision via transtemporal approach with trapezius flap reconstruction none none none none rf ablation x 2 none excision none none none none none none gross residual gross residual gross residual gross residual gross residual gross residual gross residual complete excision complete excision complete excision complete excision complete excision gross residual (intracranial) philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 33 acknowledgements i would like to acknowledge my adviser, dr. cesar v. villafuerte, jr. for his guidance in the execution and writing of this research paper. also, i would like to acknowledge dr. precious eunice r. grullo for her invaluable assistance in revising this paper. references 1. sethuraman g, yenamandra vk, gupta v. management of infantile hemangiomas: current trends. j cutan aesthet surg. 2014 apr;7(2):75-85. doi: 10.4103/0974-2077.138324; pubmed pmid: 25136206 pmcid: pmc4134656. 2. couto j, greene a. management of problematic infantile hemangioma using intralesional triamcinolone: efficacy and safety in 100 infants. j plast reconstr aesthet surg. 2014 nov; 67(11):1469-1474. doi: 10.1016/j.bjps.2014.07.009; pmid: 25104131. 3. garzon mc, lucky aw, hawrot a, frieden ij. ultrapotent topical corticosteroid treatment of hemangiomas of infancy. j am acad dermatol. 2005 feb; 52(2):281-286. doi: 10.1016/j. jaad.2004.09.004; pmid: 15692474. 4. drolet ba, frommelt pc, chamlin sl, haggstrom a, bauman nm, chiu ye, et al. initiation and use of propranolol for infantile hemangioma: report of a consensus conference. pediatrics. 2013 jan;131(1):128-140. doi: 10.1542/peds.2012-1691; pmid: 23266923; pmcid: pmc3529954. 5. marqueling al, oza v, frieden ij, puttgen kb. propranolol and infantile hemangiomas four years later: a systematic review. pediatr dermatol. 2013 mar-apr; 30(2):182-191. doi: 10.1111/ pde.12089; pmid: 23405852. 6. bennett ml, fleischer ab jr, chamlin sl, frieden ij. oral corticosteroid use is effective for cutaneous hemangiomas: an evidence-based evaluation. arch dermatol. 2001 sep; 137(9): 1208-13. pmid: 11559219. 7. sawa k, yazdani a, rieder mj, filler g. propranolol therapy for infantile hemangioma is less toxic but longer in duration than corticosteroid therapy. plast surg. 2014 winter; 22(4): 233-236. pmid: 25535459; pmcid: pmc4271750. 8. bozan n, gur mh, kiroglu af, cankaya h, garca mf. tongue hemangioma: a case report. van tip dergisi. 2014; 21 (2): 120-122. complete removal of lesions through radiofrequency ablation is difficult to achieve, hence it is done multiple times per patient. however, it has been proven a safe and effective surgical modality for the treatment of hemangiomas because incisions are not required with pain and bleeding kept at a minimum.8 in this series, 7 patients underwent radiofrequency ablation, all with gross residual lesions posttreatment. among these patients, 5 lesions involved the lip. it may be surmised that the location of the hemangioma may influence the type of surgical intervention. six patients underwent surgical excision with 5 of 6 cases claimed to have achieved complete excision. a major limitation of this study is that as a review of case records, outcome observations of propranolol and prednisone therapy were made by multiple observers and recorded observations could not be verified. the variables of measure were neither standardized nor quantified. future prospective studies should include photographic documentation and standardized measurements of tumor volume. the failure to serially analyze outcomes of radiofrequency ablation patients who had prior surgeries, as well as the short duration of follow-up for patients who underwent radiofrequency ablation and surgical excision are further limitations of this study. it is recommended that a longer follow-up for this subset of hemangioma patients be performed in order to adequately analyze the outcomes of each radiofrequency ablation procedure and to document any recurrences after surgical excision. in conclusion, the treatment response of patients in this series with hemangiomas of the head and neck to propranolol at a dose of 1 to 2 mg/kg/day may reflect international data. outcomes analysis for radiofrequency ablation and surgical excision requires a longer duration of follow-up. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles philippine journal of otolaryngology-head and neck surgery 5 philipp j otolaryngol head neck surg 2008; 23 (1): 5-8 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to determine the antimycotic activity of the four medicinal plant extracts, kalachuchi bark (plumeria acuminata ait.), atsuete bark (bixa orellana linn.), akapulko leaves (cassia alata linn.), and neem leaves (azadirachta indica adr. juss), when compared to the standard clotrimazole in the treatment of otomycosis. study design: experimental study methods: taxonomically identified plants, kalachuchi, atsuete, akapulko, and neem tree were collected and deposited in an herbarium. extracts of these plants and the standard clotrimazole were tested against isolates of aspergillus flavus, aspergillus niger, and candida albicans taken from patients with otomycosis. three trials were made for each extract using different solvents and results subjected to statistical analysis. result: of the four medicinal plant extracts studied, only kalachuchi bark extract exhibited antifungal activity against aspergillus flavus and aspergillus niger using methylethylketone as solvent when compared to the standard clotrimazole. it was equally effective in inhibiting the growth of a. flavus and a. niger. however, all plant extracts using all types of solvents were equally ineffective in inhibiting the growth of candida albicans. conclusion: this in vitro study suggested that kalachuchi (plumeria acuminata linn.) bark extract inhibits the growth of aspergillus species and was comparable to the standard clotrimazole. following appropriate further studies and clinical trials, it may be a potential alternative treatment option for otomycosis caused by aspergillus species. key words: otomycosis; kalachuchi (plumeria acuminata linn.) bark; antimycotic; aspergillus flavus; aspergillus niger in vitro antimycotic activity of four medicinal plants versus clotrimazole in the treatment of otomycosis: a preliminary study joebert m.villanueva, md marida arend v. arugay, md rachel zita h. ramos, md department of otorhinolaryngology head & neck surgery western visayas medical center correspondence: joebert m. villanueva, md western visayas medical center ent office q. abeto st, mandurriao, iloilo city 5000 phone: (6333) 509 0077 fax: (6333) 321 1797 email: joebert_md@yahoo.com.ph reprints will not be available from the author. funding support for this study was received from the west visayas medical center research committee. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at analytical research contest (1st place), philippine society of otolaryngology head and neck surgery 50th annual convention, edsa shangrila, mandaluyong city, december 1, 2006. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles 6 philippine journal of otolaryngology-head and neck surgery otomycosis, a fungal infection of the external auditory canal, is found throughout the world. its prevalence is greatest in hot, humid, and dusty areas of the tropics and subtropics. although a wide spectrum of fungi are involved, aspergillus is the most common.1 studies by geaney2 and by lakshmipathi and murti3 attributed all observed cases to either aspergillus or candida species. several studies have cited the antifungal properties of certain medicinal plants. of the 10 medicinal plants recommended by the department of health (doh) of the republic of the philippines, akapulko (cassia alata linn.) showed antifungal activity4 . a study of 10 medicinal plants in the priority list of the philippine council for health research development (pchrd) and plant resource of south east asia (prosea) by penecilla et al5 concluded that kalachuchi (plumeria acuminata ait.) and atsuete (bixa orellana linn.) had the highest activity in the assays against candida species. biswas et al observed that the extracts of neem leaf and neem seed oil kernels are effective against certain fungi including trichophyton, epidermophyton, microspor, trichosporon, geotricum and candida.6 interested in finding out which among these medicinal plants—kalachuchi (plumeria acuminata ait.) bark, atsuete (bixa orellana linn.) bark, akapulko (cassia alata linn.) leaves, and neem (azadirachta indica linn.) leaves, had fungicidal properties against the common fungal pathogens causing otomycosis, our study aimed to determine the antimycotic activity of these four medicinal plant extracts when compared to the standard clotrimazole in the treatment of otomycosis. methodology a. collection and identification of plants collection and taxonomical identification of the following plant species was performed: kalachuchi (plumeria acuminata ait.) bark, atsuete (bixa orellana linn.) bark, akapulko (cassia alata linn.) leaves, and neem (azadirachta indica linn.) leaves. a minimum of 500 grams of each species were collected and air dried for three to five days at the west visayas state university herbarium. b. extraction of plant material about 500 grams of each dried plant material (kalachuchi, atchuete, akapulko, and neem) were crushed using mortar and pestle. the solvents hexane, methylethylketone and ethanol were used to serially extract the organic constituents from the plants.7 a 30-gram sample of each was taken for extraction using hexane, methylethylketone, and ethanol respectively. the sample which was dissolved using hexane was macerated for 48 hours with constant shaking using a mechanical shaking bath bt25 (yamato, japan). the mixture was then filtered using no. 33 filter paper (whatman, u.s.a.) and evaporated to dryness using a heidolph vv 2000 rotavap (heidolph, germany) machine. the solid marc was dissolved in another solvent, methylethylketone, and the same process of shaking, filtering, and evaporation to dryness was done. this process was repeated using ethanol. extracts were stored in 10 ml amber bottles and labeled properly. c. laboratory testing 1. gathering of fungal strains with informed consent, specimens were taken from patients diagnosed with otomycosis at the out-patient department of a government tertiary hospital by a single otolaryngology resident using sterile cotton swabs and sterile saboraud’s dextrose broth tubes. sample specimens were incubated in complete darkness at room temperature for four days to one week. tubes were then examined for presence of surface growth or the appearance of mycelial growth structures and spores. 2. identification of fungal species only two species of fungi were isolated and identified – aspergillus flavus and aspergillus niger. pure isolates of candida albicans taken from the microbiology laboratory were obtained to represent candida species in order to measure the efficacy of the plant extracts against candida causing otomycosis. 3. preparation of pure culture and agar disks pure cultures were prepared using the agar-blocked method.8 4. bioassay proper the agar disc method was performed against pure isolates of aspergillus flavus, aspergillus niger and candida albicans. the agar disc size was 14.5 mm in diameter. three trials were made for the control group and for each extract using different solvents. a 100% concentration of the positive control (clotrimazole) was used. examination of all plates for any zone of inhibition formation was performed. the diameters of the zones of inhibition were philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles philippine journal of otolaryngology-head and neck surgery 7 table 1. mean zones of inhibition between the different treatment groups against fungal pathogens fungal pathogen extracts solvent mean zones of inhibition (in mm.) initial (n=3) final (n=3) aspergillus flavus aspergillus niger candida albicans kalachuchi bark atsuete bark akapulko leaves neem leaves control (clotrimazole) kalachuchi bark atsuete bark akapulko leaves neem leaves control (clotrimazole) kalachuchi bark atsuete bark akapulko leaves neem leaves control (clotrimazole) hexane mek ethanol hexane mek ethanol hexane mek ethanol hexane mek ethanol hexane mek ethanol hexane mek ethanol hexane mek ethanol hexane mek ethanol hexane mek ethanol hexane mek ethanol hexane mek ethanol hexane mek ethanol 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 38.5 46.17 34.83 14.5 14.5 35.33 14.5 14.5 14.5 14.5 14.5 14.5 44.17 24.83 41.17 33 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 43 14.5 17.33 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 14.5 22.33 then measured by getting the average of the zone measuring lengthwise and clockwise.8 d. statistical analysis the mean diameter of zones of inhibition of the different treatment groups were compared using analysis of variance in completely randomized design. pairs of treatment means were compared using the duncan’s multiple range test. absence of a statistically significant difference compared to the positive control (clotrimazole) was considered a significant finding. results the positive control (clotrimazole) had a mean zone of inhibition diameter against aspergillus flavus of 44.17 mm. among the medicinal plants, kalachuchi (plumeria acuminata ait.) using methylethylketone (mek) as solvent had the highest mean zone of inhibition diameter against aspergillus flavus of 46.17 mm. other extracts showed no increase in the mean zone of inhibition diameters against aspergillus flavus. (table 1) the zones of inhibition using the control, clotrimazole for aspergillus niger were 43.00 mm mean diameter. kalachuchi extracts using mek had mean zone of inhibition diameter at 41.17 mm. other extracts showed no increase in the mean zone of inhibition diameters against aspergillus niger. (table 1) clotrimazole had only a mean diameter zone of inhibition at 22.33 mm for candida albicans. kalachuchi bark extract using only methylethylketone as solvent had only a mean diameter zone of inhibition of 17.3 mm. the three remaining medicinal plant extracts (atsuete, akapulko, and neem) using all three solvents exhibited no increase in the mean zone of inhibition diameters against candida albicans. (table 1) since only kalachuchi extract showed a comparable zone of inhibition diameter to the control (clotrimazole), it was the only extract that was statistically analyzed. statistical analysis using analysis of variance showed that the positive control (clotrimazole) was effective for candida albicans compared to kalachuchi extract using different solvents. on the other hand, kalachuchi extract using methylethylketone (mek) as solvent exhibited the same response as clotrimazole against philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles 8 philippine journal of otolaryngology-head and neck surgery aspergillus flavus and aspergillus niger. (figure 1) discussion of the four plant extracts studied, only kalachuchi bark extract exhibited antifungal activity against aspergillus flavus and aspergillus niger using methylethylketone as solvent when compared to the standard clotrimazole. kalachuchi (plumeria acuminata ait.) belongs to the family apocynaceae. plumeria species have formally been investigated for isolation of a variety of iridoids and triterpenoids, which exhibited algicidal, antibacterial, cytotoxic and plant growth inhibitor activity. a study by pandey et al revealed that repeated column chromatography of the methanolic extract of the bark of plumeria species obtained the purified iridoid-saccharide plumieride compound.9 plumieride may be responsible for the antimycotic activity of kalachuchi in this study. this in vitro study suggested that kalachuchi bark extract inhibits the growth of aspergillus species and was comparable to clotrimazole. following appropriate further studies and clinical trials, it may be a potential alternative treatment option acknowledgement the authors wish to thank dr. jose mari fermin, medical director of western visayas medical center and its research committee for the financial support; dr. gerard penecilla and staff, for their help and guidance during the process of plant identification and extraction; professor roman sanares for the statistical analysis; professor celia p. magno for her time and service during the bioassay; and the resident staff of the department of otorhinolaryngology head & neck surgery, western visayas medical center. references 1. joy mj, agarwal mk, samant hc, et al. mycological and bacteriological studies in otomycosis. indian j otolaryngol 1980;32:72-5. 2. geaney gp. tropical otomycosis. j laryngol otol 1967;81:987-97. 3. lakshmipati g, murti rb. otomycosis. j indian med assoc 1960;34:439-41. 4. philippine council for health research and development. herbal products developed by filipino scientists. 2003. available from: http://www.pchrd.dost.gov.ph 5. penecilla g, magno c, de castro j, et al. production and testing of natural products for antimicrobial and antifungal action. west visayas state university college of arts and sciences research journal. 2001;2(1):10-20. 6. biswas, kausik, ishita c, ranajit kb, and uday b. biological activities and medicinal properties of neem (azadirachta indica). current science. 2002;82(11):1336-1345. 7. guevara bq, claustro al, aguinaldo am, madulid rs, espeso ei, nonato mg, et al. a guidebook to plant screening: phytochemical and biological. rev ed. manila: research center for the natural sciences, university of santo tomas;2005. 8. magno cp. manual in medical microbiology. 2nd ed. iloilo: west visayas state university;2005. 9. pandey r, dobhal m, graham a, oseroff a. iridoid-saccharide compound and method using same. available from: http://www.freepatentsonline.com/ep1527783.html 10. bojrab di, bruderly t, abdulrazzak y: otitis externa. otolaryngologic clin north am. 1996;29(5):761-781. figure 1. response of control (clotrimazole) and kalachuchi extract using different solvents against fungal pathogens *solvent with the same letter showed no significant difference. for otomycosis caused by aspergillus species. however, it cannot be overemphasized that the key to successful treatment of otomycosis is gentle efficient cleaning of the ear canal, carefully removing its accumulated debris, thorough drying and application of antifungal agents. 10 further research can validate the results of this in vitro study by ascertaining specific chemical properties through fractionation and structural elucidation of kalachuchi bark extract. toxicity studies and in vivo trials can then determine kalachuchi bark extract’s benefit as a topical antifungal agent against otomycosis. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 featured grand rounds 52 philippine journal of otolaryngology-head and neck surgery case a 52-year-old non-diabetic female presented with a 20-year history of hyperpigmented lower lip ulcer which gradually involved the mentum, and on punch biopsy revealed basal cell carcinoma. as a housewife, she had no excessive exposure to sunlight or radiation, and no family history of cancer. on examination, a non-healing ulcer with hyperpigmented rolled-up borders had eroded the lower lip and mentum, extending into the alveolus and mandible. wide excision with segmental mandibulectomy, bilateral supraomohyoid neck dissection and pectoralis major myocutaneous flap reconstruction were performed and radiotherapy scheduled 6 weeks after surgery. basal cell carcinoma (bcc) is the most common skin malignancy with estimated annual incidences of 1 million, over 500,000 and 190,000 in the usa, europe and australia, respectively1. more than 60% of all skin cancers in the philippines are basal cell carcinoma2. a slow-growing, locally invasive malignant epidermal tumor, it infiltrates tissues in a three-dimensional contiguous fashion through the irregular growth of sub-clinical fingerlike outgrowths3. it rarely metastasizes, with morbidity related to local tissue invasion and destruction4. most can be treated easily with a high cure rate; however, there are some lesions that are much more aggressive. advanced basal cell cancers may be arbitrarily defined as tumors > 2cm; that invade bone, muscle, or nerves; that have lymph node metastasis; or that require removal of a cosmetic or functional unit5. complications are highlighted when lesions occur in the face, particularly near orifices of the eyes, nose, ears and mouth. as with lesions close to vital structures, these pose a greater clinical challenge4. bccs develop from pluripotential cells in the basal layer of the epidermis. ultraviolet-induced mutations in the tp53 tumor-suppressor gene, which resides on chromosome arm 17p, have been implicated in some cases of bcc. furthermore, the loss of inhibition of the patched/hedgehog pathway also appears to play a role in development of bccs and influences differentiation of a variety of tissues during fetal development6. recognizing the various histological subtypes of bcc is important because aggressive therapy is often necessary for some variants3. nodular bcc appear as waxy or pearly papules with central depression, erosion or ulceration, bleeding or crusting, and rolled (raised) borders. tumor cells typically have large, hyperchromatic, oval nuclei and little cytoplasm. cells appear uniform, with few mitotic figures. pigmented bcc contain increased brown or black pigment and are most common in individuals with dark skin. superficial bcc appears as scaly patches or papules that are pink to red-brown, often with central clearing, commonly with a threadlike border, may mimic psoriasis or eczema, but they are slowly progressive. micronodular bcc, an aggressive subtype, is not prone to ulceration, it may appear yellow-white when stretched, firm to touch, and may have a seemingly well-defined border. morpheaform and infiltrating bcc present with sclerotic basal cell carcinoma of the lip and mentum florence yul n. saquian, md department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: florence yul n. saquian, md department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 phone (632) 526 4360 fax (632) 525 5444 email: goldsaquian@yahoo.com philipp j otolaryngol head neck surg 2006; 21 (1,2): 54-56 c philippine society of otolaryngology – head and neck surgery, inc. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 featured grand rounds philippine journal of otolaryngology-head and neck surgery 53 (scarlike) plaques or papules with ill defined borders extending beyond clinical margins. ulceration, bleeding, and crusting are uncommon. it may be mistaken for scar tissue7. treatment is based on clinical diagnosis and a pre-operative biopsy3. a complete history relating the onset and rate of growth of the lesion as well as sun and radiation exposure should be taken. it is also necessary to examine and palpate the extent of lesion, with special attention given to high risk areas. large extensive lesions may require radiographic examinations such as mri or ct to assess soft tissue or bony involvement, respectively8. the most appropriate treatment options should be discussed with the patient. co-morbidities may influence the choice between surgical and non-surgical treatment. elderly patients with symptomatic and high-risk tumors may opt for less aggressive treatment options, which are palliative in intent3. various surgical and non-surgical treatments are currently available. non-surgical techniques include thrice-weekly intralesional injection of human recombinant interferon α-2 for three weeks for low-risk bccs. this option is still investigational, unlikely to benefit high-risk tumor patients, and may be expensive and time-consuming3. photodynamic and oral retinoid therapies are other options undergoing investigation and are not yet widely available3. radiotherapy is an extremely useful form of treatment, but faces the same problem of accurately identifying tumor margins as standard excisional surgery9. it has been used to treat many types of bcc, including those with bony and cartilaginous involvement, but is less suitable for treating large tumors in critical sites, as these are often resistant and require radiation doses that closely approach tissue tolerance3. topical treatment options have been used in patients with contraindications for surgery and with lesions not entirely amenable to extirpative excision. 5-flourouracil (5fu) has been used for lowrisk, extrafacial bcc with unexciting results2,3. imiquimod (an immune response modifier) 5% cream has been used alone and as adjunct to mohs’ microsurgery for the treatment of bcc, with reported regression but not complete eradication of the tumor. topical neomycin was also reported to cause regression in one case3. a prospective study involving topical application of cashew nut extract (debcc®) on 14 patients with bcc in different parts of the face had no detected recurrences on follow – up periods of 11 – 49 months (28.7 months)2. excisional surgery removes the tumor entirely with a peripheral margin of normal tissue. for small lesions in the face, wide excision with adequate margins is sufficient, and various reconstructive methods can be used depending on the location of the lesion. larger lesions which involve deeper structures such as bone, warrant more radical approaches to ensure adequate margins10. in our patient, infiltration of skin, mucosa, muscle, alveolus and mandible led to a segmental mandibulectomy and subsequent reconstruction. mandibular reconstruction aims to reconstitute the mandibular arch. anterior defects result in the worst functional defects with the so-called “andy gump” deformity11. the preferred method for reconstructing anterior mandibular defects uses osseocutaneous free flaps, with the fibular free flap being most popular. the peroneal vessels act as the major blood supply to the periosteum in a segmental fashion allowing silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 featured grand rounds 54 philippine journal of otolaryngology-head and neck surgery for multiple osteotomies, which are required for bone shaping with anterior defects. for reconstruction of the intra-oral structures, a large soft tissue paddle based on septal and intramuscular perforators can be used, and osteointegrated implants can be placed in the bone graft12. another option for reconstruction is a pedicled flap, and the more commonly used is the pectoralis major osteomyocutaneous flap. its dominant pedicle is the thoracoacromial artery and vein that runs on the undersurface of the muscle. the underlying rib is also harvested to reconstitute the mandible13. the advantages of pedicled flaps include less morbidity, shorter operative time, and a more definitve blood supply, which ensures the survival of the skin flap and bone11. however, these flaps tend to be difficult to harvest and have limited arcs of rotation and limited bone graft mobility relative to the soft tissue portion of the flap. the blood supply of the bony portion is often tenuous following transfer, and the lack of bony bulk limits dental rehabilitation12. postoperative management of flap reconstruction includes gentle cleansing and application of topical antibiotics. diligent oral hygiene offsets potential complications from post-operative drooling. partial or total flap failure is a common postoperative concern. partial distal flap necrosis can be managed expectantly. cyanosis may be due to excessive wound tension or vascular pedicle compromise, and should be explored as necessary15. acknowledgement: we thank dr. camille sidonie a. espina for providing the case for discussion. references: 1. staples m, marks r, giles g. trends in the incidence of non-melanocytic skin cancer (nmsc) treated in australia 1985-95: are primary prevention programs starting to have an effect? int j cancer 1998; 78: 144-8. 2. talens e, ocampo o, et al. anacardium occidentale (linn.) cashew nut extract (de bcc ®) in the treatment of basal cell carcinoma. in publication. copy obtained though personal correspondence. 3. telfer nr, colver gb, bowers pw. guidelines in the management of basal cell carcinoma. br j dermatol 1999; 141: 415-423. 4. lo js, snow sn, reizner gt, et al. metastatic basal cell carcinoma report of twelve cases with a review of literature. j am acad dermatol 1991; 24: 715-19. 5. andrade r, gumport sl, popkin g, et al: cancer of the skin, in thawley se, panje wr (eds): comprehensive management of head and neck tumors, vol. 2. philadelphia, wb saunders, 1976, pp 899-949. 6. bale ae, yu k: the hedgehog pathway and basal cell carcinomas. human molecular genetics 2001; 10: 757-762. 7. andrade r, gumport sl, popkin g, et al: cancer of the skin, in thawley se, panje wr (eds): comprehensive management of head and neck tumors, vol. 2. philadelphia, wb saunders, 1976, pp 899-949. 8. randle hw. basal cell carcinoma, identification and treatment of the high-risk patient. dermatol surg 1996; 22: 255-61. 9. rowe de, carroll rj, day cl jr. long term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. j dermatol surg oncol 1989; 15:315-28. 10. wolf dj, zitelli ja. surgical margins for basal cell carcinoma. arch dermatol 1987; 123: 340-4. 11. greenstein b, strauch b. reconstruction. in atlas of head and neck surgery 2nd ed. silver ce and js rubin, eds. pennsylvania: churchill livingstone 1999. p48-49. 12. cheung sw, anthony jp, singer mi. restoration of anterior mandible with the free fibula osseocutaneous flap. laryngoscope 104:105 113, 1994. 13. buchbinder d, urken ml. mandibular reconstruction. in bailey bj (ed). head and neck surgery otolaryngology, philadelphia, lippincott, 1993. 14. baker sr. regional flaps in facial reconstruction. otolaryngol clin north am 1990;23:925-946. 15. mullins jb, branham gh: refinements and revision of local and regional flaps. fac plast clinic north am 4: 537-542, 1996. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 case reports philippine journal of otolaryngology-head and neck surgery 23 abstract objective: to present a rare case of laryngeal extranasopharyngeal angiofibroma, discussing its diagnosis, treatment and differences from the more typical juvenile angiofibroma. methods: design: case report setting: tertiary government hospital patient: one results: a 51-year-old male with a two-year history of hoarseness developed difficulty of breathing. direct laryngoscopy showed a 2x2x1cm glistening, multinodular, pedunculated, firm, pink mass attached to the posterior half of the right true vocal fold obstructing the glottic opening and extending superiorly to the ventricle. microlaryngeal excision was done. histopathology showing numerous vascular channels surrounded by dense paucicellular fibrous tissue was consistent with angiofibroma. conclusion: primary extranasopharyngeal angiofibroma is rare, with only four previously reported cases occurring in the larynx. we presented what may possibly be the first locally reported case. although histopathologically similar to the more common juvenile nasopharyngeal angiofibroma, this was atypically seen in the larynx of an older adult patient. direct laryngoscopy provided excellent exposure for identification as well as complete surgical resection. unlike the nasopharyngeal type, no massive bleeding was encountered. prognosis for this extranasopharyngeal angiofibroma is excellent as recurrence is noted to be rare, however, long term follow-up is recommended. keywords: extranasopharyngeal angiofibroma, laryngeal angiofibroma angiofibromas typically occur in the nasopharynx. although histologically benign, they show locally aggressive growth with bone destruction, extension to adjacent areas and possible fatal complications such as intracranial invasion or hemorrhage. nasopharyngeal angiofibromas usually occur almost exclusively in young males and they originate at the junction of the posterolateral wall and roof of the nose at the superior margin of the sphenopalatine foramen, the approximate location of the embryological buccopharyngeal membrane and not in the nasopharynx as commonly thought.1 head and neck angiofibromas arising from outside the nasopharynx are rare.2,3,4,5 extranasopharyngeal angiofibroma of the larynx connie angel j. trinidad, md1 michael joseph c. david, md1 antonio h. chua, md1, 2 1department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center 2department of otorhinolaryngology head and neck surgery university of the east-ramon magsaysay memorial medical center correspondence: connie angel j. trinidad, md department of otorhinolaryngology jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone/fax: (632) 743 6921 reprints will not be available from the author. no funding support was received for this study. the authors signed disclosures that they have no proprietary or financial interest with an organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. philipp j otolaryngol head neck surg 2010; 25 (1): 23-25 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 case reports 24 philippine journal of otolaryngology-head and neck surgery in a review of 65 cases of extranasopharyngeal angiofibromas (ena), windfuhr and remmert found only four in the larynx.5 clinical characteristics of enas do not conform with those of nasopharyngeal angiofibromas and, for this reason, these tumors must be regarded as a separate entity.6 a better understanding of this atypical entity obviates the need for unnecessary invasive procedures typically reserved for nasopharyngeal angiofibroma. we present a case of extranasopharyngeal angiofibroma affecting the glottic region. differences between ena and the more typical nasopharyngeal angiofibroma will be discussed. diagnosis and treatment of laryngeal angiofibroma will be elaborated upon. case report a 51-year-old male was admitted due to progressive difficulty of breathing. he had been hoarse for two years, described as having a coarse, strained voice which gradually developed into a weak, strained voice. he was a 20-pack-year smoker and occasionally drank alcoholic beverages. indirect laryngoscopy revealed a multinodular, non-necrotic, pink mass covering the true vocal folds and filling up the ventricles. emergency tracheotomy was done. direct laryngoscopy showed a 2x2x1cm glistening, multinodular, pedunculated, firm, pink mass attached to the posterior half of the right true vocal fold obstructing the glottic introitus and extending superiorly to the ventricle (figure 1). microlaryngeal excision was done with minimal bleeding that resolved spontaneously (figure 2). histopathological examination showed numerous vascular channels surrounded by dense paucicellular fibrous tissue (figure 3). the cells in the fibrous tissue were cytologically bland and spindle shaped. the nuclei lacked hyperchromasia and had small nucleoili. the vascular channels were slit-like or dilated, and varied in number, configuration and thickness. findings were consistent with angiofibroma. while follow-up videolaryngoscopy at one week was essentially normal, a repeat three weeks post-operatively showed nodular scar tissue on the right vocal fold where the base of the excised tumor pedicle had been located (figure 4). discussion primary extranasopharyngeal angiofibroma is very rare.7 the most common site for extranasopharyngeal angiofibroma is the maxillary sinus. the ethmoid and sphenoid sinuses, nasal septum, middle and inferior turbinate, conjunctiva, molar and retromolar region and larynx are other sites where extranasopharyngeal angiofibromas have been reported.8 our patient may be the first locally reported case of laryngeal angiofibroma. angiofibroma presenting with at least one of the following criteria such as origin or location other than nasopharynx, presenting complaints other than nasal obstruction or epistaxis, age younger than seven or older than 25, female sex and multifocality are considered figure 1. glistening, multinodular, pedunculated, firm, pink mass attached to the posterior half of the right true vocal fold obstructing the glottic introitus and extending superiorly to the ventricle figure 2. larynx after excision of mass figure 3. microphotograph of laryngeal angiofibroma consisting of numerous vascular channels surrounded by dense paucicellular fibrous tissue philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 case reports philippine journal of otolaryngology-head and neck surgery 25 references 1. neel hb. juvenile angiofibroma.in:blitzer a, lawson w, friedman w, eds. surgery at the paranasal sinuses.philadelphia,saunders,1991 quoted by gluckman jl. tumors of the nose and paranasal sinuses.in donald pj, gluckman jl, rice dh,eds. the sinuses. new york, raven, 1995, p.428. 2. bastian rw. benign mucosal and saccular disorders: benign laryngeal tumours. in: cummings cw, fredrickson jm, harker la, krause cj, schuller de, editors. otolaryngology-head and neck surgery. 2nd ed. st. louis: mosby year book; 1993. p. 1897—1924. 3. batsakis j. tumours of the head and neck, clinical and pathological considerations, 2nd ed. baltimore: williams and wilkins, 1979, pp. 296-300. 4. steele mh, nuss dw, faust bf. angiofibroma of the larynx: report of a case with clinical and pathologic literature review. head neck. 2002 aug; 24(8): 805-809. 5. windfuhr jp, remmert s, extranasopharyngeal angiofibroma: etiology, incidence and management. acta otolaryngol. 2004 oct; 124(8): 880-889. 6. hunsicker rc, koch tj, folander h. superselective embolization in two cases of laryngeal paraganglioma. otolaryngol head neck surg. 1995 jul; 113(1): 126-130. 7. antoniades k, antoniades dz, antoniades v, juvenile angiofibroma: report of a case with intraoral presentation. oral surg oral med oral pathol oral radiol endod. 2002 aug; 94(2): 228— 232. 8. dere h, ozcan km, ergul g, bahar s, ozcan i, kulacoglu s. extranasopharyngeal angiofibroma of the cheek. j laryngol otol. 2006 feb; 120(2):141–144. 9. celik b, erisen l, saraydaroglu o, coskun h. atypical angiofibroma : a report of four cases. int j pediatr otorhinolaryngol. 2005 mar; 69(3):415–421. 10. hsieh st, guo yc, tsai tl, chen wy, huang jl. angiofibroma of the hypopharynx. j chin med assoc. 2004 jul; 67(7):373–375. 11. lim ir, pang yt, soh k. juvenile angiofibroma: case report and the role of endoscopic resection. singapore med j. 2002 apr; 43(4): 208-210. atypical.9 as benign tumors of the larynx are reported to be less than 1% of all laryngeal neoplasms, it is imperative to identify these tumors since treatment and prognosis vary greatly.2 diagnostic modalities include computed tomography scan, magnetic resonance imaging and angiography.10 angiofibroma of the larynx is diagnosed with direct laryngoscopy and biopsy. while biopsy of nasopharyngeal angiofibromas may not be done, it should be done in cases of laryngeal tumors to ensure that malignancies will not be missed. surgical excision is the treatment of choice for angiofibromas. angiofibromas have characteristic endothelial-lined vascular spaces, with little or no smooth muscle layers and are devoid of an internal elastic lamina, which preclude vasoconstriction and contribute to brisk episodes of bleeding when traumatized. interestingly, the feeding arteries within the stalk of the tumor mass contain a complete muscle wall which has normal contractile ability and results in little bleeding after tumor excision from its pedicle. selective angiography has been recommended for nasopharyngeal angiofibroma as it has the ability to identify the feeding vessels and allows the option of pre-operative embolization for vascular control.11 in our case, as the mass was relatively small and easily excised at its base, minimal bleeding was encountered. it appears that angiography may not be necessary in managing laryngeal angiofibroma. the clinical presentation of our patient (table 1) was virtually similar to four previously reported cases. in two of the four, endolaryngeal endoscopic or microlaryngeal surgical excision was performed with successful results.5,11 the two other cases involved partial laryngopharyngectomy and transcervical resection, respectively.5 due to the confined space in the nasopharynx, inadequate surgical exposure and subsequent incomplete resection probably account for the higher recurrence rate in nasopharyngeal angiofibromas. although tumor recurrence is rare for laryngeal angiofibromas and is not expected in our case, long-term follow-up is recommended.9 figure 4. videoendoscopy of larynx, 3 weeks post-operatively note nodular scar tissue on the right vocal fold where the base of the excised tumor pedicle had been located. table 1. comparison of reported cases of laryngeal extranasopharyngeal angiofibroma5,11 case no. 1 2 3 4 our case age 64 29 30 25 51 sex f m f m m site left aryepiglottic area right vocal fold, subglottic interarytenoid region larynx(site not specified), pharynx right vocal fold symptom/s dysphagia and dyspnea hoarseness asymptomatic dysphagia and voice changes hoarseness and dyspnea onset 2 ½ months 7 months on orl exam 6 months 2 years therapy tracheostomy, partial laryngopharyngectomy microlaryngeal surgery tracheostomy, laryngofissure and microlaryngeal surgery transcervical resection tracheostomy, microlaryngeal surgery philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 essay 44 philippine journal of otolaryngology-head and neck surgery correspondence: anne marie v. espiritu, md room 218, dsmt manila doctors hospital united nations avenue, ermita, manila 1000 philippines phone: (632) 524 3011 local 3880 email: amespiritumd@yahoo.com reprints will not be available from the author winner (1st place), philippine academy of rhinology essay writing contest on the “the philippine society of otolaryngology head and neck surgery and its role in averting climate change,” pryce plaza hotel, cagayan de oro city, may 1, 2008. climate change and the pso-hns times have changed and seasons have changed. i remember with nostalgia the cool december mornings of my childhood, the predictable rains, the smell of clean air in open city spaces, and the sight of stars in the evening sky. there were fewer cars on the road then, travel time was much faster, and there were more rice fields to be seen by the road as one left the city limits. how different things are now. how amazingly fast have changes happened in one lifetime. where the trees and cogon fields once were, buildings now stand. the city is immersed in a soup of soot and chemicals. the sky is grey and, sometimes, light brown. so many vehicles clog the city’s thoroughfares. my eyes tear with the chemicals in the air. the heat is worrisome. i have to deal with a chronic cough that improves with asthma medications or disappears whenever i leave the city for a cleaner environment. my sense of smell has greatly declined with the increased time and frequency of my driving through the city roads. worse, the wonderful december mornings that heralded the coming of christmas are gone… they have been gone for a long time. is this what i want to bequeath to my children? is this what you want for the generations to come? are we going to fail as the previous generations have? what is it going to take to save our environment and avert climate change? acting in numbers often gets results faster than acting alone. on my own, i have been trying to make a difference but, now, i look to the specialty society that i belong to as a vehicle for greater change. as more and more people are realizing the urgency of actions to save the environment that sustains us, i am sure that there are members in the philippine society of otolaryngologyhead and neck surgery (pso-hns) who are willing to commit themselves to actions and lifestyle changes for a safe planet. the pso-hns is ideally positioned to make a difference. spread throughout the country, we, its members, see patients who suffer from environmentally influenced and lifestyle influenced illnesses. thus, we know what effects worsening climate conditions can have on health. we are in a position, not just to prescribe appropriate medications, but also to reach out and give meaningful advice. anne marie v. espiritu, md department of otolaryngology head and neck surgery manila doctors hospital philipp j otolaryngol head neck surg 2008; 23 (1): 44-45 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 philippine journal of otolaryngology-head and neck surgery 45 essay to give convincing advice to patients, we must start with ourselves. seventeen years ago, i began a journey that i ask my colleagues to now take. to decrease garbage and lessen wastage, i began to segregate my garbage into dry paper products, tin and aluminum products, glass and recyclable plastic products, dry non-recyclable items, organic material, and wet non-recyclable materials. i would bring my newspapers, dry paper products, glass and plastic items, old rubber tires, and old car batteries to a junk shop. later on, i would not have to do this anymore since garbage men and other individuals would come to the house to pick up the items that they could sell for recycling. the wet garbage went into my garden soil and into a composting drum. even now, i re-use envelopes, gift wrappers, ribbons, and papers with print on only one side. i use baskets, not plastic bags when i buy my fruits and vegetables at the organic market. i bring my own stainless steel and glass food containers when i buy cooked food in the same market. to decrease the amount of chemicals that seep back into the environment, i refrain from the use of chemical sprays and artificial scents at home. i do not use chemicals in my garden. i don’t burn garbage. i don’t use diesel as a fuel. i regularly maintain my vehicles to keep them running efficiently. i plan my trips to lessen my contribution to air pollution. i support and patronize organic food growers as well as producers of natural products. i have greatly decreased my family’s use of plastic food containers. every chance i have, i encourage people to minimize their use of chemicals, plastic and styrofoam. knowing that the earth’s resources are used inefficiently with meatcentered diets, i eat more vegetables than meat. after all, it does not make sense to use so much land and energy to plant crops for feeding cows when we could use the land to plant vegetables and fruit-bearing trees for direct human consumption! as we develop ourselves into role models, it shall become easier to talk about environmental concerns to those around us. the psohns must make a stand on threats to the environment and the need to actively address the problem of climate change. it must make this stand public. then it must affiliate itself with other groups that are committed to saving the environment. the society could launch information campaigns on the interconnections of environment, lifestyle and otorhinolaryngologic health. it could tap its own members as speakers or initiate joint projects with other like-minded organizations. in the early 90’s, i organized a symposium in my hospital with air pollution as the topic. the speakers were specialists and non-doctors who were knowledgeable about the subject matter. even at that time, the increased appreciation for environmental discussions was obvious with so many people in the audience. the interest that information campaigns would generate now would definitely be greater! the society could raise funds and sponsor activities that increase environmental awareness and create positive results for the environment. how about raising money with a fun run or fun walkathon in the la mesa dam nature reserve? why not a doctors on bikes event to underscore the significance of fuel-less travel? or a doctors go organic festival? perhaps a mahabang buhay sa gulay activity? we could also do a tulong sa ilong, tulong sa kapaligiran mission wherein giving medical help is coupled with lectures on lifestyle and environment. we could collate and publish the contents of our environment and lifestyle lectures and sell these or give away to patients. we could incorporate environment games in our society sportsfest during conventions. we could come up with pso-hns recipes (for health of self and environment), nose-friendly natural aromatherapy oils, ear-friendly biodegradable cotton tips, and recyclable masks and sell these in our clinics, at conventions and in organic markets. in the pso-hns office as well as pso-hns conventions, the commitment to the environment must be evident. the use of longlasting low wattage lights, recycled paper, natural soaps and scents, prudent use of electricity, and environmental posters on the walls will strengthen the society’s image as a champion for the planet. during conventions, pharmaceuticals may be required to use only recyclable, non-glossy fliers and posters. these same companies may be reminded to refrain from giving away non-recyclable souvenirs. the convention bag should be made of natural, not synthetic material. certificates of attendance should be given only to those who need them. clothing made from natural materials should be encouraged. meals may focus more on salads, grains, vegetables and fruits and less on meats. after starting with ourselves and reaching out to others, the psohns could go international! strengthened by local experience, the society could embark on international pro-environment activities in coordination with otorhinolaryngology organizations in other countries. the pso-hns, having interests in health, science, and otorhinolaryngology, has great potential to be an agent for change. i hope my passion for nature shall become its collective passion too. this society is blessed with intelligent, highly skilled, creative, and similarly abled individuals capable of using its influence and resources to make a significant contribution towards saving the environment. my cool december mornings may never come back, but the pso-hns can still help avert the slide towards planet disaster! philippine journal of otolaryngology-head and neck surgery 41 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 from the viewbox a 5-year-old female with bilateral profound hearing loss underwent computerized tomographic imaging of the temporal bone as part of the work-up to determine the etiology of her deafness and to delineate middle and inner ear anatomy prior to cochlear implantation. the examination revealed an inner ear malformation which based on the newest classification of cochleovestibular malformations by sennaroglu and saatci, is called an incomplete partition type i (ip-1) or cystic cochleovestibular malformation. this condition is characterized by: (1) a cochlea that is lacking the entire modiolus and cribriform area resulting in a cystic appearance; and (2) a large cystic vestibule.1 cystic cochleovestibular malformation (incomplete partition type 1) nathaniel w. yang, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila philippine national ear institute national institutes of health university of the philippines manila department of otorhinolaryngology head and neck surgery far eastern university–nicanor reyes memorial foundation medical center correspondence: nathaniel w. yang, md department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax: (632) 525 5444 email: nwyang@gmx.net reprints will not be available from the author. philipp j otolaryngol head neck surg 2010; 25 (1): 41-42 c philippine society of otolaryngology – head and neck surgery, inc. figure 1. axial view of the abnormal inner ear showing the cystic cochlea (+) and the cystic vestibule (*) without the central bony island usually found in the horizontal semicircular canal. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 42 philippine journal of otolaryngology-head and neck surgery from the viewbox references 1. sennaroglu l, saatci i. a new classification for cochleovestibular malformations. laryngoscope 2002; 112: 2230-2241. 2. preciado da, lawson l, maden c, et al. improved diagnostic effectiveness with a sequential diagnostic paradigm in idiopathic pediatric sensorineural hearing loss. otology & neurotology 2005; 26: 610-615. 3. park ah, kou b, hotaling a, et al. clinical course of pediatric congenital inner ear malformations. laryngoscope 2000; 110: 1715-1719. figure 2. axial view of a normal inner ear at the same level as figure 1, showing the “signet ring” configuration of the horizontal semicircular canal and vestibule (*) and the first turn of the cochlea (+). temporal bone imaging is among the most useful examinations in the etiological investigation of idiopathic sensorineural hearing loss in children, with up to 30%2 of the imaging studies showing an abnormality. the detection of inner ear malformations is important as some abnormalities are associated with an increased risk of meningitis or progressive hearing loss following head trauma.3 likewise, the approach to cochlear implantation may be influenced by the type of malformation. in this particular patient, the use of a cochlear implant with a full-band electrode design may be more appropriate, as the location of the neural elements within the cystic cochlea is not definitely known. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial authorship, “the state or fact of being the writer of a book, article, or document, or the creator of a work of art,”1 derives from the word author, auctor, autour, autor “father, creator, one who brings about, one who makes or creates,” from old french auctor, acteor “author, originator, creator, instigator,” directly from the latin auctor “promoter, doer; responsible person, teacher,” literally “one who causes to grow.”2 it implies a creative privilege and responsibility that cannot be taken lightly. in the biomedical arena, the international committee of medical journal editors (icmje) “recommends that authorship be based on the following four criteria: 1. substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; and 2. drafting the work or revising it critically for important intellectual content; and 3. final approval of the version to be published; and 4. agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved.”3 thus, all persons designated as authors should qualify for authorship, and all those who qualify as authors should be so listed.3 the first of these general principles means that all persons listed as authors should meet the four icmje criteria for authorship; the second principle means that all those who meet the four icmje criteria for authorship should be listed as authors.3 the first part of the statement disqualifies honorific “gift” authors, complementary “guest” authors and anonymous “ghost” authors from being listed as authors. the second part ensures the listing of all those who qualify as authors, even if they are no longer part of the institution or group from which the work emanates (such as students who have graduated or residents and fellows who have completed their postgraduate training). honorific or “gift” authorship takes place when a subordinate (or junior) person lists a superior (or senior) person as an author, even if that person did not meet the four icmje authorship criteria.4,5 bestowing the gift on a chief, chair, department head, director, dean, or such other person is often done in gratitude, but carries an unspoken expectation that the favor will be returned in the future. it can also be bestowed under coercive conditions (that may overlap with those of guest authorship discussed next).4.5 it is unethical because the gifted person does not qualify for authorship when at most only acknowledgement is his or her due. in the extreme, such a person can be put in the uncomfortable and embarrassing situation of being unable to comment on the supposedly co-authored work when asked to do so. moreover, the unqualified co-author(s) may actually attempt to wash their hands of any allegations of misconduct, claiming for example that the resident first author “plagiarized the material” or “fabricated or manipulated the data” but “i/we certainly had nothing to do with that” hence the fourth criterion for authorship came to be.3 reviewers and editors may suspect “gift” authorship when correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 554 8467 telefax: (632) 524 4455 email: lapenajf@upm.edu.ph, jflapena@up.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr. ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines authorship controversies: gift, guest and ghost authorship philipp j otolaryngol head neck surg 2019; 34 (1): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial for instance, a resident listed as first author writes the paper in the first person, using the pronoun “i” instead of “we” and thanks the consultant co-author under the “acknowledgements” section. the suspicions are further reinforced when the concerned co-author(s) do not participate in (or contribute to) revising the manuscript critically for important intellectual content during the review and editing process. guest authorship takes place when influential or well-known individuals “lend” their name to a manuscript to boost its prestige, even though they had nothing to do with its creation.6,7 they may have been invited to do so by one or more of the actual authors, but they willingly agree, considering the arrangement mutually-beneficial. thus, a student or resident may knowingly invite an adviser or consultant to be listed as co-author, even if the latter did not meet authorship criteria. the former perceives that having a known co-author increases the chances of a favorable review and publication; the latter effectively adds another publication to his or her curriculum vitae. it is not difficult to see how such symbioses may thrive in the “publish or perish” milieu of academe. research advising alone, even if editing of the research paper was performed, do not qualify one for authorship (cf. “gift” authorship). this is not to say that a research, thesis or dissertation adviser may not be listed as co-author – as long as he or she meets the 4 icmje criteria for authorship.3 a related misconduct is the practice by certain persons with seniority of insisting their names be listed first, even if more junior scholars did all the innovative thinking and research on a project. indeed, the order of authorship can be a source of unhappiness and dispute. authors should be listed in the order of their contributions to the work – the one who contributed most is listed first, and the order of listing should be a joint decision of all co-authors at the start of the study (reviewed periodically). ghost authorship usually pertains to paid professional writers who anonymously produce material that is officially attributed to another references 1. google online dictionary: “authorship” [cited 2019 june 5]. available from: https://www. google.com/search?client=safari&rls=en&q=dictionary#dobs=authorship. 2. online etymology dictionary: “author” [cited 2019 june 5]. available from: https://www. etymonline.com/word/author. 3. international committee of medical journal editors. recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals. updated december, 2018. [cited 2019 june 5]. available from: http://www.icmje.org/recommendations/browse/ roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html#two. 4. smith j. gift authorship: a poisoned chalice? bmj 1994 dec 3;309(6967):1456-57. doi:  https:// doi.org/10.1136/bmj.309.6967.1456 pmid:7804037 pmcid: pmc2541639. 5. zaki sa. gift authorship – a cause for concern. lung india. 2011 jul-sep;28(3):232-233. doi: 10.4103/0970-2113.83994 pmid: 21886969 pmcid: pmc3162772. 6. harvey la. gift, honorary or guest authorship. spinal cord. 2018 feb;56(2):91. doi: 10.1038/ s41393-017-0057-8. pmid:29422533. 7. vera-badillo fe, napoleone m, krzyzanowska mk, albhai sm, chan aw, ocana a, et al. honorary and ghost authorship in reports of randomized clinical trials in oncology. eur j cancer. 2016 oct;66:1-8. doi: 10.1016/j.ejca.2016.06.023 pmid:27500368. 8. detora lm, carey ma, toroser d, baum ez. ghostwriting in biomedicine: a review of the published literature. curr med res opin. 2019 may 22:1-9. doi: 10.1080/03007995.2019.1608101. pmid:30986084. 9. mercola j. how big pharma fools even your doctor.  [cited 2019 jan 08]. available from: https:// articles.mercola.com/sites/articles/archive/2011/11/26/medical-journals-using-ghost-writers. aspx. author.7,8 they may operate out of establishments that manufacture term papers, theses and dissertations for the right price (such as the infamous c.m. recto district in downtown manila, now replaced by numerous online services). they may also be employed by the pharmaceutical industry to write promotional, favorable studies that will list wellknown persons (professors, scientists, senior clinicians) as authors, often with consent and adequate compensation.8 examples include “a professor at the university of wisconsin” being paid “$1,500 in return for putting his name” on “an article on the ‘therapeutic effects’ of their diet pill redux (dexfenfluramine),” that was “pulled from the market” a year later “as doctors began reporting heart-valve injuries in as many as onethird of patients taking the drug” and the drug “later linked to dozens of deaths.”9 similar cases involved the “deadly drug” rofecoxib (vioxx) “eventually blamed for some 60,000+ deaths,” that “was also linked to a number of shameful scandals relating to fraudulent studies and the use of ghostwriters to boost sales.”9 the costs involved are not meager; a pharmaceutical paid “a medical education communication company (mecc) to write articles in support of the drug” neurontin (gabapentin) “to the tune of $13,000 to $18,000 per article. in turn, mecc paid $1,000 each to friendly physicians and pharmacists to sign off as authors of the articles.”9 another pharmaceutical (that acquired neurontin form the first pharmaceutical) “was found guilty of illegally promoting off-label uses of neurontin,” and “fined more than $142 million in damages.”9 whether or not morbidities or mortalities ensue from the practice, both ghosts and beneficiary-authors should be held liable in such situations. clearly, the practice of “gift,” “guest,” and “ghost” authorship should not be entertained by authors or tolerated by editors and reviewers. authorship should be based on the icmje authorship criteria. our editors and reviewers vigilantly strive to uphold and protect the rights and welfare of our authors and the integrity and soundness of their research. we call on all fellows, diplomates and residents in training to do the same. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 medicine and manipulation: aspiration and ambition “and so, light your face up with a smile, why waste your life on something really not worthwhile, look up to the stars, take your eyes off the ground, come, live your life, turn around.”1 as doctors of medicine we should be no strangers to aspiration; “a striving after something higher than oneself ” that “usually implies that the striver is thereby ennobled.”2 aspiration in this context truly earns us the full connotation of the title “doctor,” as eminent, authoritative, learned healers and teachers of the art and science of medicine. many among us deserve this title in word and deed, and are worthy of emulation. their personal and professional lives bear witness, not to self-serving accomplishments, but to their improving life and living in the world around them. aspiration may be synonymous with ambition, although the latter term which “applies to the desire for personal advancement” may equally suggest “a praiseworthy or an inordinate desire … for rank, fame or power.” 2 ambition of this sort often resorts to manipulation to achieve its ends, and manipulation in this context is “to control or play upon by artful, unfair, or insidious means especially to one’s own advantage.” 3 whether subtly stolen or brazenly grabbed at the expense of others, the means is often distorted to justify the end. in the process, rights are trampled, dreams shattered, alliances betrayed and relationships severed. according to messina and messina4, manipulation is a set of behaviors whose goal is to: • get you what you want from others even when the others are not willing initially to give it to you. • make it seem to others that they have come up with an idea or offer of help on their own when in reality you have worked on them to promote this idea or need for help for your own benefit. • dishonestly get people to do or act in a way which they might not have freely chosen on their own. • "con'' people to believe what you want them to believe as true. • get "your way'' in almost every interaction you have with people, places, or things. • present reality the way you want others to see it rather than the way it "really is.'' • hide behind a "mask'' and let people see you in an acceptable way when in reality you are actually feeling or acting in an ``unacceptable'' way for these people. • maintain control and power over others even though they think they have the control and power. manipulation also means “to change by artful or unfair means so as to serve one’s purpose” or, shameful as it may sound, to “doctor.”3 this derogatory use of the term is not untainted by our actions, whether the arena be laboratory or operating theatre, clinic or lecture hall, hospital or home, interest group or organization, community or society. blind ambition may delude us into rationalizing dodgy deals and shady maneuverings, convincing even ourselves that they are beneficent and non-maleficent. we get our way, oblivious to the injustice and injury wrought on others. when shameless machinations, “scheming, crafty actions or artful designs intended to accomplish some usually evil end”5 are engaged in by supposed practitioners of the healing art, they do more than validate the colloquial dinu-doktor or dinuktor; they invalidate the rest of us. jose florencio f. lapeña, jr. m.a., m.d. editorial 4 philippine journal of otolaryngology-head and neck surgery 1lapeña, jf. “turn around” in young life outlook colorado1981; 5(2):16. 2available from: http://www.merriam-webster.com/dictionary/ambition 3available from: http://www.merriam-webster.com/dictionary/manipulation 4messina jj, messina cm. tools for handling control issues: eliminating manipulation. available from: http://www.coping.org/ 5available from: http://www.merriam-webster.com/dictionary/machination philippine journal of otolaryngology-head and neck surgery 35 philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 featured grand rounds congenital saccular cysts of the larynx are a rare cause of airway obstruction in the neonatal population. symptoms are non-specific and common to other causes of laryngeal obstruction. prompt recognition and management is important because of the high mortality associated with undiagnosed conditions. case a 2-month-old female was seen at the pediatric emergency room because of breathing difficulty. she had productive cough two days prior, accompanied by labored breathing, vomiting and poor appetite. she was admitted at the pediatric icu with a diagnosis of acute bronchiolitis. attempting intubation, the pediatric resident noted a cystic mass partially obstructing the laryngeal inlet. the patient was successfully intubated on the third attempt. review of history revealed stridor at birth, and she was referred to the ent service for further management. awake flexible laryngoscopy revealed a cystic mass obscuring most of the right vocal fold. the impression was an anterior saccular cyst. the patient underwent microlarygoscopy. the cyst extended posterosuperiorly, resting over the false vocal fold (figure 1). the presence of a saccular cyst was confirmed by needle aspiration of whitish gelatinous fluid, immediately collapsing the cyst wall (figure 2). excision was performed with dissection of the cyst to its base at the saccule orifice. the entire sac was excised with minimal bleeding. after excision, the endotracheal tube was reduced to the next smaller size. she was extubated on the third postoperative day and did not require re-intubation. the patient was kept on intravenous antibiotics and steroids until she was discharged on the sixth postoperative day without further airway symptoms. melanie y. marino, md antonio h. chua, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: melanie y. marino, m.d. department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center rizal avenue, sta. cruz, manila 1003 telefax: (632) 743 6921 email: mimimarines@yahoo.com reprints will not be available from the author. congenital saccular cyst of the larynx philipp j otolaryngol head neck surg 2008; 23 (1): 35-36 c philippine society of otolaryngology – head and neck surgery, inc. figure 1. anterior saccular cyst arising from the left saccule. figure 2. after complete excision philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 36 philippine journal of otolaryngology-head and neck surgery featured grand rounds discussion congenital saccular cysts of the larynx are unusual lesions that commonly present with respiratory obstruction in infants and children.1 they are thought to arise in the saccule of the ventricle of the larynx. a laryngeal saccule is a small diverticulum arising out of the laryngeal ventricle. it extends upward between the false vocal fold, the base of the epiglottis, and the thyroid cartilage. it contains mucous glands and secretes mucus through an orifice in the anterior part of the roof of the ventricle. a congenital saccular cyst is believed to form as a result of a developmental failure to maintain patency of the saccular orifice. it is similar to a laryngocele in that it represents an abnormal dilatation or herniation of the saccule, however it is distinct from a laryngocele in that there is no opening to the ventricle of the larynx, and it is filled with mucus.1 on the other hand, a laryngocele is defined as a dilatation or herniation of the laryngeal saccule, which is filled with air. desanto, devine, and weiland2 classified all cystic laryngeal lesions into saccular, ductal, and thyroid cartilage foraminal cysts. they further classified saccular cysts into anterior and lateral saccular cysts. the anterior saccular cyst extends medially and posteriorly from the saccule and protrudes into the laryngeal lumen between the true and false vocal cords. the lateral saccular cyst typically extends posterosuperiorly into the false vocal cord and aryepiglottic fold. this is the larger of the two types and is the more common form encountered in infants. large lateral saccular cysts can extend into the lateral vallecula or bulge the medial wall of the pyriform sinus. it can also herniate through the thyrohyoid membrane similar to a laryngocele and can appear in the neck. recently forte, fuoco, and james3 proposed a new classification dividing laryngeal cysts into two types based on the extent of the cyst and on the embryologic tissue of origin. a cyst that is radiologically and clinically determined to be intralaryngeal and can be safely and completely excised endoscopically is classified as type i. those with extralaryngeal extension are classified as type ii, subclassified into iia (endodermal elements only) and iib (endodermal and mesodermal elements laryngotracheal duplication or diverticulum). saccular cysts cause respiratory distress and inspiratory stridor most often at birth. the cry may be muffled, and dysphagia may occur. the diagnosis is suggested by a soft tissue lateral radiograph that shows a mucus-filled sac.1 this can be confirmed by fiberoptic laryngoscopy. the anterior saccular cyst is seen as a small round swelling protruding from the anterior ventricle and overhanging the anterior part of the ipsilateral vocal fold. the lateral saccular cyst appears as a smooth, mucosa-covered swelling of the false vocal fold and aryepiglottic fold. both computed tomography and mri may be helpful in delineating the exact location and extent of the mass. in our patient, the diagnosis was arrived at on the basis of clinical presentation and endoscopic findings. a good airway must first be secured prior to definitive management. fortunately, our patient was successfully intubated, negating the need for a tracheotomy. the classic treatment of the lateral saccular cyst has been endoscopic management.1 needle aspiration through a direct laryngoscope has been suggested as the initial treatment but recurrence is the norm because of the difficulty in completely obliterating the cyst by this method.1 endoscopic marsupialization with or without stripping of the cyst lining has been advocated. abramson and zielinski4 introduced the application of carbon dioxide laser to incise the cyst and vaporize its lining. booth and birck5 used cup forceps to unroof laryngoceles and saccular cysts in neonates, followed by a 3-day intubation. holinger et al6 performed direct laryngoscopy and endoscopic removal with cup forceps. in this patient, we performed endoscopic excision using cup forceps, dissecting the cyst to its base at the orifice of the saccule before amputation. intubation was maintained to protect the infant’s airway and likewise act as a stent, similar to the technique described by booth and birck.5 large saccular cysts occasionally require an external approach. a lateral cervical approach extending through the thyrohyoid membrane immediately above the alar of thyroid cartilage is the procedure of choice in such cases.2 acknowledgement: we would like to extend our heartfelt thanks to dr. samantha s. castañeda for reviewing the manuscript. references: 1. cotton rt, prescott ca. congenital anomalies of the larynx. in: cotton rt, myer cm, editors. practical pediatric otolaryngology. philadelphia, pa: lippincott-raven; 1999. p. 508-509. 2. desanto lw, devine kd, weiland lh. cysts of the larynx: classification. laryngoscope 1970:261267. 3. forte v, fuoco g, james a. a new classification system for congenital laryngeal cysts. laryngoscope 2004;114:1123-1127. 4. abramson al, zielinski b. congenital saccular cysts of the newborn. laryngoscope 1984;94:15801581. 5. booth jb, birck hg. operative treatment and postoperative management of saccular cyst and laryngocele. arch otolaryngol head neck surg 1981;107:500 6. holinger ph, holinger ld, barnes dr, smid lj. laryngocele and saccular cysts. ann otol 1978;87:675-685. 36 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 surgical innovations and instrumentation abstract objective: to design affordable, easy-to-use self-retaining retractors that can provide adequate exposure of the operative area in head and neck surgery methods: design: surgical instrumentation setting: tertiary government hospital subjects: one results: self-retaining retractors were designed and fabricated from stainless steel with tissue prongs on one end and a loop for rubber-band attachment to surgical drapes via a towel clip on the other end. varying prong lengths were devised for different depths of required retraction. traction tension could be adjusted by varying rubber-band attachment distance. the retractors were tested on a patient undergoing open reduction and internal fixation for a mandibular fracture and evaluated according to ease of application, adequacy of exposure and tissue trauma. conclusion: the self-retaining retractors may be affordable alternatives to commercially-available self-retaining retractors. they are easily applied with adjustable tension and depth of retraction that can provide adequate exposure with minimal tissue trauma. key words: self-retaining retractor, instrumentation tissue retractors have been an integral part of surgical instrumentation throughout its history and various types in different shapes and sizes are available for various procedures. generally, retractors reposition tissues in order to expose the operative site and facilitate surgery. ease of application and a balance between appropriate tension and minimal trauma provide adequacy of exposure. tissues must be handled gently to preserve cellular integrity. excessive pressure may crush tissue, cause ischemia, necrosis and compromise wound healing. ideally, skin is retracted with hooks and when needed, fine-toothed forceps that are closed with minimal tension.¹ ideal retraction balances tissue tension with exposure of deeper tissues, facilitating surgical dissection with a knife or tissue scissors.² self-retaining retractors obviate the need for additional hands, freeing surgeons for other tasks. such instruments may retract tissues in a single or multiple directions under fixed or variable tension. for instance, the dingman and weitlaner retractors both retract tissues in two opposite directions under fixed (once locked) tension. inspired by the ingenious use of a fish hook observed on a visit to the chang gung hospital, we designed alternative instruments that retract tissues in a single direction under variable (due to rubber-band) tension. alternative self-retaining retractors for head and neck surgery roselle c. bargo, md¹ samantha s. castañeda, md1, 2,3 1department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center ²department of otorhinolaryngology head and neck surgery rizal medical center 3department of otorhinolaryngology head and neck surgery the medical city correspondence: roselle c. bargo, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal ave., sta. cruz, manila 1003 philippines phone: (632) 711 9491 local 320 fax: (632) 743 6921 reprints will not be available from the author. no funding support was received for this study. the authors signed disclosures that they have no proprietary or financial interest with an organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at the instrument design contest (3rd place), philippine society of otolaryngology head and neck surgery annual convention, hotel sofitel, pasay city, philippines december 2007. philipp j otolaryngol head neck surg 2009; 24 (2): 36-37 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 37 philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 surgical innovations and instrumentation materials and methods the retractors were fabricated from stainless steel, each with three partsthe body, proximal and distal end (figure 1). the flat body of each retractor measured 5cm x 1cm x 0.2cm. the proximal end was curved circularly inward leaving a 0.1cm gap between the tip and body of the retractor for rubber-band insertion. the distal ends were curved into two blunt-ended prongs, each 0.2cm wide, with varying depths of 1cm., 2cm. and 4cm. respectively (figure 2). references 1. georgiade g, riefkohl r, levin ls. basic principles of surgical techniques. plastic, maxillofacial and reconstructive surgery. 3rd ed. maryland, usa: williams and wilkins; 1997. p.11. 2. sherris d, kern e. mayo clinic: basic surgical skills. minnesota, usa: mayo foundation for medical education and research; 1999. pp.32-33. figure 3. the retractor used intra-operatively results the self-retaining retractors were tested on a patient undergoing open reduction and internal fixation for a mandibular fracture (figure 3). the retractors were easily applied and rubber-band tension easily adjusted by varying the distance of the towel clip from the retractor. exposure of the operative site was adequate for dissection, fracture reduction and internal fixation with plates and screws. no gross tissue trauma was observed. the post-operative course of the patient was uneventful and comparable to similar procedures using conventional retractors. discussion necessity is the mother of invention. in a developing nation, costcutting involves searching for inexpensive instrumentation as much as minimizing manpower requirements. our alternative self-retaining retractors achieve both. their properties effectively free an extra hand for other tasks while achieving their purpose. other commercially available self-retaining retractors are costly, ranging from php 5,000 to php 10,000 each. our alternative self-retaining retractors only cost php 350 making them an affordable alternative. they are easily applied with adjustable tension and depth of retraction that can provide adequate exposure with minimal tissue trauma. we recommend further trials in a larger series and in comparison with similar unidirectional self-retaining devices. figure 1. the self-retaining retractor figure 2. different prong lengths of the self retaining retractor philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 surgical innovations and instrumentation philippine journal of otolaryngology-head and neck surgery 31 abstract objective: to design an instrument for steadying instrument handling during microlaryngeal surgery using an operating laryngoscope. method: our device design takes its cue (pun intended) from professional billiards players like our very own efren “bata” reyes. the laryngeal tiririt (bridge or rake) draws inspiration from the billiards bridge (locally known as tiririt) used to extend the player’s reach when the cue ball is too far to make an accurate shot. setting: the laryngeal tiririt was used and tested by senior residents in microlaryngeal surgeries done in our institution. result: the laryngeal tiririt greatly improved the accuracy required in laryngeal surgeries without adding up huge set up or expensive equipment. keywords: laryngoscopes, instrumentation even the world’s number one billiards player, efren “bata” reyes, uses a rake or bridge, locally termed as tiririt, to extend his reach on a shot and win many tournaments. the device, sometimes called a “rake” or simply “bridge” is used to extend a player’s reach on a shot where the cue ball is too far away to achieve accurate hand bridging (figure 1). it is from this simple device that we drew inspiration to solve the problem of hand shaking or tremors that many ent surgeons encounter when performing microlaryngeal surgeries. microlaryngeal surgery is a delicate procedure which involves fine hand movements and skills. in a process which demands fine motor skills in a small operating field, steady and precise movement in instrument handling is difficult to achieve for many surgeons. the instrument, which we will fondly name the microlaryngeal tiririt, was designed to address the problem of shaky handling of instruments during microlaryngeal procedures. the microlaryngeal tiririt operates in similar principle to that of the billiard player’s bridge or rake when making a shot at the cue ball. by reducing the shaky handling of instruments, the surgeon can now focus on the precise microlaryngeal surgical procedure at hand. brent p. lavarias, md archimedes b. bagnes, md gil m. vicente, md department of ear nose throat head and neck surgery jose r. reyes memorial medical center correspondence: brent p. lavarias, md department of ear nose throat – head and neck surgery jose r. reyes memorial medical center sta. cruz, manila 1100 philippines e-mail address: blavarias@lycos.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at the instrument design contest (1st place) philippine society of otolaryngology head and neck surgery 50th annual convention, edsa shangri-la plaza hotel, mandaluyong city, december 2, 2006. laryngeal tiririt (bridge): for microlaryngeal surgery shake philipp j otolaryngol head neck surg 2007; 22 (1,2): 31-32 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 surgical innovations and instrumentation 32 philippine journal of otolaryngology-head and neck surgery materials and methods the instrument was made of 14-centimeter stainless steel wire (figure 2) with the distal end flattened and trimmed to form a v-shaped prop or bridge (figure 3). its greatest diameter was 1.5mm. the proximal end was curved and designed to fit to the lip of the laryngoscope for enhanced precision (figure 4). results the laryngeal tiririt was utilized on four microlaryngeal surgeries done in our institution. the device was not found to be obtrusive to the already narrow operating field. since the tiririt was thin, it did not present any intrusion when using the microlaryngeal instruments (figure 5). no slippage of instruments resting on the tiririt was experienced. the distal v-shaped end of the tiririt could accommodate up to two microlaryngeal instruments at a time. the tiririt also served as a guide, as well as a bridge, for most of the laryngeal instruments used (figures 6, 7). discussion the development of rigid endoscopes for ent surgery has brought our sight closer to the operating site in spite of the narrow operating field1,2,3. extended instruments facilitate microlaryngeal surgery through the operating laryngoscope. however, this makes handling of the instruments unsteady. various tables have been used to deal with shakiness and strain during surgery by serving as elbow or arm rests. this reduced strain but did not necessarily resolve unsteady handling. similarly, handles for laryngeal devices4,5 (karl storz cat. no. 8597, explorent cat. no. 632025) do not necessarily offer a rest from shaking of the distal end of laryngeal instruments. the laryngeal tiririt adds stability in handling instruments during surgery, addressing shakiness and unsteady handling by acting as a mechanical bridge and greatly improving the precision required in microlaryngeal surgeries without adding bulky set up or costly apparatus. references 1. jackson c, jackson cl. bronchoesophagology. philadelphia: w.b. saunders; 1950. p. 35-48. 2. koufman j, postma g. controversy in laryngology. in: bailey bj, calhoun kh, deskin rw, johnson jt, kohut ri, pillsbury iii hc, et al., editors. head and neck surgery-otolaryngology 2nd ed. philiadelphia: lippincott-raven publishers; 1998. pp. 859-872. 3. andrea m, dias o, newer techniques of laryngeal assessment. in: cummings cw, fredrickson jm, krause cj, harker la, schuller de, richardson ma, editors. otolaryngology-head and neck surgery, 3rd ed. st. louis: mosby; 1998; 103: 1967-1978. 4. karl storz gmbh & co., endoscopes and instruments for ent 5th ed 1996(catalogue). tuttlingen (germany) 5. explorent gmbh., micro-laryngoscopy, broncho-esophagoscopy 4th ed. 2000(catalogue) tuttlingen (germany) figure 1: billiard bridge (“billiards” printed with permission from the art of chuck currey, page 8 available from www.xaraxone.com/featured art/mar04/html/08.htm) figure 2: top, lateral view; bottom, antero-posterior view figure 3: v-shaped distal end figure 4: proximal end of the tiririt mounted on an operating laryngoscope figure 5: cup forceps resting on the tiririt figure 6: tiririt with laryngereal ligature needle mounted figure 7: laryngereal tiririt with cup forceps philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 6564 philippine journal of otolaryngology-head and neck surgery from the viewbox philipp j otolaryngol head neck surg 2023; 38 (1):65 c philippine society of otolaryngology – head and neck surgery, inc. fracture of the petrous carotid canal nathaniel w. yang, md 1department of otolaryngology-head and neck surgery college of medicine philippine general hospital university of the philippines manila 2department of otolaryngology -head and neck surgery far eastern university nicanor reyes medical foundation institute of medicine correspondence: dr. nathaniel w. yang department of otolaryngology – head and neck surgery university of the philippines manila ward 10, philippine general hospital, taft avenue ermita, manila 1000 philippines phone: (632) 8526 4360 telefax: (632) 8525 5444 email: nwyang@up.edu.ph the author declared that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. a 23-year-old male motorcyclist experienced blunt head trauma with loss of consciousness, headache and vomiting, epistaxis and right otorrhagia after a collision with a motor vehicle. fractures involving the right parietal and temporal bones, as well as acute subdural and subarachnoid hemorrhage were identified on a cranial and facial ct scan. on independent evaluation of the imaging study, a subtle but distinct fracture line in the skull base involving the petrous carotid canal was identified. (figure 1) the patient subsequently underwent ct angiography to evaluate for any injury to the internal carotid artery. in this examination, good opacification of the internal carotid arteries and their branches was noted, with no evident aneurysm, arteriovenous malformation or arteriovenous fistula formation. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. axial ct image at the level of the basal turn of the cochlea. a fracture line runs longitudinally in the right skull base (white arrow). it extends into the petrous carotid canal (white star) and the posterolateral wall of the sphenoid sinus (white chevron). in patients with temporal bone fractures, the most commonly encountered complications are: tympano-ossicular injury causing conductive hearing loss, cochlear or vestibular injury causing sensorineural hearing loss or vertigo, facial nerve trauma causing facial paralysis, and fractures of the tegmen or posterior cranial fossa plate causing cerebrospinal fluid leaks.1 on the other hand, injury to the intratemporal portion of the internal carotid artery has been described as a rare complication and as such may be overlooked.1 however, its potentially devastating and life-threatening sequelae necessitates a purposeful and intentional evaluation for its presence. these sequelae include brain ischemia from arterial dissection or complete vascular occlusion, exsanguinating epistaxis or otorrhagia from carotid pseudoaneurysms, and the formation of carotid-cavernous fistulas.2 the incidence of involvement of the carotid canal in skull base fractures has been reported to be around 24%, with around 11% of this group developing internal carotid artery injuries.3 as such, the presence of fractures involving the petrous carotid canal is an indication for ct or mr angiography to further evaluate the internal carotid artery.4 references 1. diaz rc, cervenka b, brodie ha. treatment of temporal bone fractures. j neurol surg b skull base. 2016 oct;77(5):419-29. doi: 10.1055/s-0036-1584197; pubmed pmid: 27648399; pubmed central pmcid: pmc5023437. 2. varo alonso m, utrilla contreras c, díez tascón á, garcía raya ps, martí de gracia m. traumatic injury of the petrous part of the temporal bone: keys for reporting a complex diagnosis. radiologia (engl ed). 2019 may-jun;61(3):204-214. english, spanish. doi: 10.1016/j.rx.2018.12.005; pubmed pmid: 30777299. 3. resnick dk, subach br, marion dw. the significance of carotid canal involvement in basilar cranial fracture. neurosurgery. 1997 jun;40(6):1177-81. doi: 10.1097/00006123-199706000-00012; pubmed pmid: 9179890. 4. kurihara yy, fujikawa a, tachizawa n, takaya m, ikeda h, starkey j. temporal bone trauma: typical ct and mri appearances and important points for evaluation. radiographics. 2020 jul-aug;40(4):1148-1162. doi: 10.1148/rg.2020190023; pubmed pmid: 32442046. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 from the viewbox philippine journal of otolaryngology-head and neck surgery 49 a u.s. serviceman presented with a three-month history of unsteadiness on ambulation and increasing episodes of vertigo whenever he turned his head rapidly to the right. he had previously been injured in a bomb blast while stationed in iraq four months prior to consultation. aside from multiple soft tissue and bone trauma, he had also experienced vertigo and nearly complete deafness in the right ear immediately after the blast. medical records indicated the presence of a traumatic perforation of the right tympanic membrane and spontaneous nystagmus on initial emergency medical assessment after the incident. physical examination on consultation revealed bilaterally intact eardrums, a positive right head impulse test and a normal romberg test. audiometry showed a severe right snhl. a presumptive diagnosis of a persistent perilymph fistula secondary to inner ear barotrauma was entertained, and supported by findings on temporal bone ct imaging. nathaniel w. yang, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila philippine national ear institute national institutes of health university of the philippines manila pneumolabyrinth: radiologic evidence of labyrinthine injury correspondence: nathaniel w. yang, md department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 phone: (632) 526 4360 fax : (632) 525 5444 emai: nwyang@gmx.net reprints will not be available from the author. philipp j otolaryngol head neck surg 2008; 23 (2): 49-50 c philippine society of otolaryngology – head and neck surgery, inc. figure 1 is the axial ct image of the patient’s inner ear at the level of the basal turn of the cochlea. two linear lucencies are visible within the cochlea (arrowheads). these have the same signal characteristics as the normal external auditory canal and middle ear space. as such, they indicate the presence of air within the cochlea – a condition termed pneumolabyrinth. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 50 philippine journal of otolaryngology-head and neck surgery from the viewbox references: 1. emmett jr, shea jj. traumatic perilymph fistula. laryngoscope 1980; 90: 1513-1519. 2. mcghee ma, dornhoffer jl. a case of barotrauma-induced pneumolabyrinth secondary to perilymphatic fistula. ear nose throat j 2000; 79: 456–459. 3. lao ww, niparko jk. assessment of changes in cochlear function with pneumolabyrinth after middle ear trauma. otology & neurotology 2007; 28: 1013-1017. figure 2 shows a normal cochlea at the same level for comparison. note the uniform soft tissue density within the cochlear lumen, representing the endocochlear fluids. the lucency in the round window niche (thin arrow) also represents air but this is a normal finding. barotrauma from blast injuries and traumatic tympanic membrane perforations may cause perilymph fistulas. this is probably due to a sudden pressure wave transmitted through the tympanic membrane that results in an inward rupture of the round window membrane or an inward displacement of the stapedial footplate.1 pneumolabyrinth has been identified in patients suffering from perilymph fistulas due to barotrauma,2 and therefore can bolster the diagnosis when identified in the appropriate clinical setting. it has also been identified in patients with perilymph fistulas from other causes, including iatrogenic stapes fractures during mastoid surgery, temporal bone fractures, cholesteatoma, neoplasms of the temporal bone, stapedectomy and after cochlear implantation.3 philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles philippine journal of otolaryngology-head and neck surgery 19 abstract objective: to determine the olfactory function among post-laryngectomy patients using a questionnaire adapted from that of the smell and taste clinic of hospital of university pennsylvania (hup) and the santo tomas smell identification test. methods: design: descriptive study setting: tertiary private hospital outpatient department patients: twenty five subjects who had undergone total laryngectomy and met inclusion and exclusion criteria underwent rigid nasal endoscopy and olfactory function assessment using an adaptation of the questionnaire of the smell and taste clinic of hospital of university pennsylvania (hup) and the santo tomas smell identification test (st-sit). results: twenty one male subjects completed olfactory testing. all had subjective sense of smell before laryngectomy. statistically significant correlation was noted between the subjective postoperative smell function and the objective olfactory function test scores. there was no statistically significant difference noted in the st sit scores with regards age, duration from laryngectomy to olfactory testing, number of smoking packyears, use of olfactory technique/maneuver, loss of appetite and adjunctive chemotherapy and radiotherapy. conclusion: all subjects post-laryngectomy had subjective complaints of varying levels of olfactory difficulties based on a structured questionnaire and were documented to be anosmic by an objective smell identification test. olfactory problems following laryngectomy can have significant effects on the lives of laryngectomees, and health care providers should be knowledgeable of available management options for this condition. key words: olfaction, anosmia, total laryngectomy, olfactory testing olfactory deterioration affects the quality of life of a person, impairing appreciation of food subjective and objective assessment of olfactory function in post-laryngectomy patients ricardo l. ramirez jr., md windolyn d. panganiban, md joel a. romualdez, md department of otorhinolaryngology head and neck surgery st. luke’s medical center correspondence: ricardo l. ramirez jr.,md department of otorhinolaryngology head and neck surgery st. luke’s medical center 279 e. rodriguez ave, quezon city 1102 philippines telefax: (632) 723 0101 local 5543 e-mail: rikrik_2006@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed disclosures that they have no proprietary or financial interest with an organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at the descriptive research contest (3rd place), philippine society of otolaryngology-head and neck surgery, jade valley restaurant, quezon city, philippines, september 25, 2008. philipp j otolaryngol head neck surg 2009; 24 (2): 19-22 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles 20 philippine journal of otolaryngology-head and neck surgery and beverage and depriving environmental cues to warn of potentially life-threatening situations. the perception of taste of chocolate, coffee, tea and meat are dependent on retronasal stimulation of olfactory receptors and the appreciation of such tastes will also be negatively influenced by the loss of the sense of smell.1 total laryngectomy results in a permanent separation between the upper and lower airways with a wide range of adverse effects. the change in anatomy leads to deterioration in pulmonary function as well as loss of the normal senses of smell and taste, loss of voice and associated physical and psychosocial problems.2 while some observe that the immediate, inevitable anosmia resulting from laryngectomy does not resolve even after eight years,3others have reported improvement in olfaction within the first 6 months after surgery and documented the presence of a relatively normal sense in some laryngectomees.4 laryngectomees have been divided into 2 groups, smellers and non-smellers, based on odor detection and/or odor differentiation tests.5 with the increasing number of post-laryngectomy patients, the lack of resources for olfactory rehabilitation, and the paucity of local literature on the topic, this study aims to subjectively and objectively determine the olfactory function of our subject population. materials and methods subjects twenty five subjects who had previously undergone total laryngectomy and were all members of a support group of laryngectomized patients that consulted at the out-patient department of st. luke’s medical center met inclusion and exclusion criteria, and informed consent was obtained from each. all patients had a subjective sense of smell before laryngectomy and no history of head trauma, chronic sinusitis, nasal allergies or severe respiratory infection which may cause olfactory deterioration. rigid nasal endoscopy was performed on all to detect any anatomic abnormalities like presence of nasal deviation, nasal polyposis and nasal discharge that could affect nasal airflow and impair smell. patients were excluded if their surgery, chemotherapy and radiotherapy had been performed within less than 3 months. the cut-off point of 3 months was chosen to allow most side effects of the surgery, chemotherapy and radiotherapy to subside and the physical conditions of the patient to stabilize before olfactory testing. data collection an adaptation of the questionnaire of the smell and taste clinic of the hospital of the university of pennsylvania (hup)6 was administered to each subject to assess their perceived olfactory function. the questionnaire was revised by removing sections on taste symptoms, endocrine information and questions regarding depression on the standard test questionnaire of the smell and taste clinic of the hospital of the university of pennsylvania. no local translation or validation of the revised questionnaire was made. medical history questions included history of pre and post operative radiotherapy and/or chemotherapy, sinus or nasal problems, serious upper respiratory problems, history of head and neck surgery, smoking history, nasal allergies and family history of smell problems. smell symptoms items included olfactory disorder prior to laryngectomy, sense of smell immediately after laryngectomy, present sense of olfaction, degree of change in olfaction, technique/maneuver used to improve sense of smell, and the presence of loss of appetite due to the disorder in olfaction. subjects were asked to rank problems associated with laryngectomy in order of its significance in their everyday life which included pain, smell problems, taste problems, shoulder dysfunction, physical disfigurement, and airway/tracheostomy problems, eating, chewing and swallowing. olfactory function of each subject was evaluated using the standardized, locally-validated santo tomas smell identification test (st-sit).7 this test uses 45 odorants, each enclosed in an opaque polyethylene squeeze bottle. each odorant is smelled by the subject and identified from a written list of choices. the odorants had a corresponding score and the summation of these scores serve to discriminate those with normal olfactory function from those with olfaction problems. this test was able to qualify whether a person is anosmic, hyposmic or has normal olfactory function. data analysis demographic, clinical and smell and nasal characteristics were analyzed as frequencies and percentages. paired t test was used in comparing smell functions before and after laryngectomy. a two-tailed statistical analysis was done with a p value of < 0.05 being considered significant. data analyses were computed using spss (statistical package for social sciences) for windows version 16.0. results a total of 21 male subjects with age range of 56 to 76 years were included in the study. olfactory testing was performed as early as 3 months after the total laryngectomy, chemotherapy and radiotherapy to as late as 14 years after treatment. table 1 summarizes the distribution of patients based on history of chemotherapy/radiotherapy, smoking history, degree of smell impairment, degree of change in olfactory function, compensatory techniques and length of time from surgery to the development of smell impairment. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles philippine journal of otolaryngology-head and neck surgery 21 table 1. demographic and clinical characteristics characteristics (n=21) gender (male) 21 (100) age (mean + sd) 64.95 + 6.6 yrs duration from operation to testing (mean + sd) 4.48 + 4.48 yrs chemo and radiotherapy pre-op chemo & radiotherapy 7 (33.3) post-op chemotherapy 2 (9.5) post op radiotherapy 5 (23.8) post –op chemo & radiotherapy 4 (19.0) no chemo & radiotherapy 3 (14.3) history of sinus / nasal problems, respiratory 0 (0) problems, previous head and neck operation, allergies and exposure to chemicals smoking history 19 (90.5) smoking pack years less than 20 2 (9.5) 21 to 40 13 (61.9) 41 to 60 4 (19.0) 61 to 80 2 (9.5) table 2. ranking of problems associated with total laryngectomy * mean eating speaking smell airway shoulder taste pain physical 2.25 2.40 2.90 3.00 3.14 3.60 3.38 4.15 rank 1 2 3 4 5 6 6 7 *ranked by the subjects according to its significance in their daily life there was no significant correlation between olfactory score and other demographic and clinical characteristics such as length of time post-surgery, age, number of smoking pack years, loss of appetite and interference with daily activities. table 2 summaries the different problems associated with total laryngectomy as ranked by the subjects. eating and swallowing were ranked first followed closely by communication problems. the smell problem was ranked higher than airway/tracheostomy problems. table 3 presents the olfactory characteristics before and after laryngectomy. because all subjects claimed no problems prior to laryngectomy, paired t-test results yielded p values of < 0.05 for all characteristics. there was a statistically significant correlation between subjective post-operative smell function and the objective olfactory function test scores. the subjects st-sit scores ranged from 20-65 with a mean st-sit score of 47.26, indicating that all had olfactory dysfunction, and that all had anosmia. discussion this study verified that indeed, a majority of laryngectomized patients have some level of subjective olfactory difficulty brought about by the transformation in upper airway physiology as a result of the permanently-created stoma. all our 21 male patients claimed to have no olfactory deficit prior to total laryngectomy. all claimed to have smell function disabilities post-surgery, confirmed in the course of evaluation. in the structured questionnaire, two-thirds of the subjects complained of complete loss of the sense of smell with more than half table 3. olfactory characteristics before and after laryngectomy characteristics smelling problem, n (%) changes in smell phantosmia hypersensitive partial loss complete loss degree of change mild moderate severe smell condition getting better getting worse fluctuates no improvement use of technique or maneuver technique or maneuver sniffing swallowing loss of appetite smell interferes with everyday functioning 21 (100) 1 (4.8) 2 (9.5) 4 (19.0) 14 (66.7) 3 (14.3) 6 (28.6) 12(57.1) 5 (23.8) 7 (33.3) 2 (9.5) 7 (33.3) 2 (9.5) 1 (4.8) 1 (4.8) 14 (66.7) 17 (81.0) pre-operative post-operative 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) philippine journal of otolaryngology-head and neck surgery vol. 24 no. 2 july – december 2009 original articles 22 philippine journal of otolaryngology-head and neck surgery indicating a severe change in their sensory perception occurring within a month after laryngectomy in almost all patients. majority of the respondents also felt that their smell problem affected their activities and daily functioning. although olfaction was noted to have decreased and remain unimproved among a majority of our patients, two (who had mastered esophageal speech) had consciously or unconsciously acquired techniques to improve their weakened sense of smell. one was observed to swallow in air after sniffing the odorants during the smell identification test. the other was noted to use his facial and nasal muscles excessively during sniffing. although their olfaction test scores did not reflect any relation to these maneuvers, further tests involving larger samples may corroborate hilgers8 positive correlation between quality of esophageal voice and olfaction acuity. this may reflect better control of oropharyngeal musculature in good esophageal speakers, enabling them to pump air into the nasal cavity retronasally. some smell specialists have exploited such special maneuvers to help patients recover their sense of smell with varying success. in particular, hilgers and his team7 report excellent long-term success with olfaction rehabilitation using the nasal airflow-inducing maneuver or the “polite yawning technique.” 8 the absence of significant correlation between time in years since laryngectomy and olfactory testing is supported by leon et al.9 who found no significant correlation between time in years since laryngectomy and oronasal or retronasal psychophysical testing scores. this may support the case for earlier olfactory rehabilitation following laryngectomy, rather than the practice of later (“wait and see”), or no intervention. variations in the problems associated with laryngectomy that were ranked by the subjects may be due in part to most of our respondents having had laryngectomy several years before this study. while patients with laryngectomies of several months’ duration may be more concerned about airway and tracheostomy problems, patients who have had a permanent stoma for several years may be more accustomed and adapted to it that they no longer feel that it is a major cause for concern. majority of the respondents developed loss of appetite and claimed that loss of olfaction interfered with everyday functioning in terms of taste perception leading to poor nutrition and in some cases, eventual weight loss. this may be due to laryngectomy disrupting olfaction, both retronasal (odorant molecules from the oral cavity delivered the olfactory cleft via nasopharynx and posterior choanae) and orthonasal (odorant molecules delivered to olfactory epithelium via the nares). our study showed that all subjects post-laryngectomy had subjective acknowledgement we thank mr. emer l. roxas and the members of nu vois association of the philippines and the philippine laryngectomee club for actively participating by providing subjects for this study and ms. catherine c. cristobal of the clinical epidemiology department of st. luke’s medical center for help with statistical analysis. references 1. burdarch kj, doty rl. the effects of mouth movements, swallowing and spitting on retronasal odor perception. physiol behav. 1987; 41: 353-356. 2. risberg-berlin b, ylitalo r, finizia c. screening and rehabilitation of olfaction after total laryngectomy in swedish patient: results from intervention study using the nasal airflowinducing maneuver. arch otolaryngol head neck surg. 2006; 132 (3): 301-306. 3. henkin ri, hoye rc, ketcham as, gould wj. hyposmia following laryngectomy. lancet 1968; 2: 479-481. 4. moore-gillon v. the nose after laryngectomy. j r soc med. 1985; 78: 435-439. 5. van dam fsam, hilgers fjm, emsbroek g, touw fi, van as cj, de jong n . deterioration of olfaction and gestation as a consequence of total laryngectomy. laryngoscope. 1999; 109: 1150-1155 6. deems da, doty rl, settle rg, moore-gillon v, shaman p, mester af, kimmelman cp, brightman vj, snow jb. smell and taste disorders: a study of 750 patients from the university of pennsylvania smell and taste center. arch otolaryngol head neck surg 1991; 117: 519-528 7. david j, campomanes b, dalupang j, loberiza f. smell identification test. philipp j otolaryngol head neck surg 1994;62-68. 8. hilgers fjm, van dam fsam, keyzers s, koster mn, van as c, muller mj. rehabilitation of olfaction after laryngectomy by means of a nasal airflow-inducing maneuver. arch otolaryngol head and neck surg 2000; 126: 726-732. 9. leon ea, catalanotto fa, werning jw. retronasal and orthonasal olfactory ability after laryngectomy. arch otolaryngol head neck surg 2007;133:32-36. 10. luessen aw, kobal g, wolfensberger m. assessing olfactory function in laryngectomees using the sniffin sticks test battery and chemosensory evoked potentials. laryngoscope 2000; 110:303-307. complaints of varying levels of olfactory difficulties based on a structured questionnaire and were documented to be anosmic by an objective smell identification test. olfactory problems following laryngectomy can have significant effects on the lives of laryngectomees and health care providers should be knowledgeable of available management options for this condition. philippine journal of otolaryngology-head and neck surgery 39 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports abstract objective: to describe a rare case of lipofibromatosis presenting as a head and neck mass in a 6-year-old child. method: design: case report setting: tertiary public general hospital patient: one result: a six-year-old male child admitted with a large right head and neck region mass underwent complete excision of a possible soft tissue neoplasm following investigations which included fine needle aspiration cytology, ultrasonography and computed tomography. histopathological examination yielded lipofibromatosis, a very rare lesion with a distinctive fibrofatty pattern. the patient was well with no recurrence after three months of follow up. conclusion: although lipofibromatosis is a rare lesion in children and has a predilection for distal extremities, it may also present as a mass in the head and neck area. complete surgical excision is feasible and is the only treatment option available for this rare lesion keywords: lipofibromatosis lipofibromatosis is a rare fibrofatty tumour of the paediatric age group. it has only recently been described as a clinicopathologic entity in 2000 by fetch et al. and subsequently only few case reports have been published in the literature.1 these lesions are seen exclusively in children from birth to the early second decade of life2 with an over 2:1 male predominance and predilection for distal extremities, being less common in the trunk, head and neck.3 a medline pubmed search using the terms” lipofibromatosis” and “neck mass” yielded only two cases of this lesion presenting as neck mass in the paediatric age group.4,5 the case described in this report is another instance that presented as a head and neck mass and subsequently turned out to be lipofibromatosis on histopathological examination. case report a six-year-old boy was admitted to the paediatric surgery department with a slowly growing painless mass on the right side of his neck and face for the last two years. upon examination, the mass extended from the orbital floor to the lower border of the mandible, also occupying lipofibromatosis: an unusual head and neck mass in the paediatric age group yogender singh kadian ms, mch1 kamal nain rattan ms, mch1 shalini aggarwal mbbs, md2 shilpi modi mbbs, md3 rajnish kalra mbbs, md3 department of paediatric surgery1 radiology2 and pathology3 pt b d sharma post graduate institute of medical sciences rohtak, haryana (india) correspondence: dr yogender singh kadian 6/9j, medical campus, pt b d sharma pgims, rohtak-124001, haryana, india ph:+91 1262 213778 (res.) + 91 9466626478 (cell.) email: yogarin@gmail.com, nkadian@gmail.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2011; 26 (1): 39-41 c philippine society of otolaryngology – head and neck surgery, inc. 40 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports the submandibular triangle in the neck. it was firm in consistency and not fixed to skin and underlying structures (figure 1).there was no significant lymphadenopathy of the neck. ultrasonography of the mass revealed an isoechoic to hyperechoic lesion without any flow on colour doppler. contrast-enhanced computed tomography (cect) scan showed a large non-enhancing soft tissue mass mainly of fat density with lots of fibrous septa displacing the carotid vessels posteriorly (figure 2). fine needle aspiration cytology (fnac) showed spindle cells suggesting a mesenchymal lesion. the haematological investigations were within the normal range. the tumor was excised via a large semilunar cervicofacial skin flap that was resutured without any facial reconstruction. the completely-excised tumour was 8x4cms in size on gross examination (figure 3). histopathological examination revealed lipofibromatosis (figure 4). the patient was discharged in good condition after ten days of hospitalization and he was well after three months of follow up. discussion lilpofibromatosis is a rare benign soft tissue neoplasm of childhood, previously designated as infantile fibromatosis of non-desmoid type.5 in 2000, fetch et al. proposed that although this tumour is likely to be a part of the infantile fibromatosis spectrum, it should be considered a distinctive entity because of its histological pattern and they coined the term lipofibromatosis for this rare lesion.1 these tumors had been variously diagnosed as a type of infantile fibromatosis, a variant of fibrous hamartoma of infancy and a fibrosing lipoblastoma.3 lipofibromatosis has been described from birth to the early second decade and the median age for the first surgery is one year2. there is a male predominance with a male to female ratio of 2:1.3 it is most commonly seen in hands and feet and is slightly less common in the thigh, trunk and head.3 the etiology remains unknown.4 the lesion usually measures 1 to 3 cm, with a median size of 2 cm, and it presents as a poorly circumscribed mass involving the subcutis and/or deep soft tissues. it is rare for lipofibromatosis to be over 5 cm in diameter1 and the present lesion measuring 8 x 4 cm and extending from the neck and face to the orbital floor could probably be the first case of this size in the literature. imaging generally reveals fat that appears as exaggerated adipose tissue that is more disorganised than normal, with poorly demarcated lobules, infiltration and entrapment as well as displacement of muscle with fibroblastic elements within the fat septa. ultrasound usually demonstrates poor musculature planes with hyperechoic content. cect is useful in outlining the tumour and demonstrating a lowdensity non-enhancing mass measuring fat in hounsfield units as also seen in the present case. magnetic resonance imaging (mri), though figure 2. axial and reformatted sagittal non-contrast and contrast-enhanced computed tomographic sections reveal a well-defined dumbbell-shaped lesion measuring 6 x 8 x 10cm between the maxilla and mandibular ramus on the right side, grossly displacing the adjacent bones. figure 1. clinical photograph shows a huge mass on the face and neck. not available in the case described, plays an important role in tissue characterisation with increased t1 andt2 signals that are consistent with fat. intralesional areas of signal change that are increased on t1 and become fat-saturated on t2 are also reflective of fatty content.6 as this lesion has prominent fat component, various adipocytic tumors may be considered in the differential diagnosis including angiolipoma, atypical lipomatous tumor, lipomatosis, lipoblastoma/ philippine journal of otolaryngology-head and neck surgery 41 philippine journal of otolaryngology-head and neck surgery vol. 26 no. 1 january – june 2011 case reports lipoblastomatosis, fibrous hamartoma of infancy and fibrohisticytic lipoma.7 however, the microscopic examination of this tumor revealing uniformly-sized mature adipocytes with lack of nuclear atypia, necrosis and mitotic activity exclude malignancy. moreover, the simple morphological pattern with spindle cells and fatty tissue septa without primitive mesenchymal components exclude other non –malignant conditions like lipomatosis and fibrous hamartoma of infancy.7 if facilities for immunohistochemistry are available in the hospital, immunohistochemical examination of this lesion may help in making references 1. fetsch jf, miettinen m, laskin wb, michal m, enzinger fm. a clinicopathologic study of 45 pediatric soft tissue tumors with an admixture of adipose tissue andfibroblastic elements,and a proposal for classification as lipofibromatosis. am j surg pathol 2000; 24: 1491-1500. 2. teo he, peh wc, chan my, walford n. infantile lipofibromatosis of the upper limb. skeletal radiol 2005; 34: 799-802. 3. browne tj, fletcher cdm. haemosiderotic fibrolipomatous tumour (so-called haemosiderotic lipomatous tumour): analysis of 13 new cases in support of a distinct entity. histopathology 2006, 48, 453-461 4. herrmann bw, dehner lp, forsen jw jr. lipofibromatosis presenting as a pediatric neck mass. int j pediatr otorhinolaryngol 2004; 68: 1545-1549. 5. taran k, woszczyk m, kobos j. lipofibromatosis presenting as a neck mass in eight year old boy-a case report. pol j pathol 2008;4 :217-20. 6. chien a, song d, stein s. two young girls with lipoblatoma and a review of literature. pediatr dermatol 2006; 23:152-56. 7. miettinen m, fetsch jf. lipofibromatosis. pathology and genetics of tumors of soft tissue and bone.in:fletcher cdm, uni kk, mertens f.world health organisation classification of tumors. iarc,lycon 2002,85. figure 3. photograph of gross specimen, excised tumour the diagnosis. the most common immunoprofile of lipofibromatosis is focal staining of the spindle cells with cd99, sma, bcl-2 and typically negative staining with desmin.1 complete surgical resection is the mainstay of treatment because of high predilection for recurrence in incompletely excised lesions.5 since most lesions have infiltrating borders, complete removal of the tumor might cause functional compromise. in the present case, the tumour was removed completely without any significant functional compromise. however, there are some cases with longer follow-up who experienced no recurrence even though the lesion was incompletely excised.1,5 in view of these circumstances and due to the paucity of literature that accurately predicts outcome, the conclusions regarding patient management as well as prognosis must be individualized based on the patient’s condition. in conclusion, although more documented cases of this entity have been published, insufficient clinical experience in treatment still remains. despite the rarity of its presentation as a head and neck mass, lipofibromatosis should be taken into account as a differential diagnosis in the management of head and neck masses in the paediatric age group. figure 4. haematoxylin and eosin (h&e) slide, high power magnification (100x) showing lipofibromatosisprimitive fibroblasts infiltrating between lipocytes. (haematoxylin-eosin, 100x) philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 original articles philippine journal of otolaryngology-head and neck surgery 7 philipp j otolaryngol head neck surg 2010; 25 (1): 7-12 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: 1) to describe patterns of filipino voice handicap index (vhi) scores in relation to the demographic data of dysphonic patients; 2) to describe patterns of filipino vhi scores in relation to the different pathologies of dysphonia as determined by videostroboscopy. methods: design: cross-sectional study. setting: tertiary government hospital. population: adult patients (≥18 years old), proficient in filipino. a group of 124 dysphonic patients seen at the videostroboscopy unit completed the filipino vhi. demographic data were collected. videostroboscopy diagnoses were classified into six groups: normal, mass lesions, inflammatory, mucosal irregularities, functional and neurogenic. the t-test was used to determine differences in scores among the demographic parameters and the pathology groups. anova one-way factor was used to determine difference of subscale scores within each pathology group, and to determine difference of pathology scores in each subscale. differences were considered statistically significant if p<0.05. results: statistical analyses showed that filipino vhi scores were affected by age, gender, educational status and occupation. younger patients significantly scored higher than patients >40 years old. females had significantly higher scores than males in the functional, physical and total subscales. patients with lower educational status scored higher compared to college graduates. voice professionals significantly scored higher than the non-voice professionals. dysphonic patients significantly scored higher than normal volunteers. among the pathological groups, neurogenic lesions had the highest scores. physical subscale scores were significantly higher in all lesions except in functional lesions. conclusion: the filipino vhi is comparable to the other versions of the vhi, with patterns similar to other versions. it gives the clinician a measure of a dysphonic patient’s handicap, and is an invaluable tool in quantifying severity of dysphonia. keywords: dysphonia, voice handicap index, videostroboscopy the world health organization (who) defines handicap as the loss or limitation of opportunities to take part in community life as a consequence of a physical disorder or injury. measurement of the handicap of dysphonic patients using the filipino voice handicap index aimee caroline e. lim, md1 melfred l. hernandez, md, mha1 erasmo gonzalo dv, llanes, md1,2 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2philippine national ear institute national institutes of health university of the philippines manila correspondence: aimee caroline e. lim, md department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632)526 4360 fax: (632) 525 5444 email: aimeecarolinelim@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed disclosures that they have no proprietary or financial interest with an organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at the descriptive research contest (1st place) philippine society of otolaryngology head and neck surgery, congo grille restaurant, quezon city. september 23, 2009. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 original articles 8 philippine journal of otolaryngology-head and neck surgery the severity of dysphonia and how it affects a patient’s daily activities are difficult to quantify. a lesion’s effect may be perceived differently by a salesperson whose livelihood relies on verbal communication compared to a driver. ultimately, the goal in the treatment of dysphonia is not only to remove the lesion, but more importantly to improve the voice. self-evaluation then becomes an important factor in the management plan of vocal pathology. jacobson et al. in 1997 developed the voice handicap index (vhi),1 a self-administered 30-item questionnaire to measure the functional, physical and emotional impact of voice disorders. the physical subscale items included statements representing self-perceptions of laryngeal discomfort and voice output characteristics.1 examples are “i feel as though i have to strain to produce voice” and “my voice sounds creaky and dry.” functional subscale items described the impact of a person’s voice disorder on daily activities.1 an example is “my voice problem causes me to lose income.” emotional subscale items consisted of statements representing patient’s affective responses to voice disorders.1 examples are “i feel annoyed when people ask me to repeat” and “my voice makes me feel incompetent.” this psychometric tool was developed using a diverse sample of patients with voice disorders, representing the breadth of pathology in most clinical settings. it has then been widely used to assess the effectiveness of interventions for voice disorders including voice therapy and rehabilitation,2,3 medical treatment4 and surgical procedures,5 and has been translated into several languages including german,6 chinese,7,8 french,9 portuguese,10 dutch,11 hebrew12 and spanish.13 in 2006, a filipino version of the vhi (appendix b) was developed by umali and hernandez14 with the assistance of the komisyon ng wikang filipino, divisyon ng pagsasalingwika (commission of filipino language, division of translation). the filipino version was then translated back to english and its content reviewed by a panel of laryngologists and a dyphonic patient, proficient in both filipino and english. the final filipino questionnaire was then tested for internal consistency on 392 primary and secondary teachers in different schools in metro manila. after 1 to 2 weeks, the same questionnaire was administered to the teachers to test for inter-rater reliability. the results were comparable to the original english vhi version as illustrated in table 1. the vhi is a subjective tool based on patients’ individual perception of dysphonia. certain patterns have been observed in the different translations. the chinese, french, spanish, portuguese and hebrew versions showed statistically significant difference between the score of dysphonic and non-dysphonic groups. the german and english versions associated severe dysphonia with larger vhi scores. the hebrew version reported significantly higher scores for dysphonic patients with vocal pathology compared to healthy larynges, with neurogenic causes having the highest scores. the chinese vhi9 reported glottic insufficiency with significantly higher scores than functional and mass pathology. this paper aims to 1) describe patterns of filipino vhi scores in relation to the demographic data (age, gender, education, occupation) of dysphonic patients seen in the videostroboscopy unit of the philippine general hospital; and 2) describe patterns of filipino vhi scores in relation to the different pathologies of dysphonia as determined by videostroboscopy. methods population the target population was dysphonic adult patients (aged 18 and above) proficient in filipino, referred to the videostroboscopy unit from june 2007 to august 2009. dysphonia was defined as any kind of perceived voice pathology. study setting and design the study was done in the videostroboscopy unit of the philippine general hospital, department of otorhinolaryngology. this was a cross-sectional study using convenience sampling. data collection the study protocol and informed consent were reviewed and approved by the ethics review board of the institution. after acquiring individual verbal and written informed consent, 124 patients completed the filipino vhi. data analysis the filipino vhi version of umali and hernandez14 used in this table 1. vhi versions with test-retest reliability and internal consistency results verions pearson’s test-retest reliability (r) english1 filipino14 german6 chinese8 french9 portuguese10 dutch11 hebrew12 spanish13 0.7-0.79 0.72 0.84 0.87 0.95 0.76-0.86 0.822 0.95 0.8 0.96 0.98 greater then 0.7 0.976 0.93 *pearson’s correlation: strong r ≥ 0.8, moderate 0.5 < r <0.8, weak r ≤ 0.5 **acceptable cronbach’s alpha ≥ 0.70 cronbach’s alpha internal consistency philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 original articles philippine journal of otolaryngology-head and neck surgery 9 study was composed of 30 statements of experiences and reactions to voice disorders. ten statements described the impact of a person’s voice disorder on his or her daily activities (functional subscale). ten statements described how the patient feels about the voice disorder (emotional subscale). ten statements described self-perceptions of physical manifestations of dysphonia such as laryngeal discomfort and the voice pitch (physical subscale). each patient related his/her agreement to the statements using a five-point likert scale (0-never, 1almost never, 2 sometimes, 3 almost always, 4 – always). the subscale score was the mean score of the 10 statements in each subscale. the severity of handicap was interpreted to be directly proportional to the numeric value assigned by the patient to each statement. the total assessment of handicap was measured by obtaining the mean of the scores on all 30 statements, the total vhi score. demographic data (age, gender, educational status, occupation) were collected. educational status included those who attained elementary (primary), high school (secondary) and college level (tertiary) education. occupation was subdivided into professional and non-professional voice users. the professional voice users included teachers, salespeople and a choirmaster. the rest of the study population whose occupation did not depend on voice use was grouped under the non-professional voice users. these included the housewives, the unemployed, drivers, farmers and students. videostroboscopy diagnoses were grouped as normal; mass lesions (vocal cord cyst, nodule, polyp, leukoplakia, granuloma, mass to consider tb and carcinoma); inflammatory (laryngitis, lpr, reinke’s edema); mucosal irregularities (presbylarynx, plica ventricularis, sulcus vocalis, laryngeal web); functional (hyper/hypofunctional dysphonia, muscle tension dysphonia); neurogenic (paralysis, spasmodic dysphonia). the videostroboscopy results used in the study were interpreted by either of 2 laryngologists of the videostroboscopy unit. descriptive statistics (mean and standard deviation) were used to summarize the demographic data. t-test (one-tailed) was used to determine difference between vhi score means in the functional, physical, emotional and total subscales among the demographic parameters and pathology groups. anova one-way factor was used to determine difference of subscale scores within each pathology group, and to determine difference of pathology scores in each subscale. differences were considered statistically significant if p<0.05. results population. there were 124 patients who completed the filipino vhi: 44 males (35.5%) and 80 females (64.5%). the mean age was 46.1years ±15.29. filipino vhi scores and age. patients <40 years old had significantly higher scores. the functional subscale score (f) was 16.88±9.26. the physical subscale score (p) was 24.49±10.04. the emotional subscale score (e) was 15.51±9.94. the total vhi score (t) was 56.88±25.62. these were higher than the values in patients >40 years old (14.51±11.39 f, 19.88±9.7 p, 13.72±10.25 e, 48.11±28.91 t). filipino vhi scores and gender. females (16.25±10.55 f, 23.52±9.42 p) scored significantly higher than males (13.98±10.71 f, 18.39±10.44 p) only in the functional and physical subscales. filipino vhi scores and education. significantly higher scores were noted in the primary and secondary group (16.44±10.02 f, 15.76±10.16 e, 54.17±27.17 t), compared to the college group (14.81±10.98 f, 13.03±9.91 e, 49.6±28.05 t) in all subscales except physical. filipino vhi scores and occupation. voice professionals (18.08±9.65 f, 25.27±7.81 p, 16.31±9.72 e, 59.65±24.4 t) showed significantly higher vhi scores in the functional, physical, emotional and total subscales than non-voice professionals (15.14±10.95 f, 21.02±10.53 p, 14.16±10.42 e, 50.33±28.83 t). filipino vhi scores and pathology groups. dysphonic patients (15.57±10.56 f, 21.75±10.05 p, 14.36±10.01 e, 51.68±27.68 t) significantly scored higher than non-dysphonics (2.38±3.62 f, 1.77±3.77 p, 0.23±0.44 e, 4.38±5.45 t) on all subscales and total scores. figure 1 presents the distribution of pathology groups, with mass lesions composing 61.3% of all lesions, followed by inflammation (14.5%) and neurogenic lesions (12.9%). table 2 shows the mean scores and standard deviations of the control and the pathology groups. anova results showed no significant difference among scores of the pathology groups in all subscales and the total scores (f p=0.09, p p=0.52, e p=0.05, t p=0.13). neurogenic lesions ranked highest among the pathologies, followed by mucosal, functional, mass and inflammatory lesions. in each pathology group, the physical subscale (p) had the highest score compared to the functional and emotional subscales, except for functional lesions. this was significantly different only in mass and inflammatory lesions. discussion the voice handicap index quantifies the impact of disease on patients. through its three subscales, the clinician is able to identify the specific domain where the patient is most affected: physically, functionally and emotionally. this information guides the clinician in tailoring treatment to the needs of individual patients. such a tool adapted to the local language is undeniably valuable. the younger population (<40 years old) had significantly higher scores than the older group. this is contrary to the observations of the philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 original articles 10 philippine journal of otolaryngology-head and neck surgery society,15 videostroboscopy should be included as minimal measurements in functional assessment of voice pathology and efficacy of treatment. since other objective measurements such as acoustic analysis and aerodynamics were not available due to institutional limitations, the diagnoses to which the vhi scores were compared relied solely on the videostroboscopy findings. dysphonic patients significantly scored higher than non-dysphonic volunteers in all subscales. this was also reported in the chinese,8 french,9 spanish,13 portuguese10 and hebrew12 versions. this finding was consistent with the results of the english1 and german6 versions, where the severity of dysphonia was associated with higher vhi scores. although the scores within the pathology groups were not significant, neurogenic lesions had the highest score in all subscales significantly different from the other pathologies combined. according to hsiung et al., glottic insufficiency due to vocal cord paralysis often manifests with a husky voice associated with choking, odynophagia and throat tightness in various levels of severity. these extralaryngeal manifestations in addition to dysphonia contribute to the severity of handicap and consequently, to the difficulty in treatment. this implies that a multidisciplinary approach is required for treatment to encompass all subscales and a thorough discussion on patient expectations of treatment is warranted. the physical subscale (p) had the highest scores compared to the functional (f) and emotional (e) subscales in all pathology groups except for functional lesions. functional lesions in this study included hyperfunctional and hypofunctional dysphonia, as well as muscle tension dysphonia. compared to the rest, this group’s main problem is in the coordination of the vocal cord muscle movement rather than physical laryngeal abnormalities. this inefficiency of movement is often associated with learned behavior and is affected by unhealthy voice habits. thus, treatment may be focused more on rehabilitation than on medical or surgical intervention. mass lesions composed 61.3% of all pathologies in this study. this group ranked fourth and scores were significantly lower in all subscales. this was contrary to the chinese version where mass lesions scored greater than functional lesions.7 scores in the physical subscale were significantly higher than the functional and lowest in the emotional subscale. this means that the physical manifestations of dysphonia were more significant than its effect on the patient functionally and emotionally. treatment then may be more focused on medical or surgical intervention. inflammatory lesions significantly scored lower than the other pathologies, except in the physical subscale. this finding is similar to the observations of the hebrew version.12 this means that physical figure 1. distribution of pathology groups (n=124). table 2. average filipino vhi scores with standard deviation of normal volunteers and pathology groups. neurogenic (n=16) mucosal(n=6) functional (n=5) mass (n=76) inflammatory (n=18) normal (n=3) control (n=13) functional 21.69 ± 9.24 18.67 ± 13.75 19 ± 8.22 14.59 ± 10.4 12.28 ± 10.24 10.33 ± 14.57 2.38 ± 3.62 physical 26 ± 10.4 23.83 ± 11.87 18.2 ± 7.69 21.03 ± 9.94 21.33 ± 10.04 19.67 ± 12.58 1.77 ± 3.62 emotional 21.31 ± 9.81 17 ± 14.39 17.6 ± 8.79 12.83 ± 9.55 12.89 ± 8.82 17 ± 16.64 0.23 ± 0.44 total 69 ± 17.51 59.5 ± 38.56 54.8 ± 17.51 48.45 ± 27.23 46.5 ± 23.7 47 ± 42.79 4.38 ± 5.45 portuguese10 version, where the older group had higher scores, although these were not statistically relevant. the hebrew12 version reported no significant different of scores in relation to age. females scored significantly higher than males. in the portuguese version, females also scored higher than males, although not statistically significant.10 gender did not affect the scores in the hebrew12 and dutch11 version. in this study, handicap was higher in young females. the younger group seemed to be more affected by dysphonia than the older population as they are more socioeconomically active. females were more affected physically and functionally, since most had voice dependent occupations. females and males, however, were equally affected emotionally. voice professionals expectedly had higher handicap compared to the non-voice professionals. the group with lower educational status mostly had voice-dependent occupations, which may explain the high handicap scores. the filipino vhi scores were compared with the diagnoses made through videostroboscopy. according to the european laryngological philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 philippine journal of otolaryngology-head and neck surgery 11 original articles manifestations of inflammatory lesions are the most affective, thus treatment should be focused on medical intervention. the filipino voice handicap index is comparable to the other versions of the vhi, with patterns similar to other versions. more importantly, it gives the clinician a measure of a dysphonic patient’s handicap, which is directly proportional to the score, forewarning both clinician and patient of reasonable expectations from treatment. a multidisciplinary approach to the treatment of dysphonia is facilitated by the filipino vhi, which aids the clinician in tailoring management to focus more on the specific subscale that is most affected. high scores in the physical subscale might require medical or surgical intervention. high scores in the functional subscale might require voice rehabilitation and retraining, while high emotional scores might require counseling. it provides the clinician with a baseline measurement of the patient’s handicap, which can be used to gauge the success of an intervention. the filipino voice handicap index is an invaluable tool in quantifying severity of dysphonia in patients. a multicenter application of the filipino vhi for all hoarse patients would provide a more comprehensive filipino dysphonia profile. preand post-treatment administration of the questionnaire could be used to assess effectiveness of several interventions. appendix a. voice handicap index filipino version instruksyon: ito ay mga pahayag ng mga karamihan na nakaranas ng problema sa kanilang boses at kung paano ito nakaapekto sa kanilang pang-araw-araw na gawain. bilugan lamang na sa iyong palagay na kahalintulad sa iyong mga nararamdaman. 0=hindi 1= halos hindi 2= minsan 3= halos kadalasan 4= madalas bahagi 1 1. nahihirapan ang mga tao marinig ang boses ko. 2. nahihirapan ang mga tao na maintidihan ako sa maingay na lugar. 3. nahihirapan ang aking mga kasambahay marinig ako kapag tinatawag ko sila. 4. dumadalang na ako gumamit ng telepono kaysa sa nais ko. 5. umiiwas na ako sa mga tao dahil sa boses ko 6. dumadalang na ako makipag-usap sa aking mga kamaganak, kaibigan o kapit-bahay dahil sa aking boses. 7. ipinapaulit ng aking kausap ang aking mga sinasabi. 8. dahil sa aking boses, nalilimitahan ang aking personal at sosyal na pamumuhay. 9. pakiramdam ko ay hindi ako napapasama sa mga usapan. humihina ang aking hanapbuhay dahil sa problema sa aking boses. 10. humihina ang aking hanapbuhay dahil sa problema sa aking boses. bahagi ii 1. kinakapos ako ng hininga habang nagsasalita. 2. pabago-bago ang tunog ng aking boses sa buong maghapon. 3. nagtatanong ang mga tao, “ano ba ang problema ng iyong boses.” 4. ang tunog ng aking boses ay minamalat at nanunuyo. 5. pakiramdam ko ay kailangan kong bumuwelo upang makalikha ng boses. 6. ang linaw ng aking boses ay pabago-bago/paiba-iba. 7. sinusubukan ko na ibahin ang tunog ng aking boses. 8. gumagamit ako ng malakas na puwersa para makapagsalita. 9. mas masama ang aking boses kapag pagabi na. 10. nawawalan ako ng boses sa kalagitnaan ng aking pagsasalita. bahagi iii 1. ninenerbiyos ako kapag nakikipag-usap sa ibang tao dahil sa aking boses. 2. tila naiinis ang mga tao sa aking boses. 3. pakiramdam ko ay hindi naiintindihan ng mga tao ang problema sa aking boses. 4. ikinababahala ko ang aking problema sa boses. 5. madalang na ako makisalamuha dahil sa aking problema sa boses. 6. para akong may kapansanan dahil sa aking boses. 7. naiinis ako kapag pinapaulit nila ang aking sinasabi. 8. nahihiya ako kapag pinapaulit nila ang aking sinasabi. 9. pakiramdam ko ay wala akong silbi dahil sa problema ng aking boses. 10. ikinahihiya ko ang aking problema sa boses. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 1 january – june 2010 original articles 12 philippine journal of otolaryngology-head and neck surgery acknowledgement the authors would like to thank ms. michelle mananez and ms. luz agustin for their invaluable assistance in data collection and questionnaire administration. references 1. jacobson bh, johnson a, grywalski c, silbergleit a, jacobson g, benninger ms, et al. the voice handicap index (vhi): development and validation. am j speech lang pathol. 1997;6:66-70. 2. fulljames n, harris s. voice outcome measures: correlations with patients’ assessment of their condition and the effectiveness of voice therapy. logoped phoniatr vocol. 2006;31(1):23-35. 3. roy n, gray sd, simon m, dove h, corbin-lewis k, stemple jc. an evaluation of the effects of two treatment approaches for teachers with voice disorders: a prospective randomized clinical trial. j speech lang hear res 2001 apr;44(2):286-296. 4. benninger ms, gardner g, grywalski c. outcomes of botulinum toxin treatment for patients with spasmodic dysphonia. arch otolaryngol head neck surg. 2001 sep;127 (9):1083-85. 5. nuñez batalla f, caminero cueva mj, señaris gonzalez b, llorente pendas jl, gorriz gil c, lopez llames a, et al. voice quality after endoscopic laser surgery and radiotherapy for early glottic cancer: objective measurements emphasizing the voice handicap index. eur arch otolaryngol. 2008 may;265(5):543-48. 6. nawka t, wiesmann u, gonnermann u. validation of the german version of the voice handicap index. hno. 2003 nov;51(11):921-30. (english abstract, full article in german) 7. hsiung mw, lu p, kang bh, wang hw. measurement and validation of the voice handicap index in voice-disordered patients in taiwan. j laryngol otol. 2003 jun;117 (6): 478-81 8. lam pky, chan km, ho wk, kwong e, yiu em, wei wi. cross-cultural adaptation and validation of the chinese voice handicap index-10. laryngoscope. 2006 jul;116 (7): 1192-8 9. woisard v, bodin s, puech m. the voice handicap index: impact of the translation in french on the validation. rev laryngol otol rhinol (bord). 2004;125(5):307-12. (english abstract, full article in french). 10. guimaraes i, abberton e. an investigation of the voice handicap index with speakers of portuguese: preliminary data. j voice. 2004 mar;18(1):71-82. 11. hakkesteeg mm, wieringa mh, gerritsma ej, feenstra l. reproducibility of the dutch version of the voice handicap index. folia phoniatr logop. 2006;58(2):132-138. 12. amir o, tavor y, leibovitzh t, ashkenazi o, michael o, primov-fever a, wolf m. applying the voice handicap (vhi) to dysphonic and nondysphonic hebrew speakers. j voice. 2006 jun;20(2):31824. 13. núñez-batalla f, corte-santos p, señaris-gonzález b, llorente-pendás jl, górriz-gil c, suáreznietoa c. adaptation and validation to the spanish of the voice handicap index (vhi-30) and its shortened version (vhi-10). acta otorrinolaringol esp. 2007 nov;58(9):386-92. (full article in spanish and english). 14. umali jv, hernandez ml. voice handicap index among filipino teachers in primary and secondary schools in the city of manila: reliability and preliminary validation of a questionnaire. 2006 (unpublished). 15. dejonckere ph, bradley p, clemente p, cornut g, crevier-buchman l, friedrich g, et al. a basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques. eur arch otorhinolaryngol. 2001 feb;258(2):77-82. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations philippine journal of otolaryngology-head and neck surgery 39 abstract objectives: 1) to present a technique for implanting the med-el combi 40+™ using a small incision with minimal access. 2) to describe the short term postsurgical outcomes in these patients. methods: two patients (1 child and 1 adult) underwent a novel small incision technique for implantation of the med-el combi 40+™ cochlear implant device. the short term outcomes in these two patients were described and compared with previous experience using the standard implantation technique citing advantages and possible limitations. as these two patients had bilateral implantation utilizing different techniques on the two sides interesting comparisons could be made on the same individuals. results: the preliminary experience with a novel small incision technique for the med-el combi 40+™ implantation shows encouraging results in terms of healing and initial performance of these patients. conclusion: this small incision technique may be offered to patients especially to those who wish to have bilateral implantations as this allows a less invasive approach, good cosmesis without sacrificing the safety and performance outcomes at least in the short term. keywords: cochlear implantation, minimally invasive surgery the credit goes to gibson1 for introducing small incision cochlear implant surgery. minimal access cochlear implantation techniques include modifications of the classical technique with the aims of reducing the impact of surgery while maintaining the proven safety and outcomes of conventional wide exposure approaches. previous reports of small incision cochlear implant surgery by o’ donoghue and nikolopoulos2 and james and papsin3 referred to techniques that were applied to the nucleus implants while those of jiang et al.4 and dalchow and werner5 were applied to a wider variety of cochlear implants including the clarion and med-el implant systems. the conventional technique of med-el combi 40+™ implantation utilizes a 10-12 cm incision, limited mastoidectomy, tympanotomy and cochleostomy, drilling of a bony recess for the implant receiver-stimulator with suture tie down to stabilize the latter. the objective of this paper is to describe our experience on two initial patients in whom we modified the conventional technique of med-el device implantation by utilizing a smaller retro-auricular incision (4.5 cm) and tie-down ligature, tight subperiosteal pocket with closure of overlying periosteum for device fixation without a bony recess for the receiver-stimulator. as these two patients (1 adult and 1 child) had bilateral implantations that employed the longer incision and wider exposure on one side with the modified minimal access approach on the other side, interesting comparisons of both approaches on the same individuals were then possible. small incision technique for med-el combi 40+™ implantation charlotte m. chiong, md1,2, maribel b. mueller, ma3, erwin voltaire m. ungui mclinaud2,3 1department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila 2philippine national ear institute national institutes of health university of the philippines manila 3med-el regional headquarters muntinlupa city, philippines correspondence: charlotte m. chiong, md department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 phone: (632) 526 4360 fax: (632) 525 5444 email: charlotte_chiong@yahoo.com reprints will not be available from the author. the med-el combi 40+™ cochlear implant device for the adult patient was provided by med-el regional headquarters, 1501 richville corporate tower, madrigal business park, ayala alabang, muntinlupa city 1702. cm chiong signed a disclosure that she is occasionally invited as a speaker for med-el for which she receives honoraria and travel allowances. other than this, she does not have any proprietary or financial interests with med-el or with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. mb mueller is the country manager (philippines) of med-el. evm ungui is a clinical audiologist employed by med-el. philipp j otolaryngol head neck surg 2006; 21 (1,2): 40-42 c philippine society of otolaryngology – head and neck surgery, inc. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations 40 philippine journal of otolaryngology-head and neck surgery case 1 born with congenital rubella syndrome (with cataracts, patent ductus ateriosus and profound hearing loss) this boy underwent simultaneous (single stage) bilateral cochlear implantation at age 4 on november 2005. on the right (fig 1a) an elongated 9 cm postauricular incision and on the left a smaller 4.5 cm retro-auricular incision (fig 1b) were carried out. the standard wide exposure on the right side was performed along with suture tie-down fixation for the receiverstimulator without drilling of a bony recess. on the left side, a minimal access tight subperiosteal pocket for the receiver stimulator was utilized without drilling a bony recess but suturing of the periosteum anterior to the electronic package was used to prevent anterior migration. the limited mastoidectomy and cochleostomy could be carried out similarly although the sigmoid sinus was quite anterior in the right side while on the left the facial recess was contracted as the facial nerve limited facial recess dissection in the left side. the mother noted that the healing period was shorter on the left side with the shorter incision as the right side remained tender with the home wound cleaning that was carried out by the mother one week postoperatively. the wounds at two weeks are shown in figure 2. six months post-operatively the patient had improved sound detection and could imitate some sounds. given this short observation period the parents are so far satisfied with the improvement. case 2 the first cochlear implantation was done on the left ear of this then profoundly deaf 27 year old male with bilateral congenital large vestibular aqueduct syndrome on october 1998 using the manufacturer’s prescribed surgical technique of an inverted j, limited mastoidectomy and drilling of a recess bed for the receiver stimulator with nylon tie-down suture fixation to immobilize the receiverstimulator onto the skull. he has performed well with this implant with the ability to communicate by telephone. eight years later (last january 2006) he underwent contralateral implantation using the 4.5 cm incision (fig 3a) and minimal access approach in which no bed was drilled but a tight subperiosteal pocket (fig 3b) and anteriorly placed nylon sutures (fig 4) were used to stabilize the receiver-stimulator. the wound healed uneventfully and he has reported significant subjective benefit already even only after 4 months on this second implant. a temporal bone ct provides evidence for a stable inset of the receiver-stimulator on the right side even with this minimal access approach (fig 5a). notably, the electronic package on the left side placed in the drilled bony recess has been well integrated as shown in figure 5b. discussion complications from cochlear implantation related to flap breakdown can range from 4.5% to 17%2,6,7. longer incisions that required more hair to be shaved and wider flap dissection related to the classical cochlear implant surgery have also been a source of concern among potential candidates or parents of prospective candidates figure1. (case 1) the right ear is prepared for the elongated postauricular incision with note of minimal shaving of the hair along the planned extension of this incision posterosuperiorly (a) and the left ear with the shorter (4.5 cm) retro-auricular incision (b). figure2. (case 1) this shows the scar of the longer incision in the right ear about two weeks postoperatively (a) compared to the shorter incision in the left ear (b). figure 3. (case 2) there was no need to shave the hair when the small incision is carried out for the right ear in this patient who had left cochlear implantation using a standard inverted j incision 8 years earlier (a) . the template for the receiver-stimulator is used to guide the development of a tight subperiosteal pocket (b). figure 4. (case 2) this shows the electronic package placed within the subperiosteal packet with nylon suture tie-down ligatures for device fixation. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations philippine journal of otolaryngology-head and neck surgery 41 figure 5a (case 2). ct scan showing receiver -stimulator on right side without drilling of an implant bed. figure 5b (case 2). ct scan showing receiver -stimulator on the left side with drilled implant bed. references: 1. gibson wpr,harrison hc, prowse c. a new incision for placement of cochlear implant. j laryngol otol 1995; 109:821-5. 2. o’donoghue gm, nikolopoulos tp. minimal access surgery for pediatric cochlear implantation. otol neurotol 2002;23:891-4. 3. james al, papsin bc. device fixation and small incision access for pediatric cochlear implants. int j ped otorhinol 2004;68:1017-22. 4. jiang d, bibas a, o’connor f. minimally invasive approach and fixation of cochlear and middle ear implants. clin otolaryngol 2004;29: 618-20. 5. dalchow cv and werner ja. a new instrument for minimal access surgery in cochlear implantation. otol neurotol 2005;26:678-9. 6. fayad jn, baino t, parisier sc. revision cochlear implant surgery : causes and outcome. otolaryngol head neck surg 2004; 131(4): 429-32. 7. lassig ad, zwolan ta, telian sa. cochlear implant failures and revision. otol neurotol 2005;26: 624-34. 8. nikolopoulos tp, lloyd h, archbold s, o’donoghue gm. pediatric cochlear implantation: the parent’s perspective. arch otolaryhgol head neck surg 2001;127:363-7. in considering this surgical option for hearing rehabilitation2,8. in all surgical disciplines the trend has been for minimally invasive surgery that reduces the trauma related to surgical access. the positive experience of other centers with minimal access cochlear implant surgery encouraged development of the smaller retro-auricular incision and device fixation using tiedown ligature, tight subperiosteal pocket and closure of periosteum without drilling of the bony recess for the receiver-stimulator. as both the standard incision and the small incision with minimal access technique was applied in these two patients who had bilateral cochlear implantations using the med-el combi 40+™ devices there was the unique opportunity to make these interesting comparisons on the same patients. this initial experience with a small incision and minimal access for implantation of med-el cochlear implant device is very encouraging in terms of healing and initial performance outcomes. the small incision technique can be considered especially in cases of bilateral implantation of the med-el devices given the shorter operative time, less invasive approach and good cosmesis in both adults and children as shown in this report. short term outcomes of about 6 months to 12 months at least for these two patients were indeed in favor of the minimal access approach. however further observation will be needed to ensure the long term benefit of this short incision and modified device fixation methods in our setting. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles philippine journal of otolaryngology-head and neck surgery 15 philipp j otolaryngol head neck surg 2008; 23 (1): 15-19 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: the objective of the study was to describe the distribution of keros classification among filipinos. methods: study design: retrospective review of consecutive paranasal sinus computed tomography (pns ct) scans. setting and participants: one hundred and twenty-eight consecutive pns ct scans done at the philippine general hospital from january 2006 to august 2007 were reviewed; 109 pns ct scans were included in the study. the bilateral heights of the lateral lamellae of the cribriform plate were obtained, independently coded, and classified according to keros classification. results: the mean height of the lateral lamella among filipinos was 2.21mm. one hundred sixty five cases (81.6%) were classified as keros i. fifty two cases (17.9%) were classified as keros ii and one (0.5%) case was classified as keros iii. there was no significant difference in the height of the lateral lamella (t-test: p=0.77, ci 95%) and the distribution of keros classification (fisher’s exact test: p = 0.78) among younger (1-14 year) and older (>14 year) filipino age groups. there was significant difference in the height (t-test: p=0.05, ci 95%) and the distribution of keros classification (fishers exact test: p=0.01) between filipino females and males. there was no significant difference in the height of the bilateral lateral lamellae among filipinos (paired t-test: p=0.51, ci 95%). there was no significant difference in the distribution of keros classification (fisher’s exact test: p=0.48) between the right and left lateral lamella. conclusions: in over 80% of the time, filipinos are classified as keros i. risk of inadvertent intracranial entry through the lateral lamella among filipinos is less compared to populations with majority of cases classified as keros ii or iii. keywords: keros classification, filipino, paranasal sinus, pns-ct, ethmoid roof, ethmoid anatomy radiographic analysis of the ethmoid roof based on keros classification among filipinos justin elfred lan b. paber, md1 michael salvador d. cabato, md2 romeo l. villarta, jr, md, mph3 josefino g. hernandez, md3 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2department of radiology philippine general hospital university of the philippines manila 3department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila correspondence: josefino g. hernandez, md department of otorhinolaryngology up college of medicine, university of the philippines manila ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax: (632) 525 5444 reprints will not be available from the author. no funding support was received for this study. the authors signed disclosures that they have no proprietary or financial interest with an organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at the 12th asian research symposium in rhinology research contest (1st place), sofitel philippine plaza manila, pasay city, november 30, 2007. analytical poster presentation (2nd place), philippine society of otolaryngology head and neck surgery 51st annual convention, sofitel philippine plaza manila, pasay city, november 30, 2007. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles 16 philippine journal of otolaryngology-head and neck surgery radiographic analysis through high resolution computed tomography (ct) has been considered the gold standard in the preoperative evaluation of the paranasal sinuses (pns).1 the pns ct scan provides the endoscopic sinus surgeon a “road map” to the anatomy of the ethmoid roof. the ethmoid roof is formed by the fovea ethmoidalis, an extension of the orbital plate of the frontal bone. the fovea articulates medially with the bone of the lateral lamella of the cribriform plate.2 the lateral lamella is the thinnest bone in the entire anterior skull base. the study focused on the length of the lateral lamella of the cribriform plate and classified the measurement according to keros classification. keros first described the differences in the level of the lateral lamella of the ethmoid.3 this classification depends on the length of the lateral lamella of the cribriform plate. in keros i, the olfactory fossa is 1 to 3 mm deep, the lateral lamella is short, and the ethmoid roof is almost in the same plane as the cribriform plate. in keros ii, the olfactory fossa is from 4 to 7 mm deep, and the lateral lamella is longer. in keros iii, the olfactory fossa is 8 to 16 mm deep, and the ethmoid roof lies significantly above the cribriform plate. (figure 1). figure 1. keros classification keros i keros ii keros iii 11 (34.4%) patients classified as keros i, 9 (28.1%) classified as keros ii, and 12 (37.5%) classified as keros iii5. at least one study described the keros classification in an asian population. in 176 thai patients, 11.9% presented with keros i, 68.8% with keros ii, and 19.3% with keros iii.7 data from a german study of 272 pediatric patients showed that the classification into the three types of positions of the ethmoid roof and cribriform plate according to keros is possible in children from the second year of life.8 asymmetry of the ethmoid roof has been reported in different studies. zacharek et al9 measured the height of the ethmoid roof bilaterally in the ct scans of 100 consecutive patients. their findings revealed that the right ethmoid roof was significantly lower in the right than the left. the same study also stated that the embryologic basis for the observed difference in ethmoid roof height between the right and left is not known. in another study, ct reports of 200 cases were analyzed for asymmetry of the ethmoid roof. forty-three percent of the cases in the study showed symmetry in the height and contour of the right and left fovea. asymmetry of the ethmoid roof was seen in the rest of their cases (57%): 96 scans demonstrated asymmetry in contour of the fovea ethmoidale and the remainder had asymmetry in height. among the patients with asymmetry in height, the right side was lower than the left.1 there is a paucity of descriptive studies on the keros classification among filipinos. determining the distribution of keros classification among this population may be useful in determining the risk of inadvertent intracranial entry during ess and consequently avoid post-operative complications. this study aimed to describe the distribution of keros classification of filipinos according to total number of cases, age group and gender; and the distribution and difference of keros classification of filipinos according to laterality. materials and methods all available consecutive coronal ct scans of the paranasal sinuses of patients, performed at the philippine general hospital, with the shimadzu 7000tx spiral ct scan (shimadzu, japan), between january 2006 and august 2007 were reviewed. patients with a history of trauma and/or nasopharyngeal masses having ct findings that showed disruption or invasion of the ethmoid roof were excluded from the study. measurement of the ethmoid roof was not possible among these cases. patients less than one year of age were likewise excluded. stammberger and kennedy4 as cited by gauba et al5 reported that the anatomical associations of the keros classification suggest that longer lateral lamellae pose greater risks of intracranial entry during surgery. the change in angulation along with the length of the lateral lamella also contributes to increased risk.5 the keros iii classification presents the highest risk for intracranial entry during endoscopic sinus surgery (ess) which can result in cerebrospinal fluid (csf) leakage and consequently increased risk of meningitis. hence, a more cautious approach is needed in operating on patients classified as such. conversely, keros i patients carry the least risk of entry into the cranium. the percentage distribution of the keros classification based on ct studies has been described in caucasian populations. floreani et al6 reported a distribution of 23% keros i pattern, 50% keros ii and 27% keros iii in their study of 22 cadaver heads with pns ct scans, and the mean heights of the lateral lamellae were 5.4 mm on the right and 4.7 mm on the left. gauba et al in their study of coronal ct scans from 32 consecutive patients reported philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles philippine journal of otolaryngology-head and neck surgery 17 figure 2. showing landmark used in measurement legend: height of lateral lamella the pns ct scans used the bone algorithm, with a 3-mm interscan interval. both the right and left lateral lamella in the ct scan were measured and coded separately. the measurements of the lateral lamella were simultaneously obtained by two authors (msdc and jelbp) using a single caliper with smallest unit of measurement at 0.5mm. interpretation was by consensus if there was disagreement while another author (jgh) made the decisive interpretation. correction for scale of the obtained measurements was done. (figure 2) data were encoded using microsoft excel worksheet (microsoft corp, usa). the lateral lamella measurements in this study were classified as follows: • keros i: the olfactory fossa is 1 to 3.99 mm deep • keros ii: the olfactory fossa is 4 to 7.99 mm deep • keros iii: the olfactory fossa is 8 to 16 mm deep statistical analyses were done using the statistical package for the social sciences version 15.0 for windows (spss inc., chicago, il, usa). all data were expressed as the mean +/standard deviation as frequencies and proportion. all differences in means were analyzed using the student’s t-test. differences in the distribution of nominal variables were tested by chi-square test or fisher’s exact test, whichever was appropriate. p-values less than 0.05 were considered significant. results a total of 128 consecutive pns ct scans done between january 2006 and august 2007 from patients of the philippine general hospital were reviewed. among these only 109 scans met the inclusion criteria and were included in the study. the ages of the patients ranged between 5 and 78 years, with a mean age of 40 years. fifty-eight (53%) were female patients and 51 (47%) were male patients. each ct scan was counted as two cases (right and left) for a total of 218 cases. the clinical diagnoses of the patients were classified into four types: (1) nasal polyps/papillomas, 41%; (2) nasopharyngeal/maxillary masses (malignant and benign, not including nasal polyposis), 27%; (3) rhinitis/sinusitis/nasal congestion, 12%; and (4) others (normal ct findings, oral cavity cancer, orbital diseases) 20%. the height of the lateral lamella (n=218) ranged from 0 to 10 mm with a mean 2.21 mm (sd 1.59). among the cases, 178 (81.6%) were classified as keros i; 39 (17.9%) were keros ii; and 1 (0.5 %.) was keros iii. (table 1) keros classification frequency percentage i 165 81.6% ii 52 17.9% iii 1 0.5% total 218 100% table 1. distribution of keros classification the cases were divided into two age groups. among the cases, 20 (9.2%) were in group 1 (1 to 14 years) and 198 (90.8%) were in group 2 (over 14 years). the mean height of the lateral lamella for group 1 was 2.11 mm (n=20, sd 1.65) and 2.21 mm (n=198, sd 1.58) for group 2. there was no statistical difference in the mean of both groups using independent sample t-test analysis (p=0.79, ci 95%). (table 2) age group n mean std. deviation 1 to 14 20 2.11 1.65 > 14 198 2.21 1.59 independent samples t-test: p=0.77, mean difference -0.11, 95% ci (-0.84, 0.63) table 2. distribution of mean height of lateral lamella according to age group in group 1, 16 (80%) cases were classified as keros i, 4 (20%) were keros ii. there was no case classified as keros iii in group 1. in group 2, 162 (81.8%) cases were classified as keros i; 35 (17.7%) were keros ii; and 1 (0.5%) was keros iii. there was likewise no statistical difference in the distribution of keros type between the two age groups using fisher’s exact test (p=0.78). (table 3) philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles 18 philippine journal of otolaryngology-head and neck surgery keros type females males i 102 (87.9%) 76 (74.5%) ii 14 (12.1%) 25 (24.5%) iii 0 1 (1.0%) total 116 (100%) 102 (100%) fishers exact test: p=0.01 table 5. distribution of keros classification according to gender keros type left right i 91 (83.5%) 87 (79.8%) ii 17 (15.6%) 22 (20.2%) iii 1 (0.9%) 0 total 109 (100%) 109 (100%) fisher’s exact test: p=0.48 table 6. distribution of keros classification according to laterality keros type paber et al floreani et al nitinavakarn et al gauba et al (n=218) (n=22) (n=176) (n=32) i 81.6% 23% 11.9% 34.4% ii 17.9% 50% 68.8% 28.1% iii 0.5% 27% 19.3% 37.5% table 7. distribution of keros classification: comparison with other studies gender n mean std. deviation f 116 2.01 1.37 m 102 2.43 1.78 independent samples t-test: p=0.05, mean difference -0.42, 95% ci (-0.85, 0.01) table 4. distribution of mean height of lateral lamella vs. gender keros type 1 to 14 year over 14 year i 16 (80%) 162 (81.8%) ii 4 (20%) 35 (17.7%) iii 0 1 (0.5%) total 20 (100%) 198 (100%) fisher’s exact test: p=0.78 table 3. distribution of keros classification according to age group the mean height of the lateral lamella of females was 2.01 (n=116, sd 1.37) and 2.43 (n=102, sd 1.78) for males. independent t-test analysis showed a significant difference in the value of the means between females and males (p=0.05, ci 95%). (table 4) one hundred two (87.9%) females were classified as keros i and 14 (12.1%) were classified as keros ii. no female case was classified as keros iii. seventy six males (74.5%) were classified as keros i, 25 (24.5%) were keros ii, and 1 (1.0%) was classified as keros iii. fisher’s exact test also showed significant difference in the distribution of keros type between females and males (p = 0.01). (table 5) the height of the right lateral lamella (n=109) ranged from 0 to 6 mm with a mean of 2.25 mm. the height of the left lateral lamellae (n=109) ranged from 0 to 10 with a mean of 2.16 mm (sd 1.66). paired t-test to determine the difference in paired means showed no significant difference (paired t-test: p=0.51, mean difference 0.08, 95% ci [-0.17, 0.34]) ninety-one patients (83.5%) were keros i, 17 (15.6%) keros ii, and 1 (0.9%) keros iii for the left lateral lamella (n=109). eightyseven (79.8%) and 22 (20.2%) were classified as keros i and ii, respectively, for the right lateral lamella. no patient had keros iii classification for the right lateral lamella. (table 6) comparison of the distribution of keros type between the left and right lateral lamella showed no significant difference using fisher’s exact test (p=0.48). discussion most of the ct scans included in the study had a clinical diagnosis of nasal polyps and/or papilloma (41%). only 12% had a diagnosis of rhinitis/sinusitis/nasal congestion. these findings differed from the reports of nitinavakarn et al7 where 2% of pns ct scans had clinical diagnoses of nasal polyps and almost 60% of pns ct had diagnoses of rhinosinusitis and chronic rhinitis. this difference in the clinical diagnosis of patients with rhinologic diseases may be due to the difference in the practice of filipino doctors in requesting pns ct. other possible contributing factors may be the variation in the patients’ socio-economic status, geographic location and the health care system in the philippines. the percentage distribution of keros classification among filipinos differed from the results presented by floreani et al6 and nitinavakarn et al.7 both studies had majority of cases belonging to keros ii as opposed to the present study where majority of the cases were classified as keros i. gauba5 however reported a comparable distribution between keros i and iii; with the least percentage of patients classified into keros ii. (table 7) the observed difference in the distribution of keros type of the cases in the studies mentioned earlier may be attributed to differences in the sample sizes of the study. differences in ethnicity of the cases may also contribute to the variance in the distribution. to our knowledge, there is still no literature philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 original articles philippine journal of otolaryngology-head and neck surgery 19 acknowledgements the authors would like to acknowledge regielyn p. santos-cortez, md, phd for providing assistance in statistical analysis and nadia m. mariñas, md for providing writing assistance. references 1. lebowitz ra, terk a, jacobs jb, holliday ra. asymmetry of the ethmoid roof: analysis using coronal computed tomography. laryngoscope 2001; 111:2122-2124. 2. terrier fw, ruefenacht w, porcellini db. anatomy of the ethmoid: ct, endoscopic, and macroscopic. am j rhinol 1985; 144:493-500. 3. keros p. [on the practical value of differences in the level of the lamina cribrosa of the ethmoid.] z laryngologie, rhinologie, otologie ihre grenzgeb 1962; 41:808-813. 4. stammberger hr, kennedy dw. paranasal sinuses: anatomic terminology and nomenclature. the anatomic terminology group. ann otol, rhinol laryngol 1995; 167:7-16. 5. gauba v, saleh gm. radiological classification of anterior skull base anatomy prior to performing medial orbital wall decompression. orbit 2006; 25:93-96. 6. floreani sr, nair sb, switajewski mc, wormald pj. endoscopic anterior ethmoidal artery ligation: a cadaver study. laryngoscope 2006; 116(7):1263-1267. 7. nitinavakarn b, thanaviratananich s, sangsilp n. anatomical variations of the lateral nasal wall and paranasal sinuses: a ct study for endoscopic sinus surgery (ess) in thai patients. j med assoc thai 2005; 88:763-768. 8. anderhuber w, walch c, fock c. [configuration of ethmoid roof in children 0-14 years of age]. laryngorhinootologie. 2001;80(9):509-11. 9. zacharek ma, han jk, allen r, weissman jl, hwang ph. sagittal and coronal dimensions of the ethmoid roof: a radioanatomic study. am j rhinol 2005; 19(4):348-52. correlating ethnicity with the structures of the ethmoid roof, particularly the lateral lamella of the cribriform plate. the majority of the filipino patients included in the study had keros i classification. this suggests that there is less risk of inadvertent intracranial entry through the lateral lamella among filipinos should they undergo ess as opposed to patients with keros ii or iii. the chances of csf rhinorrhea due to unintentional intracranial entry and consequently the possibility of life threatening meningitis after ess should also be less likely among filipinos. in the philippine setting, the data may be valuable for endoscopic surgeons performing sinus surgery who don’t have access to ct scans. the sinus surgeon can perform relatively safe surgery particularly in the ethmoid roof with the knowledge that in over 80% of filipinos the lateral lamella of the cribriform plate is less than 4 mm. the results of the study also revealed that there is no statistical difference in the distribution of keros type according to age group. the distribution according to age group likewise mirrored the distribution of all cases included in the study. keros i had the majority of cases and keros 3 the least in both age groups. the risk of intracranial entry through the lateral lamella during ess is similar for the younger and the older age group. hence, the same degree of caution should be practiced when performing ess in both age groups. the means of the height of the lateral lamella between filipino females and males were significantly different. the distribution of keros classification between males and females likewise differed significantly. the authors were not able to retrieve any data from literature describing and comparing keros classification according to gender. data may be useful for further studies in the analysis of variations of the ethmoid roof. there was no significant difference between the means of measurements of the height of the lateral lamella of the cribriform plate on the right from that of the left. there was also no significant difference in the keros classification of the right and left lateral lamellae. therefore the risk of intracranial entry through the lateral lamella during ess is the same regardless of laterality. there was no significant difference in the height of the bilateral lateral lamellae per patient. in addition there was also no difference in the distribution of keros classification between the right and left lateral lamella of the cases. this suggests that there is symmetry in the height of the right and left lateral lamella among filipinos. the presence of asymmetry of the ethmoid roof has been reported consistently in literature. zacharek et al9 and lebowitz et al1 both agreed that the ethmoid roof is significantly lower in the right compared to the left. data from the present study suggests that the bilaterally symmetric height in the lateral lamella does not contribute to asymmetry of the ethmoid roof. filipinos can be classified as keros i in over 80% of the time. although there may be a lower risk of inadvertent intracranial entry in this population, the same degree of caution should always be applied during endoscopic sinus surgery regardless of age or laterality as far as the lateral lamella is concerned. other radiologic landmarks of the ethmoid roof are also important, and further studies on ethmoid roof anatomy among filipinos should be conducted. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 surgical innovations and instrumentation philippine journal of otolaryngology-head and neck surgery 21 abstract objective: to fabricate an inexpensive, reproducible and portable ringlight with flexible, quick-release mount for use with point-and-shoot consumer digital cameras in intraoral photodocumentation. methods: design: instrumentation setting: tertiary care hospital procedure: a commercially-available battery-powered mountaineer’s led (light emitting diode) headlight was converted into a portable ringlight with a flexible, quick-release mount for intraoral photodocumentation. results: the flexmount ringlight delivered an even and white illumination of the oral cavity and oropharynx at a working distance of more than 5cm from the subject in focus. it resulted in sharper pictures due to its constant illumination that assisted the camera’s autofocus system in getting accurate focusing intraorally. it also allowed the camera to use smaller apertures that have put more elements in focus and faster shutter speeds that have markedly reduced motion blur. conclusion: the flexmount ringlight is an inexpensive, easy-to-assemble and portable ringlight that can be used in point-and-shoot consumer digital cameras. its constant and even illumination resulted in reproducible, sharp, shadowless photographs of the oral cavity and oropharynx. key words: ringlight, flexmount, intraoral photodocumentation medical photodocumentation has been acknowledged as an indispensible tool in the practice of medicine and surgery since gurdon buck’s first published article with preoperative illustrations of his patient in 1845.1 photographs, both film and digital, have detailed patient conditions, accurately documented surgical procedures and augmented verbal and written descriptions of communication with patients and colleagues.2 they have served as invaluable teaching tools and have also provided the flexmount ringlight: an inexpensive lighting solution for intraoral photodocumentation michael joseph c. david, md1 antonio h. chua, md1,2 1 department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center 2department of otorhinolaryngology head and neck surgery university of the east ramon magsaysay memorial medical center correspondence: michael joseph c. david, md department of ent-hns jose r. reyes memorial medical center san lazaro compound rizal avenue, sta. cruz, manila 1003 philippines phone/fax: (632)743 6921 reprints will not be available from the author. no funding support was received for this study. the authors signed disclosures that they have no proprietary or financial interest with an organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at surgical instrumentation poster contest (1st place) philippine society of otolaryngology head and neck surgery 52nd annual convention, dusit thani hotel, makati city november 29-30, 2008. philipp j otolaryngol head neck surg 2009; 24 (1): 21-26 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 surgical innovations and instrumentation 22 philippine journal of otolaryngology-head and neck surgery valuable documentation in medicolegal cases. digital cameras have become so commonplace nowadays that most physicians own or have one integrated into their cellular phones, portable notebook computers and even personal music players. but not all digital cameras are created equal. proper and formal medical photography requires the clinician to avail of the best, or at least, the optimal camera and lighting setup.3 this includes at least a 35mm-equivalent or a digital single lens reflex (slr) sized camera sensor, macro-capable lenses and specialized lighting such as ringflashes or macro lights for intraoral photography. these provide the best setting for accurate, reproducible and well-detailed documentation, but such equipment may prove too expensive or superfluous for most private practitioners and residents-in-training. point and shoot consumer-grade cameras are the next best option, with most having automated white balancing, exposure and flash intensity controls, capable of taking acceptable gross clinical photographs. special settings such as intraoral photography may prove much of a challenge with these pointand-shoot camera models which usually employ off-center and built-in flashes. the illumination that these flashes provide cannot cover much of the oral cavity and oropharynx adequately. ringflashes and lights, and macro lights (figure 1) have been designed to produce an even and virtually shadowless field of view for intraoral as well as facial photography, much like the head mirror of the otorhinolaryngologist. however, these lighting systems sold at retail prices of p18,000 and above,5 (figure 1a-b) are even more expensive than most point-and-shoot cameras, making them virtually impractical. this paper proposes an inexpensive lighting solution to taking acceptable, reproducible, intraoral photographs – the flexmount ringlight. our objective was to fabricate an inexpensive, reproducible and portable ringlight with a flexible, quickrelease mount attached to point-and-shoot consumer digital cameras that will be acceptable for intraoral photodocumentation. materials and methods materials: (1) 12-white led (light emitting diode) headlight with tilting base (ren guang company, china) (2) flexible monopod with suction cup base and quick release plate (cdr king, china) (3) mini hand drill (möller, germany) (4) perforating and grinding burrs (möller, germany) (5) soldering iron set (newstar-chitlink electrical international, china) (6) round nosed pliers (7) wire cutter/stripper (8) ½ inch wood screw (9) phillips 6x75mm screwdriver procedure: 1. the 12white led headlight with adjustable mount was disassembled (figure 2a-b). 2. the middle four led bulbs and extra resistors were removed as shown (figures 3a-b). this particular headlight featured three colored running leds around the sides. these were removed as well. note the circular configuration of the etching in the circuit board. this allowed for a 33-mm hole to be cut into the middle of the board within the innermost main concentric etching using the mini drill (figure 4). 3. corresponding holes were also cut into the front reflector component and the back plate (figure 5a). 4. the wires and one 2.5 ohm resistor were resoldered (figure 5b, appendix a) to form a parallel circuit with the power supply (3 1.5v aa batteries). 5. the headlight was then reassembled. 6. the suction cup was removed from the flexible monopod. the plastic base of the monopod was attached, using a screw and rubber washers, onto the base of the headlight as shown (figures 6a-b). device operation: to use the flexmount ringlight, 3 1.5v aa batteries should be loaded into the battery chamber. a point-and-shoot camera with macro shooting capabilities is mounted on the quick-release plate (figure 7a-b). the flexible arm is bent back to position the camera at the back of ringlight. the camera is set on shooting mode. with the aid of the lcd (liquid crystal display) viewer, the lens barrel is inserted into the ring and the zoom is adjusted to remove any vignetting caused by parts of the flexmount ringlight within the angle of view of the camera. recommended shooting settings: macro mode, flash off, auto iso, center af (autofocus), image stabilization/vibration reduction on, and smallest aperture (high f number) if available. the aperture and exposure settings are adjusted as needed. when taking intraoral pictures, the cameraflexmount ringlight setup is positioned at a minimum working distance of 6cm from the patient’s face. the maximum working distance is determined by the camera’s macro focus range. the average point-and-shoot usually has macro focus range within 10-50 cm from the subject. the camera is held by the right hand while the left hand holds the flexmount arm like a gun as demonstrated in figures 8a-c. when using smaller compact cameras, e.g. canon’s ixus or sony’s cybershot models, the flexmount ringlight may be used without attaching the camera on the monopod. philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 surgical innovations and instrumentation philippine journal of otolaryngology-head and neck surgery 23 figure 1a. examples of commercially available macroflash figure 2a. 12-led bulb headlight with adjustable mount figure 3b. circuit board stripped of unneeded components figure 1b. ringflash figure 2 b. components of disassembled headlight figure 3a. closeup view of the circuit board figure 5a. corresponding 33mm hole cut into the front reflector figure 4. a 33mm hole cut was into the circuit board philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 surgical innovations and instrumentation 24 philippine journal of otolaryngology-head and neck surgery figure 5b. resoldering of wires and resistor on the circuit board figure 6a. flexible monopod with suction cup base figure 6c. completed fleximount ringlight figure 6b. suction cup removed, and monopod base attached to headlight figure 7a. quick release plate (arrow) figure 7b. camera with attached quick release plate (circle) results the flexmount ringlight system weighed approximately 150 grams excluding batteries and camera. total production cost was p270 (appendix b). total assembly time was two hours. the flexmount ringlight was tested on a 6 megapixel pointand-shoot digital camera (canon powershot s3-is) with macro shooting capability. comparisons of intraoral photographs taken using the camera’s built-in flash and using the flexmount ringlight are shown below (figure 9). discussion due to the more superior position of the built-in flash in relation to the line of sight of the lens, intraoral pictures taken without the flexmount ringlight caused the upper lip and teeth to produce a shaded portion over the palate. the flexmount ringlight delivered a constant and even white illumination of the oral cavity and oropharynx at working distances more than 5cm from the subject in focus. the flexmount ringlight should not be used at shorter distances as the beams of the individual leds become more focused, producing distinct circles of light (figure 10a.) philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 surgical innovations and instrumentation philippine journal of otolaryngology-head and neck surgery 25 as leds emit light contained in a limited color spectrum, it is to be expected that pictures will appear as if taken in unnatural colors. appropriate white balance adjustments (flash or daylight setting in the test camera) may be needed to get the desired color temperature and hue. maintaining even lighting from an array of leds is crucial. this was achieved by inserting a 2.5 ohm resistor in the circuit. this resulted in a constant light intensity and prevents the led bulbs from burning out6. as indicated in the original packaging, the headlight used in this project was rated to run for up to 50 hours on three 1.5v aa alkaline batteries (3v total), and the leds used have a lifespan of 100,000 hours. we expect the modified headlight with 4 less leds to light to run for longer periods. figures 8 a-c. handling of a point-and-shoot camera (canon powershot s3-is) with attached flexmount ringlight figure 9b. taken with conventional ringflash figure 9a. intraoral photograph taken with the built-in flash figure 9c. taken with flexmount ringlight philippine journal of otolaryngology-head and neck surgery vol. 24 no. 1 january – june 2009 surgical innovations and instrumentation 26 philippine journal of otolaryngology-head and neck surgery figure 10a. light produced by the ringlight at a working distance of 5 cm figure 10b light produced at a working distance of 10 cm appendix a circuit board schematics of the flexmount ringlight appendix b materials used and costing for the fabrication of the flexmount ringlight materials used* item 12-white led (light emitting diode) headlight with adjustable mount flexible monopod with suction cup base and quick release plate miscellaneous items: solder wire, solder flux, wood screw total cost excluding batteries quantity 1 pc 1 pc cost p 190.00 p 80.00 p 10.00 p 280.00 references 1. rogers b. the first preand postoperative photographs of plastic and reconstructive surgery: contributions of gurdon buck (1807–1877). aesthetic plast surg 1991; 15(1):19-33. 2. haynes ds moore ba roland p olson gt. digital microphotography: a simple solution. laryngoscope2003; 113(5): 915-919. 3. yavuzer r, stefani s, jackson i, guidelines for standard photography in plastic surgery. ann plast surg 2001; 46(3): 293-300. 4. torrecillas d, soler-gonzález j, rodríguez-rosich a. digital photography in the generalist’s ofce. can med assoc j 2006; 175(12): 1519-1521. 5. dp online store [homepage on the internet]. manila: dp online store; c2008 [cited 2008 nov 10]. available from: http://dponline.com.ph/ 6. gibilisco s, teach yourself electricity and electronics. 4th ed, new york: mcgraw hill; 2006. the flexmount ringlight also resulted in sharper pictures. the constant and even illumination it provides assisted the camera’s autofocus system in getting accurate focusing when taking intraoral pictures. commercially available cameras usually have focus assist lamps that may be too laterally located for them to be of use in narrow fields such as the oral cavity. by providing bright lighting, the flexmount ringlight allowed the camera to use smaller apertures and faster shutter speeds, thus allowing more elements to be put into focus and minimizing motion blur as well. the flexmount ringlight is an inexpensive, easy-to-assemble and portable ringlight attached to point-and-shoot consumer digital cameras. its constant and even illumination resulted in reproducible, sharp, shadowless photographs of the oral cavity and oropharynx. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the usability of a smartphone application (imagemeter) by ent surgeons for pre-operative photographic analysis of facial angles for rhinoplasty using the use questionnaire. methods: design: post-test only non-experimental evaluation study setting: tertiary private training hospital outpatient clinic participants: twenty-five (25) ent residents and consultants results: of 45 ent surgeons invited, 25 ent residents and consultants (16 males, 9 females) aged 28 to 52 years old (mean age 36 years old) trialed the use of the image meter application in measuring the naso-facial, naso-frontal and naso-labial angles of pre-selected lateral images of 10 volunteers and completed our survey. the usability of the application was measured using the use questionnaire, through usefulness (cronbach a = 0.99), ease of use (a = 0.85), ease of learning (a = 0.66) and satisfaction (a= 0.69). on a scale of 1-7, results showed that for the ent surgeons surveyed, the app was generally useful (m = 6.10, sd = 0.73), easy to use (m = 6.13, sd = 0.63), easy to learn (m = 6.31, sd = 0.62) and satisfactory (m = 6.06, sd = 0.7). as for overall outcome, the ent surgeons found the application usable (m = 6.15, sd = 0.11). conclusion: when applied to human facial analysis, the imagemeter measurement of angles feature may be a usable tool for ent surgeons in the pre-operative evaluation of patients undergoing rhinoplasty. based on use questionnaire responses, it is easy to use, quick to learn, useful and satisfactory in the preoperative measurement of facial angles. keywords: imagemeter; photography; esthetic; rhinoplasty; face; anthropometry the human nose is the most prominent and central feature of the face, and rhinoplasty is thus considered one of the most challenging facial plastic surgical procedures, requiring meticulous pre-operative analysis and understanding of the patient’s needs and expectations.1-3 preoperative planning, has evolved over the years and includes manual anthropometry wherein usability of a smartphone application for pre-operative facial analysis for rhinoplasty among ent surgeons paula francezca c. padua, md1 arik paolo isaiah c. dela cruz, m.d.1,2 renato c. pascual, jr, md1 steve marlo m. cambe, md1 1 department of otolaryngology head and neck surgery st. luke’s medical center, q.c. 279 e. rodriguez sr. blvd. quezon city, philippines 2 department of otolaryngology head and neck surgery st. gabriel hospital dr. rafael s. tumbukon memorial hospital aklan, philippines correspondence: dr. paula francezca c. padua department of otolaryngology head and neck surgery st. luke’s medical center 279 e. rodriguez ave., quezon city 1102 philippines phone: (632) 727 5543 fax: (632) 723 1199 (h) email address: pfcpadua@gmail.com the authors declare that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the 10th international symposium on rhinosinusitis and nasal polyps held in conjunction with the 61st pso-hns annual convention in manila hotel, manila, november 29-december1, 2017, and the 10th international academic conference in otology, rhinology and laryngology in fairmont hotel, makati, march 1-3, 2018. philipp j otolaryngol head neck surg 2019; 34 (1): 38-43 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery original articles surface measurements are taken with calipers and flexible measuring tape, and 2d photography which entails taking photos of patients with their head positioned in special orientation with their frankfort plane horizontal to the ground.4 recently, digital photography has made photographic documentation easier more effective and economical when compared to conventional photography.5 free, downloadable smartphone applications have made an impact on the practice of medicine and have become available to measure angles in these photos. 6-10 the imagemeter is a free, downloadable smartphone application, originally designed for home/office construction and planning that lets you measure dimensions, angles and areas in your photos with ease.11 however, to the best of our knowledge based on an extensive search of pubmed (medline), embase, herdin and google scholar using the search terms “rhinoplasty,” “facial angles” “photography and facial esthetics,” “ease of use,” it has not been used to measure facial angles for rhinoplasty evaluation. this study aimed to determine the usability of the imagemeter smartphone application by ent surgeons for pre-operative photographic analysis of facial angles for rhinoplasty using the use questionnaire. methods with institutional review committee approval, this post-test only non-experimental evaluation study was conducted among ent surgeons and trainees at the outpatient clinic of the st. luke’s medical center quezon city from november 6 10, 2017. after obtaining informed consent, respondents trialed use of the image meter on pre-determined lateral photographs of patient volunteers and subsequently responded to questionnaires on the usability of a smartphone-based application for measurement of facial angles. the imagemeter version 2.19.1 (dirk farin kronenstr.49b 70174 stuttgart, germany) application for facial angle analysis was used in this survey. standard photographic lateral views of ten (10) patient volunteers stored in the researcher’s android smartphone (samsung galaxy s7 edge, sm-g935f, samsung electronics, new jersey, usa) were retrieved. (figure 1) standard views had been taken at the volunteer’s eye level at a distance of 2 feet with the volunteer being exactly 90° from the lens using the frankfort horizontal line as a guide (except for the basal view) against a solid blue background. of the standardized views for photographing patients undergoing rhinoplasty (anteroposterior, right and left lateral, right and left oblique and basal), only the left lateral views were utilized for purposes of this study with written informed consent for use of their photos in full for the study and for subsequent publication provided by all ten volunteers. for each lateral image, the following facial landmarks were identified (figure 2): nasofacial angle: nasion, pronasale, pogonion nasofrontal angle: glabella, pronasale, nasion nasolabial angle: columella, upper lip general introduction to the application and demonstration on its use was conducted at the outpatient clinic by one researcher using a single narrative. each surgeon or trainee participated individually. the respondents were informed of the basic services offered by the application, the tasks that may be performed and how users can benefit from the application in general. using the application’s angle option, each participant placed a point on and connected the facial landmarks per facial angle measured. the landmarks were adjusted as the respondent pleased, and the angle generated automatically adjusted accordingly. a single researcher ensured that each respondent could use the app correctly allowing several attempts before completing the trial on the 10 stored photos. after completing the trial on the 10 stored photos, each respondent was asked to answer the use questionnaire with no time limit to complete the survey. completion of the introduction, demonstration, trial of the app and answering the questionnaire was performed individually upon the availability of the researcher and participant. pre-testing of the questionnaire was not performed. the use questionnaire (figure 3) is a free, standardized tool to determine the usability of software, hardware, services and user support materials using 4 domains ease of use, ease of learning, and satisfaction -as dependent variables.12 it contains 30 questions organized under the headings ease of use (8 items), satisfaction (11 items), usefulness (4 items) and ease of learning (7 items) each item followed by a seven-point likert scale ranging from “strongly disagree” to “strongly agree,” plus a “not applicable” (na) option. data analysis data on respondents and their responses was compiled and analyzed using microsoft® excel for mac v. 15.22 (160506) (microsoft corp., redmond, wa, usa). descriptive statistics (mean and standard deviation) were computed for respondent data. internal consistency was computed for the use questionnaire responses using cronbach’s a. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery original articles results of 45 ent surgeons invited to participate, there were 25 respondents (16 males, 9 females), aged 28 to 52 years old (mean age 36 years old) who participated and completed our survey. there were 4 junior residents, 5 senior residents, 11 junior consultants, 3 mid-level consultants, and 2 senior consultants. the respondents had difficulty on adjusting the landmarks on the first few tries but were able to learn quickly. the perceived usability of the application was measured using the use questionnaire, through usefulness (cronbach a = 0.99), ease of use (a = 0.85), ease of learning (a = 0.66), and satisfaction (a= 0.69) on a scale from1 to 7. results showed that for the respondents, the app was generally useful (m = 6.10, sd = 0.73), easy to use (m = 6.13, sd = 0.63), easy to learn (m = 6.31, sd = 0.62) and satisfactory (m = 6.06, sd = 0.7). (figures 4 – 7) as for overall outcome, the ent surgeons found the application usable (m = 6.15, sd = 0.11). the answers of the participants showed internal consistency with no significant difference with regards to age and gender. figure 1. imagemeter screen shot using a photo of one of our test patients, displaying the interactive options for analysis. (participant photo published in full with permission). figure 2. facial angles measured a. nasofacial angle b. nasofrontal angle c. nasolabial angle. using the application’s angle option, the respondent points and connects the facial landmarks per facial angle measured. the landmarks were adjusted as the respondent pleased and the angle generated automatically adjusted accordingly. (photos of participants published in full with permission) a b c philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery original articles figure 3. use questionnaire. (reproduced with permission from lund am. measuring usability with the use questionnaire. stc usability sig newsletter. 2001; 8(2): 3-6.) please rate your agreement with these statements. • try to respond to all the items. • for items that are not applicable, use: na list the most negative and positive aspects at the end of the questionnaire 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 na na na na usefulness 1. it helps me be more effective. 2. it helps me be more productive. 3. it is useful. 4. it gives me more control over the activities in my life. 5. it makes the things i want to accomplish easier to get done. 6. it saves me time when i use it. 7. it meets my needs. 8. it does everything i would expect it to do. ease of use 1. it is easy to use. 2. it is simple to use. 3. it is user friendly. 4. it requires the fewest steps possible to accomplish what i want to do with it. 5. it is flexible. 6. using it is effortless. 7. i can use it without written instructions. 8. i don’t notice any inconsistencies as i use it. 9. both occasional and regular users would like it. 10. i can recover from mistakes quickly and easily. 11. i can use it successfully every time. ease of learning 1. i learned to use it quickly. 2. i easily remember how to use it. 3. it is easy to learn how to use it. 4. i quickly became skillful with it. satisfaction 1. i am satisfied with it. 2. i would recommend it to a friend. 3. it is fun to use. 4. it works the way i want it to work. 5. it is wonderful. 6. i feel i need to have it. 7. it is pleasant to use. strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree disagree strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree agree use of image meter application for rhinoplasty based on: lund, a.m. (2001) measuring usability with the use questionnaire, stc usability sig newsletter, 8:2. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery original articles figure 4. frequency of likert scale score responses for questions on usefulness. figure 6. frequency of likert scale score responses on ease of learning. figure 7. frequency of likert scale score responses on satisfaction.figure 5. frequency of likert scale score responses on ease of use. discussion the international standards organization (1994) defined usability as “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use”.13 the findings of this study suggest that the imagemeter has high usability with regards to its ease of use, satisfaction, usefulness and ease of learning. although software tools for facial analysis and measuring facial angles have been developed,4,14,15 our review of literature yielded no results on usability testing for these programs. in addition, we found no published studies on the use of the imagemeter application for facial analysis. moreover, the available software for measuring facial angles are desktop applications, making imagemeter very attractive, considering its convenience and portability, being a mobile phone application. although this study yielded a high usability rating by the respondents, the use of the app for facial analysis still poses a great number of limitations. first the analysis was subject to the inherent restrictions of the study design, including the lack of a control population, non-randomization and inability to control for confounding variables. secondly there are no available studies on the accuracy and reproducibility of the measurements taken using the app, restricting the authors to make any comparisons. in addition, profile photograph analysis alone has many limitations including the type of camera and lens used, patient positioning, lighting, lens to subject distance, etc. furthermore, while the answers of the participants philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery original articles acknowledgements the authors would like to acknowledge the participation and cooperation of the st. luke’s medical center, department of ent-hns residents and consultants for their patience in learning the app and answering the questionnaire, as well as the out-patient clinic staff for allowing the authors to perform the study at the clinic. references 1. sheckter cc, kane jt, minneti m, garner w, sullivan m, talving p, et al. incorporation of fresh tissue surgical simulation into plastic surgery education: maximizing extraclinical surgical experience. j surg educ. 2013 jul-aug; 70(4): 466-74. doi: 10.1016/j.jsurg.2013.02.008; pmid: 23725934. 2. chivers qj, ahmad j, lista f, warren rj, arkoubi ay, mahabir rc, et al. cosmetic surgery training in canadian plastic surgery residencies: are we training competent surgeons? aesthet surg j. 2013 jan; 33(1): 160-165. doi: 10.1177/1090820x12467794; pmid: 23169820. 3. oni g, ahmad j, zins je, kenkel jm. cosmetic surgery training plastic surgery residency programs in the united states: how have we progressed in the last three years? aesthet surg j. 2011 may; 31(4), 445-455. doi: 10.1177/1090820x11404551; pmid: 21551438. 4. ozkul t, ozkul h, akhtar r, al-kaabi f, jumaia t. a software tool for measurement of facial parameters. the open chemical and biomedical methods journal. 2009; 2(1): 69-74. doi: 10.2174/1875038900902010069. 5. dibernardo be, adams rl, krause j, fiorillo ma, gherardini g. photographic standards in plastic surgery. plast reconstr surg. 1998 aug; 102(2): 559-568. pmid: 9703100. 6. ventola cl. mobile devices and apps for health care professionals: uses and benefits. p t. 2014 may; 39(5): 356-364. pmid: 24883008 pmcid: pmc4029126. 7. aungst td. medical applications for pharmacists using mobile devices. ann pharmacother. 2013 jul-aug. 47(7-8). doi: 10.1345/aph.1s035; pmid: 23821609. 8. divali p, camosso-stefinovic j, baker r. use of personal digital assistants in clinical decision. making by health care professionals: a systematic review. health informatics j. 2013 mar; 19(1), 16-28. doi: 10.1177/1460458212446761; pmid: 23486823. 9. murfin m. know your apps: an evidence-based approach to evaluation of mobile clinical applications. j physician assist educ. 2013; 24(3), 38-40. pmid: 24261171. 10. mickan s, tilson jk, atherton h, roberts nw, heneghan c. evidence of effectiveness of health care professionals using handheld computers: a scoping review of systematic research. j med internet res. 2013 oct; 15(10), e212. doi: 10.2196/jmir.2530; pmid: 24165786 pmcid: pmc3841346. 11. farin d. imagemeter photo measure apps on google play [internet]. 2017[cited 2019 feb 3]. retrieved from google play: https://play.google.com/store/apps/details?id=de.dirkfarin. imagemeter&hl=en 12. lund am. measuring usability with the use questionnaire. stc usability sig newsletter; 2001; 8(2): 3-6. 13. international standards organization. ergonomic requirements for office work with visual display terminals. part 11: guidance on usability (iso dis 9241-11). london: international standards organization;1994. 14. loveday oe., hakeem f b, lekara d t. a software tool for facial analysis. research journal of applied sciences, engineering and technology.2012;4(6): 551-556. 15. tollefson tt, sykes jm. computer imaging software for profile photograph analysis. archives of facial plastic surgery 2007 mar-apr; 9(2): 113-119. doi: 10.1001/archfaci.9.2.113; pmid: 17372065. 16. interaction-design.org, what is usability? n.d. [cited 2017 oct]. available from: https://www. interaction-design.org/literature/topics/usability. showed internal consistency with no significant difference with regards to age and gender, it is still important to note that software literacy and familiarity with the use of mobile gadgets may contribute significantly to the success in the usage of the app. finally, data on the respondents’ ability to use the app including the correct identification of points and connection of points and accuracy of the angles generated were not measured, preventing the authors to make conclusions on the correctness of the respondents’ use of the app. it is therefore recommended that further studies on the accuracy and reproducibility of results on taking facial angle measurements using this app be done in a controlled and standardized manner. moreover, the feature used from this application which is the measurement of angles is just one of its many possible uses in pre-operative evaluation. we recommend that the other features of this application be explored for possible use in other types of procedures/surgeries. a usable product seeks to achieve three main outcomes: (1) the product is easy for users to become familiar with and competent in using it during the first contact, (2) the product is easy for users to achieve their objective through using it, and (3) the product is easy for users to recall the user interface and how to use it on later visits.16 our results showed that for the respondents, the app was easy to use, easy to learn, and satisfactory, therefore usable. in conclusion, our results suggest that when applied to human facial analysis, the imagemeter may be a usable tool for ent surgeons in the pre-operative evaluation of patients undergoing rhinoplasty. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 6564 philippine journal of otolaryngology-head and neck surgery featured grand rounds whether benign or malignant, laryngeal and neck masses may involve the upper airway and obstruct breathing. while surgically-resectable malignancies are generally extirpated with adequate margins of normal tissue, benign lesions are usually excised conservatively. however, even benign masses may behave malignantly, necessitating more aggressive surgical resection. we present one such case. case report a 35-year-old man from cotabato city consulted due to difficulty of breathing. he had a sixyear history of progressively enlarging anterior neck mass with intermittent dyspnea, foreign body sensation, progressive dysphagia and hoarseness over the last three months. physical examination revealed a well-defined, 5 x 6 cm smooth, firm, non-tender anterior neck mass that moved with deglutition. rigid endoscopy showed a right supraglottic mass with bulging of the right glottic and subglottic area with a less than 10% airway opening. (figure 1a) both arytenoids were visibly mobile but glottic closure was impaired. (figure 1b) tracheostomy and suspension laryngoscopy with biopsy yielded inconclusive results (fibromuscular tissue) and fine needle aspiration cytology (fnac) of the anterior neck mass only revealed blood and colloid. contrast computed tomography of the neck showed a well-marginated, hypodense, thickwalled, heterogeneously enhancing mass in the right laryngeal fossa measuring 2.86 x 1.78 cm with a larger extension anteriorly measuring 4.66 x 2.52 cm. effacement of the epiglottis and aryepiglottic fold was noted. the hyoid and thyroid cartilage were intact and the thyroid gland was normal. (figure 2a, b) because of inconclusive histopathological and cytological results, an incision biopsy of the anterior neck mass was performed. histopathological evaluation revealed spindle cell mesenchymal proliferation, and immunohistochemical stains showed positive immunoreactivity for cd34, with a weakly positive s-100 and negative sma, favoring a solitary fibrous tumor. (figure 3) solitary fibrous tumor of the larynx and anterior neck correspondence: dr. guinevere s. pabayos ospital ng maynila medical center department of otolaryngology head and neck surgery roxas blvd., cor. quirino blvd. malate, manila 1000 philippines phone: (63) 524 6061 local 220 fax: (63) 523 6681 email: guive_16@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. guinevere s. pabayos, md armando m. chiong jr., md department of otolaryngology head and neck surgery ospital ng maynila medical center philipp j otolaryngol head neck surg 2019; 34 (1): 64-67 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 6564 philippine journal of otolaryngology-head and neck surgery featured grand rounds figure 1 a. well-defined mass in the right supraglottis with bulge in the glottic and subglottic area causing airway obstruction and less than 10% airway opening; and b. impaired glottic closure on adduction with bilaterally mobile arytenoids. a b figure 3. hematoxylin-eosin stained histopathologic slide of anterior neck incision biopsy specimen, high power view, 40x showing spindle-cells arranged in a haphazard pattern. (hematoxylin – eosin , 40x) figure 2 a. axial and b. sagittal contrast computed tomography scans reveal a well-marginated, hypodense, thick-walled heterogeneously enhancing mass in the right laryngeal fossa with large extension anteriorly. note resulting narrowing of the laryngeal airway by about 70%. a b philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 6766 philippine journal of otolaryngology-head and neck surgery featured grand rounds discussion solitary fibrous tumor is a rare spindle-cell neoplasm, first mentioned and regarded solely as a pleural tumor.1 the general incidence of sft occurs with equal sexual predilection and all age groups are equally affected.2 extrathroracic sfts have also been documented. only 6% of sft develop in the head and neck and the oral cavity was reported to be the most commonly affected area.3 solitary fibrous tumors of the upper respiratory tract comprise <0.1% of all sfts.4 cases of sft have also been documented in the paranasal sinuses, nasopharynx and nasal cavity.5 there is one reported case of anterior neck sft in the thyroid7 and 2 perithyroidal cases6 although it rarely affects the larynx.6 laryngeal sfts have a male over female predominance.7 the subsites frequently involved are the epiglottis, ventricular fold, aryepiglottic fold, vocal fold or the commissure.7 the clinical presentation of laryngeal sft’s depends on the area involved similar to laryngeal tumors. those involving the supraglottis present with foreign body sensation, “hot potato” voice,6 and dysphagia.8 glottic involvement presents with hoarseness and in late stages (and as is the case with subglottic tumors), there is difficulty of breathing due to obstruction.8 solitary fibrous tumor is generally benign and can be seen as a painless mass that is slow-growing ranging from months to years.1,2,9,10 it is difficult to diagnose clinically and other soft tissue tumors (sarcoma, benign fibrous histiocytoma, schwannoma, neurofibroma and fibroma) should be included as differential diagnosis.2,9,11,12 the computed tomography scan in our case showed a well-defined heterogeneously enhancing lesion, with effacement of the arytenoids and epiglottis, displaying the features of a benign soft tissue tumor. despite extension of the lesion to adjacent structures of the anterior neck, the thyroid and muscles were not invaded and there were no lytic changes of the thyroid cartilage. a benign lesion was highly regarded but a malignant lesion could not be overlooked. it was possible that continuous expansion of the lesion caused the cricothyroid cartilage to efface and allow access of the mass into the right laryngeal mucosa, causing expansion into the inlet and subsequent airway obstruction. on computed tomography scan, benign sft presents as a dense, welldefined enhancing lesion with expansile growth pattern and no bony erosion or lytic changes, as may be true for other benign tumors of the head and neck-and other soft tissue tumors could not be easily ruled out.2,11 solitary fibrous tumor is an expansile lesion that can lead to remodeling of adjacent bony structures2 and the features of a benign sft on bone window can be misleading and lead us to disregard any consideration of malignancy.2 a malignant sft can appear to have benign features on ct scan such as remodeling and only a small foci of bone destruction or lytic changes may be overlooked.2 furthermore, absence of bone remodeling does not entirely rule out malignancy.2 a magnetic resonance imaging can also be done for inconclusive ct scan findings. this will show a densely well-circumscribed mass with expansile character and low to moderate enhancement on both t1 and t2-weighted imaging.12 however, we did not perform an mri in this case. gross pathological description of usual sft is a whitish to grayish, smooth, well-defined lesion.2 histological description shows wide variability of cellularity composed of bland, round to spindle-shaped cells with scanty cytoplasm, and is often associated with stromal hyalinization.4,13 the cells are arranged in a haphazard manner, often in a “patternless pattern,” no specific cellular pattern or variable cellular pattern with no cytologic atypia. 2,4,5,10,14-16 it has collagen bundles with interlaced thin-walled vascular spaces.1,4,11,16 the vascularity of sft can form a hemangiopericytoma-like pattern hence, it was previously considered a component of hemangiopericytoma.2,5,10,11,13,17 malignant sfts have also been reported and histologically display malignant differentiation, such as hypercellularity, cytologic atypia, increased nuclear to cytoplasmic ratio, and mitotically active cells of more than 4 mitosis per 10 hpf.1,2,9,13,14,18,19 there can also be note of tumor necrosis or infiltrative margins in cut sections. these were not observed in our case. however, the histologic description of benign sft could also be used to describe other soft tissue tumors, hence, there is no definitive histopathologic picture that may clearly differentiate it from other benign mesenchymal tumors.1 immunohistochemical reactivity stains are essential to identify sft from other benign mesenchymal tumor. cd34 is a hematopoietic stem cell and progenitor cell marker20 that is a sensitive marker for sfts.5 however, it is also a marker for other mesenchymal stromal cells and epithelial tumors and is a non-specific marker for sft.5 conversely, 95% of sfts consistently stain strongly for cd34.5,19 there are other reported cases of diagnosed sft that also have positive reactivity to bcl-2 markers, and commonly lack reactivity for desmin, cytokeratin, and generally negative for actin/smooth muscle actin (sma).1 this could help in the histological differentiation of other soft tissue tumors such as benign fibrous histiocytoma, fibroma and neurogenic tumors.1 in our case, the tumor had a strong reactivity to cd34 and also weak reactivity to sma. an intensely positive cd34 immunostaining favors a diagnosis of sft since around 85-100% of sft is reactive to cd34.13 however, a positive reactivity to cd34 could be a misleading diagnosis since other soft tissue tumors may be positive for both cd34 and sma. leiomyosarcoma and schwannoma could also have weakly positive reactivity to cd34 but should also be noted to have a strong reactivity to sma. furthermore, sft may have a consistently positive immunoreactivity to stat6 immunohistochemistry stains which may philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 6766 philippine journal of otolaryngology-head and neck surgery featured grand rounds references 1. alawi f, stratton d, freedman pd. solitary fibrous tumor of the oral soft tissues: a clinicopathologic and immunohistochemical study of 16 cases. am j surg pathol. 2001 jul; 25(7): 900-910. pmid: 11420461. 2. ganly i, patel sg, stambuk he, coleman m, ghossein r, carlson d, et al. solitary fibrous tumor of the head and neck: a clinicopathologic and radiologic review. arch otolaryngol head neck surg. 2006 may; 132(5): 517-525. doi: 10.1001/archotol.132.5.517; pmid: 16702568. 3. girardi f, marinez b, girardi m. solitary fibrous tumor of the larynx: report of two new cases. j bras patol med lab. 2014 may-jun; 50(3). doi: 10.5935/1676-2444.20140020. 4. barnes l., everson jw, reichart p, sidransky d. (eds.): world health organization: classification of tumors. pathology and genetics of head and neck tumors. 2005. international agency for research on cancer (iarc) press: lyon 2005. p45. 5. alobid i, alos l, maldonado m, menendez lm, bernal-sprekelsen m. laryngeal solitary fibrous tumor treated with co 2 laser excision: case report. eur arch otorhinolaryngol. 2005 apr; 262(4): 286-288. doi: 10.1007/s00405-004-0805-1; pmid: 15170575. 6. villaschi s, macciomei mc. solitary fibrous tumor of the perithyroid soft tissue: report of a case simulating a thyroid nodule. ann ital chir. 1996 jan-feb; 67 (1): 89-91. pmid: 8712624. 7. thompson l, karamurzin y, li-cheng m, kim j. solitary fibrous tumor of the larynx. head and neck pathol. (2008) 2:67-74. doi 10.1007/s12105-008-0044-7 8. sperry s, weinstein g, lacourreye o. conservation laryngeal surgery. in: flint p, haughey b, lund v, niparko j, robbins t, thomas, r, lesperance m (eds). cummings otolaryngology-head and neck surgery. sixth edition. saunders (philadelphia). 2015. p. 1674-1698. 9. bruzzone a, varaldo m, ferrarazzo c, tunesi g, mencoboni m. solitary fibrous tumor. rare tumors. 2010; 2:e64. 10. gold js, antonescu cr, hajdu c, ferrone cr, hussain m, lewis jj, et al. clinicopathologic correlates of solitary fibrous tumors. cancer. 2002 feb 15; 94(4): 1057-68. doi 10.1002/ cncr.10328; pmid: 11920476. 11. hasegawa t, hirose t, seki k, yang p, sano t. solitary fibrous tumor of the soft tissue: an immunohistochemical and ultrastructural study. am j clin pathol. 1996 sep; 106(3):325-31. pmid: 8816589. 12. kunzel j, hainz m, ziebart t, pitz s, ihler f, strieth s, et al. head and neck solitary fibrous tumors: a rare and challenging entity. eur arch otorhinolaryngol. 2016 jun; 273(6): 1589-1598. doi: 10.1007/s00405-015-3670-1; pmid: 26026772. 13. geramizadeh b, marzban m, churg a.  role of immunohistochemistry in the diagnosis of solitary fibrous tumor, a review. iran j pathol. 2016 summer; 11(3):195-203. pmid: 27799967 pmcid: pmc507945 14. devito n, henderson e, han g, reed d, bui mm, lavey r, et al. clinical characteristics and outcomes for solitary fibrous tumor (sft): a single center experience. plos one. 2015 oct; 10 (10): e0140362. doi: 10.1371/journal.pone.0140362; pmid: 26469269 pmcid: pmc4607370. 15. fletcher cd. distinctive soft tissue tumors of the head and neck. mod pathol. 2002 mar; 15(3):324-330. doi: 10.1038/modpathol.3880526; pmid: 11904345. 16. topaloglu o, ucan b, demirci t, sayki am, saylam g, onder e, et al. solitary fibrous tumor of neck mimicking cold thyroid nodule in 99m tc thyroid scintigraphy. case rep endocrinol. 2013; 2013: 805745. doi: 10.1155/2013/805745; pmid: 24194989 pmcid: pmc3806406. 17. fletcher cd, path frc. distinctive soft tissue tumors of the head and neck. mod pathol 2002 mar. 15(3): 324-330. doi: 10.1038/modpathol.3880526; pmid: 11904345. 18. dotto je, ahrens w, lesnik dj, kowalski d, sasaki c, flynn s. solitary fibrous tumor of the larynx: a case report and review of literature. arch pathol lab med. 2006 feb; 130(2):213-216. doi: 10.1043/1543-2165(2006)130[213:sftotl]2.0.co;2; pmid: 16454566. 19. doyle la, vivero m, fletcher cd, mertens f, hornick jl. nuclear expression of stat6 distinguishes solitary fibrous tumor from histologic mimics. mod pathol. 2014 mar; 27(3): 390395. doi: 10.1038/modpathol.2013.164; pmid: 24030747. 20. sidney le, branch mj, dunphy se, dua hs, hopkinson a. concise review: evidence for cd34 as a common marker for diverse progenitors. stem cells. 2014 jun; 32(6): 1380–1389. doi: 10.1002/ stem.1661; pmid: 24497003 pmcid: pmc4260088. 21. robinson dr, wu ym, kalyana-sundaram s, cao x, lonigro rj, sung ys, et al. identification of recurrent nab2-stat6 gene fusions in solitary fibrous tumor. nat genet. 2013 feb; 45(2): 180185. doi: 10.1038/ng.2509; pmid: 23313952 pmcid: pmc3654808. 22. langman g. solitary fibrous tumor: a pathological enigma and clinical dilemma. j thorac dis. 2011 jun; 3(2): 86-87. doi: 10.3978/j.issn.2072-1439.2011.03.04; pmid: 22263070 pmcid: pmc3256512. be helpful to use as a marker for inconclusive sft.16 the etiology of sft is still unknown although there is evidence of recurrent nab2-stat6 gene fusions integrative sequence due to translocations of the stat6 gene to nab2 in sft’s.21 expression of this fusion causes the activation of egr1 gene, a repressor of transcription pathways which activates the mitogenic pathways of neoplasia.21 detection of nab2-stat6 fusions in tumors is strongly associated in the proliferation of sft’s and is an important marker to be considered for an inconclusive immunohistochemical staining result.21 about 87% of sft’s are benign and conservative treatment can be considered. the use of conservative surgical procedures such as co2 laser excision could be a treatment option for laryngeal sft and there was no complication or recurrence reported.5 however, it is important to consider that this type of surgical excision will largely depend on the size of the lesion. furthermore, since studies have shown that both benign and malignant sft have a relatively high local recurrences of 21% to 47%, the surgical treatment that should be considered includes radical resection or wide resection with clear margins.14 a patient diagnosed with sft of the larynx may need total or partial laryngectomy depending on the affected subsites of the larynx. for malignant sft that underwent complete resection with clear margins, the reported 10-year survival rate ranges from 54% to 89%.14 the use of adjuvant chemotherapy is not recommended since most patients will not be responsive.14, 21 conversely, radiotherapy can be used for local recurrence or for local control, as well as an option for unresectable tumor although it does not affect overall survival rate.14 the incision biopsy result of our patient was considered to be benign solitary fibrous tumor, however, malignancy was still not completely ruled out. since the mass had already encompassed the laryngeal inlet causing obstruction, wide excision (total laryngectomy) is recommended. frequent postoperative follow-up will be necessary to monitor spread to, or recurrence in adjacent subsites. the use of radiotherapy may be considered if the final histopathologic result suggests malignancy. 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports abstract objectives: in this article, we report on two unusual cases of advanced nasopharyngeal carcinoma (npc) with distant cutaneous metastases. methods: design: case report setting: tertiary referral center patients: two results: two patients with advanced npc developed multiple nodular skin metastases, one after completing radiotherapy and another during concurrent chemo-radiotherapy. biopsies of these skin lesions confirmed metastatic npc and both patients succumbed to the disease. conclusion: nasopharyngeal carcinoma with skin metastases carries a very poor prognosis. early detection, diagnosis and treatment are still the best management strategy for nasopharyngeal carcinoma. keywords: nasopharynx, nasopharyngeal carcinoma, skin metastases, cutaneous metastases nasopharyngeal carcinoma (npc) has a higher risk of distant metastases than other malignant head and neck tumours. together with lymph node involvement, the high rate of proliferation could account for its propensity to develop distant metastases. the incidence of isolated distant metastasis is high, globally at 18%, and the risk increases with the stage of the disease (47% for stage ivb), demonstrating that locoregional treatment alone for locally advanced disease is inadequate.1 the lung is the most common site of metastasis, followed by bone and the liver.2 however, skin metastases in npc patients are extremely rare. to our knowledge, there are only a few cases reported worldwide, including four cases among the 1583 npc patients with npc diagnosed at the prince of wales hospital, hong kong over a 7-year period.3 the first case of npc skin metastasis was reported in 1949 by markson et al.4 and pack and booher.5 we present two additional cases of advanced npc with multiple nodular skin metastases. cutaneous metastases from nasopharyngeal carcinoma: a rare manifestation halimuddin sawali, mbbs, msurg (orl-hns)1 mohd razif mohamad yunus, mbbs, msurg (orl-hns)2 ong cheng ai, mbbs, msurg (orl-hns)1 primuharsa putra sabir husin athar, md, msurg (orl-hns)3 1department of otorhinolaryngology head & neck surgery queen elizabeth hospital kota kinabalu, sabah, malaysia 2department of otorhinolaryngology head & neck surgery universiti kebangsaan malaysia medical centre kuala lumpur, malaysia 3ear, nose,throat-head & neck consultant clinic kpj seremban specialist hospital seremban, negeri sembilan, malaysia correspondence: primuharsa putra sabir husin athar, md, msurg consultant ent-head & neck surgeon, kpj seremban specialist hospital, jalan toman 1, kemayan square, 70200 seremban, negeri sembilan, malaysia fax: (606) 765 3406 e-mail : putrani@yahoo.co.uk reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work; disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the 4th international federation of head & neck oncologic societies (ifhnos) world congress, lotte hotel, seoul, south korea, 15-19 june, 2010. philipp j otolaryngol head neck surg 2010; 25 (2): 32-35 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 33 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports case reports case 1 a 53-year-old man presented with a six-month history of large bilateral neck masses. these were also associated with blockage of the nose, blood-stained nasal discharge, impaired hearing and tinnitus. on clinical examination, the left neck mass measured 9 cm x 7 cm, the right neck mass measured 6 cm x 7 cm and both were above the supraclavicular fossa, were firm and not inflamed. rigid nasal endoscopy showed fungating masses arising from fossa of rosenmuller on both sides. histopathological examination of the biopsy of this mass revealed a non-keratinizing squamous cell carcinoma, undifferentiated type (who type iii). the computed tomography (ct) scan showed masses on bilateral sides of the nasopharynx with erosion of the floor of the left sphenoid sinus and extension into the left sphenoid sinus and left posterior ethmoid sinuses. a diagnosis of npc (t3, n3a mo, stage ivb) was made. the patient completed radical radiotherapy to the nasopharynx and neck bilaterally. he refused concurrent chemotherapy. about one month later, he developed multiple small subcutaneous nodules all over his entire body (figure1). fine needle aspiration cytology (fnac) of one of the nodules revealed metastatic carcinoma. he was given a course of palliative chemotherapy but unfortunately he succumbed to the disease a few weeks later. case 2 a 43-year-old woman presented with a history of multiple right neck masses of two weeks duration associated with epitaxis and tinnitus in the right ear. clinical examination revealed multiple right neck masses, the largest measured less than 6 cm in diameter and was firm-to-hard in consistency. the overlying skin was not inflamed. rigid nasoendoscopy revealed a mass confined to the nasopharynx. histopathological examination of the biopsy of this mass revealed a non-keratinizing squamous cell carcinoma (who type ii). the patient was then lost to follow-up and presented again one year later. at this time, the right neck nodes had already increased in size to more than 6 cm in diameter. the ct scan showed extension of the tumor into the right maxillary, ethmoid and sphenoidal sinuses, superiorly into the floor of the right orbit and base of skull, and inferiorly into the right parapharyngeal space, pterygoid muscles, soft palate and oropharynx. no metastases were detected at the time of this presentation. the diagnosis of nasopharyngeal carcinoma (t3, n3a, m0, stage ivb) was made. the patient was treated with a full course of radiotherapy and concurrent chemotherapy. during the course of this treatment, she developed multiple painless skin nodules over the right upper chest figure 1. nodular skin metastases on the chest. figure 2. nodular skin metastases on the upper chest and neck and neck measuring between 0.5 cm to 1.0 cm in diameter (figure 2). excisional biopsies of the nodules were consistent with metastatic npc (figure 3). the skin metastases were treated with palliative radiotherapy with partial response. she later developed multiple bone metastases and a pathological fracture of her left femur. she succumbed to the disease approximately 20 months after initial presentation. 34 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports discussion nasopharyngeal carcinoma (npc) constitutes 85% of all malignant tumours of the nasopharynx. it is divided into three types according to the world health organization (who) classification; type i, keratinizing squamous carcinoma; type ii, non-keratinizing carcinoma; and type iii, undifferentiated carcinoma. the diagnosis of nasopharyngeal carcinoma is based primarily on the history and physical examination. obviously, definitive diagnosis requires a biopsy of the lesion. molecular markers represent an exciting advance in that they can be used to generate immunotherapy that will complement conventional chemotherapy.6 markers for nasopharyngeal carcinoma include p53, epidermal growth factor receptor (egfr), angiogenic factors, ebv, proliferating cell nuclear antigen, ki-67, and c-erbb2.7 the exact mechanism of how skin metastases can occur from npc is not known. distant skin metastases are thought to develop through hematogenous spread, whereas local metastases occur by spread via the dermal lymphatics.8 pulmonary circulation and filtration can theoretically be bypassed via the azygous and vertebral venous system and batson’s plexus, allowing skin implantation.9 the frequency of skin metastases from internal malignancies varies from 0.7% to 9 % of all patients with cancer.10,11 common sites of skin metastases are the scalp, neck, chest, trunk, forearm, thigh, and penis.3 the major primary sources are the breast in women and the lung in men, but almost any internal cancer may metastasize to the skin.12 the metastases most commonly occur as a few solitary skin nodules. massive and extensive nodular dissemination or diffuse dermal lymphatic infiltration as shown in both of our cases is extremely rare. markson et al. described a 19-year-old man who presented with a transitional carcinoma of the nasopharynx that metastasized to several distant cutaneous sites.4 the mean duration between primary diagnosis and the appearance of skin metastases is 21 months with a range of 5 to 35 months following the treatment of the primary tumor.3 in addition, the diagnosis is usually associated with disseminated disease.3 in our cases, the appearance of skin metastases occurred between 6 and 15 months after the primary diagnosis and neither patient had distant visceral metastases. radiotherapy (rt) has been the mainstay treatment for nasopharyngeal carcinoma (npc). control of early-stage disease with rt alone is usually successful, but the response of locoregionally advanced npc has been poor with frequent local relapse and distant metastasis.13 for rt, a dose of 65–75 gray (gy) is normally given to the primary tumour and 65–70 gy to the enlarged cervical nodes with metastases. radiation therapy and concurrent chemotherapy have been introduced as an alternative or standard approach for patients with advanced-stage nasopharyngeal carcinomas. rt is administered according to standard fractionation and treatment of metastatic disease is based on chemotherapy. chemotherapy is classified into three categories based on when it is delivered in relation to radiotherapy: neoadjuvant (before radiotherapy), concurrent (during radiotherapy) and adjuvant (following radiotherapy). the best chemotherapy regimen during radiotherapy has not been determined so far. to date, platinum-based regimens are the standard chemotherapy for metastatic npc patients, and cisplatin-5-fluorouracil (5fu) combination remains the most used in first-line treatment.14 other active chemotherapeutic agents include doxorubicin, epirubicin, bleomycin, mitoxantrone, methotrexate, and vinca alkaloids. the general consensus that chemotherapy is of limited benefit in recurrent or metastatic head and neck cancer may not be applicable to nasopharyngeal carcinoma. high objective response rates and a substantial proportion of durable complete responses have been attained in metastatic/recurrent disease.15 the duration of survival of patients with skin metastases is generally poor due to visceral metastases or advanced disease. in reported cases, this has varied between 1 and 10 months.3,16 palliative radiotherapy, excision and different chemotherapy combinations have been used for these metastatic cases but no promising results have yet been obtained.17 although the use of palliative chemotherapy in a patient who experiences symptoms is reasonable, the use of palliative chemotherapy in a patient without any symptoms is not as clear. the desire for prolongation of life must be balanced against the patient’s figure 3. sheets of malignant cell with fibrous septae in between. the malignant cells display hyperchromatic nuclei with prominent nucleoli and abundant cytoplasm. (hematoxylin-eosin, 100x) philippine journal of otolaryngology-head and neck surgery 35 philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 case reports references 1. guigay j. advances in nasopharyngeal carcinoma. curr opin oncol. 2008 may; 20(3):264-9. 2. altun m, fandi a, dupuis o, cvitkovic e, krajina z, eschwege f. undifferentiated nasopharyngeal cancer (ucnt): current diagnostic and therapeutic aspects. int j radiat oncol biol phys. 1995 jun 15; 32(3):859–77. 3. luk nm, yu kh, choi cl, yeung wk. skin metastasis from nasopharyngeal carcinoma in four chinese patients. clin exp dermatol. 2004 jan; 29(1):28-31. 4. markson ls, stoops cw, kanter j. metastatic transitional carcinoma of the penis simulating a chancre. arch derm syphilol. 1949 jan; 59(1):50-4. 5. pack gt, booher rj. localization of metastatic cancer by trauma. ny state j med. 1949 aug 1; 49(15):1839-41. 6. agulnik m, siu ll. state-of-the-art management of nasopharyngeal carcinoma: current and future directions. br j cancer. 2005 march 14; 92(5): 799-806. 7. mould rf, tai thp. nasopharyngeal carcinoma: treatments and outcomes in the 20th century. br j radiol 2002 apr; 75(892):307-39. 8. yoskovitch a, hier mp, okrainec a, black mj, rochon l: skin metastases in squamous cell carcinoma of the head and neck. otolaryngol head neck surg. 2001 mar; 124(3): 248-52. 9. batson ov. the function of the vertebral veins and their role in the spread of metastases. ann surg. 1940 jul; 112(1): 138-49. 10. brownstein mh, helwig eb. patterns of cutaneous metastasis. arch dermatol. 1972 jun; 105(6):862-8. 11. spencer ps, helm tn. skin metastases in cancer patients. cutis. 1987 feb; 39(2):119-21. 12. jacyk wk, dinkel de, becker gj. cutaneous metastases from carcinoma of the nasopharynx. br j dermatol. 1998 aug; 139 (2):344-345. 13. chua dt, sham js, kwong dl, au gk. treatment outcome after radiotherapy alone for patients with stage i-ii nasopharyngeal carcinoma. cancer. 2003 jul; 98(1):74-80. 14. ma bb, chan at. recent perspectives in the role of chemotherapy in the management of advanced nasopharyngeal carcinoma. cancer. 2005 jan 1; 103(1): 22–31. 15. fandi a, altun m, azli n, armand jp, cvitkovic e. nasopharyngeal cancer: epidemiology, staging, and treatment. semin oncol. 1994 jun; 21(3): 382-97. 16. yücel ot, hoşal as, onerci m, sökmensüer c. skin: an unusual site of metastases in nasopharyngeal carcinoma. otolaryngol head neck surg. 1999 dec; 121(6):833-4. 17. caloglu m, uygun k, altaner s, uzal c, kocak z, piskin s. nasopharyngeal carcinoma with extensive nodular skin metastases: a case report. tumori. 2006 mar-apr; 92(2):181-4. 18. lin hs, fee we jr. malignant nasopharyngeal tumors. [article on the internet]. medscape©19942010 [cited 2010 sep 28]. available from: http://emedicine.medscape.com/article/848163overview. quality of life, which should be the first priority.18 nasopharyngeal carcinoma with skin metastases carries a very poor prognosis and current available treatment modalities remain ineffective in dealing with skin metastases. early detection, diagnosis and treatment are still the best management strategy for nasopharyngeal carcinoma. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 from the viewbox philippine journal of otolaryngology-head and neck surgery 55 about 80% of ameloblastomas are found in the mandible. radiographically, they are most commonly seen in the posterior mandible but can occur anywhere in the mandible. twenty percent are found in other parts of the body, mostly in the face. they may, rarely, occur in the maxilla and skullbase (for which ct scans are recommended). panoramic x-rays, also called panorex films, orthopantomograms or pantomograms, are adequate for assessing ameloblastomas of the mandible. the procedure is simple, with the patient’s chin placed in an immobilizer while the xray beam moves in an arc in front of the patient, taking a full view of the mandible in 1-2 minutes. because the beam converges at a midpoint in the oral cavity, the resulting image “spreads out” the mandible from angle to angle (but overlaps and is hazier at the mentum). in early stages, ameloblastomas start out as a unilocular cystic lucency, similar in appearance to any other odontogenic cyst. they are usually well-defined with scalloped borders and tend to displace, rather than destroy teeth. typically expansile & multilocular, they have been described by such terms as “honeycomb” & “soap bubble” . the many faces of ameloblastoma johanna patricia a. cañal, md, mha department of radiology college of medicine – philippine general hospital university of the philippines manila correspondence: johanna patricia a. cañal, md, mha department of radiology philippine general hospital taft ave., ermita, manila 1000 phone/fax (632) 523 4372 email: joie_canal@yahoo.com philipp j otolaryngol head neck surg 2006; 21 (1,2): 57 c philippine society of otolaryngology – head and neck surgery, inc. references: 1. dahnert w. radiology review manual 4th ed. philadelphia: william & wilkins, 1999. 2. resnick d. bone & joint imaging. 2nd ed. philadelphia: wb saunders,1996. 3. som p, bergeron t. head & neck imaging. 2nd ed. st. louis: mosby, 1991. 4. sutton d, young j. concise textbook of clinical imaging, 2nd ed. st. louis: mosby 1995. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 6564 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 6564 philippine journal of otolaryngology-head and neck surgery passages armando t. chiong, sr., md (1930 2018) a tribute from a mentee to a mentor joselito c. jamir, md dr. armando t. chiong, sr. was fondly called arman by his contemporaries. a mildmannered man, he could be interpreted as a very docile and complacent individual- but for those who truly knew him, this was far from the truth. he may have been a very accommodating person, willing to listen and extend help to anybody, but he was never complacent. too caring may be a better term to describe him. i still can vividly remember the controversy regarding the six students. though his term as chair of the department was already over, he stood his ground and supported the stand of the faculty in general but more specifically, he was even willing to resign from the college if any faculty member of the department was removed from the roster because of their stand. such was the fortitude of the man, that he was even willing to risk not only his security of tenure but whatever retirement benefits may also have accrued to him. another incident that i can recall was his stand to protect the chairman’s prerogative regarding admission to the residency program. he decided to uphold and give premium to academic performance irrespective of the gender of the applicant. where before females were only given at most two slots, he decided that as chair he had the final say on admission matters and gave another slot to an applicant with a better academic grade who incidentally was female. thus was abolished the quota system for females and academic performance upheld. he was also a man with a mission. he preferred approaching matters in a very organized manner. he required all services/sections to formulate and submit a research agenda for the section with the intention of having a guided/directed research effort/activity by the department. thus, was born the research handbook of the department. this transpired when his daughter charlotte was chief resident of the department. however, implementation and pursuit of the objective has been spotty and sporadic except for a few services. a good family man, it can be said that he was until now the only one who could claim that two of his children became faculty members of our department. a third child is presently connected with another department of upcm. it may be recalled that the early and untimely demise of another child so devastated him. that is the hallmark of his being a good family man. he was never a flamboyant person. you could always expect him to attend departmental activities in his usual attire of colored pants, never denims, topped by his trademark long-sleeved polo shirt without a necktie. this getup was his invariable uniform. he never liked to rock the boat except to drive home certain principles or rules that must stand the test of time. whenever such things did occur was when you could see him at his decisive best. he was also a very approachable person. a research-oriented person, when requested by some residents for advice on certain research matters, he would gladly listen to their query and try to help resolve any quandary that may arise from the query. you could be sure that the next time he was in the department, he would be bringing pertinent articles and researches that could assist the resident. and chances were, included in the reprints were articles he had performed on the topic/subject when he was still with the university of virginia under prof. fitz-hugh, the same institution where dr. victor s. ejercito (the younger) had his training. such was indicative of the high regard that university had for him that a simple letter of recommendation from him was enough to guarantee admission. how many of us can make the same claim? but he never mentioned or boasted about this matter. i hope we too can make possible to younger residents such easy acceptance and availability of further training abroad. this in a nutshell was dr. armando chiong, sr. -a quiet man who rarely spoke unless called for, organized and with a mission, a researcher, a father but most of all, a mentor worthy of emulation who always stood by the principles he believed in. sir, goodbye and may your ideals be better appreciated and practiced by your successors. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles 14 philippine journal of otolaryngology-head and neck surgery abstract objective: to determine the prevalence of post-tonsillectomy bleeding in our institution and to describe the clinical characteristics, tonsillectomy techniques and post-tonsillectomy bleeding intervention in these patients. methods: design: observational descriptive study setting: tertiary private hospital population: all patients who were treated for post-tonsillectomy bleeding were retrospectively reviewed from medical records of all patients who had undergone tonsillectomy between january 1, 2007 and june 30, 2009. age and sex, indication for surgery, tonsil grade, body mass index (bmi), surgical technique, post-operative medications, length of hospital stay, interval between tonsillectomy and onset of bleeding and interventions to address postoperative bleeding were noted. results: of the 662 patients who underwent tonsillectomy, 37 (5.6%) were managed for postoperative hemorrhage. most had grade 2 or 3 tonsils (18 or 48.6% and 16 or 43.2% respectively) and were obese (25 or 67.5%). the highest proportion of post-operative bleeding was 9.2% for bipolar cauterization technique (18 of 196 patients) followed by 7.4% with cold knife, monopolar cauterization and suturing (11 of 148 patients); 6.9% with harmonic scalpel (2 of 29 patients); 6.5% with monopolar and bipolar cauterization (3 of 46 patients), and 2.8% for cold knife or fischer knife (3 of 109 patients). seven patients (18.9%) required blood transfusion. onset of bleeding occurred between 4-12 days following surgery (mean: 8 days). possible causes of bleeding included heavy physical activity and cough but most had no identifiable cause. majority of the patients (29 out of 37) required surgical exploration under general anesthesia. conclusion: post-tonsillectomy bleeding is still a clinically significant complication despite advances in surgical techniques. surgeons must always consider trade-offs between benefits and risks of the procedure and be continually vigilant of this potentially serious complication. keywords: post-tonsillectomy bleeding, tonsillectomy techniques tonsillectomy is still one of the most common surgical procedures performed by otolaryngologists. different techniques have evolved through time but the indications and complications have not changed much. the most common indications for tonsillectomy are recurrent or chronic tonsillitis, surgical augmentation of the airway, and malignancy.1 post-operative hemorrhage is still the most common complication which causes subsequent absence from school or work.2 occurrence of post-tonsillectomy hemorrhage is unpredictable and potentially-life threatening. it entails clinical profile of post-tonsillectomy bleeding: a 30-month institutional review sarah d. moral, md ann kathleen c. barlin, md jose m. acuin, md, msc (clin epi) department of otolaryngology head & neck surgery the medical city hospital pasig city, philippines correspondence: sarah d. moral, md department of otolaryngologyhead & neck surgery the medical city ortigas avenue, pasig city 1600 philippines telefax: (632) 687 3349 email: sarahmoral_md@yahoo.com reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2010; 25 (2): 14-17 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles philippine journal of otolaryngology-head and neck surgery 15 substantial consequences that can be detrimental for both patients and doctors. the cost of a second admission, longer hospital stay or a return to the operating room cannot be taken lightly. most importantly, posttonsillectomy bleeding is potentially life threatening and can degrade the patient’s quality of life. for the surgeon, this complication can bring about emotional and professional trauma that can erode confidence. the different surgical techniques have varying post-operative bleeding rates reported in the literature. a retrospective study of 494 patients by ali et al. showed rates to be highest with bipolar cautery and lowest with cold knife and suturing.3 a retrospective study by lowe and van der meulen involving 13,554 patients showed that coblation tonsillectomy had a higher relative risk of post-operative bleeding compared with cold steel.4 kristensen et al. also reported higher postoperative bleeding rates for coblation than for scalpel-snare-cautery techniques in a retrospective chart review of 632 patients.6 on the other hand, collison2 et al. found a 4% post-operative bleeding rate out of 430 tonsillectomies performed by 2 surgeons using cold dissection and snare for removal of tonsils and valley lab (tyco healthcare group lp, boulder, colorado, usa) suction cautery for hemostasis and windfuhr et al. reported a 2.7% bleeding rate out of 602 patients who underwent tonsillectomy with scissors and snare, and hemostasis with suture ligation and gauze pressure.5 this paper aims to determine the prevalence of post-tonsillectomy bleeding in our institution and to describe the clinical characteristics, tonsillectomy techniques and post-tonsillectomy bleeding intervention in these patients. methods the medical records of all patients who had undergone tonsillectomy in our institution between january 1, 2007 and june 30, 2009 were retrospectively reviewed. all patients who were managed for posttonsillectomy hemorrhage (defined as any bleeding that required medical attention) during the said time period were included in the present study. this included patients who developed bleeding during the same confinement for the tonsillectomy as well as those who were previously discharged but were readmitted due to post-tonsillectomy bleeding. primary hemorrhage was defined as onset of bleeding less than 24 hours post tonsillectomy and secondary hemorrhage was defined as onset of bleeding more than 24 hours post tonsillectomy. a standard data collecting form (appendix) was used to extract the following data from each record: 1) age and sex, 2) tonsil grade and body mass index (bmi), 3) indication for the procedure, 4) surgical technique including method of removal and hemostasis, 5) postoperative medications, 6) length of hospital stay, 7) number of hours from tonsillectomy to the report of post-operative bleeding , 8) possible cause of bleeding identified, and 9) intervention or treatment for postoperative bleeding including blood transfusion. the post-tonsillectomy bleeding patients included those managed by re-operation or by conservative measures (defined as control outside the operating room by means of silver nitrate cautery stick and continous ice water gargle). results of the 662 patients who had undergone tonsillectomy at our institution during the 30-month study period, 37 patients (5.6%) were managed for post-operative hemorrhage and were included in this study. their ages ranged between 5 and 54 years old, with a mean age of 33 (+/11) and a male to female ratio of 5:1. most patients had either grade 2 or grade 3 tonsils (18 or 48.6% and 16 or 43.2%, respectively). most patients were obese (class i or bmi of 25-29.9, 18 or 48.6%; class ii or bmi > 30, 7 or 18.9 %). the most frequent indication for tonsillectomy was recurrent tonsillitis followed by obstructive sleep apnea (osa), most of whom were severe by polysomnography (table 1). five different tonsillectomy techniques were used (table 2). of the 37 patients who had post-tonsillectomy bleeding, 29 (78%) or roughly 4 out of 5 required re-operation. about half of the bleeds (18 or 48.7%) had undergone bipolar cautery, three quarters (14 or 77.8%) of whom had to be re-operated. about one-third of the bleeds (11 or 29.7%) had undergone cold knife with monopolar cautery, all of whom had to be re-operated. seven of the 37 patients had also undergone blood transfusion. most of the post-tonsillectomy bleeding involved secondary hemorrhage (28 or 75.7%), with onset of bleeding occurring between 4-12 days after surgery (mean: 8 days). discussion tonsillectomy techniques and instruments have evolved over the centuries, with aims that have included decreasing operating time and intraoperative blood loss.7 the different tonsillectomy techniques have been associated with varying intra and post operative bleeding rates. pizzuto in 20008 found that among the most commonly used techniques of cold dissection, hot knife dissection and bipolar diathermy dissection, intraoperative blood loss was far less with electrocautery than with cold dissection. he further concluded that the bipolar technique was a better choice on account of less bleeding, both intra and post-operatively, shorter recovery period and fewer days off from work and school.8 reports comparing ligation with cautery attributed a higher rate of primary bleed to the use of suture ligation for hemostasis, and a more significant secondary bleed with the use of cautery. although philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles 16 philippine journal of otolaryngology-head and neck surgery cannot be understated considering its complications, particularly hemorrhage. almost half (15/37 or 40.54%) of the patients with bleeding in our study had obstructive sleep apnea (osa) as an indication. perhaps the relatively narrow oropharynx in patients with osa made exposure difficult, resulting in a tendency to over-retract the tonsils medially. this could conceivebly overstretch tonsillar bed vessels and cause immediate or delayed intraoperative bleeding necessitating hemostasis. perhaps a first-line trial of cpap in osa patients should precede surgical options to minimize these complications of tonsillectomy. post-tonsillectomy hemorrhage was secondary in most of our patients. secondary bleeding has not received as much attention as primary bleeding in the literature. this greater emphasis on primary bleeding may be attributable to the belief that it was more common and more serious9 but there are reports of delayed bleeding as long as 3 weeks following surgery that required surgical management under general anesthesia.5 there were no episodes of recurrent post-operative hemorrhage in our series. the loss of blood notwithstanding, minimizing the incidence of this complication was important because post-operative bleeding can lead to airway compromise. the need for additional intervention such as blood transfusion increased costs and overall inconvenience for doctors and patients alike. as for possible inciting events for post-tonsillectomy bleeding, a majority of the patients did not have an identifiable cause while others reported early resumption of physical exertion or vigorous coughing. giving thorough home care instructions should not be taken lightly because the activities of patients after discharge from hospital can contribute significantly to the occurrence of bleeding. all the seven surgeons involved in this study were reasonablyexperienced consultants with an average of 8 years and a range of 512 years of practice. the small sample size did not allow us to explore differences in the surgeons’ clinical experience and their association with post-operative bleeding. however we can not discount the possibility that a clinically important association does exist and that surgical skill, rather than technique, could primarily influence complication rates. another potential limitation of this study lies in the method of identifying patients with post-tonsillectomy bleeding. it is possible that some patients with post-operative bleeding may have sought care at another facility without informing their original surgeon. this selection bias may further underestimate our post-tonsillectomy bleeding rate. post-tonsillectomy bleeding is still a clinically significant complication despite advances in surgical techniques. surgeons must always consider trade-offs between benefits and risks of the procedure and be continually vigilant of this potentially serious complication. table 1. patient characteristics & indications for tonsillectomy patient characteristics n (%) age gender tonsil grade body mass index indications for tonsillectomy 0-10 11-21 22-32 33-43 44-54 male female grade i grade ii grade iii grade iv underweight (<18.5) healthy (18.5-22.9) overweight (23-24.9) obese i (25-29.9) obese ii (>30) recurrent tonsillitis ≥ 4/ yr tonsillitis obstructive sleep apnea polysomnography moderate severe not mentioned cpap yes no not mentioned others (tonsillar mass) 1 (2.7%) 2 (5.4%) 18 (48.6%) 10 (27%) 6 (16.2%) 32 (84%) 5 (16%) 2 (5.4%) 18 (48.6%) 16 (43.2%) 1 (10.8%) 1 (2.7%) 5 (13.5%) 6 (16.2%) 18 (48.6%) 7 (18.9%) 19 (51.3%) 10 (52.6%) 9 (47.3%) 15 (40.54%) 13 3 (23%) 8 (61.5%) 2 (15.4%) 1 (6.6%) 3 (20%) 11 (73.3%) 3 (8.1%) table 2. post-tonsillectomy bleeds and interventions by surgical technique surgical technique post-tonsil bleed type of intervention to control post-operative bleed cold knife + chromic cold knife + monopolar bipolar cautery bipolar + monopolar harmonic scalpel total 3 (8.1%) 11 (29.7%) 18 (48.7%) 3 (8.1%) 2 (5.4%) 37 1 (33%) 0 (0%) 4 (22.2%) 1 (33%) 2 (100%) 8 (21.6%) surgical n (% of a) (b) non-surgical n (% of a) (c) 2 (67%) 11 (100%) 14 (77.8%) 2 (67%) 0 (0%) 29 (78.3%) the use of cautery was effective in preventing primary hemorrhage, there was a tendency to a deeper and more extensive zone of necrosis and subsequent exposure of larger vessels when sloughing of the eschar occured.2,5 this may corroborate the results of this study where a majority of the patients experiencing secondary hemorrhage underwent cauterization. the importance of strict adherence to indications for tonsillectomy n (% of total) (a) philippine journal of otolaryngology-head and neck surgery vol. 25 no. 2 july – december 2010 original articles philippine journal of otolaryngology-head and neck surgery 17 appendix checklist for post tonsillectomy bleed patients (2007-2009) name: age: date of operation: consultant: first assist: indication for tonsillectomy: (check one) o recurrent tonsillitis (rt) # of documented bouts per year: ______ # of years w/ rt: ______ medicines taken: _______ o osa (circle one) snoring? y n witnessed apnea? y n psg? y n results of psg mild moderate severe cephalometry? y n cephalometric values: cpap trial? y n if yes, how long? ______ o other indications (halitosis, biopsy etc). pls. indicate ___________ ________________________________________________________ physical examination o tonsil grade 1 2 3 4 o other pertinent oral cavity findings: ________________________ o bmi: ________ intra-op details technique : (check one) o cold knife o cold knife + monopolar cautery o bipolar cautery o monopolar + bipolar cautery o harmonic scalpel o others hemostasis: o suturing o monopolar cautery o bipolar cautery o harmonic scalpel other surgeries performed with tonsillectomy: ____________________ ________________________________________________________ blood loss: _________ post-op medications: ______________________________________ length of hospital stay: ________days length of time that had passed between tonsillectomy and onset of bleeding? o <24 hours: ______hrs post tonsillectomy o >24 hrs: ________days post tonsillectomy intervention done: o brought back to or: suturing cautery o controlled conservatively: ice gargle cautery stick packed with gauze identified possible cause of bleeding: o ate hard food. indicate food __________ o physical activity/exertion. indicate activity __________ o cough o none hemoglobin pre-tonsillectomy:____________________________ hemoglobin on re-admission (post tonsil bleed): ____________ blood transfusion done? y______ n_______ if yes, indicate blood component and how many: _________________ acknowledgment the authors would like to acknowledge the ent surgeons who generously provided pertinent data for the completion of this study. this paper has supplemented the authors’ learning regarding post-operative bleeding after tonsillectomy. it is the authors’ intention that this paper provides more understanding regarding the mechanisms and factors that contribute to this complication. references 1. bhattacharyva n. evaluation of post-tonsillectomy bleeding in the adult population. ear nose throat j, aug 2001; 80(8): 544-9. 2. collison pj, mettler b. factors associated with post-tonsillectomy hemorrhage. ear nose throat j, aug 2000; 79(8): 640-2. 3. ali rb, smyth d, kane r, donnelly m. post-tonsillectomy bleeding: a regional hospital experience. ir j med sci. dec 2008; 177(4):297-301 4. lowe d, van der meulen j. tonsillectomy technique as a risk factor for postoperative hemorrhagenational prospective tonsillectomy audit. lancet. aug 2004; 364(9435): 697-702 5. windfuhr jp, schloendorff g, sesterhenn am, prescher a, kremer b. a devastating outcme after adenoidectomy and tonsillectomy: ideas for improved management. otolaryngol head neck surg. feb 2009; 140(2): 191-6 6. kristensen s, tveteras k. post-tonsillectomy haemorrhage: a retrospective study. clin otolaryngol allied sci. dec 1984; 9(6): 347-50 7. younis rt, lazar rh. history and current practice of tonsillectomy. laryngoscope. aug 2002; 112(8 pt 2 suppl 100); 3-5. 8. pizzuto mp, brodsky l, duffy l, gendler j, nauenberg e . a comparison of microbipolar cautery dissection to hot knife and cold knife cautery tonsillectomy. int j pediatr otorhiolaryngol. may 2000; 52 (3): 239-246. 9. gabalski ec, mattucci kf, setzen m, moleski p. ambulatory tonsillectomy and adenoidectomy. laryngoscope. jan 1996; 106(1 pt 1): 77-80 10. hainer bl. fundamentals of electrosurgery. j am board fam pract. novdec 1991; 4(6):419-26 11. boughton rs, spencer sk. electrosurgical fundamentals. j am acad dermatol. april 1987;16(4):862-7. 12. walker ra, syed za. harmonic scalpel tonsillectomy versus electrocautery tonsillectomy: a comparative pilot study. otolaryngol head neck surg. nov 2001; 125(5):449–455 13. koltai pj, solares ca, mascha ej, xu m. intracapsular partial tonsillectomy for tonsillar hypertrophy in children. laryngoscope. aug 2002; 112(8 pt 2 suppl 100):17-19 14. chan kh, friedman nr, allen gc, yaremchuk k, wirtschafter a, bikhazi n, et al. randomized, controlled, multisite study of intracapsular tonsillectomy using low-temperature plasma excision. arch otolaryngol head neck surg. nov 2004; 130(11): 1303-7 15. strom bl, berlin ja, kinman jl, spitz pw, hennessy s, feldman h, et al. parenteral ketorolac and risk of gastrointestinal and operative site bleeding: a post-marketing surveillance study. jama. 1996; 275:376-82. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 passages 68 philippine journal of otolaryngology-head and neck surgery sarah d. moral-ramos, md (1979 – 2016) “an old soul, gone too soon” esperanza argelyn v. ong, md sarah completed her residency training at the medical city in 2010. as early as her residency days, she showed remarkable surgical skills, good clinical judgment, and excellent administrative insight. she spent her senior year in training as one of the best chief residents the department had seen. setting the bar high, she demanded excellence from her juniors and constantly sought progress. the department was enhanced by her initiatives, and early on, the consultant staff was certain that she would soar to great heights and achieve great things. after passing the pbo-hns diplomate exam, she went to fujita health university to pursue fellowship training in sleep medicine. her intelligence, sunny personality, and diligence impressed all she encountered while in japan, from her eminent senseis up to the allied medical personnel. she contributed to the society and co-authored several scientific papers that were published internationally. she returned after a year of training, prepared and eager to start her private practice. but god had other plans for sarah. in june 2011, a few months after completing her fellowship training, she was diagnosed with acute lymphoblastic leukemia. her treatment course was anything but smooth, and the road to recovery was challenging to say the least. but being the fighter that she was, sarah faced her trials head on, and with the support of her family, friends, and colleagues she went into remission. sarah then went on to be an active consultant of the department of otolaryngology-head and neck surgery as well as a reader at the center for snoring and sleep disorders of the medical city. it was also during this time that she passed the certifying examination given by the philippine society of sleep medicine. she was active in both her subspecialty study group and in the philippine society of otolaryngology head and neck surgery, giving lectures during meetings, round table discussions, and in the society’s annual convention. sarah’s personal life was also noteworthy. in 2015, she married the love of her life, dr. rodney marc h. ramos, a fellow otolaryngologist. their love story is inspiring and definitely one for the books. early in her career, sarah was already regarded as one of the experts in sleep medicine. she was well on her way to becoming an esteemed member of the ent community when she was faced with yet another challenge. months after getting married, they were handed the unfortunate news that her cancer had relapsed. she took a leave from her clinical duties to undergo treatment, consisting of intensive chemotherapy and a bone marrow transplant. her support group, led by her loving husband, rallied behind her and again she emerged victorious. unfortunately, despite such hopeful circumstances, sarah succumbed to complications of her treatment on august 26, 2016. she fought a good fight and she will be remembered for her tenacity, resilience, and unwavering faith. her trademark dimples, always present even during the toughest of times have been imprinted forever in the hearts and minds of her loved ones. her short, but well lived life, continues to be an inspiration to all those who had the privilege of knowing her. goodbye, our dear sarah. you are missed every day. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 editorial 4 philippine journal of otolaryngology-head and neck surgery the crimson and forest-green chevrons and piping on the long black academic gowns of surgeons and physicians, respectively, are symbols of blood and foliage, of healing with the knife or with medicaments.1 most of us are strangers to neither calling, having trained intensively in both these arts and sciences, and many proudly don the red-piped garb of the college of surgeons as well as the green-striped garments of our society of otolaryngology head and neck surgery. the latter has seen 60 years come and go, and with these years, many highlights, lowlights, and colleagues who have gone before us. red and green are also colors that mark a 35th anniversary with coral and jade, both regarded as precious gems from antiquity. corallium rubrum (red coral) “combined myth and magic,” as “its bright red color fascinated people in the east and west alike.”2 it has been regarded as the “blood of medusa, soft and diaphanous under water, as hard as stone in the air,” or a procreative “tree of blood” that “link(ed) with the divine and the supernatural.”2 green jade, “the emperor’s stone,” has been mined and worked in china since prehistoric times, eventually becoming the “royal gem.”3 red coral, green jade – precious stones on the 35th year of the philippine journal of otolaryngology head and neck surgery. coral red, jade green – precious colors that reflect our noble profession. red and green are also the colors of christmas, and their use may be traced back to the “spatial and spiritual border marked by rood screens” in 14th to 16th century medieval churches,“ whose symbolism may have carried over to the temporal boundary between the end of one year and the beginning of the next.”4 these elaborately designed dividers featured edifying illustrations of saints and holy scenes in multicolored splendor, but were predominantly green and red. “iron was one source of red pigment, and copper a source of green pigment, that colored the screens” and because “metallurgy was determined by astronomy,” also closely associated were “iron with mars, the masculine, war, and fire” and “copper with venus, the feminine, love and water.”4 hence, the colors people encountered held multiple planes of meaning for them, as they celebrated another year over, a new one begun. (figure) correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 554 8467 telefax: (632) 524 4455 email: lapenajf@upm.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines blood and foliage: coral red and jade green philipp j otolaryngol head neck surg 2016; 31 (1): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 5 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 editorial today, there is much to be thankful for, and much more to remain open to. our journal has maintained a respected position among its peers, and is ready to move forward. with this issue, we begin granting a creative commons attribution noncommercial-noderivatives 4.0 international (cc by-nc-nd 4.0) license5 to articles published in the philippine journal of otolaryngology head and neck surgery, in addition to the copyright already transferred to the philippine society of otolaryngology head and neck surgery. this license means that readers are free to share copy and redistribute the material in any medium or format under the following terms:5 references 1. hippocratic aphorisms 7.87, 4.608 l., littré e. œuvres compl`etes d’hippocrate (10 volumes, paris; 1839–61). jones whs, potter p, translators. vol. 4. boston, ma: harvard university press; 1988. 2. del mare c. the coral story: a brief history of mediterranean coral. [internet] in lewis j. stories from a trader’s life. sta fe, nm: the trade roots collection: the trusted source 2000. [cited 15 june 2016] available from:http://www.traderoots.com. 3. desjardins j. the history of jade: the emperor’s stone. [internet] vancouver, bc: visual capitalist 2016. [cited 15 june 2016] available from:http://www.visualcapitalist.com/the-history-of-jadethe-emperors-stone/. 4. bucklow s. the alchemy of paint: art, science and secrets from the middle ages. london; ny: marion boyars; 2009. 5. creative commons attribution-noncommercial-noderivatives 4.0 international (cc by-ncnd 4.0) license. [cited 1 june 2016] available athttp://creativecommons.org/licenses/by-ncnd/4.0/. 6. lapeña jf. “impact, not just impact factor: responding to the manila declaration on the availability and use of health research information” philipp j otolaryngol head neck surg 2015 jul-dec; 30(2):4-5. 7. directory of open access journals. [cited 1 june 2016] available from https://doaj.org. figure. rood screen in the 14th-century gothic église saint-pierre-le-jeune, strasbourg, france. behind is the famous pipe organ of johann andreas silbermann on which helmut walcha recorded a large part of his performances of bach’s organ works. (photo by josé florencio f. lapeña, jr.) attribution – they must give appropriate credit, provide a link to the license, and indicate if changes were made. they may do so in any reasonable manner, but not in a way that suggests the licensor endorses them or their use. noncommercial – they may not use the material for commercial purposes. noderivatives – if they remix, transform or build upon the material, they may not distribute the modified material. we hope that this further concretizes our response to the manila declaration on the availability and use of health research information6 and eventually qualifies us for inclusion in the directory of open access journals.7 in support of this, we conducted a basic medical writing workshop for authors last march 19, 2016 and a two-day research technical review workshop for reviewers last april 29-30 hosted by the psohns, and plan to continue doing so. we are seriously negotiating for migration from our current online platform to one that will better serve our needs, and those of our readers. we will soon activate our social media presence as well. indeed, we all are yin and yang, you and i, red coral and green jade. we draw blood, and apply herbal poultices. we swim with the flow, yet solidly stand our ground. we don gay apparel of coral red and jade green, and merrily yet solemnly celebrate. mabuhay! philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2019; 34 (2): 20-23 c philippine society of otolaryngology – head and neck surgery, inc. timing of tracheostomy and outcomes in adults with moderate and severe tetanus: a cross-sectional study wenrol z. espinosa, md von v. vinco, md department of otorhinolaryngology head and neck surgery corazon locsin montelibano memorial regional hospital correspondence: dr. von v. vinco department of otorhinolaryngology head and neck surgery corazon locsin montelibano memorial medical center lacson st., bacolod city 6100 philippines phone: (034) 703-1350 local 155 email: enthns_clmmrh@yahoo.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. abstract objective: this study aimed to evaluate the timing of tracheostomy and relationship to outcomes (length of hospital stay, length of mechanical ventilation, morbidity and mortality rate) in adults with moderate and severe tetanus. methods: design: cross-sectional study setting: tertiary government training hospital participants: all adult patients (19 years old and above) diagnosed with moderate and severe stage tetanus from january 2015 to january 2018 were considered for inclusion. results: there were 109 patients included in this study, majority were males (n=95) with a male to female ratio of 7:1. most belonged to the 51-60 years age group (mean: 53.7 sd: +/-16.1). based on cole tetanus staging, the majority presented with severe stage tetanus (67.9%; n=74). only 35.8% (n=39) were admitted at the intensive care unit. early tracheostomy was performed in 56.0% (n=61) of the patients (mean 6.3 hours sd: +/4.61). mortality rate was noted to be 52.3% (n=57). overall, early tracheostomy among moderate to severe stage tetanus patients showed shorter length of hospital stay and length of mechanical ventilation than late tracheostomy (tracheostomy >24 hours) (p-value < .05). however, no significant difference was noted for timing of tracheostomy in terms of morbidity and mortality rate (p-value > .05). conclusion: early tracheostomy within less than 24 hours from time of admission for moderate and severe tetanus is associated with shorter length of hospital stay and mechanical ventilation than late tracheostomy, and may play a role in tetanus management. keywords: tracheostomy; tetanus; hospital stay; mechanical ventilation; morbidity; mortality creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles despite effective efforts by world health organization (who) to reduce deaths caused by tetanus through large-scale immunization programs, the disease remains an important public health problem in many parts of the world where immunization programs are suboptimal, particularly in the least developed districts of low income countries.1 in 2016, there were 13,502 reported cases of tetanus with 72,600 estimated deaths in those less than 5 years of age despite 86% estimated dtp3 immunization coverage.2 in the philippines, morbidity and mortality trends for tetanus from 1993 to 2013 showed decreasing morbidity rates from 1.1/100,000 to 0.1/100,000 and decreasing mortality rates from 1.5/100,000 to 0.6/100,000.3 however, despite these decreasing trends, tetanus may occur at any age and case-fatality rates are still high even where intensive care is available, approaching 100% in the absence of medical intervention.2,3 securing the airway early in the disease with a tracheostomy is an important intervention in the management of tetanus where artificial ventilation is often necessary for weeks, in contrast to endotracheal intubation which can stimulate laryngeal spasms and exacerbate airway compromise.4,5 in our setting, early tracheostomy is a standard treatment for tetanus patients presenting with moderate to severe trismus, but to the best of our knowledge, there is a dearth of local studies that evaluate the significance of timing of tracheostomy in the outcomes of tetanus management. in order to guide our practice and improve patient care, this study aimed to evaluate the timing of tracheostomy and relationship to outcomes (length of hospital stay, length of mechanical ventilation, morbidity and mortality rate) in adults with moderate and severe tetanus. methods with institutional review board (irb no. 2018-37) approval, this crosssectional study considered for inclusion all adult tetanus patients aged 19 years old and above who were admitted with a cole tetanus severity diagnosis of moderate and severe stage tetanus from january 1, 2015 to january 1, 2018. initial lists were based on admission logbooks. hospital charts were obtained from the medical records section and screened. excluded were records of patients with comorbid illnesses, those in whom tracheostomy performed outside the study setting, those who did not consent to treatment or who opted to be discharged against medical advice, and those with incomplete or unavailable records. data was extracted from the medical records by the principal investigator and listed in data collection forms using microsoft excel 2013 (15.0.4420.1017) (microsoft corporation, redmond, wa, usa). data included age, sex, presenting symptoms, incubation period, period of onset, severity, site of injury and admission. for this study, early tracheostomy was defined as performed within 24 hours from the time of admission with those performed beyond 24 hours categorized as late tracheostomy. patients who had no tracheostomy performed were likewise treated as a group. length of hospital stay was calculated in days from date of admission to date of discharge. length of mechanical ventilation was calculated in days from date of ventilator set-up to date of removal. morbidity and mortality rate were defined as occurrence of a complication and death in a given number of population per unit of time, respectively. data was analyzed using spss statistics 22 (ibm corporation, chicago, il, usa). categorical variables were reported as count and percentage. means and standard deviations were computed among variables in age, incubation period and period of onset. subgroup analysis of the outcomes (length of hospital stay, length of mechanical ventilation, morbidity and mortality rate) according to timing or performance of tracheostomy (early, late, none) was performed. oneway analysis of variance (anova) was utilized to compare the means between groups with a statistical significance of p-value < .05. results out of 129 patients initially considered, this study finally included 109 adult patients with moderate and severe stage tetanus. there were 95 males and 14 females with male to female ratio of 7:1. the mean age was 52.7 years (sd: +/-16.1) with a range of 19 to 85 years. presenting symptoms included trismus (n=64), spasm (n=17), dysphagia (n=15) and dyspnea (n=8). the mean incubation period and period of onset were 8.3 days (sd: +/-5.0, range 1 to 28 days) and 2.2 days (sd: +/-2.6, range 1 to 14 days), respectively. majority of the patients presented with severe stage tetanus (n=74). the most common site of injury was in the lower extremities specifically punctured foot wounds (n=61), followed by the upper extremities (n=15) and dental-related infections (n=2). of the 109 patients, only 35.8% (n=39) were admitted to the intensive care unit while 64.2% (n=70) were admitted in the medical isolation ward. more than half of the study population (56%; n=61), were managed with early tracheostomy within one to 18 hours (mean: 6.3 hours sd: +/-4.6). of these, 96.7% (n=59) were performed in the emergency room with one each in the operating room and medical isolation ward. the no tracheostomy group comprised 35.8% (n=39) followed by the late tracheostomy group which only comprised 8.3% (n=9). tetanus related deaths occurred in 52.3% (n=57), while 47.7% (n=52) were eventually discharged from hospital. (table 1) subgroup analysis of the outcomes revealed significant differences in timing of tracheostomy versus length of hospital stay and mechanical philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles table 1. number of patients based on timing of tracheostomy and mortality outcomes variable number of patients (%) time of tracheostomy early late no outcome death discharged 61 9 39 57 52 56.0 8.3 35.8 52.3 47.7 table 3. subgroup analysis of mortality and morbidity rate based on timing of tracheostomy severity severity outcome severity timing of tracheostomy morbidity rate (%) mortality rate (%) moderate severe moderate severe early tracheostomy (n=61) 50.0 85.4 50.0 56.2 late tracheostomy (n=9) 50.0 100 50.0 71.4 no tracheostomy (n=39) 17.0 71.4 16.7 71.4 p-value .08 .28 .11 .53 table 2. subgroup analysis for length of hospital stay and length of mechanical ventilation based on timing of tracheostomy severity outcome severity timing of tracheostomy length of hospital stay (mean, days) length of mechanical ventilation (mean, days) moderate severe moderate severe early tracheostomy (n=61) 14.4 18.9 4.1 10.1 late tracheostomy (n=9) 41.0 41 18.0 19 no tracheostomy (n=39) 9.9 11.6 na na p-value .0002 .002 .004 .28 na for the no tracheostomy group because none of them were intubated or tracheotomized, and none were committed to mechanical ventilation. despite moderate to severe tetanus, they were managed conservatively (including those who did not consent to either intubation or tracheotomy). ventilation. there were significantly shorter lengths of hospital stay and duration of mechanical ventilation among those who had early tracheostomy compared to those who had late tracheostomy, except for patients who did not undergo tracheostomy (one-way anova, length of hospital stay, moderate, f(2, 21) = 13.54, p=.0002, severe, f(2,22) = 8.33, p=.002) length of mechanical ventilation, moderate, f(1, 4) = 33.64, p=.004, severe, f(1, 14) = 1.25, p=.28). (table 2) in contrast, there was no significant difference in morbidity and mortality rates for early versus late tracheostomy (one-way anova, morbidity rate, moderate, f(2, 31) = 2.76, p=0.08, severe, f(2, 72) = 1.30, p=.28, mortality rate, moderate, f(2, 34) = 2.40, p=.11, severe, f(2, 73) = 0.63, p=.53). (table 3) discussion our study found that early tracheostomy in moderate and severe stage tetanus showed shorter length of hospital and length of mechanical ventilation compared to late tracheostomy. in contrast, no significant difference were noted among timing of tracheostomy on morbidity and mortality rates. these study findings differ from those of saeed et al. and awan et al. which emphasized lower morbidity and mortality rates among early tracheostomized tetanus patients. however, the awan et al. study of 56 patients presenting with moderate trismus underscored early recovery and shorter length of hospital stay comparable to our study findings.6,7 in addition, our study further revealed shorter length of mechanical ventilation among early tracheostomy with moderate stage tetanus compared with late tracheostomy but no significant difference was noted with severe tetanus. other findings noted in this study that 67.9% (n=74) of our patients initially presented with severe stage tetanus, were similar with findings of previous studies that high mortality rate resulted from poor recognition of disease and delays in treatment.5-8 mortality rates in this study were still high at 52.3% (n=57), comparable to studies conducted in developing countries.6-8 in addition, moderate to severe trismus 58.7% (n=64) was the predominant presenting symptom among study participants, comprising the primary indication for tracheostomy referral in our setting that was consistent with practices that avoid subsequent airway compromise once a patent tracheostomy was established.9,10 only 35.8% (n=39) of our patients were admitted in an intensive care facility similar to findings of another local study, reflecting the limited resources and inadequate care for most of these patients.11,12 in contrast, earlier studies that recommend intensive care philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles references 1. tetanus vaccines: who position paper – february 2017.wkly epidemiol rec. 2017 feb 10; 92(6): 53-76. pmid: 28185446. 2. immunizations, vaccines and biologicals [internet]. tetanus; [updated 2017 aug 25; cited 2018 jan]. available from: https://www.who.int/. 3. mortality and morbidity trends [internet]. tetanus [updated 2016 jun 6; cited 2018 jan]. available from: https://www.doh.gov.ph/notifiable_diseases. 4. cook tm, protheroe rt, handel jm. tetanus: a review of literature. br j anaesth. 2001 sep; 87(3): 477-87. doi: 10.1093/bja/87.3.477; pmid: 11517134. 5. current recommendations for treatment of tetanus during humanitarian emergencies. [internet]. who technical note. 2010 jan. [cited 2018 jan] available from:https://www.who.int/ diseasecontrol_emergencies/publications/who_hse_gar_dce_2010.2/en/. 6. saeed ab, muazzam m, mansoor sa, iqbal j. impact of early tracheostomy on outcome in tetanus patients. jszmc. 2014; 5(2):597-600. 7. awan nu, sohail m, sarwar z, bashir mm, khokhar ma, chatha aa. outcome of early tracheostomy in the management of grade ii (moderate) tetanus patient. akemu. 2017; 23(4): 519-23. doi: https://doi.org/10.21649/akemu.v23i4.2232. 8. fasunla aj. challenges of tracheostomy in patients managed for severe tetanus in a developing country. int j prev med. 2010; 1(3):176-81. pmid: 21566788 pmcid: pmc3075528. 9. nakajima m, aso s, matsui h, fushimi k, yasunaga h. clinical features and outcomes of tetanus: analysis using a national inpatient database in japan. j crit care. 2018 apr; 44: 388-91. doi: 10.1016/j.jcrc.2017.12.025; pmid: 29304489. 10. weng wc, huang wy, peng ti, chien yy, chang kh, ro ls, et al. clinical characteristics of adult tetanus in a taiwan medical center. j formos med assoc. 2011 nov; 110 (11): 705-10. doi: 10.1016/j.jfma.2011.09.007; pmid: 22118315. 11. balanga-an k. clinical profile and outcome of adult tetanus patients admitted at corazon locsin montelibano memorial regional hospital from january 2013 to december 2013: a retrospective study. unpublished. 12. kawale ma, keche pn, gawarle sh, bhat sv, buche a. a prospective study of complications of tracheostomy and management in tertiary care hospital in rural area. glob j otolaryngol. 2017; 5(3): 555667. doi: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20173048. 13. lau lg, kong ko, chew ph. a ten-year retrospective study of tetanus at a general hospital in malaysia. singapore med j. 2001 aug; 42(8):346-50. pmid: 11764050. 14. derbie a, amdu a, alamneh a, tadege a, solomon a, elfu b, et al. clinical profile of tetanus patients attended at felege hiwot referral hospital, northwest ethiopia: a retrospective cross sectional study. springerplus. 2016 jun 27; 5(1): 892. doi: 10.1186/s40064-016-2592-8; pmid: 27386340 pmcid: pmc4923016. 15. chalya pl, mabula jb, dass rm, mbelenge n, mshana se, gilyoma jm. ten-year experiences with tetanus at a tertiary hospital in northwestern tanzania: a retrospective review of 102 cases. world j emerg surg. 2011 jul 8; 6:20. doi: 10.1186/1749-7922-6-20; pmid: 21740539 pmcid: pmc3159100. unit (icu) admission have shown satisfactory outcomes in the treatment of tetanus patients.13-15 our study has several limitations. the unequal sample size between groups can create bias in formulating a statistically significant comparison and although airway control is one of the crucial approaches in the management of tetanus, several equally significant treatment strategies utilized such as immunotherapy, antibiotic treatment, muscle spasm and autonomic dysfunction control, could influence the study outcomes and partially explain better outcomes noted among patients who did not undergo tracheostomy in this study. further studies have to be conducted to obviate these biases and lay the groundwork for an efficient treatment pathway in the management of tetanus. in conclusion, despite vigorous campaigns conducted by international and local health organizations to reduce deaths caused by tetanus, this study revealed an unsatisfactory mortality rate of 52.3%. early tracheostomy performed within less than 24 hours from time of admission for moderate and severe tetanus is associated with shorter length of hospital stay and mechanical ventilation than late tracheostomy, and may play a role in tetanus management. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles 12 philippine journal of otolaryngology-head and neck surgery abstract background: the philippine national ear institute (pnei) was created to promote health of hearing and balance among filipinos. over the years, it has provided audiologic services to thousands of patients annually and has published relevant hearing and balance research. objective: to describe the patients served by the pnei in terms of age, region of origin, occupation, pretest diagnosis, and audiologic results. methods: study design – cross-sectional study setting – national tertiary care center population – all records of patients referred for audiologic testing at pnei in 2006 were reviewed and encoded into analyzable format. results: a total of 1,756 patients had audiologic records for review. median age was 32.5 years, with the age distribution presented according to sex, type of tests done including common reasons for referral, and median threshold levels by frequency. coverage was national in scope, with most patients coming from the national capital region and from regions iii and iva. occupation was indicated in 37.8% of the working age group, most of whom were unemployed. the most common pretest diagnosis was chronic otitis media (26.6%), followed by hearing loss of unknown etiology (13.0%) and tinnitus (9.3%). severity of hearing impairment based on pure tone audiometry was variable, and was presented according to common diagnoses. about 39% of hearing impairment cases were sensorineural, 36% conductive and 25% due to mixed defect. bilateral type a ears were found in 45.4% of patients by tympanometry, while 29.3% were bilateral type b. for otoacoustic emissions, 69.0% were labeled as “refer” in at least one ear. conclusion: the pnei is a major national referral center for audiology that holds much promise in developing programs for national surveillance of the hearing status of different sectors in philippine society. keywords: philippine national ear institute, philippines, patient profile, audiology, audiometry, tympanometry, otoacoustic emissions, chronic otitis media the philippine national ear institute: patient and audilogic profiles regie lyn p. santos-cortez, md, phd1,2, charlotte m. chiong, md1,2, ma. luz m. san agustin, bsba1,2, charina melinda c. elgar, md3, genilou liv m. gimena, md3, scheherazade c. ibrahim, md3, rodante a. roldan, md3, ma. rina t. reyes-quintos, md, mclinaud1,2, abner l. chan, md1,2, generoso t. abes, md, mph1,2 1 philippine national ear institute national institutes of health university of the philippines manila 2 department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila 3 department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: regie lyn p. santos, md philippine national ear institute national institutes of health – university of the philippines manila 2nd floor central block philippine general hospital taft avenue, ermita, manila 1000 philippines telephone: (632) 521-8450 loc. 2153 telefax: (632) 522-0946 email: regie_san@earinstitute.org.ph reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this article. philipp j otolaryngol head neck surg 2007; 22 (1,2): 12-18 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles philippine journal of otolaryngology-head and neck surgery 13 the philippine national ear institute (pnei) was created in 2004 by republic act no. 9245 as a primary research institute for the promotion of health in hearing and balance among filipinos (http://www. earinstitute.org.ph/). from an ear unit with a single audiometer and one audiometrician, the pnei has grown to a multidisciplinary facility that performs different audiologic testing methods and promotes audiology and communication sciences through its master of clinical audiology program. with the vision statement that, “no filipino shall be deprived of a functioning sense of hearing and balance,” it now serves thousands of patients annually and, through its research initiatives, has strongly advocated hearing health not only within the surrounding communities but also across the philippine islands. one of pnei’s main mandates is to carry out epidemiologic studies that are related to hearing and balance and that have the potential to become the basis for the government’s regulatory policies. in laying the foundation for future research activities and education programs, this study aims to describe the personal and audiologic profiles of pnei patients by collating information on age, region of origin, occupation, referral information, pretest diagnosis, and audiologic results. the composite information gathered here may be useful not only for pnei staff but also for practicing otorhinolaryngologists, physicians, audiologists, communication scientists and government policy makers as well. methods all measurements for pure tone audiometry were performed in a soundproof booth using the diagnostic audiometer ad229b (interacoustics a/s, assens, denmark). play pure tone and visual reinforced observation audiometry (vroa) were also performed using the same equipment. tympanometry was done with the gsi 38 tympanometer (grason-stadler, inc, milford, nh, usa) while otoacoustic emissions (oae) were measured via otoread (interacoustics a/s, assens, denmark). auditory brainstem response (abr) testing was conducted with the patient under sedation or while sleeping and using the evostar system (pilot blankenfelde mediz. elktr. gerate gmbh, blankenfelde, germany). testing was performed as part of the clinical management of patients. information from all pnei audiology forms for 2006 were reviewed and encoded into analyzable format. the following variables were available from the request forms: name, date of birth, age, sex, address, occupation, referring unit, date of referral, pretest diagnosis, chief complaint and otoscopic findings. these information, including pretest diagnosis, were determined and reported by consultants, residents and/or medical students upon patient consultation or referral. for pure tone audiometry (including play pure tone audiometry), air and bone conduction levels were recorded per ear and per frequency at 250, 500, 1000, 2000, 4000 and 8000 hz whenever possible. when the measurement is indicated as beyond the limits of the audiometer, the default value was set at 120 db. only the latest audiometry result was included in the analysis. to determine severity of hearing, the pure tone average at 500-2000 hz was computed per ear. severity of hearing impairment was reported as normal if the pure tone average was less than 26 db, mild for 26-45 db hl, moderate for 46-60 db hl, moderately severe 61-75 db hl, severe 76-90 db hl and profound for above 90 db hl. 1 the type of hearing impairment was reported as sensorineural if the difference between the averages of air and bone conduction levels at 500-2000 hz (air-bone gap) amount to 10 db or less. on the other hand, if the air-bone gap is greater than 10 db, the hearing impairment was categorized as conductive. when some amount of conductive hearing loss existed while the bone conduction levels indicated sensorineural hearing loss, the hearing impairment was labeled as mixed. for vroa, hearing was categorized as normal at 0-40 db, mild at 41-60 db, moderate 61-80 db, severe 81-100 db and profound if more than 100 db (pnei standard, unpublished). for oae, a “pass” result was recorded for an ear which showed a signal-to-noise ratio of 10 db with an averaged noise floor value of –20 db before the maximum number of samples collected equals 500, and a failure or “refer” result was recorded when the 10 db signal-to-noise ratio was not achieved. standard descriptive statistics were performed with ms excel 2003 (microsoft corp., redmond, wa, usa, 2003) and spss 11.0.1 software (spss inc., chicago, il, usa, 2001). results a total of 1,819 patient records from all referrals for 2006 were reviewed, of which 63 were repeat tests and were therefore not included in analyses. the breakdown according to type of test follows: pure tone audiometry 1,405; play pure tone 105; vroa 56; tympanometry 372; oae 168; abr 15. there were 344 individuals who had at least two tests done, thus, the total number of patient records was less than the sum of all tests performed. patient profile general profile females comprised 50.7% of those tested. the median age was 32.5, ranging from 0 day to 93.1 years. for the age distribution, there were two peaks: one at 0-5 years, the other centered at about age 20. table 1 reports the sex distribution when the age was categorized into arbitrary groups. the pediatric age group (<18 years) accounted for 27.1%, about half of which were toddlers and infants (age 5 and below). majority of the patients (59.5%) belonged to the working age group (ages 18-60), while the remaining 13.4% were elderly. from the patients’ addresses, 1,364 were traced to different regions in the country. as expected, majority (n = 809 or 59.3%) were from the national capital region (ncr). of those from ncr, 232 (28.7%) were from manila, 99 (12.2%) from quezon city, and 68 (8.4%) from parañaque. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles 14 philippine journal of otolaryngology-head and neck surgery outside ncr, region iva had the most patients at 327 (24.0% of total cases); from this pool of patients 148 (45.3%) were from cavite, while 90 (27.5%) came from laguna. only 8.2% resided in region iii, but 63.4% of them (n = 71) lived in bulacan. for the rest of luzon, the number of patients per region follows: car – 3; i -17; ii – 14; ivb 10; v – 26. when several regions were pooled together, 26 patients were from the visayas and 12 from mindanao. there were no patients from the autonomous region of muslim mindanao. only 393 of those aged 18 and above indicated their occupation, which included 37.8% of the working age group. classification by work category was done according to the listing by the department of labor and employment. 2 of those whose jobs were known, 78 were unemployed, 41 were housewives and 21 were laborers or unskilled workers. office workers and clerks numbered 51, while 37 were trade workers, such as factory workers, farmers and garment workers. of the 23 professionals, 14 were teachers. sixteen out of 22 who worked with machines or vehicles were drivers. in addition, 22 worked overseas, mostly as seafarers. the rest were variably distributed into employment for business, technical and associate professional services, sales and service work. the referring unit was reported in 1,171 request forms. seventyseven percent of patients were seen at the charity outpatient service, while 214 (18.3%) were referred by consultants. less than 3% were referred from other departments. the median lag time from referral to testing date was 4 days (range 0 to 302). based on pretest diagnosis, chief complaint and otoscopic findings, a plausible diagnosis was derived for 1,554 patients. the most common diagnosis was chronic otitis media, which totaled 414 or 26.6% of cases. another 54 cases were reported variably as otitis media, acute otitis media, otitis media with effusion, adhesive otitis media, bullous myringitis and eustachian tube dysfunction. seventy-one cases were post-mastoidectomy or post-tympanoplasty. aside from middle ear infections, hearing loss as a complaint or diagnosis with no abnormal otoscopic finding was a common cause of referral (n = 202, 13.0%). thirty-one patients had sensorineural hearing loss clinically while 62 were diagnosed with presbycusis. tinnitus was documented in 144 cases. common diagnoses among children included: cleft palate with or without cleft lip (n = 77); congenital hearing impairment (n = 31); speech delay (n = 44); and multiple congenital anomalies (n = 14). for balance disorders, the following were observed: benign paroxysmal positional vertigo or bppv (n = 25); meniere’s disease (n = 16); cerebellopontine angle tumors (n = 13); dizziness (n = 43); and vertigo (n = 57). hearing screening was requested for 117 cases, plus 16 that were preor postchemotherapy or -radiotherapy. ototoxic hearing impairment was reported in six cases, and noise-induced hearing loss in nine patients. twenty-five referrals were trauma-related. profile per test pure tone audiometry (excluding play pure tone) was performed in patients with a median age of 38.7 years (range 4.3-93.1). five days was the median lag time from referral to testing (range 0-302). common diagnoses included chronic otitis media (n = 404), hearing loss (n = 184) and tinnitus (n = 141). the median age for play pure tone audiometry patients was 5.8 years (range 2.5-16.9). median lag time from referral to testing was 7 days (range 0–100). most common reasons for referral were speech delay (n = 26), congenital hearing impairment (n = 13) and cleft palate + lip (n = 11). for vroa patients, median age was 3.0 (range 0.5-8.0 years) and median referral lag time was 0 day (range 0-64). reasons for referral were similar to play pure tone, including speech delay (n = 9), hearing screening (n = 8), cleft palate + lip (n = 7) and congenital hearing impairment (n = 6). for tympanometry, patients with the following diagnoses had the most number: hearing loss of unknown etiology, 54; chronic otitis media, 52; cleft palate + lip, 44; and tinnitus, 43. median age was 35.7 years (range 0-88.8) while median time from referral to testing was 5 days (range 0-209). median age at oae testing was 10 months (range 0-56 years), with referrals delayed for a median of 2 days (range 0-118) and were usually for cleft palate + lip (n = 48) and hearing screening (n = 18). abr testing was done on 15 patients with a median age of 3.5 (range 8 months to 50 years). median delay for abr testing lasted 7 days (range 1-50 days). note, however, that the abr machine was out-of-service for several months. patients were referred for abr due to speech delay, global developmental delay, congenital hearing impairment, tinnitus, dizziness and vertigo. audiology results pure tone audiometry after combining formal and play pure tone audiometric results, 1,505 records were categorized according to severity based on air conduction levels per ear (table 2). when comparing the different cells in table 2, there seems to be a greater increase in severity of hearing impairment in the high frequencies compared to the speaking frequencies for both ears. the median threshold (+ standard deviation) for the right ear at the speaking frequencies 500-2000 hz was 40 db, while at 4000-8000 hz it was 50 db. for the left ear, the median threshold at 500-2000 hz was 43.3 db and at 4000-8000 hz it was 52.5 db. also on a per frequency basis, based on median values, there is about a 3 db threshold difference between ears. mean speech discrimination score (sds) for the right was 95.8 + 27.9% and for the left 95.7 + 27.9%; median sds was 100% for both ears. to determine differences in hearing thresholds by age, median threshold levels for each age category were computed while differentiating the averages at speaking versus high frequencies for either ear (table 3). it was shown that high-frequency loss of at least 5 db compared to the speaking frequencies began at about age 30 onwards. thresholds at the speaking frequencies also started to drop after age 45. however, it cannot be known if this was due to presbycusis or to the natural progression of disease since this is a non-normative and heterogeneous population. for ages 12 years and less, thresholds were higher as expected due to less reliability in threshold testing at these ages. classification according to type of hearing impairment was possible philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles philippine journal of otolaryngology-head and neck surgery 15 age categories (in years) female male total 0-1 31 73 104 1-5 65 76 141 5-12 59 64 123 12-18 54 52 106 18-30 169 168 337 30-45 187 183 370 45-60 184 150 334 60+ 137 98 235 total 886 864 1750 sex was not indicated for one patient aged 25.8 years. five females and one male did not indicate age. table 1. sex and age distribution of pnei patients for 2006 table 2. severity of hearing impairement based on pure tone audiometry per ear age (yrs) n right, 500-2000 hz right, 6000-8000 hz left, 500-2000 hz left, 6000-8000 hz <12 152 50 50 51.7 52.5 12-18 105 35 37.5 41.7 40 18-30 335 30 30 31.7 35 30-45 358 33.3 42.5 35 45 45-60 325 40 60 41.7 57.5 >60 232 53.3 72.5 58.3 75 table 3. median threshold levels (in db) per age category type right left normal 322 (23.9) 234 (17.4) conductive 373 (27.6) 401 (29.7) sensorineural 410 (30.4) 432 (32.0) mixed 245 (18.1) 281 (20.8) total 1350 1348 some patients required bone conduction level testing in only one ear. percentages are indicated in parentheses. table 4. type of hearing impairment based on pure tone audiometry per ear for 1,350 records with bone conduction levels (table 4), which excluded most of play pure tone tests. about 39% of hearing impairment cases was sensorineural, 36% conductive and 25% due to mixed defect. most of those who tested normal were referred for screening (n = 58), 22 of whom were medical transcriptionists and nine were to undergo chemotherapy. forty-three patients who complained of tinnitus had normal hearing (table 5). mild sensorineural hearing loss was found in 13 patients diagnosed as having bppv and in 67 with dizziness/vertigo/tinnitus, while 141 chronic otitis media patients had mild conductive hearing impairment. for moderate and moderately severe hearing impairment, the most common diagnoses were chronic otitis media and hearing loss of unknown etiology, which was similar to the general profile of patients. compared to other categories of severity, moderately severe hearing impairment occurred more among hearing loss and presbycusis patients (table 5). eleven of 15 patients with congenital hearing impairment and half of patients referred for speech delay (n = 37) had profound loss in at least one ear. figure 1 presents sample audiograms for common diagnoses based on median threshold levels per frequency. visual reinforced observation audiometry among vroa patients (n = 56), classification by severity of hearing impairment resulted in the following: normal, 7 (12.5%); mild, 20 (35.7%); moderate, 7 (12.5%); severe, 8 (14.3%); and profound, 14 (25.0%). of note, all seven cases referred for cleft palate + lip had only mild hearing impairment, with four having type b ears. for the other disease conditions, severity of hearing impairment was varied. tympanometry about half of patients who underwent tympanometry had normal results, followed by type b curves in about 40% (table 6). most of these cases had bilateral concordance in their results, with only a quarter of patients having unilateral disease. almost 30% had both ears as type b. in 86.4% of cleft palate + lip patients (n = 44), at least one ear was type b; 75% were type b bilaterally. remarkably only 88% of chronic otitis media cases (n = 50) had at least one type b ear. when hearing loss etiology was unknown (n = 54), bilateral type a ears were found only 44.4% of the time, that is, in more than half some middle ear pathology may have existed. among tinnitus cases (n = 43), about 40% were not type a bilaterally, indicating possible middle ear disease in at least one ear in these patients. otoacoustic emissions oae results were symmetric in about 90% of cases (table 7). high rates of hearing impairment were seen, with 69.0% labeled as “refer” in at least one ear. only 3 of 48 (6.2%) cleft palate + lip cases had “pass” results for both ears. on the other hand, 55.6% of children referred for hearing screening had at least one ear as “refer”. additionally 3 of 7 preterm babies had bilateral impairment, and 1 of 7 patients for chemotherapy was affected bilaterally. five of nine babies with suspected congenital hearing impairment were “refer” for at least one ear, while only one of 12 children with multiple congenital anomalies passed for both ears. severity right, 500-2000 hz right, 6000-8000 hz left, 500-2000 hz left, 6000-8000 hz normal 428 (28.4) 401 (26.6) 337 (22.4) 350 (23.3) mild 431 (28.6) 311 (20.7) 418 (27.8) 306 (20.4) moderate 209 (13.9) 204 (13.6) 226 (15.0) 203 (13.5) moderately 181 (12.0) 197 (13.1) 214 (14.2) 214 (14.2) severe severe 109 (7.2) 141 (9.4) 115 (7.6) 161 (10.7) profound 147 (9.8) 251 (16.7) 195 (13.0) 269 (17.9) total 1505 1505 1505 1503 five play pure tone records were not included because of lack of distinction of hearing impairment severity according to frequency. another two did not have high frequency thresholds for the left ear. percentages are indicated in parentheses. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles 16 philippine journal of otolaryngology-head and neck surgery table 5. number of cases according to severity of hearing impairment for common diagnoses* severity com† post-surgery hearing loss ‡ tinnitus presbycusis§ normal 26 (6.4) 5 (7.0) 17 (8.8) 43 (30.5) 1 (1.6) mild 144 (35.4) 25 (35.2) 44 (22.8) 56 (39.7) 11 (17.7) moderate 97 (23.8) 10 (18.3) 36 (18.7) 21 (14.9) 11 (17.7) moderately severe 67 (16.5) 10 (18.3) 52 (26.9) 14 (9.9) 27 (43.5) severe 48 (11.8) 6 (8.5) 22 (11.4) 4 (2.8) 8 (12.9) profound 25 (6.1) 9 (12.7) 22 (11.4) 3 (2.1) 4 (6.5) total 407 71 193 141 62 *severity was based on mean thresholds from 500-2000 hz averaged between two ears. percentages are indicated in parentheses. †com = chronic otitis media. ‡eight of 17 patients who complained of hearing loss but had normal hearing at 500-2000 hz had at least mild impairment in the high frequencies. §a presbycusis patient had normal hearing at speaking frequencies but had mild to moderate highfrequency impairment. type right* left* bilateral cases† a 192 (51.9) 185 (50.0) 169 (45.4) ad 9 (2.4) 17 (4.6) 0 as 15 (4.1) 8 (2.2) 0 b 146 (39.5) 151 (40.8) 109 (29.3) c 8 (2.2) 9 (2.4) 2 (0.5) total 370 370 280 (75.3) *some patients could not be tested, two for the right and two for the left ear. percentages based on total per ear are indicated in parentheses. †percentages reported were based on total number of tests performed (n = 372). table 6. tympanometry results per ear, with number of cases that were bilateral result right* left* bilateral cases† pass 63 (37.5) 57 (33.9) 52 (31.0) refer 105 (62.5) 111 (66.1) 100 (59.5) total 168 168 152 (90.5) *percentages based on total per ear are indicated in parentheses. †percentages reported were based on total number of tests performed (n = 168). table 7. otoacoustic emissions results per ear, with number of cases that were bilateral auditory brainstem response seven of 12 children who were tested with abr had intact auditory pathways, while three children had profound hearing loss in at least one ear. there was concordance with oae in four cases. three adults were diagnosed with retrocochlear lesions; each was referred for different symptoms of dizziness, tinnitus and vertigo. discussion in this article, the annual statistics of the pnei based on patient and audiologic records were comprehensively reviewed. the pnei serves a mass-based population that extends over 16 of 17 country regions and a wide range of age groups from newborn to elderly which parallels the national demographic distribution. it also offers audiologic services to both charity and pay patients, and a majority block of working-age individuals that encompasses both the unemployed and workers across a variety of job strata, including laborers, workers in the trade, service and sales sectors, office and business personnel and professionals. although majority of the patients’ diseases were otologic, a wide spectrum of otorhinolaryngologic diseases, including rhinologic and oncologic entities, was studied in tandem with audiologic measurements. therefore, it can be safely said that the pnei is a major national referral center for audiology that holds much promise in providing not only direct services but also national surveillance of hearing status among different sectors of philippine society. among the statistics that were available, the reasons for referral and pretest diagnoses when examined along with the results of different testing methods and also the different age groups may be useful to health providers. this gives rough estimates of prevalence rates for disease and audiologic states and establishes what kind of audiologic services must be provided to the population at large. although it is well-known to filipino otorhinolaryngologists that chronic otitis media is the most common otologic disease in practice that requires medical, surgical and audiologic interventions, it was shown that inner ear diseases comprise a major proportion of diseases as well. common causes of sensorineural hearing loss (e.g. congenital, presbycusis), vertigo and tinnitus, with normal tympanometry, altogether accounted for at least 317 cases or 18.1% of referrals. in comparison, middle ear diseases, if taken together, represent at least 40.6%. this may signal an increase in awareness of neurotologic disease among health practitioners, and at the same time a need to reassess current programs for possible expansion of subspecialty services. one limitation of this study, however, is the large amount of missing data particularly for occupation, region of origin and pretest diagnosis. also lag times from referral to testing was longest for abr and play pure tone, which may imply lack of patient resources and/or limitations in current capacity for pnei, and may translate to increased dropout rates. it may then be required to reformat the current system of referral to pnei and improve equipment and personnel availability to ensure better coverage of information. it is also notable that a very low percentage of referrals came from non-otorhinolaryngologic units. this may necessitate a campaign to other medical specialties on the philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles philippine journal of otolaryngology-head and neck surgery 17 indications for referral for audiology and the availability of such services at pnei. newborn hearing screening, for example, should be championed among pediatricians and obstetricians to ensure a bigger population for oae and abr screening. from the “refer” rates in this study, it was obvious that hearing screening was very much limited to the highrisk child population. the prevalence for “refer” rates for one year of age or less was 71.3%, much higher than previously reported.3-5 even though a tertiary care population was described and, therefore, hearing impairment prevalence was expected to be high, if the pool for newborn hearing screening is not expanded, the prevalence estimate for congenital and early-life hearing impairment will remain high. at face value this may mean that the truly at-risk population is better targeted for service, but in reality it also means that a larger segment of the newborn to infant population is missed for hearing screening, which has great implications on speech and language development for those who are missed. 6 among the different age groups, school-age children formed the smallest group, with children aged 5-18 making up 13.1% of the total. because the pnei is open only during office hours, this low number may reflect conflict with school hours rather than hearing health. extension and research activities for hearing screening among schoolchildren are therefore very much needed. another target for outreach services are those provinces that are close enough to pnei for patients to travel for testing and, therefore, for current lack of audiologic services within their community, patients from these provinces flock to pnei. at the same time far-flung regions that are known not to have existing audiologic services should also be targeted for outreach hearing screening. the elderly population, a traditionally underserved segment, comprised 13.4% of audiologic patients. as expected, presbycusis was diagnosed mostly within this age group, with 23.8% of those aged 60 and above having presbycusis. however it was shown in table 3 that drops in threshold at high frequencies start to occur from about age 30. the contribution of noise and other disease states to this process is not known. it also remains to be seen whether high-frequency losses from aging should be considered “expected-for –age (and sex)” as is followed in current international standards, 7 or whether such losses are definitely pathologic. establishment of normative values for the filipino population across age and sex would therefore likely impact current standards in national audiologic practice. (a) com (b) post-surgery (c) hearing loss (d) tinnitus (e) presbycusis figure 1. sample audiograms for common diagnoses based on median hearing thresholds per frequency, including both air and bone conduction levels. total numbers of patients per disease category are shown in table 4, except for hearing loss (n=184). com = chronic otitis media. post surgical cases include patients who underwent mastoidectomy and/or tympanoplasty. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles 18 philippine journal of otolaryngology-head and neck surgery in conclusion, the pnei, being located within the national tertiary care hospital, has high rates of prevalence for a wide variety of otologic diseases and audiologic abnormalities. to fulfill its basic objectives, the pnei is looking forward to better preventive health care by planning to extend current services more towards hearing screening of a wider segment of the filipino populace, including hearing surveillance across different age groups, country regions and labor sectors. acknowledgement: we are grateful to melody francisco and to drs. ma. elaine villanueva, rowald rey malahito and omar carlo sebastian for data encoding. we also thank the students of the master of clinical audiology program and also drs. sebastian, malahito and villanueva for their invaluable help in testing the patients’ hearing. references: 1. yantis pa. pure tone air-conduction threshold testing. in: katz j, editor. handbook of clinical audiology. 4th ed. baltimore, md: williams & wilkins; 1994. p.107. 2. republic of the philippines department of labor and employment [homepage on the internet]. manila: department of labor and employment; c2005-2007 [cited 2007 march 16]. available from: http://www.dole.gov.ph/. 3. llanes eg, chiong cm. evoked otoacoustic emissions and auditory brainstem responses: concordance in hearing screening among high-risk children. acta otolaryngol. 2004 may; 124(4):387-90. 4. quintos mr, isleta pf, chiong cc, abes gt. newborn hearing screening using the evoked otoacoustic emission: the philippine general hospital experience. southeast asian j trop med public health. 2003; 34 suppl 3:231-3. 5. chiong cm, llanes egd, tirona-remulla an, calaquian cm, reyes-quintos mr. neonatal hearing screening in a neonatal intensive care unit using distortionproduct otoacoustic emissions. acta otolaryngol. 2003 jan; 123(2):215-8. 6. yoshinaga-itano c, sedey al, coulter dk, mehl al. language of earlyand later-identified children with hearing loss. pediatrics. 1998 nov; 102(5):1161-71. 7. iso 7029. acoustics: threshold of hearing by air conduction as a function of age and sex for otologically normal persons. geneva: international organization for standardization; 1984. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 6362 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 passages the only reason why i wanted to become an ent as early as third year medical student was solely because of dr. llamas. he would literally deliver his lecture verbatim from boise’ textbook of otolaryngology including pauses for commas. he inspired me a lot and told myself, i wish i could do at least half of what he could memorize and that would be good enough. he was very open to inviting graduates from other institutions to join the department as exemplified by the acceptance of dr. carlos reyes for otology and dr. robie zantua for head and neck surgery. he was never threatened by other consultants practicing at ust and in fact encouraged them to do so. he was a dedicated father to his children rose, jun, beth and annie and a devoted husband to his wife lulu. he would always think of his family’s welfare over his own. his extended family would always seek his support whenever the need arose, and he would welcome them with open arms. to the family, thank you for generously sharing dr. llamas during his most productive years. the best tribute the pso-hns offered to dr. llamas was choosing him as the most outstanding teacher in 2020. we would not be where we are today if not for the selfless dedication of our dear dr. llamas. as thornton wilde said, “the highest tribute to the departed is not grief but gratitude”. maraming salamat at paalam! dr. eusebio e. llamas was the epitome of a great teacher, a devoted father and a prime mover. in 1952, he underwent residency training in bellevue, new york where he stayed for one year and then proceeded to los angeles where he trained at the house ear institute. upon his return to the philippines, he joined the ust department of eent and subsequently became the section chief of ent. in 1978, he assumed the chairmanship of the department of eent until 1983. as prime mover, he was instrumental in the separation of the dept. of otolaryngology from the dept. of ophthalmology in 1984 and led the department until 1989 earning the distinction of becoming the longest serving chair. he would invite residents (who were in awe of his demeanor in handling patients) to see interesting cases in his private clinic. he demonstrated compassion to all patients regardless of their social status. in the operating room, he exemplified finesse in doing surgeries and made it look so simply seamless. he never showed any mean streak and always appeared calm even amid adversity. whenever there were issues in the department or among residents, he would talk to them in private and would counsel them like a father to his children. he was deeply religious as he would go to the chapel first thing in the morning before he went to the opd at 8 am sharp. he taught the residents the virtue of punctuality by being at the opd ahead of them, and 30 minutes in advance of his scheduled operations. he was impeccable in his choice of apparel, always dressing up with the perfect triangle of the windsor tie. eusebio e. llamas, md (1926-2021) norberto v. martinez, md “small in feet but giant in feat” philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2023; 38 (1): 45-49 c philippine society of otolaryngology – head and neck surgery, inc. delay and completion of treatment in head and neck cancer patients employing a multidisciplinary team approach: a single institution experience jamel maita n. manaig, md1 adrian f. fernando, md1 kelvin ken l. yu, md2 1department of otorhinolaryngology head and neck surgery university of santo tomas hospital 2department of radiation oncology university of santo tomas hospital correspondence: dr. adrian f. fernando department of otorhinolaryngology head and neck surgery university of santo tomas hospital españa boulevard, sampaloc manila 1015 philippines phone : (632) 8731 3001 local 2478 email : usth.orlhns@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery virtual analytical contest (2nd place) november 16, 2022 via zoom. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international abstract objective: to explore possible associations of a multidisciplinary team approach compared to a non-multidisciplinary team approach on delay and completion of treatment of head and neck cancer patients. methods: design: historical cohort study setting: tertiary private training hospital participants: a total of 240 records of head and neck cancer patients from january 2016 and december 2018 were included in the study; 117 underwent a multidisciplinary team approach and 123 underwent a nonmultidisciplinary team approach. results: only 24.79% of head and neck cancer patients under the multidisciplinary team approach had treatment delays compared to 37.40% under the non-multidisciplinary team approach. the proportion of treatment delays was significantly higher (χ2 = 4.44, p = .035) with the non-multidisciplinary team approach. comparative treatment completion of 77.78% and 69.11% under the multidisciplinary and non-multidisciplinary team approaches, respectively, were not significantly different (χ2 = 2.31, p = .129). conclusion: the multidisciplinary approach might be associated with decreased delay in treatment among patients with head and neck cancer compared to the non-multidisciplinary team approach. a possible trend toward better treatment completion rate was also observed, but it did not reach statistical significance. keywords: patient care team; head and neck neoplasms; time-to-treatment; treatment completion; appointment and schedules; neoplasm staging philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery original articles multidisciplinary care (mdc) or the multidisciplinary team (mdt) in oncology is a collaboration of specialized medical professionals involved in cancer care with an overall goal of improving treatment efficiency and patient care.1 mdt planning is integral in head and neck cancer management. the mdt consists of a regulated committee that reviews all new cancer patients and agrees on the therapeutic plan proposed by medical and radiation oncologist and surgical specialists based on their clinical expertise and the evidence available to date.1 this approach establishes a complete assessment of each patient prior to the start of the treatment.2 the use of mdts in cancer care is endorsed internationally, although uptake varies.1,2 it has been adopted in several countries, but remains a less common model of cancer care in our local setting. it is important to maintain the patient at the core of every decision and comprehend the multidisciplinary process to deliver effective multidisciplinary care and promote treatment care involvement.3 head and neck cancer management is usually time sensitive. quantitative and qualitative measures are important bases for the success of management.4 a study showed that patients seen in a multidisciplinary clinic had fewer treatment delays, improved treatment efficacy and completeness of care.4 similar findings cannot be inferred locally as significant differences exist in different geographic areas, and there is paucity of evidence for these outcomes in the local setting. this historical cohort study aims to explore possible associations between the multidisciplinary team approach compared to the non multidisciplinary team approach on treatment delay and completion among head and neck cancer patients. as a secondary objective, the presence of treatment delay and treatment completion among early and late staged subgroups of head and neck cancer patients are analyzed based on the management approach (mdt vs non-mdt) methods with the approval of the university of santo tomas hospital research ethics committee (rec-2021-06-084-tr-fr), records of patients diagnosed with primary head and neck cancer malignancy and referred to the ust hospital benavides cancer institute from january 2016 to december 2018 were considered for inclusion. a list of all head and neck cancer patients was obtained from the patient registry of our cancer institute. patient charts were retrieved and reviewed to identify whether they met inclusion and exclusion criteria, and whether an mdt approach or non-mdt approach was performed in the management of the patient. records of all patients with primary head and neck cancer who underwent any form and combination of treatment (medical, surgical, or radiotherapy) in the ust hospital benavides cancer institute from january 2016 to december 2018 were considered for inclusion. those with incomplete medical records were excluded. the clinical profiles of eligible patients were collected using a standardized and anonymized data collection form. a reference number was assigned to each patient record and was only known to the authors. in addition, multidisciplinary consultation data forms used during the mdt meetings were also used as references. sample size computation for two independent sample proportions was conducted using g*power version 3.1.9.4. (available from https:// www.psychologie.hhu.de/arbeitsgruppen/allgemeine-psychologie-undarbeitspsychologie/gpower). using the study of townsend, et al.4 the proportion of respondents with treatment delays was 41% for those who received the multi-disciplinary treatment (mdt) approach, while those who did not receive the mdt approach had a treatment delay of 59%. with these parameters and with a minimum power of 80% at a significance level of 5% (two-tailed), a minimum sample size of 240 charts was needed. the definition of treatment delay was based on the townsend et al. definition of greater than 30 days from the day of referral to treatment initiation.4 treatment completion was defined as accomplishing the primary therapy discussed and agreed upon by the patient and the health care team (for multidisciplinary team approach) or their primary care physician (for non-multidisciplinary team approach). data were analyzed using stata statistical software, version 13 (stata corp lp, college station, tx, usa). a p-value of .05 was considered statistically significant. descriptive statistics (mean and standard deviations, frequencies and percentages) were used for variables like age, gender, division, tumor site, stage, and treatment rendered to describe outcome variables. inferential statistics included between-group comparative analyses using the chi-square test of homogeneity and independent t-test to compare outcome variables such as treatment delay and completion according to approach (multidisciplinary versus non-multi-disciplinary) and stage status (early versus late stage). results a total of 240 head and neck cancer patient records from january 2016-december 2018 were included in this study, wherein 117 underwent a multidisciplinary team approach and 123 underwent a nonmultidisciplinary team approach. the mean age of patients was 53.76 years old (sd = 16.75), and it was statistically higher philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery original articles number of participants who had surgery alone (11.97% vs. 2.44%, χ2 = 8.27, p = .004) or had a combination of all the three treatment options (29.06% vs. 10.57%, χ2 = 13.02, p = .001) were significantly higher in the multidisciplinary team approach group than in the nonmultidisciplinary team approach group. the between-group comparisons of delay and completion of treatment among the head and neck cancer patients according to management approach showed that 37.40% of participants in the non-multidisciplinary team approach had treatment delays, while 24.79% in the multidisciplinary team approach had treatment delays. comparative analysis indicated that the proportion of treatment delays was significantly higher (χ2 = 4.44, p = .035) in the non-multidisciplinary team approach, with an effect size of 1.85% denoting that 1.85% of the difference in proportion may be attributed to the multidisciplinary team approach. on the other hand, results showed that the proportions of treatment completion were 69.11% and 77.78% in the non-multidisciplinary team approach and the multidisciplinary team approach groups, respectively, which were not significantly different (χ2 = 2.31, p = .129). table 1 shows the between-group comparison of delay and completion of treatment of the early and late stages of head and neck cancer patients according to management approach. among those in the early stage, results indicated that 40% and 90% of those in the non-multidisciplinary team approach group had treatment delays and treatment completion, respectively; on the other hand, those in the multidisciplinary team approach group had a 26.09% treatment delay and 82.61% treatment completion. comparative analyses indicated that the proportion of treatment delays and treatment completion between the two approaches among early-staged cancers were not statistically different. among those in the late or advanced stage, results showed anote: mdt = multidisciplinary team approach; nmdt = non-multidisciplinary team approach *significant at 0.05 †significant at 0.01 table 1. comparison of the delay and completion of treatment of the early and late stages of head and neck cancer patients according to the management approach (n = 240) presence of treatment delay treatment completion nmdt (n=30) 12 (40.00%) 27 (90.00%) mdt (n=23) 6 (26.09%) 19 (82.61%) total (n=53) 18 (33.96%) 46 (86.79%) test statistic (p-value) 1.12 (.384) 0.62 (.451) effect size 2.12% 1.17% nmdt (n=93) 34 (36.56%) 58 (62.37%) mdt (n=94) 23 (24.47%) 72 (76.60%) total (n=187) 57 (30.48%) 130 (69.52%) test statistic (p-value) 3.23 (.082) 4.47 (.035) effect size 1.72% 2.39% clinical stage and management approacha early stage (n=53) late or advanced stage (n=187) outcomes (t = 2.12, p = .035) among the non-multidisciplinary team approach group (x= 56.09, sd = 15.75) than the multidisciplinary team approach group (x= 51.54, sd = 17.42). in addition, most of the respondents were males (60.42%), and the male to female ratios for the two approaches were not significantly different (χ2 = 1.30, p = .255). most patients came from the private division (51.67%), and comparative analysis showed that the proportion of patients in the non-multidisciplinary team approach group who came from the private division (66.67%) was significantly higher (χ2 = 22.73, p = .001) than those from the multidisciplinary team approach group. the three most prevalent tumor sites were the nasopharynx (35.42%), larynx (14.58%), and oral cavity (12.50%). between-group comparisons according to approach also showed that the number of patients in the non-multidisciplinary team approach group who had tumors in the nasopharynx (44.72% vs. 25.64%, χ2 = 3.09, p = .002), lymph nodes (8.13% vs. 1.70%, χ2 = 2.29, p = .022), thyroid (6.50% vs. 0.85%, χ2 = 2.30, p = .021), and orbit (4.87% vs. 0.00%, χ2 = 2.42, p = .016) were significantly higher than those in the multidisciplinary group. on the other hand, results showed that compared to the multidisciplinary team approach, the number of patients in the non-multidisciplinary team approach who had tumors in the larynx (8.94% vs. 20.51%, χ2 = 2.54, p = .011), paranasal sinuses (0.00% vs. 9.40%, χ2 = 3.48, p = .001), and oral cavity (2.44% vs. 23.08%, χ2 = 4.83, p = .001) were significantly lower. most participants were also in the late or advanced stage (77.92%). in terms of the treatment, most participants underwent a combination of treatment modalities. in particular, most participants had a combination of chemotherapy and radiotherapy (43.75%), a combination of all treatment options (19.58%), or a combination of surgery and radiotherapy (14.58%). results also showed that the philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery original articles that the non-multidisciplinary team approach group had a 36.56% treatment delay and 62.37% treatment completion, while those in the multidisciplinary team approach group had a treatment delay of 24.47% and a treatment completion of 76.60%. although comparative analyses among those in the late or advanced stage showed that the proportion of treatment delays between the two approaches were not statistically significant (χ2 = 3.23, p = .082), it can be noted that the proportion of treatment completion was significantly higher (χ2 = 4.47, p = .035) among those in the multidisciplinary team approach (76.60%) than in the non-multidisciplinary team approach (62.37%). in addition, the effect size for treatment completion was 2.39%, suggesting that 2.39% of the difference in the proportion of treatment completion may be attributed to the multidisciplinary team approach. discussion in terms of the primary objective, the performance of mdt was associated with lower rates of treatment delay. not only does it potentially show that mdt can be beneficial, but it refutes suggestive evidence from the literature that scheduling mdts can cause time delays in management.5 a large, retrospective study supported an association of decreased survival with longer times to treatment initiation.6 our study had similar results to those of townsend et al. showing that mdt cohorts had fewer instances of treatment delay.4 according to nash et al., initial consultation with a member of the head and neck mdt may be associated with fewer treatment delays.7 these fewer delays mentioned in their study are likely to be due to the following reasons: first, mdt ensures provision of pertinent clinical information which prevents delaying patient discussion until a later mdt meeting. second, mdt allows triaging of highly concerning patients seen in clinic requiring more pressing treatments. lastly, through improved networking among different subspecialties and diagnostic services, diagnostic tests and ancillaries can be facilitated expeditiously.7 murphy et al. showed that time to treatment initiation can independently affect the overall survival of patients with head and neck squamous cell carcinoma in that those with more than 46 to 52 days of time to treatment initiation can lead to increase mortality risk.6 on the other hand, in terms of treatment completion, the trend toward benefit with the use of the mdt approach requires a larger sample size to further confirm statistical significance. despite this, it seemed logical to infer that a reduction of treatment delay would likely translate to a greater proportion of treatment completion but this needs further study. important differences between mdt and non-mdt approaches warrant pointing out. most patients who had mdt were from the clinical division or service wards, while most private division patients utilized the non-mdt approach which is likely related to the financial cost of having a multidisciplinary team under the private division while being free of charge when done under the clinical division. this result suggests that the mdt is underutilized in the private division. moreover, our study had similar results to those of friedland and colleagues5 in terms of tumor sites, where the mdt approach was utilized more frequently in the following cancers: larynx, paranasal sinuses, oral cavity while the non-mdt approach was significantly utilized more among tumors of the nasopharynx, lymph nodes, thyroid and orbit. the result may be attributed to the complexity of laryngeal, paranasal sinus and oral cavity cancers in terms of treatment which is typically multimodal.8 in terms of staging, it is worth noting that most of the patients who underwent mdt were already diagnosed at a late stage with the majority already having stage iv disease. this possibly reflects the nature of late-stage cancers, which are often multisystemic and requires more therapeutic approaches in contrast to early stages of the disease, which are usually locoregional. this also possibly reflects how the filipino physician’s referral practices are usually reserved for late stages of disease.9 this contrasts with standard practices where the mdt approach is utilized in cancer patients, regardless of the stage. in terms of the type of treatment, those who had mdt were more likely to undergo a specific treatment regimen, whether single or multimodal. this data is suggestive that the performance of mdt can influence treatment decisions in that it can encourage patients to proceed with multimodality treatment regimens. this is exemplified in the study of agarwal et al. wherein the rate of any treatment, majority of which are multimodal, was higher among patients who underwent mdt (75%) vs non-mdt (61%); (or 2.80, 95% ci 1.71–4.59, p < .0001).10 for the secondary objective, table 1 showed that the incidence of treatment delay was statistically similar whether the patient was diagnosed at an early stage or a late stage. this may indicate that the stage of diagnosis does not significantly affect the timing of initiation of necessary treatment. this is important because it disproves the notion in the literature that mdt for early-stage cancers is not necessary as it can paradoxically lead to time delay for straightforward cases and as such, the mdt scheduling delays outweighs its intended benefits.6 to the best of our knowledge, based on a search of herdin plus and medline (pubmed) using the search terms “multidisciplinary team”, “mdt”, “head and neck cancer”, this is the first local study to look at the effect of the mdt approach among filipino head and neck cancer patients. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery original articles references 1. taberna m, gil moncayo f, jané-salas e, antonio m, arribas l, vilajosana e, peralvez torres e, mesía r. the multidisciplinary team (mdt) approach and quality of care. front oncol. 2020 mar 20;10:85. doi: 10.3389/fonc.2020.00085; pubmed pmid: 32266126; pubmed central pmcid: pmc7100151. 2. shellenberger td, weber rs. multidisciplinary team planning for patients with head and neck cancer. oral maxillofac surg clin north am. 2018 nov;30(4):435-444. doi: 10.1016/j. coms.2018.06.005; pubmed pmid: 30173901. 3. achieving best practice cancer care: a guide for implementing multidisciplinary care. melbourne australia: metropolitan health and aged care services division, 2007, pp. 1-18. [cited 2021 july 28] available from: https://content.health.vic.gov.au/sites/default/files/ migrated/files/collections/policies-and-guidelines/m/multidisciplinarypolicy0702---pdf.pdf. 4. townsend m, kallogjeri d, scott-wittenborn n, gerull k, jansen s, nussenbaum b. multidisciplinary clinic management of head and neck cancer. jama otolaryngol head neck surg. 2017 dec 1;143(12):1213-1219. doi: 10.1001/jamaoto.2017.1855; pubmed pmid: 29075744; pubmed central pmcid: pmc5824300. 5. friedland pl, bozic b, dewar j, kuan r, meyer c, phillips m. impact of multidisciplinary team management in head and neck cancer patients. br j cancer. 2011 apr 12;104(8):1246-8. doi: 10.1038/bjc.2011.92; pubmed pmid: 21448166; pubmed central pmcid: pmc3078600. 6. murphy ct, galloway tj, handorf ea, egleston bl, wang ls, mehra r, flieder db, ridge ja. survival impact of increasing time to treatment initiation for patients with head and neck cancer in the united states. j clin oncol. 2016 jan 10;34(2):169-78. doi: 10.1200/ jco.2015.61.5906; pubmed pmid: 26628469; pubmed central pmcid: pmc4858932. 7. nash r, hughes j, sandison a, stewart s, clarke p, mace a. factors associated with delays in head and neck cancer treatment: case-control study. j laryngol otol. 2015 apr;129(4):383-5. doi: 10.1017/s0022215115000687; pubmed pmid: 25788249. 8. gődény m. prognostic factors in advanced pharyngeal and oral cavity cancer; significance of multimodality imaging in terms of 7th edition of tnm. cancer imaging. 2014 apr 28;14(1):15. doi: 10.1186/1470-7330-14-15; pubmed pmid: 25608735; pubmed central pmcid: pmc4331821. 9. manalo mf. barriers and potential solutions to physician referrals to palliative care service in the philippines. [cited 2023 april 03] available from: https://www.salzburgglobal.org/fileadmin/ user_upload/documents/2010-2019/2016/session_562/barriers_and_potential_solutions_ to_physician_referrals_to_palliative_care_in_the_philippines.pdf . 10. agarwal pd, phillips p, hillman l, lucey mr, lee f, mezrich jd, said a. multidisciplinary management of hepatocellular carcinoma improves access to therapy and patient survival. j clin gastroenterol. 2017 oct 1;51(9):845-9. doi:  10.1097/mcg.0000000000000825; pubmed pmid: 28877082. this study has its own limitations, such as the lack of other relevant outcomes. other pertinent outcomes, such as survival rates and tumor response, were incomplete during the review of medical charts which would have been ideal to include in the study. the population was deemed heterogenous and therefore there may be other unidentified confounders that could have affected the results of the study. moreover, a larger sample size may improve power of the study which can possibly detect significant differences instead of trends toward benefit for treatment completion. we recommend performing a larger prospective correlation or cohort study to further characterize other pertinent outcomes such as mortality rates (both overall mortality rate and case specific mortality rate), tumor response rate, and possibly, cost-benefit analyses. this recommendation is relevant and necessary to improve the management of head and neck cancers; however, this would require a long follow-up period and funding. in conclusion, the performance of the mdt approach is associated with decreased treatment delays among patients with head and neck cancer in this study. there was also an associated trend toward benefit for the treatment completion rate, but it did not reach statistical significance. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 review article philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery abstract objective: to review the effectiveness of intravenous tranexamic acid in reduction of blood loss, surgical time and field visualization among patients who underwent endoscopic sinus surgery (ess) for chronic rhinosinusitis (crs). methods: data sources: medline (pubmed), embase, sciencedirect, herdin, and the cochrane library. eligibility criteria: randomized controlled trials (rct) between 2005-2014 that evaluated the effects of tranexamic acid or placebo in patients undergoing ess for crs. appraisal and synthesis methods: articles were selected by 2 independent reviewers and methodological quality was blindly evaluated using a jadad scale. data were compiled in tables for analysis of outcome measures (estimated blood loss, length of surgery and intraoperative surgical field visualization). results: two trials were included in the study, enrolling 128 patients. one arm of the study had been given tranexamic acid while the other arm was given placebo (saline solution). results varied for both studies. the summary of the observed difference for blood loss had a standardized mean difference of -51.20 (ci 95 [-59.44, -42.95]) showing that the blood loss in milliliters was less in the tranexamic group compared to saline solution. the summary of the observed difference in surgical time had a standardized mean difference of -19.32 (ci 95 [-24.21, -14.43]) showing that the surgical time in minutes was shorter in the tranexamic group compared to saline solution. the secondary outcome on surgical field visualization was not pooled together because the studies used different measurement scales. limitations: the most important weaknesses of the 2 included studies were the differences in dose of tranexamic acid, scales of measurement of field visibility and age groups of the patients. conclusion: tranexamic acid reduced blood loss and shortened surgical time after ess among patients with crs. however, the additional benefit of tranexamic acid for better field visualization was not clear. adverse effects were not considered in this study, however, results support the use of intravenous tranexamic acid intraoperatively as an option for ess with blood loss as a concern. further randomized clinical trials and an update on the systematic review will strengthen the evidence on the effectivity of tranexamic acid for ess. the effectiveness of intravenous tranexamic acid on blood loss and surgical time during endoscopic sinus surgery: a systematic review jona minette e. ligon, md natividad a. almazan, md, msc department of otorhinolaryngology head and neck surgery east avenue medical center correspondence: dr. jona minette e. ligon department of otorhinolaryngology head and neck surgery 6th floor, east avenue medical center east avenue, diliman, quezon city 1100 philippines phone: (632) 928 0611 local 324 fax: (632) 435 6988 email: ladyarcher11@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery analytical research contest. october 23, 2014. unilab bayanihan center, pasig city. philipp j otolaryngol head neck surg 2016; 31 (2): 8-12 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 review article philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery keywords: tranexamic acid, endoscopic sinus surgery, bleeding time endoscopic sinus surgery (ess) is a useful and widespread technique, popular among otolaryngologists, that allows the treatment of a large number of nasal pathologies with the aim of maintaining physiological function and anatomical structure.1 the most common complication during ess is bleeding2 which in excess, can hinder completion of surgery by reducing intraoperative visualization of the field. various techniques (including hypotensive anesthesia, reverse trendelenberg positioning, and administration of local vasoconstrictors) have been used by surgeons to reduce this complication.1,3,4 tranexamic acid is an antifibrinolytic drug that can be administered to decrease intraoperative bleeding. in the clotting cascade, it serves to stabilize the fibrin clot to reduce bleeding.5 tranexamic acid has been used extensively in certain surgical procedures and has been shown to limit bleeding with no increase in adverse events.5 there have been many studies on the effect of tranexamic acid in reducing blood loss in surgeries6-8 but we were particularly interested in those involving ess. the aim of this study is to determine the effectiveness of intraoperative intravenous tranexamic acid in comparison to normal saline in reduction of blood loss and duration of operation among patients undergoing endoscopic sinus surgery. surgical field visualization was also compared as a secondary outcome. methods protocol and registration the methods for analysis and criteria for this review were specified and documented in advance. this secondary research protocol was neither registered nor reviewed by an institutional review board. eligibility criteria studies: randomized clinical trials (rct) in english on the effects of intravenous tranexamic acid compared to placebo in sinus surgeries from 2005 to 2014 were considered for inclusion. participants: patients of both sexes and all ages who underwent ess for crs were included. those who underwent previous ess, had cardiovascular pathology, bleeding disorders, hypertension, kidney or liver dysfunction, anemia or were taking anti-coagulants were excluded. interventions: trials comparing the effect of intraoperative intravenous tranexamic acid and saline solution (placebo) were included. the trials given oral or topical tranexamic acid were excluded. outcome measures: the primary outcomes were intraoperative blood loss and surgical time. the secondary outcome was visualization of the surgical field. the wormald9 grading scale used by langille et al.5 and the 5-point scale adapted from boezaart et al.10 by eldaba et al.2 were used in this study. information sources and search methods we searched the following electronic bibliographic databases medline (pubmed), embase, sciencedirect, herdin and the cochrane library (cochrane database of systematic reviews, cdsr). we included studies in english published between 2005 and 2014. several databases were used to ensure that relevant articles were identified, as publication bias was more likely to be found if only one to two databases were used. the following subject headings and text words, and their combinations, were included in the medline search strategy: “bleeding and endoscopic sinus surgery”, “tranexamic acid and randomized clinical trials,” “bleeding and functional endoscopic sinus surgery”, “bleeding and endoscopic sinus surgery and randomized clinical trials”, ”tranexamic acid or functional endoscopic sinus surgery and randomized clinical trials”, “tranexamic acid and randomized control trials and sinus surgery”, “bleeding or functional endoscopic sinus surgery and tranexamic acid and randomized clinical trials”. the files and library of east avenue medical center department of otolaryngology-head and neck surgery and main libraries were also searched for unpublished papers with the same topic. additionally, we searched manually through the reference lists of the identified articles. study selection the search included all randomized controlled trials comparing intraoperative intravenous tranexamic acid and placebo (saline solution) among patients who underwent ess. there were no restrictions on eligibility according to drug dosing, duration given and we did not exclude specific populations or age groups. screening process two independent reviewers screened the citation titles and abstracts using a predesigned form. titles and abstracts that clearly did not meet inclusion criteria were excluded. for titles fulfilling inclusion criteria, full-text articles were obtained. conflicting results were resolved by consulting a third reviewer. assessment of methodological quality studies that met the criteria for inclusion were assessed independently by 2 reviewers for methodological quality using the jadad scale.11,12 randomization, blinding and dropouts were verified in each study. the range of possible scores was 0 (bad) to 5 (good). studies with a score of 4 or higher in the jadad scale were included in the study. data abstraction and analysis the data was abstracted in duplicate. information was extracted from the original reports on standardized forms. all data was entered in review manager 5 (revman v.5.2, the cochrane collaboration, 2012, copenhagen). the primary outcomes were amount of blood loss and surgical time. the secondary outcome was visualization of the field. there was no access to individual data from the authors so we used the summary data provided in the publication. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 review article 10 philippine journal of otolaryngology-head and neck surgery the jadad scale to assess risk of bias was independently used by the 2 reviewers. there were no disagreements. the fixed effect model was used to combine the treatment effect estimates from the individual studies. the combined estimate of treatment effect was reported with 95% confidence interval. between-study heterogeneity was assessed using i2 measure and a formal hypothesis test. forest plots showing the effect estimates of the individual studies and the combined effect allowed visual assessment of heterogeneity. subgroup analysis was not carried out for the different outcomes. the standardized difference in means of blood loss and duration of operation comparing intravenous tranexamic acid to placebo (saline solution) was the primary measure of treatment effect. for the secondary outcome of visualization of surgical field, the 2 studies assessed the same outcome but was measured using 2 different score scales (wormald9 and boezaart10 score scales) so the results were not pooled but reported individually. results search results and study selection overall 8 potentially relevant publications were initially identified. amongst these, 6 trials were excluded because of different comparators and outcome measures. therefore, 2 trials were finally evaluated. (figure 1) study characteristics and assessment of reporting the characteristics of the 2 included studies are summarized in table 1. the 2 relevant studies enrolled a total of 128 patients, 100 children aged 5-10 years old and 50 adults aged 28 to 78 years old. results of these studies are summarized in table 2. the study of langille, et al. was a double blind, randomized, placebo controlled trial and had a population of 28 adults aged 23-80 years old, with a median age of 45 enrolled between march 2010 and november 2011. block randomization was used and only 1 study investigator knew the randomization and was responsible for preparing the tranexamic acid or saline solutions. the said investigator was not involved in data extraction or analysis. the surgeon and anesthesiologists were also blinded to the treatment given. half of the participants (14) were given a tranexamic acid bolus of 15 mg/kg then infusion of 1mg/kg/ hr, while the other half were given normal saline. the study showed no statistically significant difference between groups in estimated blood loss (p=.40), surgical time (p=.14) and surgical field visualization (p=.89).5 the wormald grading scale9 was used to measure the surgical field visualization with the mean of 5.84 vs 5.8 for the tranexamic acid and normal saline groups, respectively. the study of eldaba, et al. had 100 children aged 5-10 years, who figure 1. flow chart for selection of randomized controlled trials citations from the electronic databases (n=279) no. of studies screened (n=270) no. of full text articles assessed for eligibility (n=8) total number of studies relevant to review (n=2) no. of studies after duplicates removed (n=270) citations from other sources (n=10) no. of studies excluded (nonrcts, non-nasal surgery, abstracts) (n=262) no. of full text excluded (different comparators, outcome measures) (n=6) references langille, et al. 2012 eldaba, et al. 2013 table 1. characteristics of included studies number of participants references age (yrs.) treatment comparison outcome measures 28 100 langille, et al. 2012 eldaba, et al. 2013 43.5±13.6 7.5 ±3.5 iv tranexamic acid 10 mg/kg iv tranexamic acid 25 mg/kg saline solution saline solution volume of blood loss surgical time field visibility volume of bleeding surgical time field visibility were randomized into 2 groups using a computer based random number generator. the first group was given a slow intravenous injection of tranexamic acid 25mg/kg diluted in 10ml of saline while the second group was given a slow intravenous injection of normal saline. anesthesiologists, operating personnel and study staff were blinded philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 review article philippine journal of otolaryngology-head and neck surgery 11 table 2. results of individual studies jadad score langille, et al. 4 eldaba, et al. 4 volume of blood loss (ml) tranexamic acid saline surgical time (minutes) tranexamic acid saline field visualization tranexamic acid saline 115 (30-600) 200 (100-400) 121.5 (63-152) 131.5 (83-177) wormald scale score* 5.8 (2.5-8.5) 5.8 (1-8) 102 ±19 153 ± 3.6 45.2 ± 12.2 65.5 ± 13.6 grade 3,boezaart scale (no. of patients)** 8 24 **grade 3, boezaart scale *wormald scale score4 used in langille, et al. study table 3. bias assessment of included randomized controlled trials: (jadad score) references randomizationreferences allocation concealment blinding no drop-outs yes yes yes yes yes yes yes yes langille, et al. 2012 eldaba, et al. 2013 visibility, as estimated by the surgeon 15 and 30 minutes after start of surgery using the boezaart scale.2 results of the study showed that at the 15th and 30th minute marks, a higher number of participants in group 2 (placebo group) had grade iii surgical field or moderate bleeding that lightly compromised the surgical field (respective p values, p=.06 and p=.01). the study also showed a significant difference between the groups for duration of surgery and volume of bleeding, both with p <.01. the study showed that intravenous tranexamic acid in children who underwent ess improved surgical field quality, and reduced intraoperative bleeding and duration of surgery. risk of bias is presented in table 3. all screened patients were randomized, and investigators, surgeons and patients were blinded. there was no evidence of selective drop out, however the data on intention to treat (itt) was not reported in both studies included. the forest plot on intraoperative blood loss shows the mean difference of tranexamic acid compared to saline solution in endoscopic sinus surgery. the summary of the observed difference was -51.00 (ci 95 [-59.27, -42.73]) for the 25mg/kg tranexamic acid vs. saline in children, and -85.00 (ci 95 [-192.95, 22.95]) for 15mg/kg tranexamic acid vs. saline in adults. the pooled analysis of the 2 studies had a standardized mean difference of -51.20 (ci 95 [-59.44, -42.95]) showing that the blood loss in ml was lower in the tranexamic acid group compared to saline solution. (figure 2) the forest plot of surgical time shows the mean difference of tranexamic acid compared to saline solution in endoscopic sinus surgery. the summary of the observed difference was -20.00 (ci 95 [-25.06, -14.94]) for the 25m/kg tranexamic acid vs. saline in children, and -10.00 (ci 95 [-28.06, 8.72]) for 15 mg /kg tranexamic acid vs. saline in adults. the pooled analysis of the 2 studies had a standardized mean figure 2. forest plot of primary endpoint comparing i.v. tranexamic acid vs saline solution on intraoperative blood loss figure 3. forest plot of primary endpoint comparing i.v. tranexamic acid vs saline solution on surgical time to the treatment groups. the same team performed all procedures. a blinded chief nurse who did not participate in the study protocol prepared the syringes. outcomes measured in the study were 1) blood loss, which was estimated by weighing sponges and measuring operative suction volume, 2) time of operation, and 3) surgical field philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 review article 12 philippine journal of otolaryngology-head and neck surgery references 1. khafagy a, osman s. does tranexamic acid, deliberate hypotension, and anti-trendelenburg position improve the quality and outcome for functional endoscopic sinus surgery. egypt j otolaryngol. 2013;29:71-75. [cited 2014 aug 12]; available at: http://www.ejo.eg.net/text. asp?2013/29/2/71/134334 doi: 10.7123/01.ejo.0000426359.69695.7c. 2. eldaba aa, amr ym, albirmawy oa. effects of tranexamic acid during endoscopic sinus surgery in children. saudi j anesth. 2013 jul; 7(3):229-233. doi: 10.4103/1658-354x.115314. pmid: 24015121 pmcid: pmc3757791. 3. fromme ga, mackenzie ra, gould ab jr, lund ba, offord kp. controlled hypotension for orthognathic surgery. anesth analg. 1986 jun; 65(6):683-6. pmid: 3706806. 4. kim rjt, douglas rg. perioperative care for functional endoscopic sinus surgery. the otorhinolaryngologist. 2012; 5(1):27–30. [cited 2014 aug 12]. available at: http://www. greenlaneresearch.co.nz/portals/1/docs/the%20otorhinolaryngologist%202012%20kim.pdf. 5. langille ma, chiarella a, cote dw, mulholland g, sowerby lj, dziegielewski pt, wright ed. intravenous tranexamic acid and intraoperative visualization during functional endoscopic sinus surgery: a double-blind randomized control trial. int forum allergy rhinol. 2013 apr; 3(4): 315-8. doi: 10.1002/alr.21100. pmid: 23044919. 6. ker k, edwards p, perel p, shakur h, roberts i. effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. bmj. 2012 may 17; 344: e3054. doi: 10.1136/ bmj.e3054. pmid: 22611164. pmcid: pmc3356857. 7. abbasi h, behdad s, ayatollahi v, nazemian n, mirshamsi p. comparison of two doses of tranexamic acid on bleeding and surgery site quality during sinus endoscopy surgery. adv clin exp med. 2012 nov-dec; 21(6):773-780. pmid: 23457130 8. thongrong c, kasemsiri p, carrau rl, bergese sd. control of bleeding in endoscopic skull base surgery: current concepts to improve hemostasis. isrn surg. 2013 jun 13; 2013: 191543. doi: 10.1155/2013/191543. pmid: 23844295 pmcid: pmc3697291. 9. athanasiadis t, beule a, embate j, steinmeier e, field j, wormald pj. standardized videoendoscopy and surgical field grading scale for endoscopic sinus surgery: a multi-centre study. laryngoscope. 2008 feb; 118(2):314-319. doi: 10.1097/mlg.0b013e318157f764. pmid: 17989575. 10. boezaart ap, van der merwe j, coetzee a. comparison of sodium nitroprusside and esmololinduced controlled hypotension for functional endoscopic sinus surgery. can j anaesth. 1995 may; 42(5 pt 1):373-6. doi: 10.1007/bf03015479. pmid: 7614641. 11. jadad scale for reporting randomized controlled trials. in: halpern sh, douglas mj, editors. evidence-based obstetric anesthesia. oxford: blackwell publishing ltd.; 2005. p. 237-238. doi: 10.1002/9780470988343.app1 12. jadad ar, moore ra, carroll d, jenkinson c, reynolds dj, gavaghan dj, et al. assessing the quality of reports of randomized clinical trials: is blinding necessary? control clin trials 1996 feb; 17(1):1ñ12. pmid: 8721797 13. wright ed, agrawal s. impact of perioperative systemic steroids on surgical outcomes in patients with chronic rhinosinusitis with polyposis: evaluation with the novel perioperative sinus endoscopy (pose) scoring system. laryngoscope. 2007 nov; 117(11 pt 2 suppl 115):1-28. doi: 10.1097/mlg.0b013e31814842f8. pmid: 18075447. 14. fawzy m, ewieda t. tranexamic acid versus hypotensive anesthesia using isoflurane for improvement of outcome of functional endoscopic sinus surgery. pan arab journal of rhinology. 2014 mar; 4(1): 32-39. difference of -19.32 (ci 95 [-24.21, -14.43]) showing that the surgical time in minutes was shorter in the tranexamic group compared to saline solution. (figure 3) the secondary outcome on surgical field visualization was not pooled together because the 2 studies used different scales of evaluation. discussion this systematic review showed that intravenous tranexamic acid reduced blood loss and surgical time in patients who underwent endoscopic sinus surgery compared to saline solution. the overall treatment effect was 51.2% less blood loss and 19.32% less surgical time. in the practice of otolaryngology, endoscopic sinus surgery is one of the common nasal surgeries and bleeding is a big concern. bleeding can cause serious complications due to interference with visibility and quality of the surgical field. poor visibility can cause greater blood loss that may lead to morbidities and possible mortality. tranexamic acid is a hydrophilic antifibrinolytic agent that can be given to reduce bleeding. evidence that tranexamic acid reduces bleeding in ess has been available for many years. it has been used in different surgeries to reduce perioperative bleeding with successful results.6 this systematic review pooled analysis of 2 very good quality randomized controlled trials with methodological assessments of 4 (jadad score). the 2 main primary outcomes of blood loss and surgical time had the same methods of measurement, recorded in milliliters and minutes, respectively. the observation periods for the 2 studies were consistent (during, and before the end of the operation). the risk of follow-up bias was not a problem in the 2 studies because all observations were made perioperatively. this systematic review had several limitations. first, the age groups were different-the langille study5 had adult patients and the eldaba study2 had children as patients. the doses of tranexamic acid given intravenously were different-15 mg/kg for the langille study and 25 mg/kg for the eldaba group. the scales used for field visualization were different-langille used the wormald grading scale9 and eldaba used the boezaart scoring scale.10 therefore, there no concrete evidence on the quality of field visualization that can be pooled. in spite of these limitations, the pooled analysis was favorable for i.v. tranexamic acid in reduction of blood loss and surgical time. cumulative data from the included studies showed that there was a significant improvement in field visibility and decrease in blood loss that could further lead to reduced operation time. this finding can be beneficial to otorhinolaryngologists in preoperative planning of their sinus cases. however, the study is limited by the trials included, showing that there is a lack of data on the subject. limited data retrieval shows that there is room for more studies to be done on this subject. the authors recommend more randomized control trials to further strengthen the significance of tranexamic acid in ess or resolve any uncertainties regarding its use. in conclusion, intravenous tranexamic acid reduces blood loss and shortens surgical time in endoscopic sinus surgery among patients with chronic rhinosinusitis. however, the additional benefit of tranexamic acid for better field visualization is not clear. adverse effects were not considered in this study but intraoperative tranexamic acid is an option for endoscopic sinus surgeries with blood loss as a concern. further randomized clinical trials are needed to strengthen the evidence on the effectivity of tranexamic acid for endoscopic sinus surgeries. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles 20 philippine journal of otolaryngology-head and neck surgery abstract objective: to review cases of adult acute epiglottitis in a tertiary government hospital and describe the clinical presentations, diagnostics performed, management and outcomes. methods: design: retrospective chart review setting: tertiary government hospital participants: records of patients admitted by or referred to the department of otolaryngology head and neck surgery with a diagnosis of acute epiglottitis from january 2008 to august 2014 were identified from the department census and charts were retrieved from the hospital record section and evaluated according to inclusion and exclusion criteria. information regarding demographic data, clinical features, laboratory and other diagnostic examinations, medical management, and length of hospital stay were collected. results: there were 20 cases in 7 years and 8 months. most were male, 18 to 37-years-old, presenting with dysphagia, odynophagia and a swollen epiglottis on laryngoscopy. abnormal soft-tissue lateral radiographs of the neck and leukocytosis were seen in 73 % and 83%, respectively. intravenous antibiotics and corticosteroids were administered in all cases, and mean hospital stay was 11.2 days. conclusion: adult acute epiglottitis should be highly suspected in patients presenting with dysphagia, odynophagia, and muffling of the voice even with a normal oropharyngeal examination. history of respiratory infection, co-morbidities, smoking and alcohol intake, concomitant laryngeal pathology and supraglottic structure insults contribute to development of the disease. laryngoscopy is still the gold standard in diagnosis. airway protection is mandatory but prophylactic intubation or tracheostomy are not advised. intravenous antibiotics are necessary and corticosteroids may be of benefit. keywords: epiglottitis, supraglottitis, epiglottis, adult, philippines adult acute epiglottitis: an eight year experience in a philippine tertiary government hospital melanie grace y. cruz, md natividad a. almazan, md department of otorhinolaryngology head and neck surgery east avenue medical center correspondence: dr. melanie grace y. cruz department of otorhinolaryngology head and neck surgery 6th floor, east avenue medical center east avenue, diliman, quezon city 1100 philippines phone: (632) 928 0611 local 324 fax: (632) 435 6988 email: eamc_enthns@yahoo.com melcruzmd@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest. september 19, 2013. natrapharm, the patriot building, parañaque city. philipp j otolaryngol head neck surg 2016; 31 (2): 20-23 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles philippine journal of otolaryngology-head and neck surgery 21 acute epiglottitis is a serious life threatening disease due to its potential for sudden airway obstruction in a previously healthy individual.1,2 structures involved include the supraglottic region of the oropharynx, epiglottis, vallecula, arytenoids and aryepiglottic folds.3 due to the loose and vascular mucosa surrounding the epiglottic area, it is vulnerable to insults caused by inflammation, irritation or allergic reaction. for this reason, the term supraglottitis is more appropriate.4 a search of local (herdin) and international databases (embase, pubmed medline, google scholar, and sciencedirect) using the following keywords: epiglottitis, supraglottitis, adult, philippines revealed that this is the second case series on acute epiglottitis in the philippines with the first study done in 1947.5 the limited documentation of adult acute epiglottitis in the country and importance of awareness of its urgency prompted this study. our objective was to review the cases of adult acute epiglottitis at a tertiary referral government hospital in the philippines over a span of 7 years and 8 months; and to describe its clinical features, risk factors, diagnostic examinations performed, treatment, and outcomes as measured by improvement of symptoms and length of hospital stay. methods this study considered all adult patients diagnosed with supraglottitis hyperemia and edema of the epiglottis via laryngoscopy, who were admitted by or referred to the department of otolaryngology head and neck surgery in a 600-bed tertiary government referral hospital from 2008 to 2014 for inclusion. those who had supraglotittis due to caustic ingestion were excluded. potential cases were identified from the department census and charts were retrieved from the hospital record section and reviewed according to inclusion and exclusion criteria. a total of 20 cases were identified but only 18 charts were available for review. information regarding demographic data, clinical features, laboratory and other diagnostic examinations, medical management, and length of hospital stay were collected. all data recovered from chart and medical records were included in the analysis. summary statistics such as mean, median (range) and frequency (proportions) were used to describe continuous ordinal and nominal variables. data encoding, processing and analysis were performed via microsoft excel for mac 2011 v 14.0.0. this study was exempted from full review by our hospital irb and conducted in accordance with the declaration of helsinki and the national guidelines for biomedical research of the national ethics committee (nec) of the philippines. data collected from the chart review were treated with confidentiality, assigning unique alphanumeric codes in consecutive order to protect the identity of patients. records were not uploaded on any open databases for public viewing. attending physicians assigned to the cases were not recorded either. results of the 20 consecutive cases of acute epiglottitis identified, 18 charts were available for review. there were 16 males and 4 females, with age range of 18 – 68 years old and a median of 33.5 years. one patient who had a recurrence of epiglottitis within the same year was counted twice. the most common presenting symptoms were dysphagia (100%), odynophagia (89%) and voice changes (83%) characterized as hoarseness or muffling. (table 1) one patient who was later intubated additionally presented with irritability, stridor and cyanosis. table 1. presenting symptoms of adult patients with acute supraglotittis (n=18) frequency (n) total (n) percent (%) symptom dysphagia odynophagia throat pain* voice changes dyspnea drooling irritability stridor 18 16 6 15 10 5 2 2 18 18 7 18 18 18 18 18 100 89 86 83 56 28 11 11 * 11 charts did not indicate presence or absence of the symptom hyperemia of the posterior pharyngeal wall and drooling of saliva were observed in half of the cases. concomitant laryngeal pathologies were observed in 39% and included cysts, pustules, ulcers and masses. granulation tissue on the epiglottis was present in the intubated patient and a supraglottic mass was seen in another patient who had a tracheostomy. of all the patients, 56% had previous consults with other physicians and were managed as cases of respiratory tract infection. other co-morbidities included hypertension (22%) and diabetes mellitus (22%). half were smokers and 13 were alcoholic beverage drinkers. interestingly, all 8 patients who had a history of fluid intake of extreme temperatures (thermal insult) prior to the onset of symptoms recalled having taken either a cold or hot beverage. on admission, 78% had leukocytosis with a mean count of 19.9 x109/l, with predominance of neutrophilis. chest radiography showed active parenchymal infiltrates in 47% of the cases and soft-tissue lateral radiographs of the neck were abnormal in 73% with the following findings: enlarged epiglottis, narrowed airway, and straightening of the vertebra. management included intravenous antibiotics (cefuroxime or ceftriaxone) and intravenous hydrocortisone. ten patients presented philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 22 philippine journal of otolaryngology-head and neck surgery original articles with dyspnea and half were given oxygen supplementation via nasal cannula. one patient developed severe dyspnea, irritability, cyanosis and stridor and was subsequently intubated. another patient had a supraglottic mass and eventually needed a tracheostomy. the time interval from the onset of symptoms to emergency room consult varied from less than 6 hours to as long as two months. the patient with rapid progression of symptoms developed dyspnea in less than 6 hours and was later intubated. hospital stay was a median of 8 days (range: 2 37 days) for all patients. one patient stayed for 34 days in the hospital due to relapse of epiglottitis within the same admission. another was admitted for 37 days because of a supraglottic neoplasm, although epiglottic swelling had decreased significantly in this patient by the 16th hospital day. this was the longest time to resolution recorded for significant decrease in epiglottic swelling on laryngoscopy which was noted as early as the second hospital day. discussion supraglottitis is an uncommon disease entity that may occur at any age.6 although classically described as a disease of childhood, it is said to have nearly disappeared in children and is now almost exclusively found in adults.7 supraglottitis is traditionally related to haemophilus influenza infection although its isolation is more common in children (68-72%) than adults (21-23%).8 other pathogens have been implicated in adult supraglottitis and may also be caused by thermal injuries suffered from smoking and illicit drug use.1,4 patients in this study were predominantly male (80%). this was comparable to other series where authors described a 55-81% preponderance of male subjects.7,9-11 the ages of the patients in this study ranged from 18-68 years and majority (55%) belonged to the 18 to 39-year-old age group. this was consistent with studies whose subjects were mostly adults in the second to fourth decade of life.1,7,10,12 the rate of 2.86 cases per year in our study is quite low compared to other single-institution studies reviewed, documenting 3.7-7.1 cases per year.2,9-10,13-14 interestingly, there was an increase in the number of patients diagnosed with epiglottitis in our institution in 2014 when 7 patients were documented. some authors suggest that increased awareness of physicians regarding the disease and the greater availability of non-invasive ways of visualizing the laryngeal structures may have contributed to the increased diagnosis rate.1 similar to previous studies,2,6-7,12 patients commonly presented in the emergency room with dysphagia, odynophagia, and voice changes. throat pain was also present in 6 out of 7 patients who were asked about this symptom. nine of the patients initially seen by other physicians were diagnosed as simple cases of urti. this may be attributed to laryngoscopy not being a part of routine examination in the general setting. in addition, patients with supraglottitis may also present with a normalappearing oropharynx, which may mistakenly preclude the need for further examination. the abovementioned factors may have possibly resulted in misdiagnosis of cases; other studies cite 67% to 71% of cases were commonly assessed to be urti, pneumonia, and angina with pharyngitis. some patients may even require intubation on follow up.2,9 adult supraglottitis has a more variable presentation depending on etiology, and the rates at which symptoms appear help prognosticate its outcome. if patients complain primarily of sore throat and dysphagia with a more gradual onset, which was as long as a two months in this study, it may be more likely have a milder course.1 in contrast, patients who present with dyspnea, stridor, drooling and isolation of h. influenza are more likely to have airway complaints and a more aggressive course of disease.1 the patient who presented with a sudden onset of dyspnea, dysphagia, odynophagia, drooling, and stridor 6 hours prior to consult was immediately intubated in the emergency room. a thorough history and physical examination is vital to diagnosis. comorbidities such as hypertension, diabetes, alcoholism, smoking history and a recent upper respiratory infection that may be elicited in the history may play a role in the course of the disease, as was also found in patients in this study.1,6,10,14 other findings may include epiglottic abscesses, history of nasopharyngeal carcinoma, tonsillitis, and vallecular cysts.1,2,4,6,10,14 in this study, 39% of patients showed any of the following supraglottic findings on laryngoscopy: pustules, cyst and granulation tissue on the epiglottis and hypopharyngeal mass. abnormal chest radiographs in 8 out of 17 patients had active parenchymal infiltrates which may be attributed to pneumonia, empyema or pulmonary edema.1,4,9 soft tissue lateral radiographs of the neck were positive in 73% of the cases. this was consistent with other studies which yielded a positive result in 68-89% of cases.1,6,9,10,14 swelling of the epiglottis, classically described as the “thumb sign” may be found in as many as 71% of patients.5 laryngoscopy is still the gold standard in diagnosis and should be done in all cases if possible. it is important to note that laryngoscopy did not precipitate airway obstruction in any of the patients in this study. this was consistent with the findings of mayo-smith et al. wherein none of the 364 patients seen over 18 years developed airway obstruction philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles philippine journal of otolaryngology-head and neck surgery 23 references 1. mayo-smith mf, spinale jw, donskey cj, yukawa m, li rh, schiffman fj. acute epiglottitis. an 18-year experience in rhode island. chest. 1995 dec;108(6):1640-7. pubmed pmid: 7497775. 2. wick f, ballmer pe, haller a. acute epiglottitis in adults. swiss med wkly. 2002 oct 12; 132(37-38): 541-7. pubmed pmid: 12557859. 3. gompf sg, bowman jg. epiglottitis. medscape. 2013 apr 13 [cited 2013 jun 17]. available from: http://emedicine.medscape.com/article/763612-overview 4. rivers rl. acute epiglottitis (supraglottitis). j forensic sci. 1979 apr;24(2): 470-2 5. yambao cv. acute epiglottitis. j philipp med assoc. 1947 feb; 23(2):47-9. pubmed pmid: 20254008. 6. ng hl, sin lm, li mf, que tl, anandaciva s. acute epiglottitis in adults: a retrospective review of 106 patients in hong kong. emerg med j. 2008 may;25(5): 253-5. doi: 10.1136/emj.2007.050153. pubmed pmid: 18434453. 7. briem b, thorvardsson o, petersen h. acute epiglottitis in iceland 1983-2005. auris nasus larynx. 2009 feb; 36(1):46-52. doi: 10.1016/j.anl.2008.03.012. pubmed pmid: 18502071. 8. berg s, trollfors b, nylen o, hugosson s, prellner k, carenfelt c. incidence, aetiology, and prognosis of acute epiglottitis in children and adults in sweden. scand j infect dis. 1996;28(3):261-4. pubmed pmid: 8863357. 9. sheikh kh, mostow sr. epiglottitis-an increasing problem for adults. west j med. 1989 nov; 151(5):520-524. pubmed pmid: 2603419 pubmed central pmcid: pmc1026785. 10. sarkar s, roychoudhury a, roychoudhury bk, acute epiglottitis in adults – a recent review in an indian hospital. indian j otolaryngol head neck surg. 2009 sep; 61(3):197–199. pubmed pmid: 23120634. pubmed central pmcid: pmc3449988. 11. qazi im, jafar am, hadi ka, hussain z. acute epiglottitis: a retrospective review of 47 patients in kuwait. indian j otolaryngol head neck surg. 2009 dec; 61(4):301–305. doi: 10.1007/s12070009-0087-4. pubmed pmid: 23120655. pubmed central pmcid: pmc3450074. 12. bizaki aj, numminen j, vasama jp, laranne j, rautiainen m. acute supraglottitis in adults in finland: review and analysis of 308 cases. laryngoscope. 2011 oct; 121(10):2107-13. doi: 10.1002/lary.22147. pubmed pmid: 21898436. 13. cheung ch. case and literature review: adult acute epiglottitis – rising incidence or increasing awareness? hong kong j emerg med. 2001 oct; 8(4): 227231. 14. lon sa, lateef m, sajad m. acute epiglottitis: a review of 50 patients. indian j otolaryngol head neck surg. 2006 apr; 58(2):178-80. doi: 10.1007/bf03050781. pubmed pmid: 23120278. pubmed central pmcid: pmc3450762. 15. al-qudah m, shetty s, alomari m, alqdah m. acute adult supraglottitis: current management and treatment. south med j. 2010 aug;103(8):800-4. doi: 10.1097/smj.0b013e3181e538d8. pubmed pmid: 20622745. 16. sack jl, brock cd. identifying acute epiglottitis in adults. high degree of awareness, close monitoring are key. postgrad med. 2002 jul; 112 (1):81-2, 85-6. pubmed pmid: 12146095. secondary to laryngoscopy.1 leukocytosis was seen in 83% of the cases. this was slightly lower compared to studies showing leukocytosis in 91100% of patients.2,8,11,14 although the test is sensitive, blood counts are not known to be helpful in diagnosing acute supraglottitis.15 the presence of concomitant laryngeal pathology (17%), a history of thermal insult to the supraglottic structures (22%), with 22% having both conditions is suggestive that non-infectious external factors may contribute to the development of supraglottitis. the most important aspect of management is airway protection. in this study, 5 patients were given oxygen supplementation via nasal cannula, one was intubated and one other underwent tracheostomy. prophylactic intubation may be unnecessary in the absence of warning signs of airway compromise. sack and brock emphasized that the key to management is awareness of the disease and close monitoring of the airway.16 in the presence of more than 50% narrowing, intubation may be performed depending on the severity of the patient’s condition.11 therefore, instead of routine prophylactic intubation, management should be focused on the patient’s needs and condition.9 antibiotic treatment is also necessary and should cover the most common etiologic agents. cephalosporins such as ceftriaxone, cefuroxime, and cefotaxime have been used.7,9 all patients in our study were started on intravenous cefuroxime or ceftriaxone, and intravenous hydrocortisone. corticosteroids have been used prophylactically, with conflicting findings in the literature. some claim their use has not been found to provide reduction in the need for intubation, nor affect the total length of hospital stay.1,2 however, the limited number of patients in their study did not allow for a firmer conclusion regarding corticosteroid use.1,2 it is advocated that patients be admitted to the icu for close monitoring.3 however, if this is not feasible, patients may be admitted to the ward provided they are stable with an adequate airway and are being managed with antibiotics and corticosteroids. patients in this study were observed in the ward for a median of 8 days (2-37 days). personnel equipped with the ability to intubate or perform tracheostomy must always be available. repeated attempts at intubation should be avoided as it may increase periepiglottic swelling causing more morbidity.16 in summary, adult acute epiglottitis should be suspected in patients who present with progressive dysphagia, odynophagia, voice changes, and throat pain especially when there is a normal oropharyngeal examination. leukocytosis and positive soft tissue lateral radiograph of the neck may support its diagnosis and may warrant the need for laryngoscopy for confirmation. airway protection is mandatory but prophylactic intubation or tracheostomy are not advised. intravenous antibiotics are necessary and corticosteroids may be of benefit. the limitations of the study include a small sample size and few correlations and analyses on the other unusual factors that can also have effects on the development of the condition such as concomitant laryngeal pathology, thermal injuries, smoking and alcoholism. we recommend a larger-scale, multicenter prevalence study of adult acute epiglottitis. studies concerning other factors that may be relevant in the clinical course of the disease such as concomitant laryngeal pathology, recent thermal injury to the supraglottic region, smoking, alcoholism, and hyperemia of the pharynx are also suggested. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 philippine journal of otolaryngology-head and neck surgery 55 featured grand rounds branchial cleft anomalies are among the most common causes of congenital anterior neck masses in the pediatric population. they present as epithelial-lined, single cysts.1,2 the definitive management is surgical excision.3 however, failure to remove the entire cyst and tract may lead to recurrence of the mass.3 unusual presentations of this condition may lead to incomplete excision if inadequately evaluated. there is a scarcity of material documenting atypical presentations of branchial cleft anomalies-in particular, presentation as 2 distinct cysts in one region. in our literature search of pubmed, google scholar and herdin using the terms: “congenital mass,” “branchial cleft cyst,” and “multiple cysts,” only 3 similar cases were found. we report a case of a second branchial cleft anomaly presenting as a dumbbell-shaped mass (two cystic structures, connected by a tubular structure) in the right lateral neck, the subsequent management and outcomes. case report a 2-year-old girl presented with a 0.5 cm x 0.5 cm right anterior neck mass since birth which was soft, non-tender and movable with no other associated complaints. they consulted at a government institution where the parents were reassured that the mass was “excess fat.” no further investigations were done. three months prior to consult, after a bout of upper respiratory tract infection (urti), the caregivers noted an increase in size of the mass to approximately 4 x 4 cm which was still soft but tender and erythematous with a central draining sinus. she was seen at our clinic and was diagnosed with an infected branchial cleft cyst type ii, right. she was admitted and given appropriate antibiotics. physical examination showed the mass located at the level of the thyroid notch, anterior to the medial border of the sternocleidomastoid (scm) muscle, immediately superior to the right clavicular head. (figure 1) contrast enhanced computed tomography (ct) scans of the neck showed thin-walled, sharply circumscribed, minimally enhancing cystic masses at the right upper jugular region, anterior to the sternocleidomastoid muscle, 1.5 x 2.4 x 1.8 cm (figure 2a), mid jugular region along the anterior margin of sternocleidomastoid muscle measuring, 0.6 x 1.2 x 0.8cm, and in the lower jugular region anterior to the thyroid gland measuring 2.0 x 3.1 x 2.2 cm. (figure 2b) the cystic a second branchial cleft cyst presenting as a dumbbell-shaped anterior neck mass correspondence: dr. samantha s. castañeda department of otorhinolaryngology head and neck surgery rizal medical center barangay pineda, shaw boulevard, pasig city 1600 philippines phone: (632) 865 8400 local 207 email: ent.hns_rmc@yahoo.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest presented at the philippine society of otolaryngology head and neck surgery inter hospital grand rounds. august 30, 2017. saint luke’s medical center, quezon city. ann bernadette g. sunga, md samantha s. castañeda, md department of otorhinolaryngology head and neck surgery rizal medical center philipp j otolaryngol head neck surg 2017; 32 (2): 55-57 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 a b featured grand rounds 56 philippine journal of otolaryngology-head and neck surgery masses showed no obvious communications with each other and with the pyriform sinus and laryngeal ventricle. there was no tumoral encasement of the vessels and cervical trachea or evident invasion of vascular structures. a month after resolution of the infection, the patient underwent surgery. intraoperatively, there were 2 masses observed, the first mass more superficial located anterior to the scm and upon further exploration there was a bottle-neck narrowing and another cystic structure located deep to the right scm. (figure 3) the excised mass was composed of 2 cystic structures attached to one another that still appeared to have different compartments. (figure 4) the second cyst was followed superiorly until the upper jugular region at the level of the body of the mandible ending in a blind sac. no further exploration was done and no dye was infiltrated into the cyst or tract. histopathologic studies showed a cyst wall lined with squamous cells. (figure 5) higher magnification showed the inner lining with lymphoid aggregates and possible chronic inflammation as evidenced by infiltration of mononuclear cells. (figure 6) on latest follow-up 1 month post-operatively, the patient had good wound healing with no persistent draining sinus. figure 1. right anterior neck mass with a draining sinus figure 2. contrastenhanced ct-scan of the neck, axial view showing thinwalled, minimally enhancing cystic structures, a. upper jugular region b. lower jugular region figure 3. intraoperative findings: superficial cyst, anterior to the sternocleidomastoid muscle (scm) connected by a tract to a second cyst, deep into the scm figure 4. excised mass philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 philippine journal of otolaryngology-head and neck surgery 57 featured grand rounds acknowledgements we would like to thank dr. mark jansen d.g. austria for the details of the case and intraoperative pictures and dr. ivan de guzman for interpreting the slides. references 1. rizzi md, wetmore rf, potsic wp. differential diagnosis of neck masses. in: flint pw, haughey bh, lund vj, niparko jk, robbins kt, thomas jr, et al. (editors). cummings otolaryngology. 6th edition. philadelphia, pa: elsevier, saunders. 2015. p. 3057. 2. ahuja at, king ad, metreweli c. second branchial cleft cysts: variability of sonographic appearances in adult cases. am j neuroradiol. 2000 feb; 21(2): 315-319. pmid: 10696015. 3. myers en. branchial cleft cyst and sinuses. in: myers en, carrau rl (editors). operative otolaryngology. saint louis: elsevier health sciences. 2008. p.5-7. 4. emerick k. differential diagnosis of a neck mass. in deschler dg, sullivan dj (editors). uptodate. [last updated 2016 may 16; retrieved 2017 august 1]. available from: https://www.uptodate. com/contents/differential-diagnosis-of-a-neck-mass. 5. chen ey, sie kcy. developmental anatomy. in: flint pw, haughey bh, lund vj, niparko jk, robbins kt, thomas jr, et.al. (editors). cummings otolaryngology. 6th edition. philadelphia, pa: elsevier, saunders. 2015. p. 2823-28. 6. muñoz-fernández n, mallea-cañizares i, fernández-julián e, de la fuente-arjona l, marcoalgarra j. double second branchial cleft anomaly. acta otorrinolaringol esp. (english edition). 2011 jan-feb; 62(1): 68-70. doi: 10.1016/j.otorri.2010.01.008; pmid: 20236623. 7. kim jy, yoo ys, choi jh, cho kr. a case of non-communicating dumbbell shaped fourth branchial cleft cyst. korean journal of otolaryngology-head and neck surgery. 2009; 52(2): 189-192. doi: https://doi.org/10.3342/kjorl-hns.2009.52.2.189. [korean], [abstract available in english]. 8. hu yj, li yd, qu xz, wang lz, zhong lp, liu l, zhang cp. [clinical analysis of branchial cleft cyst (fistula): report of 284 cases]. shanghai kou qiang yi xue. 2008 oct; 17(5): 461-464. pmid: 18989583. 9. fagan j. resecting branchial fistulae, sinuses and cysts. the open access atlas of otolaryngology, head & neck operative surgery. [retrieved 2017 oct 11]. available from: https://vula.uct.ac.za/ access/content/group/ba5fb1bd-be95-48e5-81be-586fbaeba29d/resecting%20branchial%20 cysts%2c%20fistulae%20and%20sinuses.pdf. 10. rattan kn, rattan s, parihar d, gulia js, yadav sp. second branchial cleft fistula: is fistulogram necessary for complete excision. int j pediatr otorhinolaryngol. 2006 jun; 70(6); 1027-1030. doi: 10.1016/j.ijporl.2005.10.014; pmid: 16343647. 11. houck j. excision of branchial cysts. operative techniques in otolaryngology. 2005; 16: 213-222. can be used to follow the tract but is not absolutely necessary.10 other methods may be used to follow the tract such as injecting methylene blue dye placing a catheter or using a wire probe on the external opening.11 our patient presented with a cyst that ended in a blind pouch at the level of the mandible and a tract could no longer be appreciated. unusual presentations of such conditions may pose intraoperative surgical challenges and good preoperative evaluation as well as detailed imaging is necessary to ensure the complete and safe removal of this congenital mass. discussion branchial cleft anomalies are congenital epithelium-lined cysts theorized to result from entrapment of elements of the cervical sinus of his.1 clinically, they can present as a non-painful, fluctuant and single mass identified at birth or as late as adulthood when the mass becomes infected and forms an abscess during episodes of urti.1,4 these factors were noted to be consistent with our patient’s case where the reason for consult was an abrupt increase in mass size due to an infection. there are four known types of this condition, the second branchial cleft anomaly being the most common4 comprising more than 90% of all branchial cleft anomalies.3 on physical examination, they appear as masses located anterior to the scm at the below the mandible.4 the fistulous forms of this type extend from an external opening in the anterior neck coursing superiorly in between the in between the internal and external carotid arteries then travels up the level of the tonsillar fossa.5 radiologic evaluation of this condition includes ultrasonography, ct scans and magnetic resonance imaging (mri).1 the contrastenhanced ct scan of our patient identified 2 separate cystic masses. histopathologic studies that showed epithilium-lined cysts are also consistent with the diagnosis. our patient presented with an infected second branchial cleft cyst. recommended management consists of initial antibiotics followed by definitive surgery. the entire tract must be explored and removed to prevent recurrences.3 on surgical excision the mass was noted to have a dumbbell-shaped appearance with two (2) cystic structures connected by a tubular structure. three other studies also reported similar presentations-a double second branchial cleft cyst by muñozfernández et al.,6 a dumbbell shaped 4th branchial cleft cyst by kim et al.7 and two more cases of multiple branchial clefts reported in a study of 284 cases by hu et al.8 the definitive treatment for branchial cleft anomalies is surgical excision ideally up to the level of the tonsillar fossa.3,9 a fistulogram figure 5. scanner view of the excised mass under h & e staining, showing an epithelium-lined cyst (hematoxylin – eosin , 40x) figure 6. high power magnification of the excised mass under h & e staining, showing the inner lining with lymphoid aggregates, and infiltration with mononuclear cells which represents chronic inflammation (hematoxylin – eosin , 400x) abstract objective: to present a case of pleomorphic adenoma arising from heterotopic salivary gland tissue in a supraclavicular lymph node. methods: design: case report setting: tertiary government hospital patient: one results: a 38-year-old female consulted with a six month history of an enlarging right supraclavicular mass. fine needle aspiration biopsy was negative for malignant cells. no primary tumor could be demonstrated elsewhere. excision biopsy was performed and final histopathology revealed pleomorphic adenoma surrounded by a normal lymph node. atypical tumor cells and mitoses were not found. conclusion: criteria were met for diagnosing heterotopic salivary gland in a supraclavicular lymph node which subsequently developed into pleomorphic adenoma. the rare location of the lesion as well as the unusual histopathological result of pleomorphic adenoma arising from a lymph node merited submission of this case report. key words: heteroplasia, heterotopic, cancer, metastasis, tumor a neck mass is any abnormal enlargement, swelling or growth from the base of the skull to the clavicles.1 it is a common clinical finding that presents in patients of all ages.2 the differential diagnosis can be extremely broad owing to the various structures located in the neck. any neck mass in an adult patient must be considered neoplastic and possibly malignant unless proven otherwise.3,4 in fact, it is the fear of cancer that usually brings the patient to the physician.5,6 an enlarged lymph node is by far the most common neck mass encountered.7 it results from a vast array of disease processes ranging from simple lymphadenitis to the more complex neoplastic processes. hayes martin emphasized that asymptomatic enlargement of one or more pleomorphic adenoma arising from heterotropic salivary gland tumor in a supraclavicular lymph node grace naomi b. galvan. ���� �a. �elhia a. �e leon �� romulus a. instrella, �� nixon s. see, �� department of otorhinolaryngology head & neck surgery armed forces of the philippines medical center philipp j otolaryngol head neck surg 2008; 23 (2): 35-37 c philippine society of otolaryngology – head and neck surgery, inc. correspondence: grace naomi b. galvan, �� armed forces of the philippines �edical center v. luna road, �iliman, quezon city 0840 philippines phone number: (632) 426 2701 local 6972 e-mail: gracenaomigalvanmd@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed disclosures that they have no proprietary or financial interest with an organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study presented at the 10th annual north east �anila ent consortium interesting case contest, valdes hall, veteran’s �emorial �edical center, �arch 27, 2008 philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports philippine journal of otolaryngology-head and neck surgery 35 cervical lymph nodes in the adult is almost always cancer and is due to metastasis from a primary lesion in the mouth or pharynx. 8 case report a 38-year-old female from nueva ecija was seen for a right supraclavicular mass. six months prior, the patient noted a mungbean sized mass in the right supraclavicular area, with no associated symptoms such as cough, night sweats or fever. four months later, the mass had grown to the size of a corn-kernel, still with no other signs or symptoms. a physician treated her for tuberculous adenitis since she had a history of pulmonary tuberculosis two years earlier. the mass continued to grow and after three months, she was referred to our institution for further evaluation and management. on examination, a 2x2cm well-circumscribed, firm, non-tender, right supraclavicular mass was noted. fine needle aspiration biopsy was negative for malignant cells. computed tomography scan with contrast revealed a fat-density mass lesion with heterogeneously enhancing structure within the base of the right neck (supraclavicular region). the rest of the vascular, osseous, and soft tissue structures were unremarkable. a hemangiolipoma or inflammatory process was considered. referral to, and evaluation by the pulmonology, general surgery, gastroenterology and gynecology services failed to identify a primary, and excision biopsy of the right supraclavicular mass under local anesthesia yielded a homogenous, yellowish-white, firm tumor. histopathological findings revealed a well-demarcated typical pleomorphic adenoma showing variously arranged epithelial cells, large amounts of fibrous tissue and numerous small cysts. there was a thin layer of lymphoid tissue at the periphery of the pleomorphic adenoma. (figure 1 a,b) serial sections showed the tumor was surrounded completely by lymphoid tissues similar to those of the cortex of lymph node (figure 1c), suggesting that the pleomorphic adenoma arose in a supraclavicular lymph node and not in major or minor salivary glands which metastasized to the lymph node (figure 1d). atypical tumor cells and mitoses were not found. this case was signed out as benign pleomorphic adenoma occurring as a primary lesion in the supraclavicular lymph node. discussion pleomorphic adenoma or benign mixed tumor is the most common tumor of the salivary glands. it occurs commonly in the major salivary glands which include the parotid (70%), submandibular (10%) and sublingual (4%).9 approximately 6.5% are located in the minor salivary glands distributed in the mucosa of the lips, cheeks, palate, floor of the mouth, tongue, retromolar area and peritonsillar region. histopathologic diagnosis of pleomorphic adenoma necessitates demonstrating epithelial and myoepithelial cells and a stroma of fibroid, myxoid, chondroid, vascular or myxochondroid characteristics.10 existence of normal salivary gland tissue at sites other than the three major salivary glands and minor salivary glands is described as heterotopia.11 heterotopic salivary gland tissues have been reported in numerous sites throughout the body, including the mandible, ear, palatine tonsil, mylohyoid muscle, pituitary gland, cerebellopontine angle, lower neck and thyroid gland.12 it was described for the first time in 1950 by thompson and bryant that lymph nodes of varying sizes and shapes are seen within and in close association with parotid gland and parotid tissue.13 in 1958, bernier and bhaskar first reported the case of a lymph node with pleomorphic adenoma.14 according to baldi et al, pleomorphic adenoma arising in a lymph node is quite rare with less than 20 reported cases in the scientific literature.15 cervical heterotopic salivary tissue may present as a mass, cyst or a draining sinus.16 �ost of these lesions present early in life, the majority being noticed at birth. the usual clinical presentation is a draining sinus associated with swelling in the right side of the lower neck. bilateral presentation may also occur. intermittent drainage is normally reported and has been described as mucoid, clear or saliva-like fluid, sometimes related to meals.17 the precise embryogenesis of the heterotopic cervical salivary tissue is still unknown and most theories remain speculative. �ifferent theories are based on their location in the neck. as for heterotopic salivary tissue in the lower neck, youngs and scofield suggested a relationship to the branchial apparatus,18 with defective closure of the sinus with salivary gland tissue giving rise to heteroplasia of the ectodermal lining within the remnants of the precervical sinus of his. willis in 1968 proposed three main hypotheses to explain heterotopia.19 first, an abnormal persistence and development of vestigial structures; second, dislocation of a portion of a definitive organ rudiment during mass movement and development; and third, abnormal differentiation of the local tissues (heteroplasia). the incidental finding of pleomorphic adenoma in the supraclavicular lymph node would be consistent with the embryonic theory of late invagination of salivary tissue in the parotid region. this leads to the incorporation of salivary tissues within lymph nodes.16 neoplasms arising from heterotopic salivary tissues are uncommon, with about 80% being benign.16 oncogeneseis of cervical salivary tissue is the presumed origin of these tumors. in a 1999 review of the literature on heterotrophic salivary glands, ferlito et al found that warthin’s tumor was the most common benign neoplasm with pleomorphic adenoma being the second most commonly reported.19 as in our case, the appropriate management for benign neoplasms of cervical heterotopic salivary tissue was local excision with close follow-up.20 when pleomorphic adenoma is found in lymph nodes it is important to ascertain whether these are metastases. chen and freeman reported that regardless of the primary, metastasizing pleomorphic adenoma maintained benign microscopic appearance except for high mitotic activity and infiltrating growth patterns.21,22 the diagnosis of metastasizing pleomorphic adenoma in the lymph node is unlikely in our case, as histopathology revealed pleomorphic adenoma surrounded by a normal lymph node. further, atypical tumor cells were not found, and there was no sign of mitotic activity or an infiltrating growth pattern, with no primary tumor identified. according to various authors, the diagnosis of a tumor arising in lymph node is based on the following findings: the tumor was a philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports 36 philippine journal of otolaryngology-head and neck surgery references 1. �adigan army �edical center [homepage on the internet] united states army �edical command (�e�co�) and western regional �edical command (wr�c) 2007. referral guidelines by specialty; ears, nose, throat: “neck mass” [cited 2008 �arch 10] available from: http://www.mamc.amedd.army.mil/referral/guidelines/ent_neckmass 2. �epartment of otolaryngology/head and neck surgery, columbia university �edical center [homepage on the internet], new york: columbia university ; c2002-2008 [updated 2008 january 27; cited 2008 �arch 10]. head and neck masses. available from: http://www. entcolumbia.org/hnmass.html. 3. �c guirt wf. �ifferential diagnosis of neck masses. in cummings cw, flint p,w harker l,a haughey bh, richardson �a, robbins kt, schuller �e, thomas jr editors. otolaryngology head & neck surgery. 4th edition volume 3, philadelphia: elsevier �osby; 2005. p.2540-53. 4. �cguirt wf: the unknown primary in metastatic head and neck cancer: a clinical approach , nc med j 1978; 39:299 5. jakobsen j: lymph node metastases in the neck from unknown primary tumor, acta oncol 1992; 31:653. 6. nguyen c: �etastatic squamous cell carcinoma to cervical lymph nodes from unknown primary mucosal sites, head neck 1994; 16:58. 7. acs surgery: principles and practice, [homepage on the internet].chicago: american college of surgeons; c2004. [updated 2008 �arch 10] available from: http://beta.acssurgery.com/ acssurgery/institutional/payperadd.action?chapterid=part02_ch03. 8. �artin h, romieu c: the diagnostic significance of a lump in the neck, postgrad med 1952; 11:491. 9. eveson jw, cawson ra. salivary gland tumors: a review of 240 cases with particular reference to histologic types, sites, age, sex, and sex distribution. j pathol.1985; 146:51-58. 10. felix jap, tonon s, saddy j, �eirelles r, felix f. pleomorphic adenoma of the nasal septum: a case report and review of literature, intl arch otorhinolaryngol, 2006; 10: 154-8. 11. rosai j, �ajor and minor salivary glands. in: houston �, editor. surgical pathology. vol. 1, new york : �osby; 2004. p.873-916. 12. �artinez -�adrigal f, bosq j, casiraghi o. �ajor salivary glands. in: sternberg ss, editor. histology for pathologists. philadelphia: lipincott-raven;1997 p.418-419. 13. thompson as, bryant hc. histogenesis of papillary cystadenoma lymphomatosum (warthin’s tumor) of the parotid salivary glands. am j pathol 1950; 26: 807-49. 14. takeda y, suzuki a. a benign pleomorphic adenoma arising in a parotid lymph node. virchows arch[pathol anat histol].1982;396:351-6. 15. baldi a, persichetti p, �i �arino �p, nicoletti g, baldi f. pleomorphic adenoma of cervical heterotopic salivary glands. j exp clin cancer res. 2003;22:645-7. 16. �aniel e, �c guirt wf. neck �asses secondary to heterotopic salivary gland tissue: a 25-year experience. am j otolaryngol.2005; 26:96-100. 17. atienza ll, rios f, �artin g, benito a, bronchalo f, tello f, vincent j, et al : salivary gland heterotopia in lower neck: a report of five cases. int j pediatr otorhinolaryngol. 1998;43:153-61. 18. youngs la, schofiled hh. heterotopic salivary gland tissue in the lower neck. arch pathol lab med 1967; 83: 550-6. 19. ferlito a, bertino g, rinaldo a. a review of heterotopia and associated salivary gland neoplasms of the head and neck. j laryngol otol.1999;113:299-303. 20. rodgers g, felder h, yunis ej. pleomorphic adenoma of cervical heterotopic salivary gland tissue: a case report and review of neoplasms arising in cervical heterotopic salivary gland tissue. otolaryngol head and neck surg.1991;104:533-6. 21. freeman sb, kennedy ks, parker gs, tatum sa .�etastasizing pleomorphic adenoma of the nasal septum, arch otolaryngol head neck surg.1990;116:1331-3. 22. chen ktl, �etastasizing pleomorphic adenoma of the salivary gland. cancer. 2002; 42: 240711. 23. shinohara �, ikebe t, �akamura s, takenoshita y, oka �, �ori �,et al. �ultiple pleomorphic adenomas arising in the parotid and submandibular lymph nodes. brit j oral and maxillofac surg 1996;34:515-19. primary lesion with no sign of malignancy, serial section showing that the tumor was confined to the lymphoid tissue and the surrounding lymphoid tissue had the essential characteristics of the lymph node with marginal sinuses and lymph follicles.14,23 fulfilling these criteria, our case is likely that of heterotopic salivary gland in a supraclavicular lymph node which subsequently developed into pleomorphic adenoma. the rare location of the lesion as well as the unusual histopathological result of pleomorphic adenoma arising from a lymph node merited submission of this case report. figure 1-a. low magnification of pleomorphic adenoma arising in a supraclavicular lymp node. there is a narrow mantle of dense lymphoid tissue around the tumor mass and intranodal heterotopic salivary gland tissue. figure 1-b. the tumor showed various epithelial cells and prominent eosinophilic hyalinized stroma. figure 1-c. high manification of lymphoid tissue. the essential characteristics of the cortex of the lymph node were found. figure 1-d. intranodal salivary gland tissue. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports philippine journal of otolaryngology-head and neck surgery 37 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 surgical innovations and instrumentation 54 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2016; 31 (2): 54-57 c philippine society of otolaryngology – head and neck surgery, inc. medialization thyroplasty using a pocket and silicone implant technique maria margarita f. taningco, md emmanuel l. ibay, md department of otorhinolaryngology head and neck surgery makati medical center correspondence: dr. maria margarita f. taningco department of otorhinolaryngology head and neck surgery 2nd floor, tower 1, makati medical center #2 amorsolo st., legaspi village, makati city 1229 philippines tel:(632) 888 8999 local 2282 email: marga.flores.taningco@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery surgical innovation and instrumentation poster contest, december 2, 2014. sofitel philippine plaza hotel, manila. abstract objective: to describe a new method of medialization thyroplasty using a modified preformed nasal silicone implant. methods: design: surgical innovation setting: tertiary private hospital participants: four patients underwent medialization thyroplasty using a pocket and nasal implant technique performed by the senior co-author. the indication for medialization thyroplasty for these patients was hoarseness secondary to unilateral vocal fold paralysis of more than 6 months duration, and documented by flexible fiberoptic laryngoscopy. the outcomes were described with comparison of preand post-operative subjective voice assessment. results: operative time was 15–30 minutes. postoperative subjective improvement of voice quality was evident. scars were minimal and aesthetically acceptable. the procedure could be done on an outpatient basis. conclusion: medialization thyroplasty via a pocket and silicone implant technique is initially effective and may be a worthwhile alternative to the usual window technique. keywords: unilateral vocal cord paralysis; medialization thyroplasty; isshiki thyroplasty; silicone implant it is generally accepted that “laryngeal framework surgery is the current gold standard treatment for unilateral vocal fold paralysis. it provides a permanent solution to glottic insufficiency caused by injury to the recurrent laryngeal nerve.”1 a common technique of medialization thyroplasty involves the creation of a window on the thyroid lamina, the superior aspect of which is at the vocal fold level, incising and removing the outer perichondrium and cartilage window, dissecting the inner perichondrium off the surrounding cartilage, and placing a prosthesis in the most effective position to push the paralyzed vocal fold medially. this carries a risk for perforation of the endolaryngeal mucosa, wound infection, chondritis, implant migration or extrusion, and airway obstruction. with written informed consent, we performed a technique that did away with this window, instead utilizing a pocket created at the same level, with insertion of a modified silicone nasal implant of appropriate size under direct visualization of vc medialization using a flexible nasolaryngoscope. we report our preliminary experience. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 55 surgical innovations and instrumentation methods surgical technique after an acceptable period of observation that has deemed the vocal cord paralysis to be permanent (usually around 6 months to 1 year), medialization thyroplasty may be recommended for a patient with unilateral vocal cord paralysis. documentation of vocal cord paralysis via videolaryngostroboscopy is done. voice quality is also assessed preoperatively for comparison during the postoperative period. the procedure starts after general anesthesia has been induced using a laryngeal mask airway (lma) to will enable unobstructed visualization of the vocal folds as needed. the level of the vocal fold is determined by palpating the thyroid notch and inferior border of the thyroid ala anteriorly. surgical markings are placed and 2% lidocaine hcl with epinephrine (1:100,000) is infiltrated at the incision site. (figure 1) a three cm incision is made over the area of the inferior thyroid ala on the side of the paralyzed cord. blunt and sharp dissection with mosquito forceps is performed until the inferior border of the thyroid cartilage is reached. (figure 2) a pocket is created by incising perichondrium at the inferior border of the thyroid cartilage with a blade no. 15 and freeing the inferior surface of the thyroid cartilage from the perichondrium using a freer elevator. (figure 3) a flexible fiberoptic laryngoscope is inserted transnasally at this point and the laryngeal inlet viewed while creating the pocket taking care not to puncture the perichondrium. (figure 4) the silicone nasal implant is prepared by measuring the blunted dorsal part and trimming it to fit the pocket created. (figure 5) under endoscopic visualization, the silicone implant is inserted in the pocket and pushed in until the posterior glottis is apposed with slight over-correction to account for deterioration in voice quality after intraoperative edema has resolved. (figure 6) the pocket is closed by suturing the perichondrium to the cartilage using silk 5-0 sutures. the incision is closed in layers using polyglactin 910 (vicryl 4-0, ethicon, johnson & johnson, nj, usa) sutures for the muscle and silk 5-0 sutures for the skin. (figure 7) the procedure usually lasts for 15-30 minutes. results case 1 an 18-year-old man diagnosed with left congenital vocal cord paralysis presented to the clinic with hoarseness since birth and shortness of breath upon exertion. on laryngoscopic examination, the left vocal cord was noted to be immobile. he underwent medialization thyroplasty under general anesthesia after cardiopulmonary clearance. operative time was 22 minutes. the postoperative course figure 1. marking on the ipsilateral inferior thyroid ala and infiltration with 2% lidocaine hcl + epinephrine (1:100,000) figure 2. blunt and sharp dissection until inferior border of ipsilateral thyroid cartilage is reached was unremarkable and he was discharged on the same day. he had improved voice quality and less episodes of shortness of breath on the first month of follow-up. case 2 a 62-year-old man was referred to our service from internal medicine with 3 years of progressive hoarseness. flexible fiberoptic laryngoscopy showed a paralyzed vocal cord on the left. since there was no history of previous surgery to the neck, a ct scan was ordered, revealing an aortic aneurysm. he underwent medialization thyroplasty under sedation after cardiopulmonary clearance. operative time was 18 minutes. his voice quality improved postoperatively. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 surgical innovations and instrumentation 56 philippine journal of otolaryngology-head and neck surgery figure 3. broken arrow and line show pocket created where modified silicone implant is to be placed figure 6. placement of implant into created pocket under endoscope guidance figure 4. creation of pocket under endoscope guidance figure 5. nasal implant modified, dorsal part measured, tip discarded case 3 a 49-year-old woman was referred to our service after she had hoarseness following a total thyroidectomy. flexible fiberoptic laryngoscopy showed a paralyzed left vocal fold. she was advised to undergo medialization thyroplasty on the first year anniversary of her thyroid surgery if symptoms did not improve. she underwent the procedure one year later. operative time was 30 minutes with satisfactory results. case 4 a 69-year-old man who had also undergone total thyroidectomy for papillary thyroid carcinoma had hoarseness post operatively. flexible fiberoptic laryngoscopy showed a paralyzed left vocal fold. he was advised to undergo medialization thyroplasty after 1 year if his voice did not return to normal. he underwent the procedure at the prescribed time. operative time was 28 minutes. he was satisfied with his voice post operatively. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 57 surgical innovations and instrumentation discussion the important functions of the human larynx are protection of the lower airways, phonation and respiration. unilateral vocal cord paralysis is one of the most common neurogenic disorders affecting the larynx and can be a complication of thyroid surgery when there is damage to the recurrent laryngeal nerve.2 it can also be caused by any lesion affecting or impinging on the path of the nerve. when this happens, it can be distressing to the patient. aside from dysphonia, aspiration episodes and shortness of breath with exertion can ensue. unilateral laryngeal paralyses can evolve in 3 ways through spontaneous recovery of mobility with no recovery but with compensation by the contralateral vocal cord or with no recovery or compensation and flaccid paralysis.2 the probability of recovery depends greatly on the etiology, there is a good prognosis for recurrent idiopathic paralysis or when the cause is surgical injury.3 several techniques have been advocated to achieve medialization of the paralyzed vocal folds. isshiki and associates and koufman4 have reported their experiences with medialization and tensioning procedures for the management of vocal fold bowing and dysphonia resulting from sulcus vocalis and soft tissue deficits fahkry, flint, and associates4 prefer injection laryngoplasty via a lateral, percutaneous approach through the thyroid ala at the level of vocal fold determined by palpation of the thyroid notch and inferior border of the thyroid ala anteriorly. transoral injection and laryngoscopic injection have also been mentioned for specific groups of patients. medialization thyroplasty is the procedure of choice for management of unilateral vocal cord paralysis.1 carved silastic® implants, prefabricated silastic® implants, and dense hydroxyapatite implants, as well as gore-tex® strips have also been used with success.5 this procedure makes static changes to the laryngeal framework and its lack of effect on vocal fold muscle mass, innervation, and vocal references 1. danierro jj, garrett cg, francis do. framework surgery for treatment of unilateral vocal fold paralysis. curr otorhinolaryngol rep. 2014 jun 1; 2(2): 119–130. doi: 10.1007/s40136-014-0044-y pubmed pmid: 24883239 pubmed central pmcid: pmc4036824. 2. woodson ge. laryngeal and pharyngeal function. in: flint pw, haughey bh, niparko jk, richardson ma, robbins kt, thomas jr, editors. cummings otolaryngology head and neck surgery. 5th ed, vol 1. philadelphia: mosby elsevier; 2010. p. 805-12. 3. bothe c, lopez m, quer m, leon x, garcia j, lop j. [aetology and treatment of vocal fold paralysis: retrospective study of 108 patients]. acta otorrinolaringol esp. 2014 jul-aug; 65(4):225-230. doi: 10.1016/j.otorri.2014.02.003 pubmed pmid: 24780305. 4. fakhry c, flint p, cummings c. medialization thyroplasty. in: flint pw, haughey bh, niparko jk, richardson ma, robbins kt, thomas jr, editors. cummings otolaryngology head and neck surgery. 5th ed, vol 1. philadelphia: mosby elsevier; 2010. p. 904-11. 5. elnashar i, el-anwar m, amer h, quiriba a. voice outcome after gore-tex medialization thyroplasty. int arch otorhinolaryngol. 2015 jul; 19(3): 248-254. doi 10.1055/s-0034-1397339. pubmed pmid: 26157500 pubmed central pmcid: pmc4490926. 6. chrobok v, pellant a, šram f, frič m, praisler j, prymula r, švec jg. medialization thyroplasty with a customized silicone implant: clinical experience. folia phoniatr logop. 2008;60(2):91–96. doi: 10.1159/000114651. pubmed pmid: 18235197. fold motility is its inherent limitation.4 other disadvantages include subjecting the patient to an open procedure, limited closure of the posterior glottis, and technical difficulty.4 factors affecting outcome include size and shape of the implant position of the implant, maintaining proper position of the implant, and limiting the duration of the surgical procedure.4 a study by chrobok, et al. evaluating the use of customized silicone implant in medialization thyroplasty concluded that successful and safe medialization thyroplasty using a silicone implant is possible based on improvement of maximum vocal sound pressure level, phonation time, and jitter and shimmer reduction. 6 a review of medline (pubmed), embase and herdin using the keywords “unilateral vocal cord paralysis; medialization thyroplasty; isshiki thyroplasty; silicone implant” did not reveal a technique similar to our pocket and silicone implant method. in this series, all our patients presented with hoarseness of more than 6 months duration with documented unilateral vocal fold paralysis. they underwent the medialization technique described with positive results. the technique we propose is a cross between the traditional open method and injection laryngoplasty. the incision and extent of surgery is such that exposure of a larger area is not necessary. endoscopic guidance also ensures that we are in the right position. the short operative time and comparatively less-invasive nature of this technique makes it worth considering. the authors suggest further studies with more subjects and a more objective way of assessing voice quality preand postoperatively, as well as long-term follow up of these patients. figure 7. closure by suturing the perichondrium to the cartilage using silk 5-o. incision is closed in layers, using vicryl 4-0 reinforced with histoacryl glue for the muscle and silk 5-0 for the skin. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles 24 philippine journal of otolaryngology-head and neck surgery abstract objectives: to determine the efficacy of a 7-day treatment of methylprednisolone 16mg in reducing the size of nasal polyps and on improvement of nasal symptoms. methods: design: randomized double-blind placebo-controlled trial setting: out-patient department of the east avenue medical center patients: patients 18 years old and above with nasal polyposis determined by history and endoscopic examination results: there was a significant decrease in polyp size by an average of 16% (p < .05) among 12 out of the 23 patients (52.17 %) in the steroid group versus placebo. the treatment group also exhibited an improvement in nasal symptoms of rhinorrhea, congestion and anosmia compared to the placebo. conclusion: medical treatment with oral methylprednisolone given at a low dose of 16 mg for one week resulted in reduction of the size of nasal polyps and improved the symptoms of rhinorrhea, nasal congestion and anosmia. other associated symptoms like headache, epistaxis, sneezing, itchiness, epiphora, cough, postnasal drip, throat discomfort, facial pain, eye complaints and fever did not differ between the steroid and placebo groups. recommendation: one week of oral steroids can be used to treat nasal polyps initially. if there is response, this mode of management can be combined with a long-term course of intranasal steroid sprays9,10. patients who do not respond may be referred for surgery. keywords: nasal polyposis, methylprednisolone, rhinorrhea, nasal congestion, anosmia nasal polyposis is a condition resulting from chronic inflammation of the nasal and paranasal sinus mucosa, leading to a projection of benign edematous masses from the meatus to the nasal cavity. multiple factors interact to initiate the surge of inflammatory responses that culminate in polypoid nasal growth1. altered sinonasal functions lead to a variety of symptoms like nasal stuffiness and obstruction, anterior and posterior rhinorrhea, loss of the sense of smell, and facial pain. these make it the most incapacitating illness of the nasal cavity and paranasal sinuses2. corticosteroids are the mainstay in the medical management of nasal polyps. systemic corticosteroids are considered the most effective pharmacological agents as they dramatically decrease mucosal inflammation and suppress the immune response against environmental low dose, short-term oral methylprednisolone for nasal polyps: a randomized double-blind placebo-controlled trial romeo c. sanchez jr., md1, benjamin sa campomanes jr., md 1,2, natividad a. aguilar, md, msc 1,3 1department of otorhinolaryngology head and neck surgery east avenue medical center 2department of otolaryngology head and neck surgery st. luke’s medical center 3department of otolaryngology head and neck surgery manila central university correspondence: romeo c. sanchez jr., md department of orl-hns east avenue medical center east avenue, diliman, quezon city 1100 philippines phone: (632) 9271128 e-mail: dooderts1@yahoo.com reprints will not be available from the author. funding support: the test drug methylprednisolone and the placebo were provided by pfizer inc., 23/f ayala fgu, 6811 ayala ave., makati city. other than this, the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at: 1. analytical research contest (3rd place) philippine society of otolaryngology head and neck surgery 49th annual convention, westin philippine plaza hotel, manila, december 1, 2005. 2. 3rd east avenue medical center residents’ organization research paper contest (3rd place), east avenue medical center, east ave., diliman, quezon city, december 16, 2005. philipp j otolaryngol head neck surg 2006; 21 (1,2): 24-27 c philippine society of otolaryngology – head and neck surgery, inc. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles philippine journal of otolaryngology-head and neck surgery 25 table 1. dose of oral steroids as recommended by different authors recommended dose 12 mg tapered to 3 mg within 9 days 64 mg tapered to 10 mg within 11 days 1mg/kg/day tapered to ¼ of the dose within 16 days 60 mg tapered to 5 mg within 16 days 1mg/kg/day for 5 days 1mg/kg/day for 10 days 560 mg oral tapered for 12 days or 715 mg tapered for 20 days author lund, 199513 rasp, 2000 14 tuncer, 2003 9 van camp, 1994 6 bonfils, 2003 10 slavin, 1995 16 damm, 1999 5 corticosteroid dexamethasone methylprednisolone prednisolone fluocortolone table 2. four-point grading scale for polyps (mckay and lund) no polyps small polyps not reaching the edge of the lower edge of the middle turbinate medium-sized polyps extending between the upper and lower edges of the inferior turbinate large polyps extending below the lower edge of the inferior turbinate grade 0 grade i grade ii grade iii table 3. subjective clinical scoring system symptom score: 0 = absent; 1 = mildest; 10 = worst headache epistaxis rhinorrhea congestion sneezing itchiness epiphora 1 2 3 4 5 6 7 cough post-nasal drip throat discomfort facial pain eye complaints fever anosmia 8 9 10 11 12 13 14 irritants and bacterial/fungal antigens3. they can reach all parts of the nose and sinuses, including the olfactory cleft and middle meatus, and can better improve the sense of smell, in contrast to intranasal topical steroids4. woodworth3 demonstrated a significant decrease (radiographically and endoscopically) in extent of nasal polyps and an improvement of nasal symptom scores with systemic corticosteroids. other studies of oral steroids reported success rates of 50 and 72%5,6, but these were non-randomized. most randomized control trials involving the use of topical intranasal steroids reported overall success rates between 60.9 to 80%7,8. other studies combining a short-term course of oral steroids and a long-term course of intranasal steroids showed a reduction of polyp volume in 85 to 88% of patients with concomitant improvement in nasal symptoms9,10. the main concerns with the use of systemic corticosteroids are adverse effects that can occur after prolonged use. patients given daily doses of 100mg hydrocortisone (or the equivalent 20 mg amount of synthetic steroid methylprednisolone) for longer than 2 weeks may undergo “iatrogenic cushing’s syndrome11”. other serious adverse effects include peptic ulcers and their consequences, hypomania or acute psychoses, sodium and fluid retention and loss of potassium11. in the management of nasal polyps, oral corticosteroids are given as a short-term course of 5-10 days with or without tapering12 or a longterm course of 12-21 days with tapering3,5,6,9 (table 1). this study aims to assess the efficacy of low-dose systemic corticosteroids given for 7 days in the treatment of nasal polyps. materials and methods the study was conducted at the east avenue medical center from august 2004 to september 2005. of an initial 113 patients, 48 patients met the inclusion criteria: (1) age 18 years or older and (2) presence of nasal polyps on endoscopic examination. excluded were patients with: (1) co-morbidities like diabetes mellitus, hypertension, acid peptic disease/gastritis, psychosis: (2) purulent sinonasal discharge; (3) use of rhinitis or asthma medications; (4) hypersensitivity to corticosteroids. informed consent was obtained for the study. the 48 patients were randomized equally into steroid and placebo groups using computer-generated numbers. the steroid group was treated with methylprednisolone, 16 mg once a day after breakfast for 7 days. clinical outcome measures included reduction of nasal polyps using the mackay and lund scoring system (table 2) and improvement of symptom scores. reduction of nasal polyps was defined as downgrade of polyp rating or decrease in size in those polyps that did not change in polyp grade. patients were seen at the clinic before, and a week after treatment and examined by the same physician. nasal endoscopy was performed with a 30-degree xenon sinuscope. polyps were rated on the four-point grading scale proposed by mackay and lund15 (table 2). preand post treatment video recordings were rated by 3 independent observers. grade score scale 0 i ii iii 0 1 – 10 11 – 20 21 30 table 4. score scale system nu m be r of no st ri ls (le ft & ri gh t) steroid group placebo group total patients silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles 26 philippine journal of otolaryngology-head and neck surgery fourteen symptoms associated with nasal polyps were assessed through a symptom scoring system ranging from 0 to 10, where a score of 0 corresponded to absence of symptoms and a score of 10 meant experiencing the worst symptoms (table 3). all data was analyzed using spss for windows version 9 statistics software package. to be able to provide an analysis for the data on the decrease in polyp size, the following values were introduced as listed in (table 4). a patient initially diagnosed to have a grade ii polyp would be given a score of 20. if after treatment the patient’s polyp size improved from grade ii to grade i, the patient would now have a score of 10 on the second visit. if the polyp grade did not change, but had a 30% size reduction, the score would decrease from 20 to 17. results there were a total of 48 patients in the study, 32 males (66.67%) and 16 females (33.33%). two (2) were lost to follow up after the initial visit. of the 46 remaining patients, 23 received methylprednisolone while the other 23 received placebo. on pretreatment endoscopic assessment, table 5. percentage of the different grades of polyps in total and in each group total patients (both nostrils) 7.61% 10.87% 53.26% 28.26% 100% grade 0 grade i grade ii grade iii total placebo group (both nostrils) 6.52% 10.87% 52.17% 30.43% 100% medrol group (both nostrils) 8.70% 10.87% 54.35% 26.09% 100% steroid group -15.8696 placebo group -2.6087 table 7. average change in polyp size 7/46 (15.22%) had unilateral nasal polyps and 39/46 (84.78%) had bilateral polyps. polyps were graded per nostril since half of the patients (50%) had different-sized polyps in each nasal cavity (table 5). grade 3 polyps were seen in 26/92 (28.26%) of the total number of nostrils examined during the initial consult. 49/92 (53.26%) had grade 2 polyps and 10/92 (10.87%) had grade 1 polyps. 7/92 (7.61%) of the nostrils had grade 0 polyps (figure 1). in the steroid group, 8 out of the 23 patients had a one step grade reduction in both nostrils (table 6). another 2 patients had a one step grade reduction in 1 nostril while the polyp in the other nostril remained in the same grade but had a 20% decrease in size. two (2) patients had a 30-50% decrease of nasal polyp size in both nostrils while remaining in the original grade. in all, 12 patients (52.17%) had a reduction of nasal polyp size in various degrees after treatment with methylprednisolone. using the wilcoxon signed rank test, the reduction in nasal polyp size was statistically significant (0.002 and 0.004 in the right and left nostril respectively, at p < .05). there was an average 16% reduction in polyp size for patients who took methylprednisolone compared to the 3 % figure 1: polyp grading table 6. size reduction of polyps number of patients in steroid group 8 (34.7%) 2 (8.70%) 2 (8.70%) 11 (47.83%) 12 (52.17%) 23 (100%)t number of patients in placebo group 0 0 5 (21.74%) 18 (78.26%) 5 (21.74%) 23 (100%) downgrade of polyp in both nostrils by 1 grade downgrade of polyp in 1 nostril + decrease in size but still in initial grade in the other nostril decrease in size but still in initial grade in both nostrils no change total no. of patients with polyp reduction (in all degrees) total figure 2-a: reduction in polyp size in steroid group figure 2-b: reduction in polyp size in placedo group silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles philippine journal of otolaryngology-head and neck surgery 27 acknowledgements: we would like to thank dr. felix nolasco for facilitating this study; drs. dwight alejo, martin derek peteza, ramon portugal iii, emerson catudio, ryan adan, nino timbungco and stephanie santiago, our participating investigators; and ms. menchie gapasin, our statistician. references: 1. shin sh, park jy, jeon ch, choi jk, lee sh. quantitative analysis of eotaxin and rantes messenger rna in nasal polyps: association of tissue and nasal eosinophils. laryngoscope 2000;110(8):13537. 2. radenne f, lamblin c, vandezande lm, et al. quality of life in nasal polyposis. j allergy clin immunol 1999;104:79-84. 3. woodworth b, joseph k, kaplan a, schlosser, r. alterations in eotaxin, monocyte chemoattractant protein-4, interleukin-5, and interleukin-13 after systemic steroid treatment for nasal polyps. otolaryngol head neck surg 2004;131(5):585-9. 4. assanasen p, naclerio r. medical and surgical management of nasal polyps. current opinion in otolaryngology & head & neck surgery 2001;9(1):27-36. 5. damm m, jungelhulsing m, eckel h, schmidt m, theissen p. effects of systemic steroid treatment in chronic polypoid rhinosinusitis evaluated with magnetic resonance imaging. otolaryngol head neck surg 1999;126:517-23 6. van camp c, clement pa. results of oral steroid treatment in nasal polyposis. rhinology 1994 mar;32(1):5-9. 7. tos,m, svendstrup f, arndal h, orntoft s, et al. efficacy of an aqueous and a powder formulation of nasal budesonide compared in patients with nasal polyps. am j rhinol 1998;12:183-9. 8. lildholdt t, rundcrantz h, lindqvist n. efficacy of topical corticosteroid powder for nasal polyps: a double-blind, placebo-controlled study of budesonide. clin otolaryngol 1995;20:26-30. 9. tuncer u, soylu l, aydogan b, karakus f, akcali c. the effectiveness of steroid treatment in nasal polyposis. auris nasus larynx 2003;30:263-8. 10. bonfils p, nores jm, halimi p, avan p. corticosteroid treatment in nasal polyposis with a three-year follow-up period. laryngoscope 2003;113:683-687. 11. chrousos g, margioris a. adrenocorticosteroids & adrenocortical antagonists. in: katzung b, ed. basic & clinical pharmacology 8th edition. new york: the mcgraw-hill companies, inc., 2001:66078. 12. medical management of nasal polyps in adults. in: up-pgh department of otorhinolaryngology clinical practice guidelines. 2003:8-13. 13. lund v. diagnosis and treatment of nasal polyps. bmj 1995;311:1411-14. 14. rasp g, kramer mf, ostertag p, kastenbauer e. a new system for the classification of ethmoid polyposis. effect of combined local and systemic steroid therapy. larynorhinootologie 2000 may;79(5):266-72. 15. mackay is, lund vj. imaging and staging. in: mygind n, lilholdt t, eds. nasal polyposis: an inflammatory disease and its treatment. copenhagen: munksgaard, 1997:137-144. 16. slavin r. nasal polyps and sinusitis. jama 1997;278(22):1849-54. reduction in those on placebo (table 7). in the placebo group, 5 patients out of the 23 (21.74%) had a 10-50% reduction in nasal polyp size after treatment but still remained in the initial grade. this decrease was not statistically significant (0.063 and 0.066 in the right and left nostril respectively, at 5% level of significance). using the mann-whitney test, comparison of the size reduction between the 2 groups was statistically significant (0.015 and 0.034 in the right and left nostril respectively, at 5% level of significance). using the wilcoxon signed rank test, the steroid group exhibited significant improvement in symptoms # 1 to 7, 9 to 11, 13 and 14 (headache, epistaxis, rhinorrhea, congestion, sneezing, itchiness, epiphora, post-nasal drip, throat discomfort, facial pain, fever and anosmia, at 5% level of significance). there was a slight improvement in symptom # 8 (cough, at 10% level of significance) and # 12 (eye complaints at 15% level of significance). in the placebo group, there was a significant improvement in symptoms #1 to 5, 7 and 10 to 12 (headache, epistaxis, rhinorrhea, congestion, sneezing, epiphora, throat discomfort, facial pain and eye complaints, at 5% level of significance). there was a slight improvement in symptoms # 6,9,13 and 14 (itchiness, post-nasal drip, fever and anosmia, at 10% level of significance). using the mann-whitney test, the steroid group was shown to have a significant improvement in symptoms # 3, 4 and 14 (rhinorrhea, congestion and anosmia, at 6% level of significance) compared to the placebo group. there was also a slight improvement in treating symptoms # 8 and 9 with methylprednisolone than with placebo (cough and post-nasal drip, at 17% level of significance). there was no significant difference in improvement in the other symptoms between the 2 groups, nor were there adverse effects reported in either group. discussion the characteristics of the study population reflect those of patients with nasal polyps in the general population16 with reference to age (mean age, 35.30 years) and male-to-female ratio (2:1). the results of the study showed that there was a significant decrease in polyp size among patients in the steroid group by 1 grade. the volume of the polyps was reduced in 12/23 patients (52.17 %) by an average of 16%. among these 12 patients, 10 reported general improvement in a majority of their symptoms based on the subjective clinical scoring system. there was also a significant difference when comparing the reduction in nasal polyps to that in the placebo group. these findings correspond to those of damm et al.9 where oral steroid therapy (oral fluocortolone 560 mg tapered for 12 days in group 1 and 715 mg tapered for 20 days in group 2) significantly reduced the extent of polyps on magnetic resonance imaging (>30%) in 50% of patients and diminished most sinus-related symptoms in 80% of the patients. the symptom scores of the patients in both steroid and placebo groups improved for most symptoms. however, the steroid group had significantly better improvement in the symptoms of rhinorrhea, congestion and anosmia compared to placebo. this study showed that a low dose, short-term treatment course of oral methylprednisolone (16mg a day for 7 days) can lead to significant reduction in the size of nasal polyps, and improvement of nasal symptoms of rhinorrhea, congestion and anosmia. this treatment course can also be used as a screening tool prior to prescribing intranasal steroid sprays, which are quite expensive. non-responders can be referred for surgery, avoiding further costly medical management. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery practice pearls philipp j otolaryngol head neck surg 2023; 38 (1): 58-60 c philippine society of otolaryngology – head and neck surgery, inc. intradermal hyaluronidase: the answer to treatment in softening a fibrous thick supratip skin in rhinoplasty? eduardo c. yap, md1, 2 john michael porquez, md3 1belo medical group 2department of ent, metropolitan medical center 3department of otolaryngology – head and neck surgery university of the philippines philippine general hospital correspondence: dr. eduardo c. yap unit 3, 28 times st., west triangle, quezon city 1104 philippines phone: (632) 8254 1111 email: edcyap88@gmail.com the authors declare that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. abstract keywords: rhinoplasty; supratip break; supratip fullness; hyaluronidase; fibrous thick supratip skin; bulbous tip it is a common goal for rhinoplastic surgeons to make the best-looking tip with proper projection, maintaining the tip lobule appearance with a supratip break. (figure 1) however, a fibrous thick skin with fullness may not achieve the ideal tip. it is one of the nuisances in rhinoplasty that makes tip definition surgery difficult. the supratip area remains firm and convex causing a wide bulbous feature of the tip. several techniques have been introduced with good results however some may still result in supratip fullness because of the firm fibrous nature of thick skin.1-3 hyaluronidase is an enzyme that depolymerizes hyaluronic acid which is present in the epithelium.4 the use of intradermal hyaluronidase for thick skin was discovered by the junior author (jmp) in one of his rhinoplasties when he injected hyaluronidase in a nose with fillers containing hyaluronic acid. the fillers not only instantly dissolved but the skin also softened, so he tried injecting intradermally in his subsequent rhinoplasties on non-filler noses with fibrous thick skin and indeed found the same effect of softening of the fibrous supratip skin. we here describe the technique used in this preliminary clinical series. methods a vial of 1,500 i.u. of hyaluronidase (liporase, skin lab medical, essex, uk) is mixed with 1.0 ml of normal saline solution (nss) and 0.1 0.2ml (150u – 300u) is aspirated and may be diluted with 0.8ml of pnss in a 1 cc tuberculin syringe or given as concentrated dose. intradermal injection into fibrous thick skin can be performed intraoperatively before incision or after closure when defatting and tip grafts are put in place but still with supratip fullness. the areas to be injected are the supratip and its sides. (figure 2) a disposable hypodermic needle gauge 30 is used to inject intradermally or subdermally in minute amounts until blanching is noted. these injections are given at equally random spacing. immediately after injection, finger pressure massage is applied at the supratip area for 1-3 minutes to soften the skin and allow redraping of the skin and soft tissue envelope (sste). creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery practice pearls an instant effect is noted thereafter. (figure 3, 4) because of the transient softening effect, immediate taping and pressure cast dressing is applied post operatively. the procedure may be repeated a week post operatively if there is still residual supratip fullness. results our initial clinical experience involved 16 patients, aged 22 to 43, with 5 males and 11 females. all patients gave written informed consent for the possible additional procedure of hyaluronidase injection for the supratip skin if tip projection is not well-defined intraoperatively despite defatting and tip grafts. the 16 patients with various thickness in their supratip skin had immediate improvement of nasal profile with good tip definition. sample cases with pre-operative and postoperative photographs are shown. (figure 5,6,7) discussion our initial clinical experience suggests that intradermal hyaluronidase may soften fibrous thick supratip skin and allow a nice aesthetic redraping of the sste in rhinoplasty. hyaluronidase is an enzyme that breaks down hyaluronic acid. hyaluronic acid or hyaluronan is a polysaccharide found in connective, epithelial and neural tissues. it has been shown that hyaluronidase improve systemic delivery of injectable medications because it depolymerizes hyaluronic acid.4 it is used in subcutaneous fluid infusion (hypodermocylysis) as well as an adjuvant to accelerate the absorption and dispersion of drugs in subcutaneous tissue. it is also used as an adjunct to promote the absorption of contrast media in urinary tract angiography (subcutaneous urography). it is also approved for used in increasing hematoma absorption in europe.5 one of the off-label uses of hyaluronidase is the reversing of cosmetic facial filler, hyaluronic acid. this practice is widely accepted in cosmetic medicine and surgery.6 since the epithelium is rich in naturally occurring hyaluronic acid, injecting hyaluronidase causes degradation of hyaluronic acid causing the skin to soften. a fibrous thick tip skin in rhinoplasty may not result in a nose with nice tip projection. a convexity may occur causing supratip fullness and polly beak deformity.1,7 several surgical techniques recommended to correct such a deformity include skin excision, cartilage suturing, suturing of the dermis to the cartilages, soft tissue resection, multiple layered tip grafts.1,2 medical treatments include post operative supratip triamcinolone injection.3 the above-mentioned treatments improve the supratip up to a certain extent with a supratip fullness. using hyaluronidase intradermally to soften the supratip skin may be added to the surgical armamentarium to allow molding and redraping. the skin softens significantly with finger massage and pressure allowing figure 1. ideal tip should have a supratip break figure 2. markings at supratip skin and its sides where hyaluronidase is injected intradermally figure 3. intraoperative appearance of the nose after open structured rhinoplasty which still showed convexity and supratip fullness figure 4. intraoperative appearance of the nose after intradermal injection of hyaluronidase. note the immediate loss of convexity and softening of the supratip skin. additional tip grafting can be performed to create a more pronounced supratip break. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery practice pearls references 1. bhatt m, brandstetter m, gubisch w, haack s. supratip excision in rhinoplasty. otolaryngology case reports. 2017 aug;5:8-12. doi: 10.1016/j.xocr2017.08.002. 2. kim sk, kim jc, lee kc, kim hs. correction of the supratip deformity of the nose. aesthet surg j. 2012 nov;32(8):943-55. doi:10.1177/1090820x12463386; pubmed pmid: 23110926. 3. goyuron b, deluca l, lash r. supratip deformity: a closer look. plast reconstr surg. 2000 mar;105(3):1140-51. doi: 10.1097/00006534-200003000-00049; pubmed pmid: 10724276. 4. wasserman rl. recombinant human hyaluronidase-facilitated immunoglobulin infusion in primary immunodeficiency diseases. immunotherapy. 2017 sep;9(12):1035-1050. doi: 10.2217/ imt-2017-0092; pubmed pmid: 28871852. 5. jung hw. hyaluronidase: an overview of its properties, applications, and side effects. arch plastic surg. 2020 jul;47(4): 297-300. doi:10.5999/aps.2020.00752; pubmed pmid:  32718106; pubmed central pmcid: pmc7398804. 6. paap mk, silkiss rz. the interaction between hyaluronidase and hyaluronic acid gel fillers – a review of literature and comparative analysis. plast aesthet res. 2020 jul;7:36. doi: 10.20517/2347-9264.121. 7. saadoun r, risse e, crisan d, veit ja. dermatological assessment of thick-skinned patients before rhinoplasty-what may surgeons ask for? int j dermatol. 2022 jul 3. doi:  10.1111/ ijd.16341; pubmed pmid: 35781878. 8. kim hj, kwon sb, whang ku, lee js, park yl, lee sy. the duration of hyaluronidase and optimal timing of hyaluronic acid (ha) filler reinjection after hyaluronidase injection. j cosmet laser ther. 2018 feb;20(1):52-57. doi: 10.1080/14764172.2017.1293825; pubmed pmid: 29199877. central, and google scholar using the search terms “hyaluronidase,” “ rhinoplasty,” “fibrous thick skin,” and “bulbous tip,” there are no english language articles to date on the use of hyaluronidase for fibrous thick skin. is intradermal hyaluronidase the answer to treatment in softening a fibrous thick supratip skin in rhinoplasty? our initial clinical experience suggests that intradermal hyaluronidase may be an adjunct treatment and the answer to softening a fibrous thick supratip skin in rhinoplasty, but the main procedure for producing a nice tip lobule with supratip break is still tip grafting and defatting. figure 6. a 34-year-old male: a. preoperative and b. immediate post operative photograph (photo rotated upright for comparison purposes) showed a remarkable nasal lengthening and tip definition. intraoperatively after tip grafting and defatting, 300 u of hyaluronidase was injected intradermally to soften the skin and soft tissue thus allowing a slimmer look of the tip. figure 7. a 43-year-old female: a. preoperative and b. one week post operative photographs showed a projected tip. intraoperatively after rhinoplasty, 300u of hyaluronidase was injected intradermally at supratip area aside from defatting resulting in a softer, slimmer tip. a bba molding of the supratip area, creating a supratip break. the effect is transient intraoperatively so immediate taping and pressure cast should be applied. there are possible limitations to our series. first, hyaluronidase is known to be short acting, lasting 3-6 hours and we do not know how long the effects will ultimately last.8 because this is a report of our very early experiences, we do not have any long term follow up either. future studies with long term follow up can address this issue. second, we did not perform objective measurements of the supratip break, supratip lobule and tip-defining point, tip lobule, infratip lobule using standardized views and angles. a future formal trial can better document these. indeed, our intraoperative results may be easily produced by finger pressure and molding, and the volume effect of hyaluronidase injection itself can be argued to cause tip projection and relative supratip depression. however, our longstanding combined experience in performing rhinoplasties convinces us that there is a marked softening of fibrous supratip skin after hyaluronidase injection that we have not seen with any other intervention to date. we cannot objectively report this softening, but long term follow-up results and future trials may confirm our initial experience. perhaps a future formal trial using high resolution ultrasound to measure the supratip skin and sste, with long-term follow up may demonstrate the true effect of hyluronidase. to the best of our knowledge, based on a search of herdin plus, the asean citation index, the global index medicus – western pacific region index medicus and index medicus of the south east asia region, the directory of open access journals, medline (pubmed and pubmed figure 5. a 24-year-old female: a. intraoperatively after rhinoplasty, despite the tip grafts, there is still lack of tip projection because of the thick supratip skin causing fullness. b. 150u of hyaluronidase injected intradermally at the supratip area resulted in softening, allowing a nice re-draping of skin and soft tissue over the tip for a supratip break. a b philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 case reports philippine journal of otolaryngology-head and neck surgery 47 philipp j otolaryngol head neck surg 2016; 31 (2): 47-50 c philippine society of otolaryngology – head and neck surgery, inc. a 15-year occult foreign body in the subglottic area of a 50-year-old woman donnie jan l. segocio, md christine d. dayanghirang, md joseph e. cachuela, md department of otorhinolaryngology head and neck surgery southern philippines medical center correspondence: dr. donnie jan l. segocio department of otorhinolaryngology head and neck surgery southern philippines medical center davao city 8000 philippines phone: (+63) 922 896 9978; (+63) 917 869 2111 email: ronaldonnie@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery interesting case contest. june 2, 2015, menarini building, bgc, taguig city. presented at the southern philippines medical center annual residents’ interesting case contest. august 2013. jica building, southern philippines medical center, davao city. abstract objective: to present a case of subglottic foreign body (fb) impaction in a 50-year-old woman diagnosed with bronchial asthma for 15 years. methods: design: case report setting: tertiary public hospital patient: one results: a 50-year-old woman with recurrent cough and dyspnea for 15 years that had been managed as bronchial asthma developed stridor and halitosis in the last 5 years. flexible laryngoscopy revealed a subglottic mass and ct scan confirmed a suspicious foreign body in the lumen of the subglottis. signs and symptoms resolved after peroral endoscopic removal of the foreign body from the larynx. histopathology of the extracted material from the airway confirmed it to be “bone tissue.” conclusion: foreign body aspiration can occur in adults without predisposing factors. its diagnosis can be challenging as it can mimic respiratory disorders such as bronchial asthma. endoscopy and computed tomography are valuable for correct diagnosis and management. an incorrect initial diagnosis should be considered in the light of unresolved symptoms and prompt referral to an appropriate specialist may prevent undue suffering and dangerous complications. keywords: foreign body aspiration, occult airway foreign body foreign body aspiration commonly occurs in patients with neurological impairment, alcohol intoxication, and head trauma, more commonly in children and elderly.1 foreign body aspiration in adults without these risk factors is rare, and long-standing persistence for 15 years is even rarer. we present a case of subglottic foreign body (fb) impaction in a 50-year-old woman diagnosed with bronchial asthma for 15 years. case report a 50-year-old local government employee consulted because of cough, recurrent dyspnea, biphasic stridor and halitosis. she had complained of recurrent cough and dyspnea for 15 years. her family physician diagnosed bronchial asthma and treated her with inhaled bronchodilators, mucolytics, antibiotics and corticosteroids. several other consults were made because symptoms only partially resolved and would recur despite multiple interventions for asthma and respiratory creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 48 philippine journal of otolaryngology-head and neck surgery case reports tract infection. there were also multiple hospital admissions for bouts of cough and dyspnea treated with inhaled corticosteroids, bronchodilators and occasional antibiotics. several peak flow tests revealed a low normal result. repeated chest radiographs were unremarkable. she developed halitosis and episodic biphasic stridor in the last 5 of those 15 years eventually prompting otolaryngologic consult. on examination, the patient had supraclavicular retractions, a respiratory rate of 20 per minute and oxygen saturation of 98-100%. there was episodic biphasic stridor especially on deep breathing with inspiratory and expiratory wheezes on auscultation. halitosis was evident. flexible laryngoscopy showed a suspicious mass in the subglottic area causing about 30% airway obstruction. the vocal cords were fully mobile but edematous. (figure 1) a computed tomography (ct) scan of the neck revealed a y-shaped radiopaque foreign body in the lumen of the subglottic region oriented in a sagittal plane with swelling of the `mucosa and corresponding narrowing of the airway. there was also obliteration of the paralaryngeal fat indicating mild edema of the larynx. the airway above the larynx and below the foreign body was normal. (figure 2) review of history revealed a choking incident while eating 15 years ago, followed by paroxysms of cough then breathiness of the voice. a general physician consulted advised the patient to rest. breathiness persisted for about a year associated with recurrent cough and dyspnea. after one year of breathiness and hoarseness, vocal production returned to normal, but she had repeated consults with and admissions under different physicians due to recurrent cough and dyspneic episodes. for 15 years, she had been managed without relief as a case of bronchial figure 1. flexible laryngoscopic view of subglottic foreign body with granulation tissue and airway obstruction of about 30%. figure 3. extracted foreign body measuring 1.5cm x 0.3cm x 0.7cm with granulation tissue. figure 2. ct scan of the neck a. coronal view b. axial view showing sagitally-oriented radiopaque foreign body in the lumen of the subglottic region. a b philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 49 case reports asthma. she had even been advised to quit work due to the frequency and progressive intensity of exacerbations. with a diagnosis of laryngeal foreign body impaction, a tracheostomy was performed to secure the airway and ensure adequate ventilation during foreign body extraction. direct laryngoscopy and removal of foreign body and granulation tissue yielded a bony hard, 1.5 x 0.3 x 0.7 cm object surrounded by granulation tissue causing 30% obstruction of the airway immediately below the vocal cords. (figure 3) the subglottic airway diameter at the level of the foreign body was collectively 7 mm. the procedure was well tolerated. she was decannulated on the 3rd postoperative day and discharged improved on the 4th postoperative day. dyspnea, retractions, halitosis and biphasic stridor resolved completely one week following surgery. the final histopathologic report revealed “bone tissue.” (figure 4) manifestations.9 the first phase occurs immediately following the incident. the main symptoms are coughing (72%), wheezing (53%), and dyspnea (25%).2 these were manifested by the patient for 15 years. the occurrence of death is very high during this phase of aspiration especially in children.7 however, irregular foreign bodies tend to orient in a sagittal plane, as manifested by this patient, and may produce only partial obstruction.10 this affords adequate airflow allowing the foreign body to remain undetected for a long period of time.10 the second phase is the asymptomatic period that can last from minutes to months or even years following the incident.11 the duration of this period depends on the location of the foreign body, the degree of airway obstruction, and the type of material aspirated.11 this phase is the most treacherous and accounts for large percentage of misdiagnosed and overlooked foreign bodies9 as presented by our patient. the third clinical phase is the renewed symptomatic period due to the presence of complications secondary to the aspirated foreign body.2,9 airway inflammation or infection from the foreign body will cause symptoms of cough, wheezing, halitosis, fever, sputum production, and occasionally, hemoptysis.3,12 obstructive lung disease like bronchial asthma was strongly considered since the patient had recurrent cough and dyspnea temporarily relieved by bronchodilators and steroids. furthermore, she had a peak flow below normal and repeatedly unremarkable chest radiographs. although she had not been diagnosed with asthma in childhood, she could have had adult-onset asthma, because it is less well controlled and more likely to be non-atopic.13 risk factors include obesity, allergies and exposure to asthma-triggers like tobacco smoke and dust.13,14 which were not significantly present in the patient. asthma can be clinically diagnosed when presented with wheezing associated with shortness of breath, usually relieved with bronchodilators and corticosteroids, as partly manifested by the patient. however, to appropriately diagnose asthma, we need further tests like spirometry and bronchial challenge testing.14,15 the current medical practice of treating asthmatics with antibiotics and corticosteroids may obscure signs and symptoms that would normally be expected with a retained foreign body.9 clearing of symptoms with these agents cannot always be assumed to be diagnostic of a specific disease process. the fact that a wheeze disappears or a pneumonic process temporarily clears may merely mean that the reaction to a foreign body has been temporarily controlled.9 recurrence after tapering of therapy should heighten a physician’s suspicion of an aspirated foreign body.9 with the patient’s clinical manifestations and poor response to medications, a diagnosis other than asthma should have been considered. although rare with prolonged use of corticosteroids advancing age discussion foreign bodies in the aero-digestive tract are frequently encountered in otolaryngology. they are most common among toddlers (peaking at 3 years of age) and rare in adults.2 this is because airway-protective reflexes are not as effective in children. adults with predisposing factors such as advancing age, history of dental extraction and altered level of consciousness from sedation, trauma, intoxication or other neurologic problems are prone to foreign body aspiration.3-5 adults with no known risk factors like this patient can aspirate a foreign body if there is interference in the normal reflex action such as when laughing, playing or other circumstances where there is sudden inhalation while eating.6 the most frequently reported foreign bodies encountered in adults are dentures, meat bolus and bones that usually lodge in the bronchus (80%) but rarely in the subglottic area.7,8 there are three distinct clinical phases that occur after a foreign body is aspirated and these are associated with various clinical figure 4. histolopathologic specimen, hematoxylin – eosin, high power magnification (40x) revealed foreign body consistent with bone tissue. (hematoxylin – eosin, 40x) philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 case reports 50 philippine journal of otolaryngology-head and neck surgery acknowledgements the authors would like to thank dr. veronica magnaye and dr. hannah grace b. segocio who provided input, support, encouragement and helped critique and appraise this paper to, residents of the department of orl-hns spmc who assisted in performing the surgical technique. references 1. mise k, jurcev savicevic a, pavlov n, jankovic s. removal of tracheobronchial foreign bodies in adults using flexible bronchoscopy: experience 1995-2006. surg endosc 2009 jun;23(6):13601364. doi: 10.1007/s00464-008-0181-9. pubmed pmid: 18923871. 2. enzan k, mitsuhata h, sato w, suzuki m. [statistical analysis of tracheobronchial foreign bodies]. masui. 1991 sep: 40(9): 1417-1422. pmid: 1942519. pubmed pmid: 1942519. 3. ben-dov i, aelony y. foreign body aspiration in the adult: an occult cause of chronic pulmonary symptoms. postgrad med j. 1989 may; 65 (763): 299-301. pubmed pmid: 2692009 pubmed central pmcid: pmc2429316. 4. khan ns, khan ar, din s, sattar f. management of subglottic foreign body, a therapeutic challenge. jpmi journal of postgraduate medical institute 2004; 18(4):658-662. 5. rolfe lm, rayner cf. a wheezy man with a bony abnormality. postgrad med j. 1999 aug; 75(886): 503-505. doi: 10.1136/pgmj.75.886.503. pubmed pmid: 10646039 pubmed central pmcid: pmc1741311. 6. musani ma, khambaty y, jawed i, khan fa, ashrafi sk. an unusual foreign body in trachea. j ayub med coll abbottabad. 2010 jan-mar; 22(1):178-179. pubmed pmid: 21409938. 7. baharloo f, veyckemans f, francis c, biettlot mp, rodenstein do. tracheobronchial foreign bodies: presentation and management in children and adults. chest. 1999 may; 115(5):1357-62. pubmed pmid: 10334153. 8. umana an, offiong me, ewa au, francis p, adekanye a, mgbe rb, et al. foreign body (disk battery) in the oesophagus mimicking respiratory problem in a 13 months old baby-delayed diagnosis. journal of medicine and medical science. 2011 mar; 2(3):714-717. 9. wei jl, holinger ld. management of foreign bodies of airway. in: shields tw, locicero iii j, reed ce, feins rh, editors. general thoracic surgery. philadephia: lippincott williams and wilkins; 2009. p. 927-930. 10. philip a, rajan sundaresan v, george p, dash s, thomas r, job a, et al. a reclusive foreign body in the airway: a case report and a literature review. case rep otolaryngol. 2013; 2013: 347325, 4 pages. doi: 10.1155/2013/347325 pubmed pmid: 24312739 pubmed central pmcid: pmc3838836. 11. fong ew. foreign body aspiration. in: yamamoto lg, inaba as, okamoto jk, patrinos me, yamashiroya vk, editors. case based pediatrics for medical students and residents. [monograph on the internet] honolulu: department of pediatrics, university of hawaii john a burns school of medicine; c2004. [cited 2013 may 6] available from: http://www.hawaii.edu/medicine/ pediatrics/pedtext/ p. 311-314. 12. sardana p, bais as, singh vp, arora m. unusual foreign bodies of the aerodigestive tract. indian j otolaryngol head neck surg. 2002 apr; 54(2):123-126. doi: 10.1007/bf02968730 pubmed pmid: 23119872 pubmed central pmcid: pmc3450538. 13. burdon j. adult-onset asthma. aust fam physician 2015 aug; 44(8): 554-57. pubmed pmid: 26510141. 14. dundas i, mckenzie s. spirometry in the diagnosis of asthma in children. curr opin pulm med. 2006 jan; 12(1):28-33. pubmed pmid: 16357576. 15. sumino k, sugar ea, irvin cg, kaminsky da, shade d, wei cy, et al. methacholine challenge test: diagnostic characteristics in asthmatic patients receiving controller medications. j allergy clin immunol. 2012 jul; 130(1):69-75. doi: 10.1016/j.jaci.2012.02.025 pubmed pmid: 22465214. 16. apostolova m, zeidan b. a case of idiopathic tracheal stenosis. respir med case rep. 2013 jul 24; 10:15-18. doi: 10.1016/j.rmcr.2013.05.002 pubmed pmid: 26029504 pubmed central pmcid: pmc3920420. 17. singh a, kaur m. recurrent pneumonitis due to tracheobronchial foreign body in an adult. jiacm journal, indian academy of clinical medicine. 2007 jul-sep; 8(3):242-244. 18. zohny ag. bronchoscopy for foreign body removal: practical guidelines. ejentas egyptian journal of ear, nose, throat and allied sciences. 2009 dec; 10:31-36. 19. wu th, cheng yl, tzao, c, chang h, hsieh cm, lee sc. longstanding tracheobronchial foreign body in an adult. respir care. 2012 may; 57(5):808-810. doi: 10.4187/respcare.01445 pubmed pmid: 22152102. 20. murray ad, talavera f, meyers ad, kelly dj. foreign bodies of airway. medscape. 2015 may: (about 6 p.). [cited 2016 oct 6]. available from: http://emedicine.medscape.com/article/872498overview#a5 . and female sex, the patient may be predisposed to develop tracheal stenosis. this can also present with gradual onset of dyspnea associated with wheezing and a low normal peak flow values but is unresponsive to steroids and bronchodilators. this can be further investigated with spirometry to determine the characteristic flow volume loops that would differentiate asthma from upper airway-narrowing pathologies like tracheal stenosis, laryngeal neoplasms and laryngeal foreign body impaction. with the characteristic flattening of the flow-volume loop in spirometry,16 asthma can be ruled out and investigation for obstruction via direct visualization of the airways using fiberoptic laryngobronchoscopy should be performed. laryngeal malignancy and inflammatory and granulomatous diseases of the larynx may also be considered in a patient with recurrent cough and dyspnea with biphasic stridor, halitosis and an endoscopic finding of suspicious mass in the subglottic area. however, the history and physical examination findings and ct scan demonstrating a bony opacity in the upper airway ruled these out. the diagnosis of fb aspiration can be challenging despite the availability of advanced imaging techniques. foreign body aspiration in adults tends to be long-standing with a lack of history of aspiration.17 occult foreign bodies can remain undetected for a long time leading to a delay in the diagnosis especially in cases where the clinical picture mimics a more common condition such as respiratory tract infection or asthma.5 a chest radiograph is the initial imaging modality. in this case, chest radiographs failed to demonstrate the foreign body in the airway as it was not significant enough to cause radiologic lung changes. chest x-rays have poor sensitivity for aspirated foreign bodies, which are not all visible on radiographs.18 the most common findings are pulmonary infiltrations, atelectasis, hyperinflation, bronchiectasis, or even normal appearance. the chance of having a normal chest x ray was as high as 24%.1 therefore, the diagnosis relies on a high level of clinical suspicion not on imaging studies.19 extraction is the definitive treatment of foreign body aspiration. until the late 1800, airway foreign body was removed via bronchotomy. with the advent of technology, rigid bronchoscopes and flexible bronchoscopes are now widely used for airway foreign body extraction. in cases of endoscopic failure, thoracotomy is an option.20 during surgery, the airway must be secured and any soft tissue swelling that could lead to airway obstruction must be taken into account.19 in this case, the patient was not in respiratory distress with good oxygen saturation thus no urgent intervention was initiated. an elective tracheostomy was performed prior to the operative removal of the foreign body. indeed, the caveat, “not all that wheezes is asthma” is truly demonstrated in this patient. as seen in our case, foreign body aspiration can occur in adults without predisposing factors. failure to recall an incident of choking does not rule out its diagnosis, which can be challenging as it can mimic respiratory disorders such as bronchial asthma. endoscopy and computed tomography are valuable for correct diagnosis and management. an incorrect initial diagnosis should be considered in the light of unresolved symptoms and prompt referral to an appropriate specialist may prevent undue suffering and dangerous complications. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery introduction this statement revises our earlier “wame recommendations on chatgpt and chatbots in relation to scholarly publications” (january 20, 2023). the revision reflects the proliferation of chatbots and their expanding use in scholarly publishing over the last few months, as well as emerging concerns regarding lack of authenticity of content when using chatbots. these recommendations are intended to inform editors and help them develop policies for the use of chatbots in papers published in their journals. they aim to help authors and reviewers understand how best to attribute the use of chatbots in their work, and to address the need for all journal editors to have access to manuscript screening tools. in this rapidly evolving field, we will continue to modify these recommendations as the software and its applications develop.  a chatbot is a tool “[d]riven by [artificial intelligence], automated rules, natural-language processing (nlp), and machine learning (ml)…[to] process data to deliver responses to requests of all kinds.”1 artificial intelligence (ai) is “the ability of a digital computer or computer-controlled robot to perform tasks commonly associated with intelligent beings.”2 “generative modeling is an artificial intelligence technique that generates synthetic artifacts by analyzing training examples; learning their patterns and distribution; and then creating realistic facsimiles. generative ai (gai) uses generative modeling and advances in deep learning (dl) to produce diverse content at scale by utilizing existing media such as text, graphics, audio, and video.”3, 4 chatbots are activated by a plain-language instruction, or “prompt,” provided by the user. they generate responses using statistical and probability-based language models.5 this output has some characteristic properties. it is usually linguistically accurate and fluent but, to date, it is often compromised in various ways. for example, chatbot output currently carries the risk of including biases, distortions, irrelevancies, misrepresentations, and plagiarism – many chris zielinski,1 margaret a. winker,2 rakesh aggarwal,3 lorraine e. ferris,4 markus heinemann,5 jose florencio lapeña, jr.,6 sanjay a. pai,7 edsel ing,8 leslie citrome,9 murad alam,10 michael voight,11 farrokh habibzadeh,12 on behalf of the wame board 1vice president, wame; centre for global health, university of winchester, uk 2 trustee, wame; usa 3president, wame; associate editor, journal of gastroenterology and hepatology; director, jawaharlal institute of postgraduate medical education and research, puducherry, india 4 trustee, wame; professor, dalla lana school of public health, university of toronto, canada 5treasurer, wame; editor-in-chief, the thoracic and cardiovascular surgeon, professor, universitaetsmedizin mainz, germany 6 secretary, wame; editor-in-chief, philippine journal of otolaryngology head & neck surgery;  professor, university of the philippines manila 7director, wame; working committee, the national medical journal of india   8 director, wame; section editor, canadian journal of ophthalmology; professor, university of toronto and university of alberta, canada 9 director, wame; editor-in-chief, current medical research and opinion; topic editor for psychiatry for clinical therapeutics;  clinical professor of psychiatry & behavioral sciences, new york medical college, usa 10director, wame; editor-in-chief,  archives of dermatological research; professor, northwestern university, usa 11director, wame; executive editor-in-chief; international journal of sports physical therapy; professor, belmont university school of physical therapy, usa 12past president, wame; editorial consultant, the lancet; associate editor, frontiers in epidemiology; iran chatbots, generative ai, and scholarly manuscripts: wame recommendations on chatbots and generative artificial intelligence in relation to scholarly publications revised may 31, 2023 special announcement correspondence: chris zielinski centre for global health, university of winchester sparkford road winchester hampshire so22 4nr united kingdom phone: +44 (0) 1962 841515 fax: +44 (0) 1962 842280 email: chris@chriszielinski.com disclosures: all authors report that they have no competing interests aside from any affiliations as editors. disclaimer: this policy statement is being republished from: zielinski c, winker ma, aggarwal r, ferris le, heinemann m, lapeña jf, pai sa, ing e, citrome l, alam m, voight m, habibzadeh f, for the wame board. chatbots, generative ai, and scholarly manuscripts. wame recommendations on chatbots and generative artificial intelligence in relation to scholarly publications. wame. may 31, 2023. available from: https://wame.org/page3.php?id=106 philipp j otolaryngol head neck surg 2023; 38 (1): 7-9 c 2023 wame. all rights reserved. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery special announcement of which are caused by the algorithms governing its generation and heavily dependent on the contents of the materials used in its training. consequently, there are concerns about the effects of chatbots on knowledge creation and dissemination – including their potential to spread and amplify misand disinformation6 – and their broader impact on jobs and the economy, as well as the health of individuals and populations. new legal issues have also arisen in connection with chatbots and generative ai.7 chatbots retain the information supplied to them, including content and prompts, and may use this information in future responses.8 therefore, scholarly content that is generated or edited using ai would be retained and as a result, could potentially appear in future responses, further increasing the risk of inadvertent plagiarism on the part of the user and any future users of the technology. anyone who needs to maintain confidentiality of a document, including authors, editors, and reviewers, should be aware of this issue before considering using chatbots to edit or generate work.9 chatbots and their applications illustrate the powerful possibilities of generative ai, as well as the risks. these recommendations seek to suggest a workable approach to valid concerns about the use of chatbots in scholarly publishing. a note on changes introduced since the previous wame recommendations l a new recommendation (#4) has been added to the four original principal recommendations: 1) only humans can be authors; 2) authors should acknowledge the sources of their materials; 3) authors must take public responsibility for their work; 4) editors and reviewers should specify, to authors and each other, any use of chatbots in evaluation of the manuscript and generation of reviews and correspondence; and 5) editors need appropriate digital tools to deal with the effects of chatbots on publishing. l in addition, this revision acknowledges that chatbots are used to perform different functions in scholarly publications. currently, individuals in scholarly publishing may use chatbots for: 1) simple word-processing tasks (analogous to, and an extension of, word-processing and grammar-checking software), 2) the generation of ideas and text, and 3) substantive research. the recommendations have been tailored for application to these different uses. wame recommendations on chatbots and generative artificial intelligence in relation to scholarly publications wame recommendation 1: chatbots cannot be authors. journals have begun to publish articles in which chatbots such as bard, bing and chatgpt have been used, with some journals listing chatbots as coauthors. the legal status of an author differs from country to country but under most jurisdictions, an author must be a legal person. chatbots do not meet the international committee of medical journal editors (icmje) authorship criteria, particularly that of being able to give “final approval of the version to be published” and “to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.”10 no ai tool can “understand” a conflict-of-interest statement, and does not have the legal standing to sign a statement. chatbots have no affiliation independent of their developers. since authors submitting a manuscript must ensure that all those named as authors meet the authorship criteria, chatbots cannot be included as authors. wame recommendation 2: authors should be transparent when chatbots are used and provide information about how they were used. the extent and type of use of chatbots in journal publications should be indicated. this is consistent with the icmje recommendation of acknowledging writing assistance11 and providing in the methods detailed information about how the study was conducted and the results generated.12 wame recommendations 2.1: authors submitting a paper in which a chatbot/ai was used to draft new text should note such use in the acknowledgment; all prompts used to generate new text, or to convert text or text prompts into tables or illustrations should be specified. wame recommendation 2.2: when an ai tool such as a chatbot is used to carry out or generate analytical work, help report results (e.g., generating tables or figures), or write computer codes, this should be stated in the body of the paper, in both the abstract and the methods section. in the interests of enabling scientific scrutiny, including replication and identifying falsification, the full prompt used to generate the research results, the time and date of query, and the ai tool used and its version should be provided. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery special announcement wame recommendation 3: authors are responsible for material provided by a chatbot in their paper (including the accuracy of what is presented and the absence of plagiarism) and for appropriate attribution of all sources (including original sources for material generated by the chatbot). authors of articles written with the help of a chatbot are responsible for the material generated by the chatbot, including its accuracy. noting that plagiarism is “the practice of taking someone else’s work or ideas and passing them off as one’s own”,13 not just the verbatim repetition of previously published text. it is the author’s responsibility to ensure that the content reflects the author’s data and ideas and is not plagiarism, fabrication or falsification. otherwise, it is potentially scientific misconduct to offer such material for publication, irrespective of how it was written. similarly, authors must ensure that all quoted material is appropriately attributed, including full citations and that the cited sources support the chatbot’s statements. since a chatbot may be designed to omit sources that oppose viewpoints expressed in its output, it is the authors’ responsibility to find, review and include such counterviews in their articles. (of course, such biases are also found in human authors.) authors should identify the chatbot used and the specific prompt (query statement) used with the chatbot. they should specify what they have done to mitigate the risk of plagiarism, provide a balanced view, and ensure the accuracy of all their references. wame recommendation 4: editors and peer reviewers should specify, to authors and each other, any use of chatbots in the evaluation of the manuscript and generation of reviews and correspondence. if they use chatbots in their communications with authors and each other, they should explain how they were used. editors and reviewers are responsible for any content and citations generated by a chatbot. they should be aware that chatbots retain the prompts fed to them, including manuscript content, and supplying an author’s manuscript to a chatbot breaches confidentiality of the submitted manuscript. wame recommendation 5: editors need appropriate tools to help them detect content generated or altered by ai. such tools should be made available to editors regardless of ability to pay for them, for the good of science and the public, and to help ensure the integrity of healthcare information and reducing the risk of adverse health outcomes. many medical journal editors use manuscript evaluation approaches that were not designed to deal with ai innovations and industries, including manipulated plagiarized text and images and papermill-generated documents. they have already been at a disadvantage when trying to differentiate the legitimate from the fabricated, and chatbots take this challenge to a new level. editors need access to tools that will help them evaluate content efficiently and accurately. this is of particular importance to editors of medical journals where the adverse consequences of misinformation include potential harms to people. references 1. what is a chatbot? oracle cloud infrastructure. https://www.oracle.com/chatbots/what-is-a-chatbot/ accessed may 27, 2023. 2. copeland bj (fact-checked by the editors of encyclopaedia britannica). artificial intelligence. britannica last updated: may 26, 2023). https://www.britannica.com/technology/artificial-intelligence accessed may 27, 2023. 3. gui j, sun z, wen y, tao d, ye j. a review on generative adversarial networks: algorithms theory and applications. ieee trans knowl data eng. 2023; 35:3313-3332. doi: 10.1109/ tkde.2021.3130191. 4. abukmeil m, ferrari s, genovese a, piuri v, scotti f. a survey of unsupervised generative models for exploratory data analysis and representation learning. acm comput surv. 2021;54(5):1-40. 5. wun sty, he sz, liu jp, sun sq, liu k, han ql, tang y. a brief overview of chatgpt: the history, status quo and potential future development. ieee/caa j autom sinica. 2023;10(5):1122–1136. doi: 10.1109/jas.2023.123618. 6. bhuiyan j. openai ceo calls for laws to mitigate ‘risks of increasingly powerful’ ai. the guardian. may 16, 2023. https://www.theguardian.com/technology/2023/may/16/ceo-openai-chatgpt-ai-tech-regulations accessed may 27, 2023. 7. appel g, neelbauer j, schweidel da. generative ai has an intellectual property problem. april 07, 2023. harvard business review. https://hbr.org/2023/04/generative-ai-has-an-intellectual-property-problem accessed may 27, 2023. 8. thorbecke c. don’t tell anything to a chatbot you want to keep private. cnn business. april 6, 2023. https://www.cnn.com/2023/04/06/tech/chatgpt-ai-privacy-concerns/index.html accessed may 27, 2023. 9. recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals. updated may 2023. https://www.icmje.org/news-and-editorials/icmje-recommendations_annotated_may23.pdf accessed may 27, 2023. 10. who is an author? defining the role of authors and contributors. icmje.  https://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html. accessed may 27, 2023. 11. non-author contributors. defining the role of authors and contributors. icmje. https://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html. accessed may 27, 2023. 12. methods. preparing a manuscript for submission to a medical journal. icmje. https://www.icmje.org/recommendations/browse/manuscript-preparation/preparing-for-submission.html#d accessed may 27, 2023. 13. plagiarism. oxford reference, https://www.oxfordreference.com/display/10.1093/oi/authority.20110803100329803;jsessioni d=d1759da0fd79acb96407cdb4b7bc8fa0 accessed may 27, 2023. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles 22 philippine journal of otolaryngology-head and neck surgery abstract objective: to determine the risk of vocal fold paralysis in patients who underwent total thyroidectomy with and without intraoperative recurrent laryngeal nerve identification. methods: design: retrospective cohort study setting: tertiary military hospital participants: two hundred thirty seven (237) adult patients who underwent total thyroidectomy for benign lesions based on post-operative histopathology operated on by senior third or fourth year residents. excluded were those who underwent lobectomy with isthmusectomy or reoperation/completion thyroidectomy, had intrathoracic goiters, confirmed malignancies based on post-operative histopathology, or cases wherein the rln had to be sacrificed due to gross involvement of the nerve caused by malignancy. results: group a, wherein intraoperative identification of rln was done, had a temporary and permanent rln injury incidence of 2.75% and 0.92% respectively. group b, wherein intraoperative identification of rln was not done, had a temporary and permanent rln injury incidence of 17.19% and 12.5%, respectively. through binary linear regression, the probability of having temporary paralysis increases almost two-fold if the nerve is not identified, and the probability of having permanent paralysis increases by almost nine-fold if the nerve is not identified. conclusion: we recommend routine intraoperative rln identification, which has a lower risk for temporary and permanent vocal fold paralysis when compared to non-identification of the rln. keywords: cranial nerve injuries/prevention and control, recurrent laryngeal nerve injuries, thyroid neoplasms/surgery, thyroidectomy/adverse effects, vocal cord paralysis/prevention control vocal fold paralysis with intraoperative recurrent laryngeal nerve identification versus non-identification of recurrent laryngeal nerve in total thyroidectomy: a retrospective cohort study andrie jeremy formanez, md department of otorhinolaryngology head and neck surgery armed forces of the philippines medical center quezon city, philippines correspondence: dr. andrie jeremy formanez department of otorhinolaryngology-head and neck surgery armed forces of the philippines medical center 7th floor armed forces of the philippines medical center v. luna avenue, quezon city 0840 philippines phone: (632) 426 2701 local 6172 email: docdrie@yahoo.com the author declared that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest philipp j otolaryngol head neck surg 2016; 31 (1): 22-25 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 23 iatrogenic recurrent laryngeal nerve (rln) injury remains one of the most common complications of thyroid surgery. temporary rln injury occurs in 2.5% to 5% of thyroidectomy patients of complications following thyroidectomy.1 permanent rln injury occurs in approximately 1% to 1.5% of total thyroidectomy procedures.1 patients with this complication suffer from different manifestations, the least serious of which is hoarseness. however, this can be particularly devastating in patients for whom the quality of their voice is integral to their occupation.2 more serious manifestations include aspiration and dyspnea, which are potentially life-threatening.3 further hospitalization is required to address these problems, which would have been unnecessary had the integrity of the rln been preserved. the risk factors that contribute to morbidity following thyroid surgery are well-defined, but their actual contribution is still open to question.4 increased extent of dissection, surgeon experience, malignancy, underlying thyroid disease, and intraoperative technique have been shown to affect post-thyroidectomy morbidity.5 in addition, operation for completion6 and addition of neck dissection7 are additional risk factors for postoperative thyroid morbidity. surgical technique, more specifically intraoperative rln identification, is one of the factors which may affect the outcome of thyroid surgery, but some surgeons still do not routinely identify the rln as can be gleaned from studies in india,8 turkey,9 and china.10 in our institution, the department of otorhinolaryngology head and neck surgery receives 3 5 referrals for hoarseness following thyroid surgery annually. this number is significant given the number of thyroid surgeries done per year and gives cause for alarm given the potentially catastrophic complications of rln injury. the significant number of referrals warrants investigation of the possible causes. furthermore, to the best of our knowledge, no local data has been published regarding the incidence and causative factors of rln injury following thyroidectomy. hence, the purpose of this study is to determine the risk of vocal fold paralysis in patients who underwent total thyroidectomy with and without recurrent laryngeal nerve identification. methods with ethical review board (erb) approval, this retrospective cohort study consisted of 237 adult patients who underwent total thyroidectomy and presented with benign lesions based on postoperative histopathology from january 2009 to december 2014 at the v. luna general hospital, a tertiary military hospital. operations were performed by senior third year or fourth year residents. patients who underwent only lobectomy with isthmusectomy or underwent reoperation/completion thyroidectomy were excluded from the study. patients who presented with prior vocal fold paralysis, intrathoracic goiters, or with suspicious/confirmed malignancies based on post-operative histopathology were also excluded. furthermore, cases wherein the rln had to be sacrificed due to gross involvement of the nerve by malignancy were excluded. preoperative evaluation of the patients included thyroid ultrasound, free t4 and thyroid stimulating hormone determination, serum calcium concentration, fine-needle aspiration biopsy and evaluation of vocal fold mobility by flexible or rigid laryngoscopy. patients were divided into two groups based on a review of operative techniques in their records. patients in group a were those wherein the surgeon indicated that he/she identified and preserved the rln during the procedure whereas patients in group b were those where the surgeon did not indicate that he/she identified or preserved the rln. intraoperative dimensions of the thyroid tumors were also recorded. records of flexible nasopharyngolaryngoscopy or rigid laryngoendoscopy performed by resident physicians of the department of orl -hns on patients who manifested with hoarseness post-operatively were reviewed. vocal fold paralysis was defined as having decreased or absent vocal fold mobility upon assessment. (figure 1) patients thus assessed were then followed-up regularly at three-month intervals for the first post-operative year. permanent vocal fold paralysis was diagnosed when vocal fold mobility did not return 6 months after surgery. figure 1. still photo of the glottis and supraglottis of a patient with paralysis of right recurrent laryngeal nerve following total thyroidectomy philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 24 philippine journal of otolaryngology-head and neck surgery original articles age, sex, tumor size, temporary and permanent post-operative vocal cord paralysis were tabulated using microsoft office excel 2007 (microsoft corp., washington, usa). ibm spss 23 (international business machines corp.) was used for the independent t-test and binary logistic regression analysis. the prevalence of temporary and recurrent vocal fold paralysis were expressed as percentages of the total number of cases per group. independent t-test was used to determine if there was a significant difference in tumor size between both groups. binary logistic regression analysis was used to evaluate the relationship between intraoperative rln identification and rln preservation. results a total of 237 patients with an age range of 20 to 65 years old (median age 41 years old) were included. there were more females than males (163:74). there were 109 patients in group a, wherein 3 demonstrated temporary rln injury with an incidence of 2.75%. the rln injuries in all these 3 patients were unilateral. furthermore, the average tumor size in these patients taken as the widest diameter was at 5.6 ± 0.93 cm. in comparison, there were 128 patients in group b wherein 22 patients presented with temporary rln injury and an incidence 17.19%. ( table 1) of these patients, 3 had bilateral rln injury. average tumor size in this group was 5.3 ± 0.78 cm. there was no significant difference in tumor size between the two groups based on independent t-test at 95% confidence interval (p = 1.96). group a over group b was found to be e-2.158925 = 0.1154. obtaining its reciprocal leads to 8.67, meaning that the probability of having permanent paralysis increases by almost nine-fold if not identified. discussion this study found that intraoperative rln identification has a lower risk for temporary and permanent vocal cord paralysis compared to non-identification of the rln. the importance of preservation of the rln cannot be overemphasized. in agreement with pradeep et al., our findings suggest that the key to achieving preservation is to trace the entire course of the nerve along the tracheoesophageal groove up to its entry into the larynx.9 in this study, confounding factors which may cause or contribute to vocal cord paralysis such as malignancy, reoperation, completion thyroidectomy, were taken out of the equation based on inclusion and exclusion criteria. tumor size, which is another confounding factor, was not statistically significant, with similar tumor sizes in both groups. however, since this was a retrospective cohort study, it was not able to control for the uniformity of the entire operative technique as well as the skill of the surgeon. since the study was done at a training institution, the experience of senior residents is limited to the number of cases to which they are exposed. post-hoc analysis revealed that third year surgeons accounted for 67% of temporary paralysis in group a while a fourth year surgeon was responsible for the remaining case. in group b, third year surgeons accounted for 45% of temporary paralysis compared to the 55% of cases handled by fourth year surgeons. the lone case of permanent paralysis in group a was performed by a fourth year surgeon. in group b, 75% of the cases of permanent paralysis were handled by third year surgeons, compared to the 25% which were handled by fourth year surgeons. this may suggest that experience does play a role in cases when the recurrent nerve was not routinely identified. the results of this study showed less temporary and permanent vocal cord paralysis in patients where intraoperative rln identification was performed. moreover, statistical analysis using binary linear regression confirms that intraoperative rln identification serves as a protective factor against temporary and permanent rln injury following thyroid surgery as evidenced by the increased probability of rln injury if the nerve was not identified during surgery. the prevalence of temporary and permanent vocal paralysis for group a at 2.75% and 0.92%, respectively are slightly higher when compared to the finding of canbaz et al. and veyseller et al. who reported no paralysis for the group where the rln was preserved and identified.9, 10 table 1. incidence of temporary and permanent rln paralysis group a group b number of patients patients with temporary paralysis incidence of temporary paralysis patients with permanent paralysis incidence of permanent paralysis bilateral rln injury 109 3 2.75% 1 0.92% 0 128 22 17.19% 16 12.50% 3 through binary linear regression, the odds of having temporary paralysis in group a over group b was found to be e-0.6819142 = 0.5056. its reciprocal 1.98 means that the probability of having temporary paralysis increases by almost two-fold if the nerve is not identified. there was only one patient with permanent rln injury in group a, with an incidence of 0.92%. in contrast, there were 16 patients in group b who had permanent rln injury, and an incidence of 12.5%. of these, 2 had bilateral rln injury. the odds of having permanent paralysis for philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 25 references 1. lai sy, mandel sj, weber rs. management of thyroid neoplasms. in: flint pw, haughey bh, lund vj, niparko jk, richardson ma, robbins kt, et al, editors. cummings otolaryngology head and neck surgery. philadelphia: mosby-elsevier; 2010. p. 1770 1771. 2. zakaria hm, alwad na, kreedes as, al-mulhim am, al-sharway ma, hadi ma, et al. recurrent laryngeal nerve injury in thyroid surgery. oman med j. 2011 jan; 26(1): 34–38. 3. bergamaschi r, becouarn g, ronceray j, arnaud jp. morbidity of thyroid surgery. am j surg. 1998 jul; 176(1):71-75. 4. dackiw apb, rotstein le, clark oh. computer-assisted evoked electromyography with stimulating surgical instruments for recurrent/external laryngeal nerve identification and preservation in thyroid and parathyroid operation. surgery. 2002 dec; 132(6):1100–1108. 5. thomusch o, sekulla c, dralle h. is primary total thyroidectomy justified in benign multinodular goiter? results of a prospective quality assurance study of 45 hospitals offering different levels of care. chirurg. 2003 may; 74(5):437–443. 6. shaha ar, jaffe bm. completion thyroidectomy: a critical appraisal. surgery. 1992 dec; 112(6):1148–1152. 7. betka j, mrzena l, astl j, nemec j, vlcek p, taudy m, skrivan j. surgical treatment strategy for thyroid gland carcinoma nodal metastases. eur arch otorhinolaryngol. 1997; 254(s1):169–174. 8. pradeep pv, jayashree b, harshita s. a closer look at laryngeal nerves during thyroid surgery: a descriptive study of 584 nerves. anat res int. 2012; 2012: 490390, 6 pages. available from http://dx.doi.org/10.1155/2012/490390 9. veyseller b, aksoy f, selim y, karatas a, ozturan o. effect of recurrent laryngeal nerve identification technique in thyroidectomy on recurrent laryngeal nerve paralysis and hypoparathyroidism. arch otolaryngol head neck surg. 2011 sep; 137(9):897-900. 10. canbaz h, dirlik m, colak t, ocal k, akca t, bilgin o, et al. total thyroidectomy is safer with identification of recurrent laryngeal nerve. j zhejiang univ sci b. 2008 jun; 9(6): 482–488. 11. kandil e, abel khalek m, aslam r, friendlander p, bellows cf, slakey d. recurrent laryngeal nerve: signifance of the anterior extralaryngeal branch. surgery 2011 jun: 149(6):820-824. 12. pascoal aaf, fernandes jr, ruiz cr, person oc, nascimento srr. terminal branch of recurrent laryngeal nerve. advances in anatomy volume 2014, article id 858539, 5 pages, 2014. 13. megherbi mt, graba a, abid l, oulmane d, saidani m, benabadji r. complications and sequela of benign thyroid surgery. j chir (paris) 1992 jan; 129(1):41–46. 14. zambudio ar, rodriguez j, riquelme j, soria t, canteras m, parrilla p. prospective study of postoperative complications after total thyroidectomy for multinodular goiters by surgeons with experience in endocrine surgery. ann surg. 2004 jul; 240(1):18–25. likewise, the rates of temporary and permanent vocal cord paralysis in group b at 17.19% and 12.15%, respectively, are higher than those of the two aforementioned studies (0%, 7.9%) and (1%, 1.5%). the higher incidences of temporary and permanent rln injury in this study may be attributed to the fact that the surgeons in group a only followed the main trunk of the rln up to its entry into the larynx while the surgeons in group b did not identify the rln as compared to the previous studies where the rln and its branches were meticulously followed up to its entry to the larynx.9,10 injury to the rln can be brought about by inadvertent transection of a bifurcation of the nerve prior to its entry into the larynx, this bifurcation being present 34% 70% of the time.11,12 a considerable number of surgeons do not perform routine intraoperative rln identification since it is said to cause hypoparathyroidism, mainly through devascularization of the parathyroid glands.13 however, among experienced surgeons who routinely identify the rln, temporary and permanent hypoparathyroidism was not high, with incidences of 9.6% and 0.7%, respectively.14 it can be concluded from this study that intraoperative rln identification has a lower risk for temporary and permanent vocal cord paralysis when compared to non-identification of the rln. the probability of having temporary paralysis increases almost two-fold if the nerve is not identified, and the probability of having permanent paralysis increases by almost nine-fold if the nerve is not identified. while future studies may assess rln injury and other complications of thyroidectomy by comparing surgeons who routinely perform intraoperative rln identification and others who do not, we recommend routine identification of the rln. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the presence or absence of gross laryngeal or vocal cord pathology during endoscopic examination and determine if there is a relationship between these findings, the number of years in teaching and the presence of other risk factors among teachers in a public secondary school in bacolod city. methods: design: cross-sectional study setting: secondary public school in bacolod city, philippines participants: a total of 50 school teachers participated in the study conducted from july 2016 to may 2017. they completed a questionnaire on demographic data, professional profile and lifestyle profile and underwent laryngoscopic examination. results: the most common pathologic laryngoscopic findings were vocal fold nodule (12%), swollen arytenoids (10%), paretic vocal cords (6%) and epiglottic mass (6%). there was no significant relationship between laryngoscopic findings and number of years teaching (x2 = 0.103, df = 1, p = .748. however, there was a significant relationship between laryngoscopic findings, smoking (x2 = 6.419, df = 1, p = .011) and daily water intake (x2 = 10.208, df = 2, p =.006). conclusions: results of this study suggest that in terms of voice care, public school teachers may benefit from avoidance of smoking and increased water intake. keywords: teachers, vocal cord, hoarseness, voice, laryngoscopy, videostroboscopy hoarseness is a term used to describe voice changes and is one of the most common symptoms seen in otolaryngologic practice, ranking among the top ten most seen conditions in the corazon montelibano memorial regional hospital otorhinolaryngology out-patient department. it may be the earliest manifestation of a large variety of conditions (benign or malignant) directly or indirectly affecting the larynx.1-3 such conditions that may be seen on laryngoscopy include vocal fold edema, polyps, nodules and glottic masses.4-5 many factors are involved in the development of hoarseness.4, 6-9 these factors include occupational risk factors, demographic factors such as gender and socioeconomic status and lifestyle factors such as smoking and a history of poor respiratory health.3,4,10,11 teachers are especially prone to hoarseness, and the risk factors that increase the likelihood of voice changes pathologic laryngoscopic findings, number of years in teaching and related factors among secondary public-school teachers in bacolod city, negros occidental nathalie p. mundo, md von v. vinco, md department of otorhinolaryngology head and neck surgery corazon locsin montelibano memorial regional hospital correspondence: dr. von v. vinco department of otorhinolaryngology head and neck surgery corazon locsin montelibano memorial regional hospital lacson, st. bacolod city 6100 philippines phone: 0922 832 3345 / 0917 806 5269 email: drlhenvon@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery analytical research contest, november 9, 2017, menarini office, bonifacio high street, taguig city. philipp j otolaryngol head neck surg 2018; 33 (2): 28-31 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles among teachers include the number of working hours, number of years of experience, interval between classes, usage of microphone or not, and teaching against background noise.7,8,12,13 to the best of our knowledge based on a search of pubmed, herdin and google scholar using the keywords “teachers,” “vocal cord,” “hoarseness,” “voice,” “laryngoscopy,” and “videostroboscopy” there have been no studies evaluating hoarseness, its risk factors and pathological causes among teachers in the province of negros. thus, it is the aim of this study to determine the presence or absence of gross laryngeal or vocal cord pathology during endoscopic examination and determine if there is a relationship between these findings, the number of years in teaching and the presence of risk factors among teachers in a public secondary school in bacolod city. methods with approval by the research ethics review committee of corazon locsin montelibano memorial regional hospital, this cross-sectional study purposively sampled 55 teachers from a single secondary public school in bacolod city for participation from 1 july 2016 to 31 may 2017. considered for inclusion were all fulltime secondary teachers regardless of teaching experience who gave written informed consent. excluded were those diagnosed with pulmonary tuberculosis, those diagnosed with a thyroid disorder and those who had undergone surgery of the larynx, thyroid and neck. recruitment of participants was done through a group meeting. a lecture on voice misuse was conducted by the primary researcher at the start of recruitment. this 30-minute lecture concluded with a short discourse on the type of research to be conducted, the procedure to be performed, the possible side effects and discomfort of the procedure and particulars about result outcomes. the decision to participate in this study was voluntary and participants were allowed to drop out of the study anytime. a questionnaire was then distributed to the participants after the 30-minute lecture. it was formulated based on the profile of participants and risk factors that the study wished to measure (e.g. personal profile, professional profile, lifestyle profile, and medical history) and prescreened by three orl-hns consultants. participants underwent history taking and a physical examination was conducted by the primary investigator including recorded laryngoscopy using a 70 degree rigid laryngoscope (shenda, china) attached to a locally-fabricated video camera system (muracam endoscopic camera system, quezon city, philippines). topical anesthesia (lidocaine 10% 10mg/dose spray, astrazeneca ab, sweden) was administered prior to each procedure. all procedures were performed in the school clinic. the primary investigator reviewed the recorded videos independently of participant profiles and made notes of observations specifically pathologic findings using ms excel version 15.0.5031.1000 (microsoft corporation, redmond, wa, usa). these recorded videos were then reviewed and evaluated by the co-investigator who was blinded to the participants and their responses to questionnaires. the diagnoses were compared with initial diagnoses listed on the excel file. pathologic findings had to be congruent for data to be analyzed. data were analyzed using frequency distribution for categorical variables and measures of central tendency and dispersion for continuous variables. the outcome prevalence was estimated based on the independent variables by testing differences between proportions using pearson chi-square test for independence. the software used was the ibm spss v.20 (ibm corporation, armonk, ny, usa) with the level of significance set at 0.05. results of the 55 teachers originally screened for the study, two did not consent for laryngoscopic examination, two backed out from the study and one did not meet inclusion criteria. a total of 50 participants completed this study. of the 50 participants, 39 (78%) were female and 11 (22%) were male. twenty-three (46%) were aged 41-50 years, 12 (24%) were 31-40 years old, 9 (18%) were 21-30 years old, 5 (10%) were 51-60 years old and 1 (2%) was 61-70 years old. twenty-eight (56%) had worked as teachers for more than 10 years, 14 (28%) had only been teaching for 1-5 years and the remaining 8 (16%) had been teaching for 6-10 years. (figure 1) during the time of interview, 41 (82%) handled 4-6 classes per day, only 5 (10%) handled more than 6 classes per day and the remaining 4 (8%) handled 1-3 classes a day, each spending 1-2 hours per class per day. (figure 2) lifestyle profiles of the participants covered their extracurricular, smoking and drinking activities. extracurricular activities entailed the use of voice other than teaching including singing, speaking (radio broadcasting) and coaching. only 13 (26%) were involved in any of the three extracurricular activities. the frequency of these activities among the 13 participants involved were: 1 participated in the public speaking on a monthly basis, 10 participated in singing and coaching on a weekly basis and only 2 participated on coaching on a daily basis. (table 1) other lifestyle practices investigated were drinking (alcoholic beverages), smoking and amount of daily water intake. only 14 (28%) of the participants drank alcoholic beverages occasionally while the remaining 36 (72%) were non-drinkers. majority were non-smokers while only 5 (10%) smoked cigarettes, around 15-20 packed years each. for water intake, 28 (56%) drank 5-10 glasses daily, 11 (22%) drank 1-4 glasses daily and 11 (22%) drank more than 10 glasses daily. for symptoms reported by the participants: hoarseness was not experienced by 12 (24%) participants, 24 (48%) reported experiencing it occasionally, 7 (14%) on a monthly basis, 4 (8%) on a weekly basis and 3 (6%) on a daily basis. loss of voice was reportedly experienced philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles by 5 (10%) of participants occasionally and 1 (2%) on a monthly basis and the majority 43 (86%) did not experience it. dysphagia was not experienced by a majority of the participants (60%), while 16 (32%) had it occasionally. and lastly, foreign body-sensation was reportedly experienced occasionally by 27 (54%) of the participants, 5 (10%) on a monthly basis, 2 (4%) on a weekly basis and 4 (8%) on a daily basis by the participants. of the 50 participants, 16 (32%) were asthmatic, 19 (38%) suffered from allergic rhinitis, 19 (38%) had nasal drip, only 24 (48%) suffered from colds, 12 (24%) reported having had sinusitis and only 1 (2%) had a history of laryngitis. pathologic laryngoscopic findings were congruent for both investigators and showed that 3 (6%) manifested paretic vocal cords, 6 (12%) had vocal cord nodules, 5 (10%) presented with swollen arytenoids and 3 (6%) were noted to have an epiglottic mass. there was no significant relationship found between pathologic laryngoscopic findings and age, sex, civil status, year level taught, number of classes per day, number of hours per class, extracurricular activities or alcohol intake. no significant relationship was found between pathologic laryngoscopic findings and number of years in teaching (x2 = 0.103, df = 1, p = .748). however, a significant relationship was noted between pathologic laryngoscopic findings and smoking (x2 = 6.419, df = 1, p = .011) and with water intake (x2 = 10.208, df = 2, p = .006). discussion the most common pathologic laryngoscopic findings among the public secondary school teachers surveyed in bacolod city were vocal fold nodule, swollen arytenoids, paretic vocal cords and epiglottic mass. there was no significant relationship between laryngoscopic findings and number of years teaching but there was a significant relationship between laryngoscopic findings with smoking and with water intake. the most common symptoms reported in this study were foreign body sensation, hoarseness, dysphagia and loss of voice. these are similar to the findings of sophie yick-yu lee et al, where the common symptom experienced by 498 teachers in their study was hoarseness followed by throat pain and dry throat.8 although the study population was different, these findings are also consistent with those of a local study by carrillo et al. showing that the most common chief complaint among patients who underwent videostroboscopy examination was hoarseness (77.6%), followed by globus sensation (5.9%), dysphonia (4.8%) and dysphagia (4.6%), while the most common pathology was vocal fold nodules (17.4%), followed by laryngoesophageal reflux (16.6%), vocal cord paralysis or paresis (12.9%), vocal cord cyst (10.4%), vocal cord polyps (8.1%) and presumptive cancer (6.1%).14 this is in contrast to a study by yogesh et al. of 110 teachers with 70 symptomatic subjects, where 34.2% had vocal cord edema, 28.57% had incomplete glottis closure, 12% had vocal nodule, 1.42% had vocal polyps, 1.42% number of classes per day 1-3 class 4-6 class >6 class 1-3 class; 4; 8% 4-6 class; 41; 82% >6 class; 5; 10% years in teaching 1-5 years 6-10 years >10 years 1-5 years; 14; 28% 6-10 years; 8; 16% >10 years; 28; 56% figure 1. pie chart shows distribution of participants (n) according to years of teaching experience and percentage (%) of total participants figure 2. pie chart shows the distribution of participants (n) and percentage (%) of total in terms of classes handled per day table 1. distribution (n) and percentage (%) of participants according to extracurricular activities that entail the use of voice other than teaching broken down by frequency (daily, weekly, monthly) extracurricular activities none singing speaking coaching total 37 9 1 3 50 74 18 2 6 100 monthly 0 1 0 1 weekly 9 0 1 10 daily 0 0 2 10 9 1 3 13 frequency activity n % total philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles references 1. samlan ra, kunduk m. visualization of the larynx. in: flint pw, haughey bh, lund vj, niparko jk, robbins kt, thomas jr, et al. (editors). cummings otolaryngology head and neck surgery. 6th edition, volume 1, 2015. philadelphia: mosby, pp. 834-844. 2. schwartz sr, cohen sm, dailey sh, rosenfeld rm, deutsch es, gillespie mb, et al. clinical practice guidelines: hoarseness (dysphonia). otolaryngol head neck surg. 2009 sep; 141(3suppl2). s1s31. doi: 10.1016/j.otohns.2009.06.744; pmid: 19729111. 3. von leden h. the clinical significance of hoarseness and related voice disorders. j lancet. 1958 feb; 78(2): 50-53. pmid: 13514269. 4. lundy ds, casiano rs, sullivan pa, roy s, xue jw, evans j. incidence of abnormal laryngeal findings in asymptomatic singing students. otolaryngol head neck surg. 1999 jul; 121(1): 69-77. doi: 10.1016/s0194-5998(99)70128-2; pmid: 10388882. 5. bigenzahn w, steiner e, denk dm, turetschek k, fruhwald f. stroboscopy and imaging in interdisciplinary diagnosis of early stage of laryngeal carcinoma. radiologe. 1998 feb; 38 (2):101-5. pmid: 9556808. 6. banjara h, mungutwar v, singh d, gupta a. hoarseness of voice: a retrospective study of 251 cases. international journal of phonosurgery and laryngology. 2011 jan-jun; 2011; 1(1):21-27. 7. marcal cc, peres ma. self-reported voice problems among teachers: prevalence and associated factors. rev saude publica. 2011 jun; 45(3): 503-11. pmid: 21519720. 8. lee sy, lao xq, yu it. a cross-sectional survey of voice disorders among primary school teachers in hong kong. j occup health. 2010; 52(6): 344-352. pmid: 20924152. 9. glannini sp, latorre mdo r, ferreira lp. factors associated with voice disorders among teachers: a case control study. codas. 2013; 25(6): 566-76. doi: 10.1590/s2317-17822014000100009. pmid: 24626982. 10. carroll t, nix j, hunter e, emerich k, titze i, abaza m. objective measurement of vocal fatigue in classical singers: a vocal dosimetry pilot study. otolaryngol head neck surg. 2006 oct; 135(4): 595-602. doi: 10.1016/j.otohns.2006.06.1268; pmid: 17011424 pmcid: pmc4782153. 11. ruotsalainen j, sellman j, lehto, l, verbeek j. systematic review of the treatment of functional dysphonia and prevention of voice disorders. otolaryngol head neck surg. 2008 may; 138(5): 557-565. doi: 10.1016/j.otohns.2008.01.014; pmid: 18439458. 12. yogesh s, daharwal a, prasad r, singh s, shankari v. videostroboscopy study of larynx in primary school teacher. national journal of otorhinolaryngology head and neck surgery. 2014 jan; 11(1):32-33. 13. chong ey, chan ah. subjective health complaints of teachers from primary and secondary school in hong kong. int j occup saf ergon. 2010; 16(1): 23-39. doi: 10.1080/10803548.2010.11076825; pmid: 20331916. 14. carrillo rj, holdago jw, hernandez ml, tuazon rs. prevalence of early laryngeal cancer and benign vocal cord pathology among patients undergoing videostroboscopy in philippine general hospital from 2008-2010. acta medica philippina. 2012; 46(3): 18-20. 15. souza cl, carvalho fm, araujo tm, reis ej, lima vm, porto la. factors associated with vocal fold pathologies in teachers. rev saude publica. 2011 oct; 45(5): 914-21. pmid: 21829977. 16. courey ms, fink ds, ossoff rh. the professional voice, in: flint pw, haughey bh, lund vj, niparko jk, robbins kt, thomas jr, et al. (editors). cummings otolaryngology head and neck surgery. 6th edition, volume 1, 2015. philadelphia: mosby, pp. 868-883. 17. akinbode r, lam kb, ayres jg, sadhra s. voice disorders in nigerian primary school teachers. occup med (lond). 2014 jul; 64(5):382-386. doi: 10.1093/occmed/kqu052; pmid: 24803677. had sulcus vocalis, and 1.42% had contact ulcer.12 another study done by souza et al. reported an 18.9% prevalence of vocal cord pathologies.15 a significant relationship was noted between smoking and laryngoscopic findings in this study. this suggests a high probability that a person would have a laryngoscopic pathology if that person smoked. inhaled smoke is irritating to the mucosa and may induced esophageal reflux which reduces vibratory efficiency of the vocal folds.16 smoking was also recognized as one of the risk factors in acquiring voice disorders in a study done by akindobe r et al.17 although a study by sophie yick-yu lee et al. did not identify smoking as a risk factor.8 a significant relationship was also noted between water intake and laryngoscopic findings. this suggests that with each increase of water intake, there is a probable decrease in the chances of acquiring pathologic manifestations in the larynx. constant speaking causes significant, insensible loss of fluids via the respiratory system.4,7 dehydration affects the mucosal lining causing it to lose its integrity, thus making it prone to developed pathologies.16 the present study has several limitations. first, there was no control group, and the cross-sectional design captured participants at one point in time (and not all confounding variables may have been accounted for). a case-control or cohort study may yield better data to better investigate the causes of disease as well as establish links between risk factors and health outcomes. second, the study population was very small. should there be a replication of this research study, we recommend a pre-survey of the targeted population in order to gain a more accurate picture of their characteristics and to help ensure that sub groups within that population are properly represented. third, our questionnaire should have been properly pre-tested and validated. this may explain why the frequency of laryngitis was only 2% (1 person), given the very large number of participants having history of hoarseness and loss of voice. perhaps, by doing this, data from this study may be replicated, expanded, verified or improved on. from the outset, the significance of this study has been tethered to the vocal well-being of public school teachers because of their need to be able to continue to speak effectively in class. significant results were discovered in this study regarding factors that may lead to unfavorable conditions that may threaten the future use of their voices. but apparently, years of service do not relate to pathological findings. according to the results of the study, specific points to be taken up should be: 1) cessation of smoking, 2) emphasis on the need to increase water intake to properly maintain adequate hydration, 3) support and/or therapy to help those who find it difficult to take on lifestyle changes, 4) facilitate consultation and/or treatment regimens for those in whom it is indicated, and 5) collaborate with the teachers for them to negotiate with the school administration to provide necessary training/ seminars and/or equipment to improve their teaching and classroom management techniques. in conclusion, our results suggest that public school teachers may benefit from avoidance of smoking and increased water intake in terms of voice care, factors contributing to acquiring pathologic manifestations in the larynx. problems in voice production and the ability to communicate may affect teaching quality, teaching performance and job satisfaction. it is therefore necessary to share this particular information with them through follow-up health teachings and collaborative efforts designed to minimize the chances of permanent damage to their larynges. information on voice and laryngeal status of this population can aid in guidance on proper vocal hygiene. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 philippine journal of otolaryngology-head and neck surgery 41 case reports abstract objective: this report aims to describe unique manifestations of proboscis lateralis and highlight the importance of a multidisciplinary approach to address the problems that arise from this rare congenital anomaly. methods: design: case report setting: tertiary government hospital patient: one results: a 13-year-old girl diagnosed with proboscis lateralis presented with a trunk-like appendage projecting from the surface of the right supramedial canthal area. she also had clear nasal discharge, nasal congestion, mouth-breathing and snoring since birth. paranasal sinus (pns) ct scan with 3d reconstruction showed agenesis of the right paranasal sinuses and expansile aeration of the left paranasal sinuses. due to her condition, the drainage system of the paranasal sinuses was obstructed causing chronic rhinosinusitis (crs). this hindered plans for reconstructive surgery despite medical management, hence, the patient underwent endoscopic sinus surgery (ess). conclusions: proboscis lateralis is a rare congenital anomaly that results in aesthetic problems as well as airway concerns such as rhinosinusitis and obstructive sleep apnea syndrome (osas). management entails a multidisciplinary approach to address functional and aesthetic problems of the patient. keywords: proboscis lateralis, chronic rhinosinusitis, obstructive sleep apnea, endoscopic sinus surgery, multidisciplinary approach, plastic surgery, reconstructive surgery proboscis lateralis is a rare congenital anomaly of the craniofacial anatomy with an incidence of 1:1,000,000 to 1:100,000 caused by abnormal embryonic nasal development that results in a trunk-like appendage from the facial surface projecting frequently from the region of the medial canthus.1 this report aims to describe the unique manifestations of proboscis lateralis associated with chronic rhinosinusitis (crs) and obstructive sleep apnea syndrome (osas), which, to the best of our knowledge, have not been previously described in the english literature. it also aims to highlight the importance of a multidisciplinary approach to address functional and aesthetic problems that arise from this rare condition. proboscis lateralis with rhinosinusitislaurence michael n. vera cruz, mdgil m. vicente, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. gil m. vicente department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 711-9491 local 320 e-mail: drgmvicente@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery interesting case contest (1st place). april 8, 2017. plaza del norte hotel & convention center, ilocos norte. philipp j otolaryngol head neck surg 2017; 32 (1): 41-43 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 case reports 42 philippine journal of otolaryngology-head and neck surgery case report this is the case of a 13-year-old girl who presented with a trunklike appendage projecting from the surface of the right supramedial canthal area and was born preterm at 32 weeks age of gestation via normal spontaneous delivery to a 30 year-old primigravid. her mother had fever followed by threatened abortion at the sixth week age of gestation and was managed successfully with isoxsuprine. her mother denied exposure to teratogens. since birth, the patient had also been manifesting with clear nasal discharge, nasal congestion, mouth-breathing and snoring. she was referred to a tertiary hospital for reconstructive surgery of the aesthetic anomaly. however, repeated attempts at reconstructive surgery were deferred due to persistent nasal discharge despite aggressive medical management. this caused her to be quiet and socially withdrawn with low self-esteem. three years prior to admission, the patient was seen at our institution by the plastic surgery service but surgery was deferred again due to persistent nasal discharge and sinus infection which could result in failure of the reconstructive surgery. a few months prior to admission, she was referred to our otorhinolaryngology service for management of chronic nasal discharge and congestion. she had severe manifestations with a visual analog score (vas) of 9 for crs. on physical examination, she had hypertelorism and a nasal appendage located at the right supramedial canthal area. (figure 1) paranasal sinus (pns) ct scan with 3d reconstruction revealed a rudimentary right nasal structure attached at the right supramedial canthal area with agenesis of frontal, maxillary, ethmoid and sphenoid sinuses on the right. the left sphenoid and maxillary sinuses had expansile aeration with deviation towards the contralateral side. the left anterior ethmoid cells were aerated. (figure 2) because of the combination of crs, osas, hypertelorism and possible depression arising from the aesthetic problem, a multidisciplinary team figure 1. preoperative photographs of the patient (published in full with permission) figure 2. a. coronal view using 16-slice helical ct scan b. three-dimensional ct scan reconstruction approach was necessary. the patient was referred to the snoring clinic to explore treatment of the osas and to the ophthalmology department to assess what can be done for the hypertelorism. the ophthalmology service also evaluated the patient’s hypertelorism, weighed risks and benefits and leaned towards conservative management since the condition was not visually disturbing. the patient was likewise referred to the psychiatry department to ensure that the dynamics of a normal growing child in the adolescent stage were evaluated and addressed properly. the pediatrics service addressed the patient’s general health, and developmental pediatrics also played a role in counselling. the otorhinolaryngology, plastic surgery, and anesthesia teams collaborated to plan surgical interventions. the teams on board carefully weighed risks of possible complications of surgery against possible outcomes on the future of a growing child if surgery was delayed or not done. she first underwent endoscopic sinus surgery. nasal videoendoscopy showed the clear nasal discharge from the left nasal cavity and from the rudimentary nasal appendage. the endoscope could not be inserted further into the nasopharynx through the left nasal cavity due to the distorted nasal anatomy. (figure 3) intraoperatively, the nasal turbinates, uncinate process, and ethmoid air cells were identifiable but were noted to have abnormal structures. uncinectomy, antrostomy, anterior ethmoidectomy and frontal sinusotomy were performed endoscopically. significant clinical improvement was noted on follow-up 9 weeks after the procedure. the patient reported improved nasal airflow, resolution of snoring and decrease in amount and frequency of rhinorrhea. visual analog score (vas) for crs decreased from the preoperative score of 9 (severe) to 2 (mild). no complications were noted. in addition to functional improvement, there was also an improvement in self-esteem. with otorhinolaryngology, pediatrics, and anesthesia on board, she successfully underwent initial reconstruction by the plastic surgery service. (figure 4) future plans are directed towards a second stage reconstructive surgery after the pubertal growth spurt which occurs at around 16-18 years of age.2 philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 philippine journal of otolaryngology-head and neck surgery 43 case reports discussion under the revised sakomoto grouping system,3 this case of proboscis lateralis with hypertelorism, nasal defect but no cleft lip or palate is classified under group iii. proboscis lateralis is commonly associated with median facial clefts which cause hypoplasia or agenesis of one side of the nose.4,5 this was consistent with the findings in this patient with agenesis of the right side of the nose and nasal sinuses. however, to the best of our knowledge, there are no published reports in the english literature of proboscis lateralis complicated by the presence of crs and osas. this case showed that proboscis lateralis may be associated with anatomical defects that obstruct drainage of the developed contralateral paranasal sinuses, leading to chronic rhinosinusitis. the patient’s chronic and non-resolving sinusitis was due to obstruction of the ostiomeatal unit. the abnormal nasal anatomy caused an obstruction of the left ostiomeatal unit which then resulted in obstruction of drainage of the left paranasal sinuses. computed tomography and magnetic resonance imaging have been used as the imaging modalities for preoperative evaluation of patients with this anomaly.4,5,7-10 in this case, pns ct scan was crucial for planning the surgical management of the functional airway problem. previous reports largely focused on the successful outcomes of reconstructive surgery4,7,9,11,12 but for this case, crs had to be addressed first. endoscopic sinus surgery addressed this functional problem by removing the ostiomeatal unit obstruction. references martin s, hogan e, sorenson ep, cohen-gadol aa, tubbs rs, loukas m.1. proboscis lateralis. childs nerv syst. 2013 jun; 29(6): 885-91. doi: 10.1007/s00381-012-1989-0; pmid: 23354442. bhatt yc, bakshi hs, vyas ka, ambat gs, laad h, panse ns. complete cleft of the upper limb: 2. a very rare anomaly. indian j plast surg. 2008 jul;41(2):195-9. doi: 10.4103/0970-0358.44842; pmid: 19753263; pmcid: pmc2740503. chauhan ds, guruprasad y. proboscis lateralis. 3. j maxillofac oral surg. 2010 jun; 9(2):162-5. doi: 10.1007/s12663-010-0046-3; pmid: 22190778; pmcid: pmc3244101. vaid s, shah d, rawat s, shukla r. proboscis lateralis with ipsilateral sinonasal and olfactory 4. pathway aplasia. j pediatr surg. 2010 feb; 45(2):453-6. doi: 10.1016/j.jpedsurg.2009.10.044; pmid: 20152374. sakamoto y, miyamoto j, nakajima h, kishi k. new classification scheme of proboscis lateralis 5. based on a review of 50 cases. cleft palate craniofac j. 2012 mar; 49(2):201-7. doi: 10.1597/10127.1; pmid: 21219222. verma p, pal m, goel a, singh i, bansal v. proboscis lateralis: case report and overview. 6. indian j otolaryngol head neck surg. 2011 jul; 63(suppl 1):36-7. doi: 10.1007/s12070-011-0182-1; pmid: 22754832; pmcid: pmc3146664. magadum sb, khairnar p, hirugade s, kassa v. proboscis lateralis of nose-a case report. 7. indian j surg. 2012 apr; 74(2):181-3. doi: 10.1007/s12262-011-0279-5; pmid: 23543614; pmcid: pmc3309082. mohsen n, mehdi b. proboscis lateralis: a unique case with choanal atresia and bilateral 8. ophthalmopathy. otolaryngology. 2015 jan; 5: 183. doi:10.4172/2161-119x.1000183. franco d, medeiros j, faveret p, franco t. supernumerary nostril: case report and review of the 9. literature. j plast reconstr aesthet surg. 2008; 61(4): 442-446. doi: 10.1016/j.bjps.2006.04.007; pmid: 18358435. da silva freitas r, alonso n, de freitas azzolini t, busato l, dall’oglio tolazzi ar, azor de oliveira 10. e cruz g, et al. the surgical repair of half-nose. j plast reconstr aesthet surg. 2010 jan; 63(1): 1521. doi: 10.1016/j.bjps.2008.08.040; pmid: 19046661. johns hopkins medicine [homepage on the internet]. endoscopic sinus surgery. 11. otolaryngology-head and neck surgery. [cited 2015 dec 07]. available from: http://www. hopkinsmedicine.org/otolaryngology/specialty_areas/sinus_center/procedures/endoscopic_ sinus_surgery.html. kapocheva-barsova g, nikolovski n. justification for rhinoseptoplasty in children–our 10 12. years overview. open access maced j med sci. 2016 sep 15; 4(3): 397–403. doi: 10.3889/ oamjms.2016.080; pmid: 27703562; pmcid: pmc5042622. bircher a. proboscis lateralis. [homepage on the internet] the fetus.net. [cited 2017 feb 09]. 13. available from: https://sonoworld.com/fetus/page.aspx?id=2370. figure 3. preoperative nasal videoendoscopy showing obstruction of the nasal cavity. a. nasal septum. b. lateral nasal wall. c. inferior turbinate. d. nasal septum. e. uncinate process. f. middle turbinate. figure 4. before and after photographs (published in full with permission) significant clinical improvement was noted on follow-up. a literature review of eleven studies on the outcomes of ess in children with crs showed that success rate ranged from 82 to 100%. safety profile was excellent with rate of complications as low as 1.4%.11 however, none of the subjects had congenital anomalies of the nasal cavity. to the best of our knowledge, this is the first report of the successful treatment with ess of crs related to proboscis lateralis. proboscis lateralis presents with aesthetic and functional problems. ess played a pivotal role in addressing the functional problems and in paving the way towards definitive reconstruction. the first stage of reconstruction aimed to restore the external anatomy and promote normal development and growth of the nose. future management includes secondary surgical repair after complete facial growth. however, due to the complex nature of this malformation, achieving a favorable result is often a challenge.13 because of this, it is important to have different services working together for holistic and optimal management. in summary, this paper described the unique manifestations of proboscis lateralis that resulted in chronic rhinosinusitis and osas. a multidisciplinary approach involving the otorhinolaryngology, plastic surgery, anesthesiology, pediatrics, psychiatry, and ophthalmology services was essential for the successful management of functional and aesthetic problems arising from proboscis lateralis. the patient is a living testimony to this successful cooperation. philippine journal of otolaryngology-head and neck surgery 6564 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 6564 philippine journal of otolaryngology-head and neck surgery passages carlos f. dumlao, md (1950-2018) alfredo q. y. pontejos jr., md carlos f. dumlao, ‘caloy’ as he is fondly called by friends, was born in bayombong, nueva vizcaya on november 4, 1950. he studied in the bayombong central school for elementary, then to nueva vizcaya high school, graduating valedictorian from both schools. he took his b.s. pre-med from the university of the philippines (u.p.) diliman, finishing in 1970. he then entered the u.p. college of medicine and graduated in 1975. he is a brod in the mu sigma phi fraternity where i got to know him. he was one-year senior and he would always have a helping hand to anyone in need. he looked fearsome because of his bulk and stance but deep inside he had a soft heart and was very humble, for a guy who happened to be a son of a governor. faith would have that we would be together again in the department of otolaryngology in the philippine general hospital. he was my immediate senior. he helped and taught me the rudiments of surgery. he was one of the “fastest guns alive” that he could finish a laryngectomy in an hour. because of the prodding of dr. mariano b. caparas he took up the challenge of practicing in baguio with the objective of establishing a training program there. the first few years were a challenge to him because he was not welcome there. the senior surgeons frowned on the fact that he performed head and neck surgery, particularly thyroidectomy. but he persisted and even befriended them. he succeeded in forming a department of otolaryngology head and neck surgery in baguio general hospital. he gave much of his time and talent to that department and has produced a good number of diplomates and fellows. he was unpretentious. what you see is what you get. he was also a true friend and a dedicated family man. he was faithful to josie, his wife and children janie, dessy, biboy, joboy and popo. one measure of success of a leader is the number of successors you have produced. he has done well in this. he has given much of himself to baguio general hospital, the philippine society of otolaryngology – head and neck surgery (pso-hns) northern luzon chapter and to the pso-hns as a whole. his legacy will live on in his graduates in baguio general hospital and through his son popo who just passed the philippine board of otolaryngology – head and neck surgery diplomate board examinations. caloy, you have left your mark in northern luzon, particularly in baguio city. may you rest in peace in god’s bosom. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 63 from the viewbox a 48-year-old man presented with a unilateral right hearing loss of four months’ duration. a right middle ear effusion was noted on physical examination. endoscopic examination of the nasopharynx was unremarkable. due to the duration of the symptoms, myringotomy with ventilation tube insertion was offered as a treatment option. upon myringotomy, clear pulsatile liquid flowed out of the incision. more than 5cc of liquid was collected which continued to flow out despite active suctioning. due to the realization that the liquid most likely represented cerebrospinal fluid, insertion of a ventilation tube was not performed. the ear canal was packed with sterile cotton, and the patient was given a short course of acetazolamide to decrease csf production. upon further questioning, the patient did not have any prior head trauma. the patient then underwent both computerized tomographic (ct) imaging and magnetic resonance imaging (mri) of the temporal bone to look specifically for evidence of a dehiscence in the middle fossa plate (tegmen) or posterior fossa plate, as well as the presence of a meningoencephalocele. computerized tomographic imaging of the temporal bone in the axial plane showed a soft tissue density completely occupying the air-containing spaces of the middle ear, epitypanum and mastoid air cells without any evidence of bony erosion of the scutum, the ossicles, or the bony septations of the mastoid air cells. t2-weighted magnetic resonance imaging in the axial plane showed that the soft tissue densities in the middle ear, the epitympanum and mastoid air cells had a naturally high signal intensity characteristic of fluid. (figure 1) spontaneous middle fossa encephalocele correspondence: dr. nathaniel w. yang department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax: (632) 525 5444 email: nwyang@gmx.net the author declared that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2016; 31 (2): 63-64 c philippine society of otolaryngology – head and neck surgery, inc. nathaniel w. yang, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila department of otolaryngology head and neck surgery feu-nrmf institute of medicine department of otorhinolaryngology head and neck surgery the medical city figure 1. ct imaging in the axial plane. a. at the level of the head of the malleus, incus body and lateral semicircular canal shows a homogenous soft tissue density in the right epitympanum and mastoid air cell system. note that the bony septations are intact and are similar to that on the uninvolved left side. t2-weighted mr imaging at the same level in the axial plane. b. the high signal intensity of the soft tissue densities similar to the csf in the cerebellopontine angle cisterns. the ossicles (white arrow with black outline) can be clearly seen within the fluid-filled epitympanum. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international a b philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 from the viewbox 64 philippine journal of otolaryngology-head and neck surgery references 1. rao ak, merenda dm, wetmore sj. diagnosis and management of spontaneous cerebrospinal fluid otorrhea. otol neurotol. 2005 nov; 26(6): 1171-1175. pmid: 16272936. 2. gubbels sp, selden nr, delashaw jb jr, mcmenomey so. spontaneous middle fossa encephalocele and cerebrospinal fluid leakage: diagnosis and management. otol neurotol. 2007 dec; 28(8): 1131-1139. doi: 10.1097/mao.0b013e318157f7b6 pmid: 17921911. on coronal ct imaging, a dehiscence of the middle fossa plate (tegmen) was noted lateral to the superior semicircular canal. magnetic resonance imaging in the same plane revealed a soft tissue density in the region of the dehiscence that was contiguous with, and isointense with the temporal lobe. this soft tissue density appeared to originate from the temporal lobe, and extended downwards into the upper portion of the mastoid antrum. no enhancement was noted on gadolinium-enhanced t1-weighted imaging. (figure 2) with these imaging findings, a middle fossa encephalocele was considered. exploratory mastoidectomy confirmed the diagnosis, and the patient subsequently underwent a transmastoid repair of the tegmen and dural dehiscence using both temporalis fascia and mastoid cortical bone after the herniated brain tissue was amputated. a middle fossa encephalocele is a condition of the temporal bone that may arise as a complication of chronic otitis media, temporal bone fractures, or after surgery involving the temporal bone. although rare, spontaneous middle fossa encephaloceles may also occur.1,2 one must maintain a high degree of clinical suspicion for this condition in an adult patient presenting with a unilateral middle ear effusion or watery otorrhea in the absence of an identifiable cause of otologic disease2 or nasopharyngeal pathology. it should definitely be highly considered if profuse, persistent clear otorrhea is encountered during a myringotomy for what may initially appear to be a chronic middle ear effusion. surgical treatment of the encephalocele and repair of the skull base defect is generally recommended, as life threatening complications such as meningitis, brain abscess and temporal lobe seizures have been known to occur.2 figure 2. ct and mr imaging in the coronal plane at the level of the superior semicircular canal (white outlined arrow, all images). ct imaging. a. a dehiscence in the tegmen mastoideum (white solid arrow). t2-weighted mr imaging. b. the high signal intensity of the fluid in the mastoid air cells (white solid arrow). the soft tissue density seen directly under the tegmen dehiscence in all of the images (white asterisk) has the same signal intensity as the overlying brain in all of the mr sequences. this soft tissue density is directly connected to the overlying temporal lobe in both the t2-weighted image. b. and the non-contrast enhanced t1-weighted image. c. no enhancement is seen in the gd-enhanced t1-weighted image d. a b c d philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation philipp j otolaryngol head neck surg 2018; 32 (2): 48-52 c philippine society of otolaryngology – head and neck surgery, inc. phonetovox: a novel prototype device for alaryngeal speech michaelsam e. econ, md ronaldo g. soriano, md department of otolaryngology head and neck surgery st. luke’s medical center correspondence: dr. michaelsam e. econ 2nd floor department of otolaryngology head and neck surgery st. luke’s medical center 279 e. rodriguez ave., quezon city 1102 philippines phone: +63 2 723 0101 local 5543 / +63 0908 862 3269 email: mikeeconmd05@gmail.com the authors declare that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngologyhead and neck surgery poster session contest on surgical innovation & surgical instrumentation (1st place) december 1, 2017. manila hotel, manila, philippines. abstract objective: to describe a prototype improvised hand held device for alaryngeal speech. methods: design: instrumental innovation setting: tertiary private hospital participants: four listeners with normal hearing were native tagalog-speakers and had no previous experience with alaryngeal speech types participated in initial trials. results: the prototype phonetovox was fabricated using a soundproofed cellphone casing with an intra-oral sound port attachment and a cellphone was loaded with pocket talkbox v. 1.4.0 software. the device was tested for its ability to produce intelligible speech by using the cellphone as a substitute for the larynx using oral cavity resonators and articulators producing a synthesized sound mimicking the human voice. the phonetovox produced intelligible words. initial testing using a c-v-c tagalog word list had 4 listeners identify 34, 35, 47 and 54 out of 93 words (37 to 58%) with an overall average intelligibility of 46%. conclusion: despite its restrictions in articulation and the wide range of results from the four listeners, our initial results may suggest the potential of phonetovox as another modality for alaryngeal speech comparable to the 36 – 38 % intelligibility of commercially-available devices. further trials with actual laryngectomees are needed to further establish intelligibility and acceptability. keywords: laryngectomy, alaryngeal speech, laryngeal cancer total laryngectomy is a surgical procedure involving removal of the entire larynx resulting in airway interruption and respiration being accomplished through a tracheal stoma in the lower anterior cervical area. the surgery is usually performed for advanced laryngeal carcinoma or malignancy of adjacent structures as well as severe laryngeal trauma that does not allow functional reconstruction of the organ, severe laryngeal stenosis and recurrent laryngo-tracheal papillomatosis.1 following total laryngectomy, the generator of vibration is essentially eliminated and patients are rendered voiceless with an altered airway. thus, voice restoration is essential in maintaining the quality of life in these affected individuals. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation alaryngeal speech modalities for voice restoration include the esophageal (se), tracheoesophageal (te) and electrolaryngeal (el).2-7 esophageal speech uses air injected into the upper esophagus that is expelled voluntarily setting the pharyngoesophageal segment into vibration thereby producing a new sound for phonation.3 tracheoesophageal speech has the same vibratory mechanism but is achieved by creating a fistula between trachea and esophagus such as involving the use of trachea-esophageal mucosa in a one-stage procedure as described in the amatsu technique and its modification such as the ureta technique.4,5 tracheoesophageal speech is also possible using a silicon voice prosthesis that is surgically implanted based on the principles introduced by mozolewski in 1972 and refined by blom-singer in 1978.2,6 electrolaryngeal speech uses an electrolarynx for speech production.7 despite reported successes with tracheoesophageal speech, 8 the surgery requires a level of mastery not all surgeons can achieve, esophageal speech may require a long learning curve on the part of laryngectomees and few master this skill, 9,10 and the high cost of electrolaryngeal devices,11 limit other alternatives for patients in our setting. we therefore describe a new alaryngeal device as is an alternative for intelligible speech production. methods this prototype study was undertaken as proof-of-concept required for institutional review board (irb) approval; an application for irb approval has been made for the formal trials following this report. a. materials • 360º full shell casing made from rubber, thermoplastic polyurethane, electroplated photonic crystals (shenzen super electronic co. ltd, china) • 70mm x 5mm x 2mm ethylene-vinyl acetate rubber sheet from commercially-available mouse pad (cd-r king, philippines) • samsung galaxy s7 edge cellphone (samsung electronics co. ltd, south korea) • pocket talkbox free apk version 1.4.0 for android version 2.3 and up (vito biliti, cayman islands) • simplex® mucus extractor (inmed corp., philippines) • cyanoacrylate adhesive glue (mighty bond®, pioneer adhesives inc. philippines) • craft cutter (maped, france) b. procedure 1. creating a sound port and intra-oral attachment fabrication a commercially-available 360° full shell casing made from rubber, thermoplastic polyurethane and electroplated photonic crystal (shenzen super electronic co. ltd, china) was used to provide a tightseal over a commercially-available cellphone (samsung galaxy s7 edge, samsung electronics co. ltd., gyeonggi-do, south korea). the sound port came from the suction attachment of a commercially-available mucus extractor (simplex®, inmed corp., quezon city, philippines) with inner diameter of 8mm and outer diameter of 12mm. the polymerizing vinyl chloride (pvc) suction attachment and tubing were detached from the collection chamber. (figure 1a) the portion where the suction attachment tapers into the tubing was cut using the cutter. (figure 1b) the cut end of the suction attachment was inserted into the preformed speaker hole on the phone casing. cyanoacrylate adhesive glue was used to hold it in place. (figure 1c). the remaining flexible pvc tubing which was removed from the suction attachment with length 380 mm, outer diameter 4 mm, inner diameter 3 mm and thickness of 1 mm was used as an intraoral device. the cut end was inserted into the sound port while the transparent end was meant to be placed into a user’s mouth. (figure 1d) 2. soundproofing cellphone case an ethylene-vinyl acetate rubber sheet with dimensions of 70mm x 5mm x 2mm (lxwxh) was cut from a mouse pad (cd-r king, quezon city, philippines) using a craft cutter (maped, france). (figure 2a) cyanoacrylate adhesive glue (mighty bond, pioneer adhesives inc., quezon city, philippines) was used to stick the rubber to the inner bottom compartment of the case. (figure 2b) 3. downloading and using the software the pocket talkbox free apk version 1.4.0 for android version 2.3 and up (vito biliti, cayman islands) was downloaded from google play store (https://play.google.com/store/apps/details?id=com.bright_blue_led. pockettalkbox) and installed (september 5, 2017). the program was opened and maj tab was pressed. the f musical key tab (violet) was used during articulation. (figure 3) 4. use of the device and proper articulation technique the intra-oral attachment was held in place towards the oropharynx in the midline over the posterior third of the tongue by each author. (figure 4a) lip, tongue, mouth and jaw movements were exaggerated during articulation to produce sound. (figure 4b) c. pre-testing the device volunteers with normal hearing on pure tone audiometry and no previous experience with alaryngeal speech types were recruited from personal and professional acquaintances to participate in the initial philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation a c b d figure 1 a. simplex® mucus extractor, detached suction attachment and pvc tubing; b. cutting suction attachment (sound port) from tubing (intra-oral attachment); c. attaching sound port using cyanoacrylate glue; d. phonetovox (360 full shell casing with soundport and intra-oral attachment). a b figure 2 a. using a craft cutter, a 70mm x 5mm x 2mm eva rubber sheet was taken from a mouse pad; b. sound-proofing; arrow points to eva rubber sheet glued to inner bottom compartment of case. philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation figure 3. keynote panel of pocket talkbox (free); arrow points to f (violet) panel used figure 4. a. positioning of intra-oral attachment inside oral cavity; b. pre-testing the phonetovox with proper placement of intra-oral attachment and handling of device. trials. all listeners had to be native tagalog speakers and possess at least a high school education. informed consent was obtained from volunteers meeting these criteria. the authors tested the intelligibility of the device using the speech material consonant-vowel-consonant tagalog word list in a quiet room.12 the listeners were blinded to the words comprising the word list. one author used the phonetovox to articulate each word from the list two times. each listener was instructed to not look at the speaker and list the intelligible words that they heard, using a pen and a blank piece of paper. d. data analysis data analysis was accomplished using simple descriptive statistics. the testing author checked the written lists against the actual word list and tabulated the raw scores and corresponding percentages. results were compared with values obtained from a review of related literature. results the prototype phonetovox was successfully fabricated using a soundproofed cellphone casing with an intra-oral sound port attachment. the cellphone was easily loaded with pocket talkbox v. 1.4.0 software. the device utilized the sound produced by the cellphone as a substitute for the larynx, transmitting sounds from the oral cavity resonators and articulators, producing a synthesized sound mimicking the human voice. four listeners (3 female and 1 male) aged 26 to 29 (mean age 27.8) with normal hearing on pure tone audiometry and no previous experience with alaryngeal speech types participated in the initial trials. all listeners possessed at least a college education and were all native speakers of tagalog. the phonetovox produced intelligible words. initial testing using a c-v-c 93 item tagalog word list had 4 listeners identify 34, 35, 47 and 54 out of 93 words (37 to 58%) with an overall average intelligibility of 46%. (table 1) discussion the prototype phonetovox /fonetovox/, which means “phone to voice” is an improvised device for alaryngeal speech fabricated from a modified cell phone casing reinforced with eva rubber sheet for soundproofing and connected to a pvc sound port and intraoral tubing. the concept behind phonetovox is different from other aforementioned modalities of alaryngeal speech because it utilizes the principles of a talkbox. a talkbox is a sound-effect gadget that allows musicians to modify the sound of their musical instrument by table 1. initial phontovox trial among 4 listeners using a 93-item c-v-c word list percentage (%)score (n out of 93)participants listener a listener b listener c listener d average 58 51 38 37 46 54 47 35 34 42.5 a b philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation acknowledgements the authors would like to thank dr. william lim and dr. ray casile for sharing their expertise in the field of laryngology and mrs. sheryl sibug -wong for sharing her expertise in the field of speech and language pathology. references 1. ceachir o, hainarosie r, zainea v. total laryngectomy – past, present, future. maedica – a journal of clinical medicine. [internet] 2014 jun 18; 9(2): 210-216. [cited 2017 nov 17]; available from: https://docksci.com/total-laryngectomy-past-present-future_5a626073d64ab25013ae9f3e. html. 2. lorenz kj. rehabilitation after total laryngectomy—a tribute to the pioneers of voice restoration in the last two centuries. frontiers in medicine [internet] 2017 june; 4:81. [cited 2018 oct 25]; available from: https://www.frontiersin.org/articles/10.3389/fmed.2017.00081/ full. 3. kapila m, deore n1, palav rs, kazi ra, shah rp, jagade mv. a brief review of voice restoration following total laryngectomy. indian journal of cancer. [internet] 2011 jan-mar;48(1):99-104. [cited 2018 oct 25]; available from: https://www.ncbi.nlm.nih.gov/pubmed/21248437. 4. vieira m, maia a, ribeiro j. speech rehabilitation after laryngectomy with the amatsu tracheoesophageal shunt. auris, nasus, larynx. [internet] 1999 february; 26. 69-77. [cited 2018 oct 25]; available from: https://www.researchgate.net/publication/13214190_speech_ rehabilitation_after_laryngectomy_with_the_amatsu_tracheoesophageal_shunt. 5. ureta c. v., go c. e . primary voice reconstruction in total laryngectomy using the funnel technique. philippine journal of otolaryngology – head and neck surgery. [internet] 1998; 13:5258. [cited 2018 oct 25]; available from: https://journal.pso-hns.org/2015/05/07/vol-13-no-11998/. 6. blom, e. d. tracheoesophageal voice restoration: origin – evolution – state-of-the-art. folia phoniatrica et logopaedica. [internet] 1999; 52(1-3), 14–23[cited 2018 oct 25]; available from: https://www.karger.com/article/pdf/21508. 7. liu h, ng m. electrolarynx in voice rehabilitation. auris, nasus, larynx. [internet] 2007 january; 34. 327-32. [cited 2018 oct 25]; available from: https://www.researchgate.net/ publication/6562618_electrolarynx_in_voice_rehabilitation. 8. sleeth le. exploring intelligibility in tracheoesophageal speech: a descriptive analysis. [electronic thesis and dissertation repository]. the university of western ontario. [internet] 2012 jun. [cited 2017 nov 16] available from: https://www.researchgate.net/publication/266853779. 9. hillman r,walsh m,wolf g, fisher s, hongw. functional outcomes following treatment for advanced laryngeal cancer. part 1. voice reservation in advanced laryngeal cancer. part ii. laryngectomy rehabilitation: the state-of-the-art in the va system. ann otol rhinol laryngol. [internet] 1998; 107(suppl 172, pt 2):1–27. [cited 2018 oct 25]; available from: https://www. ncbi.nlm.nih.gov/pubmed/9597955#. 10. kresić s, veselinović m, mumović g, mitrović sm. possible factors of success in teaching esophageal speech. med pregl [internet] 2015; lxviii (1-2): 5-9. [cited 2018 oct 25]; available from: https://www.ncbi.nlm.nih.gov/pubmed/26012237. 11. maruthy s, mallet mk, bellur r. comparison of esophageal and tracheoesophageal speech modes in dual-mode alaryngeal speakers. j laryngol voice [internet] 2014 4(1); 6-11. [cited 2017 oct 4]; available from: http://www.laryngologyandvoice.org/text.asp?2014/4/1/6/141444. 12. lim rk, bernhardt bm, stemberger jp. university of british columbia cross-linguistic project, tagalog words list 2015. [internet]. [cited 2017 sep 25] available from: http://phonodevelopment. sites.olt.ubc.ca/tagalog-word-lists_basic_extension-a_extension-b_mar2015/. 13. mccarron b. the talkbox faq [internet] c1996-2014 [cited 2017 september 3] available from: http://www.blamepro.com/talkbox.htm. 14. mcgrath, j. how talkboxes work. howstuffworks [internet]. [updated 2011 jun 27; [cited 2017 sep 3] available from: http://electronics.howstuffworks.com/gadgets/audio-music/talk-box. htm. 15. woodford c. soundproofing. explain that stuff! [internet] c2009-2016 [last updated 2016 dec 18; [cited 2017 nov 15] available from: http://www.explainthatstuff.com/soundproofing.html 16. weiss ms, basili ag. electrolaryngeal speech produced by laryngectomized subjects: perceptual characteristics. j speech hear res. [internet] 1985 jun [cited 2017 nov 17]. 28(2): 294-300. available from: https://jslhr.pubs.asha.org/article.aspx?articleid=1778128. remodeling the resonance of the sound.13 the phonetovox utilizes commercially-available pocket talkbox ver 1.4.0 software to produce a monotone sound but other musical software such as morphwiz-play ver. 1.1 software (jordan ruddess, u.s.a) downloaded from (http:// www.wizdommusic.com), or your own digitally synthesized recorded sounds may be used. substituting the eliminated sound-generating organ with a monotone sound produced by the cellphone and using the capacity of the oral cavity to alter sound to produce speech is what makes phonetovox unique from other types of alaryngeal speech.14 in constructing the device, the case should fit tightly to promote soundproofing and fullness of sound coming out of the sound port. this is achieved by lining a rubber sheet around the casing’s speaker hole.15 holding the tube in place, avoiding contact with the tongue or mucosa of the oral cavity, pooling of saliva inside the tube, and synchronization of articulation with key note tab pressing minimizes distortion of the sound leading to unnecessary noise production and unintelligibility of sound. slow articulation with exaggeration of lip, tongue, mouth, jaw movements during articulation may enhance word intelligibility. vowel articulation may be achieved with forward movement and high tongue positions.11 the authors identified that the more polysyllabic a word the more intelligible it may become. monosyllabic words in phonetovox speech are unintelligible (e.g. tren, zoo, nars). in a study by weiss et al., the intelligibility of two transcervical electrolarynges, model 5 (western electric company, new york, u.s.a) and servox (siemens, berlin, germany) was compared using a 66-item english word list comprising primarily of cvc syllables.16 the talker intelligibility was assessed from six laryngectomized men. the highest score for the western electric prosthesis was 54% and the lowest was 16%. the scores for the servox were 55% and 19%, respectively. the overall intelligibility range scores were 38% and 36%, respectively.16 in another study by sleeth the overall intelligibility of tracheoesophageal speech of 15 laryngectomy patients using modified rhyme’s test was 71% with most intelligible speaker at 89%, and the least intelligible at 54%.8 in our study, the overall intelligibility of phonetovox was 46%, with highest score for intelligibility at 58% and the lowest at 37%. despite phonetovox showing a higher intelligibility over both electrolarynges in the study of weiss et al., our trial is not comparable to the previous study since we tested the device on a non-laryngectomized individual. thus, we cannot rule out the contribution of the speaker’s intact larynx to the speech produced. other limitations of our trial include lack of a standard comparator, testing in an unblinded manner, and only using a tagalog word list for intelligibility testing. the authors recommend actual trials among total laryngectomees to establish the intelligibility and acceptability of phonetovox and in comparison with other types of alaryngeal speech. our irb application for such a trial is in process. other applications of the device such as use in tracheostomy patients may also be investigated later. in conclusion, our initial results may suggest the potential of phonetovox as another modality for alaryngeal speech. despite its restrictions in articulation and the wide range of results from the four listeners, it may be comparable to the 36 – 38 % intelligibility of commercially-available devices. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 case reports 20 philippine journal of otolaryngology-head and neck surgery abstract objective: to describe an unusual presentation of langerhans cell histiocytosis in the craniofacial skeleton in a patient previously diagnosed with pott’s disease. methods: design: case report. setting: tertiary care center. patient: one (1) result: a 30-year-old male who previously underwent cervical spine surgery for pott’s disease, presenting with watery ear discharge and mandibular resorption was initially diagnosed with tuberculosis. on mri, a mildly contrast-enhancing soft tissue mass involving the left infratemporal and middle cranial fossae consistent with residual or recurrent tumor as well as an inflammatory process was seen. he underwent transtemporal excision of the mass with external auditory canal blind sac closure and obliteration. final histopathology revealed langerhans cell histiocytosis. a review of slides of the specimen from the previous spine surgery was done and signed out as langerhans cell histiocytosis. conclusion: langerhans cell histiocytosis occurs rarely, but has frequent head and neck manifestations. it may also be confused with other diseases in the head and neck, such as tuberculosis, in this case. otorhinolaryngologists and head and neck surgeons should be well aware that isolated lesions in the bony framework of the head and neck should include langerhans cell histiocytosis in the differential diagnosis. early detection is the key to preventing disease progression and instituting timely definitive management. key words: langerhans cell histiocytosis, watery ear discharge, mandibular resorption langerhans cell histiocytosis: an unusual presentation kathleen r. fellizar, md1 charlotte m. chiong, md1,2 1 department of otorhinolaryngology philippine general hospital university of the philippines manila 2 philippine national ear institute national institutes of health university of the philippines manila correspondence: kathleen r. fellizar, md department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax: (632) 525 5444 email: orlpgh@yahoo.com reprints will not be available from the author no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this report presented at the interesting case contest (1st place) philippine society of otolaryngology head and neck surgery midyear convention, legazpi city, bicol, april 28, 2006 philipp j otolaryngol head neck surg 2008; 23 (1): 20-24 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 case reports philippine journal of otolaryngology-head and neck surgery 21 langerhans cell histiocytosis (lch) comprise a group of idiopathic disorders characterized by the proliferation of specialized bone marrow–derived langerhans cells as well as mature eosinophils. it is considered rare and the reported prevalence is higher among whites than other races and greater in males than females with a ratio of 2:1. the head and neck are commonly involved especially the temporal bone. previous reports noted that 25-30% of patients with various forms of this disease have temporal bone destruction. one case series has found nearly 50% involvement in the remainder of the head and neck. these consist mostly of isolated lesions of the mandible and skull.1 the frequency of head and neck manifestations, as well as possible confusion with other diseases in the head and neck make an understanding of the disease and its peculiarities important for the otolaryngologist. we report the rare case of a 30-yearold male presenting with watery otorrhea and mandibular resorption, the diagnostic examinations requested, the dilemma that arose with the case, and the surgical treatment done. case report a 30-year-old male from lucena city underwent cervical spine surgery in 2001 for pott’s disease. histopathologic results were read as tuberculosis for which he took anti-tuberculosis medications for two months. the present consult involved a oneyear history of recurrent, clear, watery nonfoul-smelling left ear discharge, which was resistant to medical management, associated with gradual decrease in the size of the mandible, clear discharge coming from the lower tooth sockets and loosening and eventual extrusion of the lower teeth. there was also gradual hearing loss in the left ear. three months prior to admission, the patient consulted an otolaryngologist who noted active milky-white discharge from the left ear with a positive fistula test, milky-white discharge from previous tooth extraction sites in the mandible and retrognathia. this led to a diagnosis of tuberculous otitis, left and tuberculous osteomyelitis of the mandible. a cranial ct scan was requested, but the patient was lost to follow-up. two months later, the patient returned with the ct scan, revealing a heterogenous soft tissue mass in the left masseter space with extension into the left middle cranial fossa. a bony defect involving the floor and lateral wall of the left middle cranial fossa was noted. the cochlea, jugular bulb and sigmoid sinus were absent in the left side (figure 1). a soft tissue sarcoma was figure 1. cranial ct scan with bone window algorithm showing a large bony defect involving the floor and lateral wall of the left middle cranial fossa as well as destruction of the cochlea and the posterior fossa plate (white arrows). c = cochlea; j = jugular bulb; s = sigmoid sinus. note the absence of the cochlea, jugular bulb and sigmoid sinus plate in the left side. figure 2. mri of the skull base showing a mildly contrast-enhancing soft tissue mass involving the left middle cranial fossa (arrows). figure 3. panoramic radiograph of the patient, mandible absence is noted. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 case reports 22 philippine journal of otolaryngology-head and neck surgery called hand-schüller-christian disease.2 lch is seen in different ages, but a clear predominance exists for the pediatric age group.3 it is a rare condition in adults.4 thus, a 30-year-old male presenting with otorrhea, mandibular resorption and cervical spine erosion does not typify a patient with langerhans cell histiocytosis. destruction of the temporal and mastoid bones manifest as mastoid swelling, middle ear polyps, and in this case, csf otorrhea, and erosion of the posterior bony external auditory canal. infiltration of the mandible will present with loose teeth and eventual resorption as seen in this patient. vertebral collapse with spinal cord compression has occasionally been described, which may have happened in the patient when he was initially diagnosed with cervical pott’s disease four years prior to the onset of watery ear discharge. there may be confusion with langerhans cell histiocytosis and other diseases in the head and neck, particularly granulomatous inflammations, such as tuberculosis (tb). many of the clinical features of langerhans cell histiocytosis mimic this highly endemic disease in the philippines.5 as seen in this case, radiographs were not able to differentiate between tb and lch. even the final histopathology of the cervical lesion was initially read as tuberculosis. both langerhans cell histiocytosis and tuberculosis may present with multisystem involvement. symptoms in this patient presented in a sequential manner with cervical erosion, followed by mandibular resorption, and finally otorrhea, which is more in accordance with langerhans cell histiocytosis.6 in the case of tuberculosis, symptoms usually appear simultaneously although progressive multi-organ involvement sequentially occurs in many cases. histologically, a typical tuberculous granuloma would normally be described as chronic granulomatous inflammation with caseation necrosis and langhans’ type giant cells mixed with chronic inflammatory infiltrates consisting of lymphocytes. (figure 4a) in the patient’s cervical spine specimen, cells were arranged in a granuloma-like pattern, and as such may have been mistaken for a tuberculous granuloma. (figure 4b) both diseases show aggregates of histiocytes. histiocytes of tuberculosis are epithelioid and spindle-shaped. (figure 5a) on the other hand, histiocytes seen in langerhans cell histiocytosis are atypical, in that they are large, ovoid, mononuclear cells. (figure 5b) aside from this, lch also presents with a large component of eosinophils in contrast to lymphocytes seen in tb.7 considered, for which cytologic correlation was recommended. the patient was referred to a neurosurgeon who requested an mri of the skull base. this showed a mildly contrast-enhancing soft tissue mass in the left infratemporal and middle cranial fossae (figure 2). a biopsy was the next logical step but there was a dilemma on how to approach the mass. another otolaryngologist saw the patient and noted watery, clear, pulsatile non foul-smelling discharge from the left ear. retrognathia was noted, for which a panoramic radiograph was done, showing total absence of the mandible (figure 3). an assessment of csf otorrhea secondary to tb lytic destruction with mandibular resorption was made. in order to address both biopsy of the primary lesion and treatment of the csf otorrhea, transtemporal excision of the mass with external auditory canal blind sac closure and obliteration under general anesthesia was done at the philippine general hospital. intra-operative findings include the absence of the posterior bony external auditory canal wall, and an “eatenout” temporal bone. a fleshy mass was seen in the area of the mastoid cavity. part of the mass was sent for frozen section which was read as chronic inflammation with gliosis. near total gross excision of the mass was done. blind sac closure of the external auditory canal was followed by temporalis muscle flap rotation and obliteration of the temporal bone defect to address the csf leak. final histopathologic diagnosis was langerhans cell histiocytosis. a review of slides of the specimen from the previous spine surgery was requested, which likewise revealed langerhans cell histiocytosis. to strengthen the diagnosis, immunostaining with s-100 protein was done. both specimens were positive. the post-operative course was uneventful except for episodes of dizziness and vomiting. the patient was discharged after 12 days, but was again lost to follow-up. despite repeated calls, the patient refused the recommendation to undergo chemotherapy. discussion langerhans cell histiocytosis (lch), formerly known as histiocytosis x, denotes a group of diseases characterized by infiltration or proliferation of histiocytes in various body tissues. the clinical spectrum includes the acute fulminant, disseminated letterer-siwe disease, solitary or few, indolent and chronic, lesions of bone or other organs called eosinophilic granulomas, (under which the patient may fall) and the intermediate form philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 case reports philippine journal of otolaryngology-head and neck surgery 23 figure 4. h&e photomicrographs. (a) typical tuberculous granuloma versus (b) granuloma seen in the cervical spine specimen of the patient. figure 5. h&e photomicrographs of tuberculosis specimen and lch specimen of the patient. histiocytes (arrows) of tuberculosis (a) versus histiocytes (arrows) of langerhans cell histiocytosis in the specimen of the patient (b). table 1. similarities and differences between langerhans cell histiocytosis and tuberculosis noted in the case langerhans cell histiocytosis tuberculosis multisystem involvement appearance of symptoms histologic arrangement of cells appearance of histiocytes inflammatory infiltrates s-100 reactivity present sequential granuloma-like pattern atypical; large, ovoid mononuclear cells eosinophils positive present often simultaneous , may be sequential over time chronic granulomatous inflammation with caseation necrosis and langhans’ type giant cells epitheliod, spindle-shaped lymphocytes negative s-100 staining strengthened the diagnosis of lch in this case. both normal and diseased langerhans cells will stain positive for s-100. tuberculosis cells do not. the similarities and differences between langerhans cell histiocytosis and tuberculosis noted in this case are summarized in table 1. the initial misleading histopathologic diagnosis of tuberculosis of the cervical spine specimen allowed progression of the disease to involve the mandible and then the temporal bone. the patient’s poor follow-up record compounded this progression, adding to delays in diagnosis and treatment. transtemporal excision of the mass with blind sac closure of the external auditory canal was considered for the definitive philippine journal of otolaryngology-head and neck surgery vol. 23 no. 1 january – june 2008 case reports 24 philippine journal of otolaryngology-head and neck surgery acknowledgement the authors wish to thank the following individuals from the university of the philippines college of medicine philippine general hospital without whose help this paper would not have been possible: dr. jose maria avila, chairman, department of pathology who was our resource person for pathology; drs. joselito jamir and romeo villarta jr. former chairman and consultant, respectively of the department of otorhinolaryngology, who were our scientific advisors; dr. gerardo legaspi, consultant, department of neurosciences section of neurosurgery who was the co-managing neurosurgeon; and dr. sherjan kalim, resident of the department of pathology for assisting with the photomicrographs. references 1. jones ro, pillsburry hc. histiocytosis x of the head and neck. laryngoscope. 1984;94:10311035. 2. smith rj, evans jn. head and neck manifestations of histiocytosis x. laryngoscope, 1984;94:395399. 3. kilpatrick se, wenger de, gilchrist gs, shives tc, wollan pc, unni kk. langerhans’ cell histiocytosis (histiocytosis x) of bone: a clinicopathologic analysis of 263 pediatric and adult cases. cancer. 1995;76(12):2471-2484. 4. malpas js. langerhans cell histiocytosis in adults. hematol oncol clin north am. 1998;12(2): 159-165. 5. lorenzo pr, martinez nv. histiocytosis x: a pathologist’s challenge. philipp j otolaryngol head neck surg. 1992:140-145. 6. bertram c, madert j, eggers c. eosinophilic granuloma of the cervical spine. spine. 2002;1:27(13):1408-13. 7. avila jm. professor of pathology, university of the philippines college of medicine. (personal communication, march 2006). 8. davis se, rice dh. langerhans cell histiocytosis: current trends and the role of the head and neck surgeon. ear nose throat j. 2004 may:83(5):340-350. management of csf otorrhea in this case while, at the same time, obtaining a good specimen for biopsy. in retrospect, had a correct diagnosis been made at the time of cervical spine surgery, the resultant csf otorrhea could have been prevented. though initially managed by topical drops, the diagnosis of csf otorrhea and definite management with external ear canal blind sac closure was very important. the latter is most relevant in preventing the possible lifethreatening condition of meningitis. however, the contralateral temporal bone is likewise at risk. definitive treatment, in the form of chemotherapy consisting of low to moderate doses of methotrexate, prednisone, and vinblastine hopefully can save this patient from further lytic destruction of other bony sites.8 this option has been presented to the patient, as well as the possible side effects of chemotherapy, including hair loss and vomiting. the patient was not open to these particular side effects, thus refusing this therapeutic option. otorhinolaryngologists and head and neck surgeons should be well aware that isolated lesions in the bony framework of the head and neck should include langerhans cell histiocytosis in the differential diagnosis because, as in the case of the different diseases that have plagued mankind throughout the centuries, early detection is still the key to preventing disease progression with timely definitive management. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery captoons assistant professor william u. billones, md de la salle health sciences institute creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international doknet’s world philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery contents cover images editorial 4 truth and transparency, compromise and climate change lapeña jff guest editorial 6 cop27 climate change conference: urgent action needed for africa and the world atwoli l, erhabor ge, gbakima aa, haileamlak, a, kayembe ntumba jm, kigera j, laybourn-langton l, mash r, muhia j, mulaudzi fm, ofori-adjei d, okonofua f, rashidian a, el-adawy m, sidibé s, snouber a, tumwine j, yassien ms, yonga p, zakhama l, zielinski c original articles 8 hearing and clinical otologic profile of filipinos living in southern tagalog region iv-a (calabarzon), philippines: the southern tagalog ent hearing specialists (stents) survey 2012-2017 pardo pjm, niñal-vilog a, acuin jm, calaquian cme, onofretelan rdc 16 the complete and two-turn cochlear duct length among filipinos kasilag rma, aquino-diaz k 20 quality of life among sars-cov-2 (covid-19) positive patients with anosmia using the short version questionnaire of olfactory disorders negative statements translated in filipino (sqod-ns ph) mallari-bernarte a, cruz ets 26 quality of sleep among shift work nurses at the baguio general hospital: a pilot cross-sectional study andaya kes 30 initial outcomes of endoscopic co2 laser posterior cordectomy and partial arytenoidectomy among patients with bilateral vocal cord paralysis: a case series velasco kjs, de la cruz apc, carrillo rjd, madrid dad 34 a new extraoral closed reduction technique for temporomandibular joint dislocation: a preliminary case series sangalang mb, gansatao fm, dizon apje, onofre-telan rdc case reports 38 airway obstruction from intralaryngeal extension of thyroglossal duct cyst in an elderly man: a case report contreras gs, lingan mb 42 multifocal tuberculosis presenting as mandibular swelling in a 3-year-old boy: a case report yambot kkk, peñaflor nai surgical innovations and instrumentation 46 a makeshift blue light filter for endoscopic identification of traumatic cerebrospinal fluid leak using fluorescein edora bde, chua ru, estolano pjl featured grand rounds 50 hearing loss from s. suis meningitis in a middle-aged couple martinez nv, hosujima ms from the viewbox 53 can i diagnose a vestibular schwannoma using non-contrast imaging? yang nw under the microscope 55 intercalated duct adenoma of the parotid gland aquino jb, carnate jm letters to the editor 57 otitic hydrocephalus or obstructive hydrocephalus? yang nw 58 response from the authors plumo cgt, cruz ets captoons 60 doknet’s world billones wu “surhano in cubism” acrylic on canvas 18”x24” by joseph joel cristobal contrast ct scan (saggital view) showing mass (asterisk), with peripheral rim enhancement and fenestra of tracheostomy tube outside the tracheal lumen (arrow). by gerson s. contreras, md histopathologic slide showing well-circumscribed, encapsulated proliferation of closely packed tubular ducts adjacent to non-neoplastic lobules of parotid serous acini and fat cells (h&e, 40x). by jose m. carnate, jr., md “bountiful catch” 5d mark 3 17-40mm l iso 100 by rene louie gutierrez, md “girl with flowers in her hair” 10” x 14” oil on canvass by camille espina, md truth and transparency, compromise and climate change cop27 climate change conference: urgent action needed for africa and the world hearing and clinical otologic profile of filipinos living in southern tagalog region iv-a (calabarzon), philippines: the southern tagalog ent hearing specialists (stents) survey 2012-2017 the complete and two-turn cochlear duct length among filipinos quality of life among sars-cov-2 (covid-19) positive patients with anosmia using the short version questionnaire of olfactory disorders negative statements translated in filipino (sqod-ns ph) quality of sleep among shift work nurses at the baguio general hospital: a pilot cross-sectional study initial outcomes of endoscopic co2 laser posterior cordectomy and partial arytenoidectomy among patients with bilateral vocal cord paralysis: a case series a new extraoral closed reduction technique for temporomandibular joint dislocation: a preliminary case series airway obstruction from intralaryngeal extension of thyroglossal duct cyst in an elderly man: a case report multifocal tuberculosis presenting as mandibular swelling in a 3-year-old boy: a case report a makeshift blue light filter for endoscopic identification of traumatic cerebrospinal fluid leak using fluorescein hearing loss from s. suis meningitis in a middle-aged couple can i diagnose a vestibular schwannoma using non-contrast imaging? intercalated duct adenoma of the parotid gland otitic hydrocephalus or obstructive hydrocephalus? response from the authors doknet’s world philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2019; 34 (1): 14-19 c philippine society of otolaryngology – head and neck surgery, inc. levothyroxine versus levothyroxine with iodine in reduction of thyroid nodule volume: a double-blind randomized controlled trial donnie jan d. segocio, md joseph e. cachuela, md department of otorhinolaryngology head and neck surgery southern philippines medical center correspondence: dr. donnie jan d. segocio department of otorhinolaryngology head and neck surgery southern philippines medical center davao city 8000 philippines phone: (082) 227-2731 local 353 fax: (082) 221-7029 (h), 225-3414 (c) email: dmc_ent@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery, analytical research contest, november 9, 2017, menarini office, bonifacio high street, taguig city. interim analysis presented at the spmc annual residents’ analytical research poster contest december 2016 (3rd place, best poster, best presentor), mahogany hall, jica building southern philippines medical center. abstract objective: to compare levothyroxine alone and in combination with iodine on thyroid nodule volume reduction. methods: design: double-blind randomized controlled trial setting: tertiary government hospital participants: nineteen (19) euthyroid patients age 19 -54 with at least 1 cytologically benign thyroid nodule were randomized to receive either levothyroxine + iodine or levothyroxine + placebo, taken once a day for 6 months with ultrasound and thyroid stimulating hormone monitoring on the 3rd and 6th month of intervention. results: main outcome measures included thyroid nodule volume reduction after six months of intervention. the mean change in volume from baseline to six months of levothyroxine + iodine group showed no statistically significant difference in nodule volume across time between levothyroxine + placebo group, -0.010 ± 1.250 (ci -0.521 0.501) versus 0.507 ± 1.128 (ci 0.025 0.990), p=.158. there were also new nodules (4 nodules) in the placebo group and none in the iodine group. no major adverse events were noted during the study. conclusion: the two groups did not significantly differ in terms of nodule volume reduction. keywords: thyroid nodule, prevention and control; drug therapy; iodine compounds, therapeutic use; levothyroxine, therapeutic use thyroid nodules are among the most common endocrine disorders. in the general population, the incidence of clinically apparent thyroid nodule is 4 to 75% although autopsy studies reveal a higher percentage of about 50% with thyroid nodularity.1 the rates may be even higher in endemic goiter areas or those with iodine deficiency areas.2 in the philippines, 6.6/100,000 of the general population have a thyroid mass with female predominance of 9.8/100,000 compared to males 3.1/100,000.3 despite being common worldwide, there is still no consensus with regards to the management of thyroid nodules. several clinical trials have creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery original articles demonstrated the efficacy of levothyroxine suppression therapy in shrinking nodules.4,5,6 however, there are also studies which showed contradicting results7,8 thus making the appropriate course of action controversial. results could be affected by several factors such as the degree of suppression and the individual’s iodine supply status. thus, one study recommended combining thyroid hormone suppression therapy with iodine therapy on the premise that iodine plays an important role in the pathogenesis of thyroid nodules.4 despite government efforts in iodine food fortification to reduce iodine deficiency in the philippines, certain areas of the country remain iodine deficient. among these areas is the davao region where children six to twelve years old still have mild iodine-deficiency disease.9 data regarding the use of iodine for thyroid nodules especially in combination with levothyroxine is lacking in the philippines and even in asian countries. the use of iodine alone or in combination with levothyroxine is not even part of the treatment options recommended in our local guidelines for thyroid nodule management.10 the study by grussendorf4 comparing levothyroxine with and without iodine showed reduction in the size of nodules in nodular non-toxic goiter. validating foreign recommendations against local data is an important step in ensuring the best clinical practices for important diseases. to the best of our knowledge, there has been no placebo-controlled trial using levothyroxine with iodine therapy for nodular goiters in our locality, which is known to be mildly iodine deficient. we aim to replicate the study of grussendorf4 by comparing levothyroxine alone and in combination with iodine on thyroid nodule volume reduction. methods research design this was a double-blind, randomized, placebo-controlled trial conducted in the ear, nose, throat – head and neck surgery (enthns) outpatient department of the southern philippines medical center (spmc) from april 2016 to december 2016 with approval of the department of health (doh) region xi cluster ethics review committee. participants adults aged 18 to 60 years old, euthyroid, with at least one thyroid nodule in a normal-sized or enlarged thyroid were considered for inclusion. the nodules had to be histopathologically benign on fineneedle aspiration biopsy (fnab) and not more than 3ml in volume. excluded were patients with prior thyroid stimulating hormone (tsh) suppression therapy within the last six (6) months, purely cystic nodules, those with contraindications to iodine, those with previous figure 1. screening, randomization and follow-up of participants use of iodine-containing medications within the last 6 weeks, or who underwent radioactive iodine/surgery, and patients with acute illness and co-morbidities. figure 1 outlines the screening, randomization and follow up of participants. randomization and interventions after obtaining informed consent from participants, we gathered baseline demographic and clinical data including age, sex, family history of goiter, thyroid nodule volume, thyroid gland volume and tsh value. a randomization list was prepared and given to a nurse assistant who assigned the treatment for groups a and b and prepared treatments according to the randomization list. placebo pills were identical in appearance to iodine pills. patients were randomly assigned to either one of the following treatment arms: treatment group a: (lt4) levothyroxine + (p) placebo treatment group b: (lt4) levothyroxine + (i) iodine philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery original articles the nurse also dispensed the treatment drugs. the investigators and participants were blinded to treatment arms. randomization codes were secured until analysis of all data was completed. tsh suppressive dosage was computed using the participant’s weight x 2.1-2.4, depending on the degree of suppression. levothyroxine (lt4) doses were adjusted for a tsh target range of <0.1mu/l. four visits were performed: screening (v1), randomization (v2), and two follow-up visits under therapy after 3 (v3) and 6 months (v4). at v1, v3 and v4, sonography was performed by a blinded radiology consultant who was an ultrasound specialist, using arietta u70 hitachi with a 7.5or 10mhz transducer (himex corporation, japan). the same blinded sonologist measured the thyroid size and thyroid nodule volume all throughout the study period. tsh was measured at v1, v3, and v4 in a central laboratory under regular external quality control. at each follow-up, a pill diary and any unused medications were collected and counted to estimate patient compliance. data was tabulated using a predesigned, pretested form. independent variables included demographic factors such as age, sex, family history of thyroid disease and the assigned treatment group. the main outcome measure was the volume reduction of nodules measured by ultrasound. resolution was defined as complete disappearance of previously described nodule for the duration of the study. significant nodule volume reduction was defined as reduction of at least 20% of nodule volume from the baseline for the duration of the study. furthermore, the different side effects encountered while taking the drug were reported. statistical analysis main outcome include mean change in thyroid nodule volume from baseline to 6 months. continuous data such as age, tsh values, thyroid nodule volume, thyroid gland volume at baseline, 3 months and 6 months were summarized as means ± standard deviations. comparison of means between the 2 treatment groups were performed using paired t-test. categorical data such as sex, number of nodules, family history and percentage of decrease in nodule volume at end of 6 months were summarized using frequencies and percentages, and comparison of proportions between the 2 treatment groups was performed using chi-square test or fisher exact test. a two-tailed p-value of < .05 was considered statistically significant. all statistical tests were done using epi info 7.1.4.0 (cdc, atlanta, ga, usa). missing continuous data were filled in by last-observation-carried-forward method. results patient characteristics a total of 47 patients were screened but only 19 patients, aged 19-54 years old (44 nodules) were included in the study. a total of 28 patients were excluded following exclusion criteria. the 19 patients recruited into the trial were randomized either to the levothyroxine + placebo group (n of patients=9; n of thyroid nodules=21) or to the levothyroxine with iodine group (n of patients=10; n of thyroid nodule=23). there were 4 dropouts from the levothyroxine alone group for the duration of the study comprising 3 patients with data up to 3 months only and 1 patient who was lost to follow-up on the 3rd month. there was also one patient from the levothyroxine with iodine group who failed to have repeat ultrasound on the 6th month and was lost to follow-up. four patients belonging to the levothyroxine with iodine group and 3 patients belonging to the levothyroxine alone group were noted to be poorly compliant with the intervention. of the adverse effects, only palpitations were reported by 16% (3 out of 19) of participants, 1 from the levothyroxine alone group and 2 from the levothyroxine with iodine group. baseline characteristics of the 19 patients are shown in table 1. there was no significant difference in baseline characteristics between the two groups except for age (p=.018). a total of 44 nodules were observed during the study. there were 23 nodules examined from the lt4 + iodine group (n of patients=10) with a mean volume of 0.89 ± 0.95 ml and 21 nodules in the lt4 + placebo group (n of patients=9) with a mean volume of 0.89 ± 0.88 ml (p=.988). patient follow up on the third month, one patient (having one nodule) from the levothyroxine + placebo group was lost to follow up. by the sixth month post-intervention, a total of three patients (having 11 nodules) from the levothyroxine + placebo group were lost to follow up. hence, perprotocol analysis of the outcome measures only included 5 patients (9 nodules) from the levothyroxine + placebo group. no drop-outs were seen on the levothyroxine + iodine group. thyroid nodule volume the mean change in volume from baseline to six months of levothyroxine + iodine group showed a trend of decreasing size of the nodule as compared to levothyroxine + placebo group, -0.010 ± 1.250 (ci -0.521 0.501) versus 0.507 ± 1.128 (ci 0.025 0.990), however this was not statistically significant (p=.158). (table 2) philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery original articles thyroid gland volume a trend of decreasing thyroid gland volume from baseline to six months was also seen in the levothyroxine + iodine group as compared to the levothyroxine + placebo group, -1.291 ± 4.874 (ci -3.427 0.845) versus 1.467 ± 4.059 (ci -0.408 3.342) and but this was not significant (p=.068). (table 2) tsh suppression tsh suppression from baseline to six months when comparing both groups, was well suppressed in the levothyroxine + placebo group with mean change in tsh of -0.937 ± 0.812 and a confidence interval of -1.467 to -0.406 (p-value for change .007*) and -0.256 ± 0.733 for the levothyroxine + iodine group (ci -0.711 0.199). however, this was not statistically significant. (p=.072). (table 2) greater than 20% reduction greater than 20% nodule volume reduction was noted in 10/21 (47.6%) nodules for the levothyroxine + iodine group as compared to 7/21 (33.33%) for the levothyroxine + placebo group, (granting all dropouts had the outcome), with 4/48 (8.33%) without any change in volume. however, this was not statistically significant (chi-square value of 1.96, df = 2, p = .375). (table 3) resolution resolution was noted in five out of twenty-three (21.74%) nodules from the levothyroxine + iodine group as compared to 13/21 (61.90%) from the levothyroxine + placebo group, granting all dropouts had the outcome. this is statistically significant with p-value of .007*. however, this was not the same with per protocol analysis excluding the dropouts, where only 1/9 (11.11%) nodules showed resolution with p-value of .648** (chi-square 7.3259), which was not statistically significant when both groups were compared. adverse effects twenty percent (2/10) of patients in the iodine group complained of palpitations in the first month of intervention, compared to 11% (1/9) of patients from the placebo group. this patient complaint led to dose adjustment of levothyroxine that could be well tolerated. for patients who could not tolerate suppressive doses without experiencing palpitations, doses were tapered as tolerated. no other adverse effects were observed in both groups. new nodule formation it was worth noting that for the duration of six months of treatment for both groups, 4 new nodules were found in 2 patients (1 nodule table 1. demographic and clinical profile of patients at the beginning of the trial *significantly different at <0.05 **fisher exact test philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery original articles table 2. effect of the different treatment groups versus placebo on the nodule volume, thyroid volume and thyroid function at 6th month *significantly different at <0.05 **fisher exact test # intention-to-treat analysis – all dropouts has the outcome table 3. distribution of percent change in thyroid nodule volume between the two treatments chi square 1.96, df=2 p = .375 philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery original articles acknowledgements we would like to extend our deepest gratitude to dr. alvin s concha for his guidance in the completion of this research. we would also like to thank the southern philippines medical center as well as the southern mindanao chapter of the philippine society of otolaryngology head and neck surgery (pso-hns) for their support in this study. references 1. singer pa. evaluation and management of the solitary thyroid nodule. otolaryngol clin north am. 1996;29(4):557-91. 2. larijani b, pajouhi m, bastanhagh mh, sadjadi a, aghakhani s, zare f, et. al. role of levothyroxine suppressive therapy for benign cold nodules of thyroid: a randomized, double-blind, placebocontrolled clinical trial. therapy. 2005. 2(6): 883-888. doi: 10.1586/14750708.2.6.883 3. caro rm, jose em, llanes egdv, arquiza cjs, calaquian cme, claridad jrv, et al. up-pgh department of otorhinolaryngology clinical practice guidelines thyroid nodules. 2003. caliraya laguna: philippine general hospital. 30-39. 4. grussendorf m, reiners c, paschke r, wegscheider k. reduction of thyroid nodule volume by levothyroxine and iodine alone and in combination: a randomized, placebo-controlled trial. j clin endocrinol metab. 2011 sep; 96(9):2786–2795. doi: 10.1210/jc.2011-0356; pmid: 21715542 pmcid: pmc3206705. 6. wémeau jl, caron p,  schvartz c,  schlienger jl, orgiazzi j, cousty c, et al. effects of thyroidstimulating hormone suppression with levothyroxine in reducing the volume of solitary thyroid nodules and improving extranodular nonpalpable changes: a randomized, double-blind, placebo-controlled trial by the french thyroid research group. j clin endocrinol metab. 2002 nov; 87(11):4928–4934. doi: 10.1210/jc.2002-020365; pmid: 12414852. 7. bayani m, amani m, moazezi z. efficacy of levothyroxine on benign thyroid nodule. caspian j intern med. 2012;3(1):359-362. 8. reverter jl, lucas a, salinas i, audí l, foz m, sanmartí a. suppressive therapy with levothyroxine for solitary thyroid nodules. clin endocrinol (oxf ). 1992 jan;36(1):25-8. 9. perlas l, capanzana m. careful quantitative monitoring of salt iodine levels in the philippines is critical to ensure adequate iodine intake. idd newsletter. fnri-dost: manila. 2011. 10. lopez fl, ampil ide, aquino mld, de los santos nc, castañeda ss, claridad jrv, et al. the pcspsgs-pahnsi evidence-based clinical practice guidelines on thyroid nodules. philipp j surg spec. 2008 jul-sep; 63(3): 91-125. 11. uy jd, mercado-asis lb. prevention of recurrence of diffuse and nodular nontoxic goiter with lifetime physiologic levothyroxine maintenance.  philipp j intern med. 2009. 47:207-210. 12. koc m, ersoz ho,  akpinar i,  gogas-yavuz d,  deyneli o,  akalin s. effect of lowand high-dose levothyroxine on thyroid nodule volume: a crossover placebo-controlled trial. clin endocrinol (oxf ). 2002 nov; 57(5):621-8. pmid: 12390336. in 1 patient and 3 nodules on another patient) belonging to the levothyroxine + placebo group. discussion we did this study in order to find out whether the addition of iodine to levothyroxine in the management of benign thyroid nodules for the duration of six months would have better results compared to levothyroxine alone. there were no statistically and clinically significant differences between those given levothyroxine and levothyroxine with iodine for 6 months, in terms of 20% nodule volume reduction, glandular volume and occurrence of palpitations. four new nodules were also noted in the placebo group with none in the iodine group. the effectiveness of levothyroxine given in suppressive doses in reducing the size of thyroid nodules remains controversial. many studies have conflicting results.4 the addition of iodine in the treatment of thyroid nodules and its effectiveness remains unclear, as we have not found sound recommendations for doing so. a similar (but multicenter) study in germany with 12 months follow-up of more than 1024 patients comparing levothyroxine with or without iodine provided promising results even in iodine sufficient areas, showing reduction in nodule volume, however minimal.4 when compared after six months of intervention, there was a significant difference favoring the iodine group over the placebo group in terms of thyroid nodule volume reduction.4 after 6 months of intervention, a trend was also noted for levothyroxine with placebo, with nodule volume and gland volume showing increase in size and appearance of new nodules despite tsh suppression, in contrast to the levothyroxine with iodine group, which showed decrease in size of nodule volume and thyroid gland volume with adequate tsh suppression. our study only employed a 6-month follow-up of patients with limited sample size for each arm. hence, the variability in the outcomes measured. in another study, the possibility of prevention of new nodule formation is suggested by the levothyroxine + iodine group results as new nodule formation was not prevented in the placebo group11 similar to our study findings. the tsh was not adequately suppressed in 6 patients (2 from the placebo group and 4 from the iodine group) because of poor compliance and palpitations requiring dose adjustment. however, most of these patients showed increasing nodule size after 6 months of intervention in contrast to the findings by koc et al. in 2002, that low or high-dose levothyroxine was equally effective in reducing thyroid nodule volume, recommending the use of low-dose therapy to reduce thyroid nodule size.12 our study has several limitations. we presented data for 6-months duration of intervention. we were unable to demonstrate statistical significance in comparing both groups especially in terms of thyroid nodule volume reduction. this is probably related to the limited power of the study to generate inferences from only those patients who were able to return for follow up assessment. we had 4 drop outs during the study, and 7 patients were poorly compliant. the study population was adequate at the start of the study and up to 3 months only, especially for the levothyroxine + placebo group. we were also unable to recruit any male patients for the study. we recommend multicenter trials involving more patients, a longer duration of intervention extended to 1 year with better treatment compliance, and monthly follow-up to adjust dosage to attain suppressive doses of levothyroxine. other parameters like measurement of iodine excretion in the urine to establish degree of iodine deficiency, measurement of thyroglobulin level at baseline and its decrease as a useful predictor of outcome in levothyroxine therapy may be included. we further recommend that nodule volume reduction be studied using suppressive and non-suppressive doses of levothyroxine. in conclusion, in this randomized controlled trial, there were no significant differences between levothyroxine alone versus levothyroxine with iodine; the two groups did not significantly differ in terms of thyroid nodule volume reduction. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to compare actual tracheostomy tube sizes with estimated endotracheal tube sizes using age-related formula and tracheal diameter from preoperative radiographs among pediatric filipino patients aged 0-18 years old undergoing tracheostomy. methods: design: review of records setting: tertiary private university hospital in dasmarinas, cavite, philippines patients: pediatric patients regardless of gender, aged 0 to 18 years old with a preoperative radiograph of the tracheal and who subsequently underwent tracheostomy anytime from january 1, 2007 to december 31, 2016 were considered for inclusion. radiographs were measured, endotracheal tube sizes were computed using age-related formula and recorded tracheotomy tube sizes were retrieved. results: twenty-two patients (12 males, 10 females) aged 10 months to 18-years-old (median age: 11 years) were included in the study. mean tube sizes were 6.46mm (+/1.492 sd) for agerelated formula, 5.67mm (+/1.1849 sd) for radiograph-based estimation and 5.0 for actual tracheostomy tube inserted in each patient. the bland-altman plot showed the bias estimate at 0.7913 and the lower and upper limits of agreement at -1.3598 and 2.9423 (confidence level 95% or 2 standard deviations away from the mean). conclusion: the average value derived from radiograph-based estimation is less than the corresponding average value from age-related formula. there is a significant difference between age-related formula-based estimation and actual tracheostomy tube inserted. since the range of differences between the two estimation methods is high, these results imply that the bias or the difference between measures from the two methods is not consistent with the two methods exhibiting very poor agreement. keywords: tracheostomy, intubation, intra tracheal, penlington formula, trachea radiograph measurement, age related formula for endotracheal tube estimation tracheal diameter estimates using age-related formula versus radiographic findings: which approximates the actual tracheostomy tube in pediatric patients? isaac cesar s. de guzman, md department of otorhinolaryngology head and neck surgery de la salle university medical center correspondence: dr. isaac cesar s. de guzman department of otorhinolaryngology head and neck surgery de la salle university medical center congressional avenue, dasmarinas city, cavite 4114 philippines phone: (046) 416-0226 local 1340 email: ayceedg@gmail.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part in in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual, passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery, analytical research contest, november 9, 2017, menarini office, bonifacio high street, taguig city. philipp j otolaryngol head neck surg 2018; 33 (2): 32-36 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles tracheostomy is a commonly performed surgical procedure to manage the airway. choosing the correctly sized tracheostomy tube is vital since failing to predict a suitable tube size may cause potentially devastating complications. this concern is even more critical in children due to the smaller caliber of the pediatric airway and the potentially lifelong impact of airway injury. there are very limited studies published on techniques used for estimation of tracheostomy tube size and methods for matching airway tube size to tracheal diameter are limited.1 anesthesiologists sometimes use the size of the fifth digit.2 others use several formulas, the most common being (16 + age)/4 or variations thereof2 to predict the internal diameter of the tube and the corresponding tube size. this age-based formula is not always reliable because of differences in children’s physical development.3 park et al. used an airway radiographbased formula to predict the appropriate endotracheal tube size in children aged 3 to 6 years old, measuring the diameter of the tracheal airway column using a routine chest ap radiograph.4 to the best of our knowledge based on a search of pubmed (medline), herdin and google scholar, there is no published study to date that compares the results obtained from the age-related formula with those from airway radiographs in terms of selecting the correct tracheostomy tube size. thus, the aim of this study is to compare actual tracheostomy tube sizes with estimated endotracheal tube sizes using age-related formula and tracheal diameter from preoperative radiographs among pediatric filipino patients undergoing tracheostomy. methods study design with approval of the institutional independent ethics committee, this study reviewed patient records at the de la salle university medical center in collaboration with the departments of ear, nose, throat head and neck surgery (ent-hns), anesthesia, radiology, and medical records. participants using the who definition of children, pediatric patients regardless of gender, aged 0 to 18 years old who underwent tracheostomy between january 1, 2007 and december 31, 2016 and had a preoperative radiograph of the trachea were considered for inclusion in the study. exclusion criteria included conditions which may affect normal tracheal size like tracheal tumors, mediastinal tumors, congenital airway anomalies and those with poor quality radiographs. a list of all pediatric patients who underwent tracheostomy was obtained from the operating room complex records. the availability of operative notes and chest x ray results in the medical records of these patients were then ascertained by chart review starting in december 2016 and sequentially going back in time. a sample size of 22 patients was calculated to detect an effect size of 0.65 with a 95% confidence level and power of 80%. standard deviation of the difference was set at +/-1.0.3 patients were included until the required sample size was reached. preoperative radiographs were then retrieved from the hospital radiology picture archive system. the informed consents signed by the parents cover use of patient information for research. data collection procedure a data abstraction form was developed based on study objectives. information was abstracted from the medical charts. age based estimation of tracheostomy tube size used the penlington formula for estimating endotracheal tube size wherein internal diameter, id = (16 + age)/4. radiographic estimates of the tracheal diameter of the subjects was estimated by a single radiology resident using the preoperative chest radiograph by measuring the transverse width of the trachea between 3rd and 4th tracheal ring in millimeters on the ap hospital radiology picture archive system. this measurement corresponds to the outer diameter of the tracheostomy tube. the radiologist was blinded to the records of the actual tube size and the results of the penlington formula. data analysis data was encoded in microsoft excel v. 16.15 (180709) (microsoft corp., redmond, wa, usa) and analyzed using sas for windows v 6.0 (sas instiute inc., cary, north carolina, usa). measures of central tendency and dispersion were used to summarize continuous variables including age, weight, height and tracheostomy tube measurements including age-related estimation, preoperative radiograph and actual size of tracheostomy tube used. frequency tables and percentage distributions were used to summarize age group and gender of subjects. shapiro-wilk test was used to determine normality of data. wilcoxon-signed rank test was used to test any significant difference in tracheostomy tube size between age-related formula and methods of penlington formula results. the mean difference of the 2 methods of estimation was computed with a 95% confidence interval. a blandaltman plot was used to describe the differences between internal diameters computed using the penlington formula and internal diameters corresponding to measurements obtained from the chest radiographs. a p-value less than .05 was considered statistically significant. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery original articles results in total, 23 patients were considered upon reviewing records from january 2007 to december 2016; one patient was excluded because of unavailable x-ray image. table 1 below shows that among the 22 patients, 12 were males and 10 females. ages ranged from 10 months to 18 years (median 11 years). sizes. in contrast, pearson’s test on radiograph-based estimation vs. actual tracheostomy tube sizes yielded a coefficient of correlation of 0.511(p-value <.0151, r2 26.10%). figure 1 which correlates the two estimates shows that radiography-based estimates are significantly lower than the corresponding age-related formula-based estimates (p = .0028). variables mean std. dev. median min max age (yrs.) weight (kg) age-related formula estimate (mm) radiography-based estimate (mm) actual tt tube size (mm) 9.86 30.21 6.46 5.67 5.01 5.97 16.57 1.49 1.19 1.21 11 30 6.75 5.25 5.0 0 8.0 4.21 3.5 3.0 18 60 8.5 8.9 6.4 table 1. frequency distributions and summary statistics wilcoxon signed-rank test test statistic p-value age-related formula estimates vs radiograph-based estimates actual tracheostomy tube sizes vs age-related formula estimates actual tracheostomy tube sizes vs d radiography-based estimates 2.763 4.015 -2.446 .0057 .0001 .0143 table 2. comparing means between age-related formula estimates, radiography-based estimates and actual tracheostomy tube sizes as observed, the diameters of tracheostomy tubes used among these patients ranged from 3mm to 6.4mm with an average diameter of 5.01 (sd, 1.21). the average actual tracheostomy tube sizes were less than the average estimates derived from the two methods. also, the minimum and the maximum values from actual tracheostomy tube sizes were less than the minimum and maximum estimates being observed from the two methods of estimation. estimates derived from the age-related formula ranged from 4.20 mm to 8.50 mm with an average diameter of 6.46 mm (sd, 1.49). on the other hand, estimates based on radiography ranged from 3.5 mm to 8.9 mm with an average diameter of 5.67 mm (sd, 1.18). table 2 shows that there were indeed significant differences between estimates as well as between each estimate and tracheotomy tube size actually used. pearson’s tests for correlation yielded a coefficient of correlation of 0.838 (p-value <.0001) and a coefficient of determinations (r2) of 70.29% between age-related formula estimates and actual tracheostomy tube figure 1. identity line plot for age related formula versus radiograph-based estimation. note numerous data points below the identity line implying that radiograph-based estimation exhibits a significant negative bias compared to age-related formula-based estimation (p = .0028) figure 2. bland-altman plot for age-related formula versus radiograph-based estimation solid green line, trend line of data points; blue dashed line, mean difference; red dotted lines, standard deviation or limits of agreement; green circles, data points of patients. figure 2 shows that the differences between age-based and radiograph-based estimates increased as the means of these two estimates increased. this supports the previous finding that tracheotomy tube size was more strongly correlated with age-based identity line plot age-related formula estimation versus radiography-based estimation r ad io gr ap hy -b as ed e st im at es 3 4 5 6 7 8 9 age-related formula-based estimates 3 4 5 6 7 8 9 r ad io gr ap hy -b as ed e st im at e f or m ul aba se d es tim at e m in us (age-related formula versus radiography estimation) mean of formula-based estimate and radiography-based estimate bland-altman plot 4 3 2 1 0 -1 -2 -3 4 5 6 7 8 9 -1.4 -1.96 sd 0.8 2.9 mean +1.96 sd philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery original articles estimates than with radiograph-based estimates and that radiographbased estimates are lower than age based estimates. note that the bias estimate is 0.7913, with a 95% confidence interval of 0.3046 to 1.2779. discussion our study found that there is a significant difference between age-related formula-based estimation and actual tracheostomy tube inserted, as well as between age-related formula and radiographbased estimation. the average value derived from radiograph-based estimation is less than the corresponding average value from agerelated formula. this difference is also clinically important since the estimates differ one tracheostomy tube size bigger than the actual tube size used. the difference in the means of the radiograph-based formula and age-related formula may be due to the small sample size used in this study, making variances in patient characteristics more significant. the difference in the mean of the size estimates for the age-related formula and radiograph-based estimation (0.79mm) is statistically significant and clinically important as well since the increment of internal diameters between sizes of tracheostomy tubes is only 0.5mm. the results support the findings of park et al. comparing radiographbased formula and age-related formula in estimating endotracheal tube size. the study involved a larger sample size and observed that there is a smaller difference between the actual tube size inserted and radiograph-based estimation than the difference between actual tube size inserted and age-related formula-based estimation.4 the correlation analysis indicates there are indeed significant differences between the measurements derived from age-related formula estimation and radiograph-based estimation. the agerelated formula estimates exhibit stronger correlation with the actual tracheostomy tube sizes. also, age-related formula estimation provides higher predictive capability against radiograph-based estimation in explaining the variability present among actual tracheostomy tube sizes. these findings are expected since the age-related formula estimation method is already being practiced in our institution compared to the proposed estimation method based on radiography. however, it cannot be concluded yet at this stage whether radiograph-based estimation can be used as an alternative estimation procedure in predicting actual tracheostomy tube sizes. the sizes may differ significantly but the difference can be considered important if it is constant and has a pattern. the identity line plot allows us to quickly see if there is a fixed bias or not by directly comparing the radiograph-based estimation to the age-related formula-based estimation. since the data points are widely scattered away from the identity line, this makes the radiographbased estimation not a relevant substitute for the age-based formula. almost all of the data points lie below the identity line. this implies that radiograph-based estimation exhibits a negative bias compared to the age-related formula-based estimation. that is, it is expected that radiograph-based estimation will constantly yield smaller estimates compared to age-related formula estimation. adding a constant value could probably address this bias that will then make radiograph measurements a possible alternative to the age-based formula. further research especially with a larger sample size may allow the formulation of an equation for computing the proper tracheostomy tube size using the tracheal diameter measured from the radiograph. as observed in the bland altman analysis, the points are widely scattered within the limits of agreement and unfortunately, there are two points lying outside the limits of agreement. since the range of differences between the radiograph-based and age-related formula methods is rather high, these results imply that the bias or the difference between measures from the two methods is not consistent. these results suggest that radiograph-based estimation exhibits very poor agreement with age-related formula estimation suggesting that they cannot be used interchangeably. there are no standard formulas for determining proper tracheostomy or endotracheal tube size. due to limitations, chest x-ray images are frequently used to measure the transverse tracheal width. the measurement of transverse tracheal width is usually performed using non-invasive methods such as chest x-ray, ct5 mri6, or ultrasonography.7 however, high-quality laryngeal images provided by ct and mri are not routinely obtained and the quality of ultrasonography is operator dependent.6 furthermore, in adults, neither height nor weight predicts transverse tracheal width.8,9 different algorithms and formulae have been proposed to choose the best-fitting size of the tracheal tube. the most widely accepted is the age-based formula wherein the inner diameter in mm = (16 + age)/4. this calculation overestimates the correct size in more than one in four cases.10 the age-based formula is reliable and easily applied and accepted for routine anesthesia in the pediatric population.11 however, the age-related formula considers only the patients age with no regard for the actual size of the patient. on the other hand, the radiographbased formula measures the trachea of the patient directly. smaller tracheostomy tubes inserted can also be attributed to the physician’s personal choice such as surgical convenience. also, inserting a tube too large for the lumen may compromise mucosal vascular supply resulting in ischemia and necrosis along the lining of the trachea. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery original articles acknowledgements i would like to acknowledge dr. jose lito acuin, the department research coordinator and dr. patrick pardo, the department resident training officer, for providing assistance in writing this article. they served as my scientific advisor and critically reviewed the study proposal. i would also like to thank the radiology resident who helped with the data collection for the measurements of the radiographs, dr. gale malbas. also, i would like to acknowledge prof. danaida b. marcelo for providing help with the statistical analysis of the results. references 1. behl s, watt jw. prediction of tracheostomy tube size for paediatric long term ventilation: an audit of children with spinal cord injury. br j anesth. 2005 jan; 94(1):88-91. doi: 10.1093/bja/ aeh296; pmid: 15486000. 2. barash pg. clinical anesthesia. 7th ed. philadelphia: lippincott williams & wilkins, a wolters kluwer business. 2013. chapter 42. p. 1237. nlm id: 101598359. 3. park hp. appropriate tube size selection based on radiological images. korean j anesthesiol. 2014 mar; 66(3): 181–182. doi: 10.4097/kjae.2014.66.3.181; pmid: 24729837 pmcid: pmc3983411. 4. park hp, hwang jw, lee jh, nahm fs, park sh, oh ay, et al. predicting the appropriate uncuffed endotracheal tube size for children: a radiograph-based formula versus two age-based formulas. j clin anesth. 2013 aug; 25(5):384–387. doi: 10.1016/j.jclinane.2013.01.015; pmid: 23965215. 5. chen sj, shih tt, liu kl, chiu is, wu mh, chen hy, et al. measurement of tracheal size in children with congenital heart disease by computed tomography. ann thorac surg. 2004 apr; 77(4): 1216–1221. doi: 10.1016/j.athoracsur.2003.08.002; pmid: 15063238. 6. lakhal k, delplace x, cottier jp, tranquart f, sauvagnac x, mercier c, et al. the feasibility of ultrasound to assess subglottic diameter. anesth analg. 2007 mar; 104(3): 611–614. doi: 10.1213/01.ane.0000260136.53694.fe; pmid: 17312218. 7. carp h, bundy a. a preliminary study of the ultrasound examination of the vocal cords and larynx. anesth analg. 1992 oct; 75(4): 639–640. pmid: 1530186. 8. seymour ah, prakash n. a cadaver study to measure the adult glottis and subglottis: defining a problem associated with the use of double-lumen tubes. j cardiothorac vasc anesth. 2002 apr; 16(2): 196–198. pmid: 11957170. 9. randestad a, lindholm ce, fabian p. dimensions of the cricoid cartilage and the trachea. laryngoscope. 2000 nov; 110(11): 1957–1961. doi: 10.1097/00005537-200011000-00036; pmid: 11081618. 10. mostafa sm. variation in subglottic size in children. proc r soc med. 1976 nov; 69(11):793-95. pmid: 1005455 pmcid: pmc1864717. 11. turkistani a, abdullah km, delvi b, al-mazroua ka. the ‘best fit’ endotracheal tube in children – comparison of four formulae. middle east j anaesthesiol. 2009 oct; 20 (3): 383-7. pmid: 19950731. koha bv, jeon is, andre jm, mackay i, smith rm. postintubation croup in children. anesth analg 1977 jul-aug; 56(4):501-5. pmid: 560135. 12. lee kw, templeton jj, dougal rm. tracheal tube size and postintubation croup in children. anesthes. 1980; 53:325. 13. magill iw. technique in endotracheal anaesthesia. br med j. 1930 nov 15; 2(3645): 817–9. pmid: 20775829 pmcid: pmc2451624. 14. mir f, sandhu g, poncia j. size matters: choosing the right tracheal tube. the association of anaesthetists of great britain and ireland. anaesthesia. 2012 dec; 67(12): 1402-1403. doi: 10.1111/anae.12026. 15. brown es. resistance factors in pediatric endotracheal tubes and connectors. anesth analg. 1971 may-jun; 50(3):355-60. pmid: 5103767. 16. divatia jv, bhowmick k. complications of endotracheal intubation and other airway management procedures. indian j anaesth. 2005; 49 (4): 308 -318. 17. shih mh, chung cy, su bc, hung ct, wong sy, wong tk. accuracy of a new body length-based formula for predicting tracheal tube size in chinese children. chang gung med j. 2008 may-jun; 31(3): 276-80. pmid: 18782950. 18. karsli ch, isaac la, roy wl. induction of anesthesia. in: bissonnette b, dalens bj (editors). pediatric anaesthesia principles and practice (edition 1) 2002. new york, ny, mcgraw-hill. pp. 483-527. 19. litman rs, keon tp. postintubation croup in children. anesthesiology. 1991 dec; 75(6):1122-3. pmid: 1741506. 20. finholt da, henry db, raphaely rc. factors affecting leak around tracheal tubes in children. can anaesth soc j. 1985 jul; 32(4): 326–329. pmid: 4027762. 21. schwartz re, stayer sa, pasquariello ca. tracheal tube leak test—is there inter-observer agreement? can j anaesth, 1993 nov; 40(11): 1049–1052. doi: 10.1007/bf03009476; pmid: 8269566. 22. takita k, morimoto y, okamura a, kemmotsu o. do age-based formulae predict the appropriate endotracheal tube sizes in japanese children? j anaesth. 2001; 15(3):145-48. doi: 10.1007/ s005400170016; pmid: 14566512. 23. finholt da, henry db, raphaely rc. a “leak” test: a standard method for assessing tracheal tube fit in pediatric patients. anesthesiology. 1984; 61:450. 24. covidien. (2011). tracheostomy products quick reference guide. [retrieved 2017 feb 27]. available from: : https://www.vitalitymedical.com/pdf/shiley-quick-ref-guide.pdf. 25. covidien. (2015). tracheostomy products quick reference guide. [retrieved 2017 feb 27]. available from: http://www.medtronic.com/content/dam/covidien/library/us/en/ legacyimport/patientmonitoringrecovery/airway /1/shiley-tracheostomy-products-quickreference-guide.pdf. the major limitation of this study is the lack of available patients in our institution caused by the low number of pediatric patients undergoing tracheostomy. some patients also have the procedure performed bedside due to lack of funds (and are not listed in the operating room records). strictly speaking, 18-year-old patients do not have a pediatric sized trachea. however, the who definition of pediatric patients was adapted in order to be consistent with other studies in children. in the future, a follow up study with greater sample size can be done. results can be used to create a regression analysis and may provide a new formula for estimating tracheostomy tube size. in conclusion, the average value derived from radiograph-based estimation is less than the corresponding average value from agerelated formula. there is a significant difference between age-related formula-based estimation and actual tracheostomy tube inserted. the tracheal size measurement obtained from radiographs is significantly different from but consistently larger than the actual tracheostomy tube size. if we were to correct for this difference, then a tube one size larger should be selected (with consideration for patient characteristics other than age). since the range of differences between the two estimation methods is high, these results imply that the bias or the difference between measures from the two methods is not consistent with the two methods exhibiting very poor agreement. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles philippine journal of otolaryngology-head and neck surgery 17 philipp j otolaryngol head neck surg 2008; 23 (2): 17-22 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: the study aims to present the clinical and demographic profile of subjects who have undergone auditory brainstem response (abr) test at the philippine children’s medical center over a 10-year period. methods: design: retrospective chart review setting: tertiary children’s hospital subjects: all patients referred for abr testing from january 1996 to december 2005. results: a total of 2783 cases were included in the study with 1.63:1 male-to-female ratio. almost 50% belonged to the 2-to 5-year-old age group. there were 111 different indications for referral, with speech and language disorders ranking first at 38%. patients with congenital rubella had the highest incidence of pathologic abr results with 90.62%. there was no significant difference in the degree of hearing loss between the pre-school (2-5 years old) and school age (>5 to 10 years old) group. our patients who presented with speech delay had a much older average age of hearing loss detection by abr compared to foreign studies. conclusion: speech and developmental delays were the leading causes for abr referral across age groups with most belonging to the 2-to-5-year-old age group. there was no statistically significant difference in the degree of hearing loss between the preschool and school-age groups with speech delay. abr in hearing screening of neonates and children constitutes only a small fraction of the total indications for abr testing at the philippine children’s medical center. detection of hearing loss at an earlier age may reveal the true burden of illness and facilitate earlier intervention. universal hearing screening should be performed for all newborns and not just for high risk infants. key words: hearing loss, speech delay, auditory brainstem response, abr the american speech-language hearing association estimates the prevalence of newborns with congenital hearing loss in the united states at between 1 to 6 per 1,000.1,2 the average age of detection in the pediatric population is between 12 and 25 months3, 4, 5,6 with patients at risk and more severely impaired children being identified earliest. children with no risk factors for hearing loss and children with mild to moderate hearing loss typically were not identified until about 28 months of age; with many undetected until identified at preschool and kindergarten a 10-year review of brainstem auditory evoked response testing at the philippine children’s medical center: patient demographics and outcomes mary jane c. tipayno, md department of otolaryngology philippine children’s medical center correspondence: mary jane c. tipayno, md rm. 204 notre dame de chartres hospital general luna rd. 2600 baguio city philippines phone: 619 8530 loc. 204/09175066561 e-mail: janetipaynomd@yahoo.com reprints will not be available from the author. no funding support was received for this study. the author signed a disclosure that she has no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study presented at the philippine children’s medical center annual research contest, poster category on november 5, 2007, quezon city, philippines philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles 18 philippine journal of otolaryngology-head and neck surgery hearing screening programs, or when hearing was tested because of concerns regarding speech, language and cognitive delays. the joint committee of infant hearing year 2000 proposed that all infants born with hearing loss be screened by 1 month of age, diagnosed by 3 months and enrolled into early intervention by 6 months of age. this strong recommendation for early detection and intervention for infants with hearing loss cannot be overemphasized, as yoshinaga-itano and colleagues7 showed that children in whom hearing loss was identified, and remediation instituted before 6 months of age had significantly higher scores on tests of vocabulary, expressive language and language comprehension than those diagnosed after 6 months. the screening tools of choice for newborns include oto-acoustic emission (oae) and auditory brainstem evoked response (abr) tests, with the latter being more reliable for the difficult to test and for very young patients. as one of the first local institutions to acquire an auditory brainstem response (abr) machine, the philippine children’s medical center (pcmc) has tested children from all over the country for the past 13 years. the study aims to present the clinical and demographic profile of subjects who have undergone auditory brainstem response (abr) test at the philippine children’s medical center over a 10-year period. research objectives general objective: to present the clinical and demographic profile of subjects who have undergone abr test at pcmc from january 1996 to december 2005. specific objectives: 1. to present abr patient distribution as to age, sex, working diagnosis (pertinent to abr testing/ reason for referral), source of referral (physician’s specialty); 2. to determine the incidence and degree of auditory pathway pathology for the ten most common working diagnoses/indications for abr referral and compare them with existing international literature; 3. to rank the leading causes of referral for each age group over the 10-year period; 4. to determine the average age of auditory pathology detection by abr among patients presenting with speech delay over the 10-year period; 5. to determine if there is a significant difference in the degree of hearing loss detected during the preschool (2-5 years old) and school age (more than 5 years old) group of patients with speech delay; 6. to determine the number of subjects 3 months and younger referred specifically for hearing screening and with no indicated risk factor/s for hearing loss; and 7. to present the most common reasons for referrals and degree of hearing loss in the neonatal age group. operational definition of terms hearing losshearing threshold greater than 35 db mild hearing losshearing threshold more than 35 to less than 45 db moderate hearing losshearing threshold at 45 to 65 db severe hearing losshearing threshold more than 65 to less than 85db severe to profound hearing losshearing threshold at 85db or more methodology a retrospective review was conducted on charts of all patients who underwent abr testing at the philippine children’s medical center between january 1996 and december 2005. patients with incomplete data pertinent to the information being collected were excluded. patient data of interest included the following: 1. patient name and case number 2. age 3. sex 4. working diagnosis pertinent to abr testing/reason for referral. 5. source of referral as to physician’s specialty 6. abr findings a. degree of hearing loss (mild, moderate, severe, severe to profound) b. laterality (unilateral/bilateral) of deficit the subjects were sub-grouped according to age level as follows: a. 0 to less than 24 months b. 24 months to 5 years old c. more than 5 to 10 years old d. more than 10 to 15 years old e. more than 15 to 18 years old f. more than 18 years old clinical impressions of speech and language disorders were consolidated under speech delay. global developmental delay and psychomotor delay were labeled under developmental delay while pdd (pervasive developmental delay) encompassed clinical of impressions of pdd, autism, autistic spectrum disorder and rett syndrome. descriptive statistics using means and proportions were applied. the ztest of association was used to analyze the difference in the hearing loss detected during the preschool (2-5 years old) from the school-aged group (>5 to 10 years old) of patients with speech delay. the abr machine test parameters used were the following: stimulus parameters type: click duration: 100µsec rate: 15/sec polarity: alternating intensity: (100) 90, 70, 50 and 30 db transducer: elega td 531 acquisition parameters amplification : none electrodes: cz to ipsilateral mastoid with forehead ground filter settings: 100-3000 hz notch filter: none number of sweeps: 2000, replicated philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles philippine journal of otolaryngology-head and neck surgery 19 the average age of auditory pathology detection was determined by taking the total age in months of the affected patients at the time of detection divided by the total number of affected patients. results a total of 2783 patients were included in the study with an overall female to male ratio of 1:1.63 (table 1). the 2-to-5 year-old age group was largest, making up 49% (figure i). there were 111 total listed indications for referral. close to 85% of the total cases were shared by the top 10 clinical entities; of these, 38% were represented by the speech delay disorders (appendix i, figure 2). the remaining 15 % were shared by 101 other indications. sixty-one percent of the referring physicians were residents and fellows, child neurology consultants contributed sixteen percent 16% followed by neurodevelopmental pediatricians and otolaryngologists with 8 and 4%, respectively (figure3). the incidence and degree of pathologic abr results for the 10 leading indications are listed in table 2. table 3 shows comparative results with selected foreign studies on these 10 indications of referral. no direct comparison could be found in published studies regarding abr results of patients with seizure disorder per se and patients primarily suspected for hearing loss. table 4 shows the most common causes for abr referral for each age group. global developmental delay was the primary reason for referrals in subjects under 2 years old, followed by speech delay. bacterial meningitis was also a notable cause in this age group. speech delay was the leading indication for ages 2-10 years old while hearing loss dominated the older age group. the overall average age of auditory pathology detection in speechdelayed patients was 46.48 months, with no trend observed in the yearly average age of auditory pathology detection except for a peak in 2002 (appendix 2, figure 4). for all degrees of hearing loss, there was a slight increase in the >5-10-year-old age group compared to the 25-year-old age group (table 5). these differences were not statistically significant using the ztest of association (appendix 3a, 3b). table 1. gender and age group distribution female male total 0-<24m 343 480 823 2-5y 490 912 1402 >5-10y 177 290 467 >10-15y 37 36 73 >15-18y 2 2 4 >18y 7 7 14 total 1057 1726 2783 figure 1. age group distribution table 2: incidence and degree of auditory pathology of top 10 ranked abr referrals speech delay gdd hl autism meningitis cp seizure pt con. rubella down indication for referral total results (ears tested) total incidence patients tested ears tested intact mild hl moderate hl severe hl severe to profound hl n % n % n % n % %n n % 1073 391 259 163 128 124 92 55 48 47 2146 782 518 326 256 248 184 110 96 94 1350 530 139 303 165 137 152 61 9 44 62.91 67.77 26.83 92.94 64.45 55.24 82.61 55.45 9.38 46.81 90 45 10 10 19 6 7 6 5 9 4.19 5.75 1.93 3.30 7.42 2.42 3.8 5.54 5.20 9.57 142 66 20 6 20 16 8 9 5 22 6.62 8.44 3.86 1.98 7.81 6.45 4.35 8.18 5.20 23.40 119 26 34 0 7 2 3 6 12 4 5.54 3.32 6.56 0 2.73 0.81 1.63 5.54 12.50 4.26 445 115 315 9 45 87 14 28 65 15 20.74 14.71 60.81 2.97 17.58 35.08 7.61 25.45 67.71 15.96 796 252 379 25 91 111 32 49 87 50 37.09 32.23 73.17 7.67 35.55 44.76 17.39 44.55 90.62 53.19 figure 2. percent distribution of abr indications philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles 20 philippine journal of otolaryngology-head and neck surgery there were 57 (2%) patients aged 3 months and younger in the study, 4 of these were well babies, specifically referred for hearing screening. it is interesting to note that in patients 6 months and under, 7 were referred as follow ups to a “refer” result of a previous otoacoustic emission test. only 6 (0.22%) neonates were referred, 2 for aural atresia and 1 each for bacterial meningitis, prematurity, cerebral palsy and sepsis. discussion speech and developmental delays were the leading causes for abr referral across age groups with most (almost 50%) belonging to the 2-to-5-year-old age group. because intelligible speech is expected from a child of this age, verbal delay prompts parents and guardians to consult. abnormal abr results for speech delay in our study were more than twice those of a european study.8 congenital rubella syndrome presented with the highest incidence of abnormal abr results at 90.62 %, slightly higher than that published by roizen in 19999 while niedzielska10 and sadijhi, j. et al11 reported a much lower incidence. our results for hearing loss in children with global developmental delay fell within the wide range of other studies exemplified by haggard12 and rupa.13 our incidences for autism were 5.28% and 2.97% for mild to moderate, and severe to profound hearing loss, respectively, lower than the 7.9% and 3.5% reported by rosenhall14 in a european population. taylor15 similarly showed a higher incidence in his study considering only autistic children without associated features. bacterial meningitis was the most common reason among the infectious causes for abr referral. the incidence of hearing loss as a sequel of bacterial meningitis were reported at 10% by tarlow16 and 7% by koomen,17 much lower than our results which were similar to those conducted at a children’s hospital in nepal.18 our results of more than 50% abnormal abr in down syndrome support the consistently high incidence of hearing impairment in this clinical entity as diagnosed by abr.19,20 we had a 44.55% incidence of abnormal abr in cerebral palsy patients, twice higher than the findings of robinson21 and zafeiriou22 and much higher than the 2-6% average incidence of hearing loss in the preterm infant population reported elsewhere.23 it is possible that co-morbid conditions in a majority of our patients with cerebral palsy may have increased the incidence of abnormal abr results. while the incidence of abnormal abr results for developmental delays, post bacterial meningitis, down syndrome and congenital rubella were at par with foreign statistics, our incidence for autism was slightly lower. the myriad etiologies for, and different classifications of seizure disorders precluded making any direct comparisons with the literature. no trend was noted on the average age of hearing loss detected in speech-delayed patients with respect to time; the peak average in year 2000 was attributed to an adult patient tested. our results showed that we are 21 to 34 months behind the world’s average age of detecting hearing loss in the pediatric population using speech delay as the presenting symptom. reasons for late consultation may include a lack of awareness of the early signs of hearing loss on the part of parents and guardians. on the other hand, significant observations of concerned parents may have been disregarded by well-meaning health care givers table 3. comparative table on the incidence of patholigic results of top 10 ranked abr referrals rank 1 2 3 4 5 6 7 8 9 10 indication speech delay gdd hl autism meningitis cp seizure pt down con rubella pcmc 37.09 32.23 73.17 7.96 35.55 44.76 17.39 44.55 53.19 90.62 foreign studies 13.3 (psarommatis i.m. et al, 2001) 18 (haggard m. 1992) 91 (rupa v. 1995) ** 9.5 (rosenthal et al, 1999) 18.75 (taylor et al, 1982) 10 (tarlow, 1997) 36 (kanti children’s hospital, 1984) 7 (koomen i., grobbee et. al 2003) 20 (robinson, 1983) 22.7 (zafeiriou, 1999) * 2-6 (jcih, 1994) 66 (roizen, 1997) >75 (cunningham & mcarthur 1981) 50 (neidzieska, 1999) 90 (roizen, 1999) 12 (sadijhi,j. et al, 2004) figure 3. distribution of referral source figure 4. yearly average age of auditory pathology detection in patients presenting with speech delay philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles philippine journal of otolaryngology-head and neck surgery 21 appendix 1. percent distribution of abr referral indications cases female male total (%) sd 349 724 1073 38.53 dd 185 206 391 14.04 hl 113 146 259 9.30 pdd 32 131 163 5.85 men 51 77 128 4.60 cp 59 65 124 4.45 sz d 35 57 92 3.30 pt 20 35 55 1.97 cr 25 22 47 1.69 ds 21 26 47 1.69 oi 166 240 406 14.58 total 1056 (38%) 1729 (62%) 2785 legend: sd speech delay sz d seizure disorder dd developmental delay pt prematurity hl hearing loss cr congenital rubella pdd pervasive developmental delay ds down syndrome men meningitis cp cerebral palsy oi other indications legend: cor cause of referral sz seizure disorder gdd global developmental delay pt prematurity sd speech delay coru congenital rubella men meningitis dosy down syndrome cp cerebral palsy hybil hyperbilirubinemia hcp hydrocephalus om otitis media hl hearing loss mr mental retardation pdd-pervasive developmental delay table 4. ranked leading causes of referral for each age group rank 1 2 3 4 5 6 7 8 9 10 0-<24 mos cor gdd sd men cp hl sz pt conru dosy hybil n 153 118 83 69 59 33 31 29 29 27 2-5 y/o cor sd gdd pdd hl cp sz men coru dosy hybil n 754 173 125 113 47 37 33 15 14 9 >5-10 y/o cor sd hl pdd gdd mr sz men cp hybil coru hcp om n 183 67 61 56 27 18 11 6 5 3 3 3 >10-15 y/o cor hl sd gdd mr men pdd om sz n 16 15 8 8 4 3 3 3 >15-18 y/o cor hl n 2 >18 y/o cor hl n 3 table 5. degree of hearing loss in preschool (2-5 y/o) and school aged (>5-10 y/o) group with speech delay 2-5yo >5-10yo p value result (ears tested) abnormal auditory pathwayage grp patients tested ears tested inact mild mod severe sev-pro total % %%%%n n n n n 760 183 1520 366 1006 200 59 20 3.88 5.46 87 31 5.72 8.47 89 23 5.86 6.28 279 92 18.36 25.14 514 166 33.82 45.36 >.05 >.05 >.05 >.05 who downplayed the possibility of hearing loss. costs associated with hearing screening may also contribute to delay. although it may be posted that a more severe degree of hearing loss in younger patients prompts earlier referral than among school-aged children in whom it was usually an incidental finding, this was not the case in our study. further, there was no statistically significant difference in the degree of hearing loss between the preschool and school age groups with speech delay. less than 1% of the overall indications for referral were for follow-up of failed hearing screening and only 2% of the subjects were 3 months old and younger. these values may reflect the minimal usage of abr for hearing screening in our institution as well as a lack of awareness of the importance of newborn hearing screening in general. this may be exacerbated by the absence of a mandate to screen all newborns for potential hearing loss, and not just the high risk group as traditionally done. an important study among patients with congenital hearing loss showed that 50% did not have any risk factors.24 apart from delayed cognitive complications of hearing loss, economic and societal repercussions are not to be disregarded. it is estimated in an american study that households lose $122 billion in lost income and reduced federal tax revenues by another $18.4 billion.25 abr in hearing screening of neonates and children constitutes only a small fraction of the total indications for abr testing at the philippine children’s medical center. detection of hearing loss at an earlier age may reveal the true burden of illness and facilitate earlier intervention. finally, to improve on the poor average age of hearing loss detection so that subsequent remedial measures are administered, it is strongly recommended that universal hearing screening be performed for all newborns and not just for high risk infants. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 original articles 22 philippine journal of otolaryngology-head and neck surgery acknowledgements my heartfelt thanks to my kind mentors, drs. adonis b. jurado, gretchen navarro-locsin, and ma. rina t. reyes-quintos, to my technical adviser paul matthew pasco and the research development board of pcmc, the staff of the pcmc neurodiagnostic lab, my loving family and finally to the almighty who made all these things possible. references 1. kemper ar and downs sm. a cost effectiveness analysis of newborn hearing screening strategies. arch pediatr adol med, 2000 may; 154(5): 484-488. 2. cunningham m, cox eo. hearing assessment in infants and children: recommendations beyond neonatal screening. pediatrics, 2003 february; 111(2): 436-440. 3. elsmann s, matkin n, sabo m. early identification of congenital sensorineural hearing impairment. hearing journal 1987; 40: 13. 4. harrison m, roush j. age of suspicion, identification and intervention for infants with hearing loss: a national study. ear hearing 11: 210, 1990. 5. mace a, wallace k, whan m, stelmachowicz p. relevant factors in the identification of hearing loss. ear hearing 1991; 12: 287. 6. stein lk, jabaley t, spitz r, stoakley d. and mcgee t. (1990). the hearing-impaired infant: patterns of identification and rehabilitation revisited. ear hearing, 11 (3), 201–205. 7. yoshinaga-itano c, sedey al, coulter dk and mehl a l. the effect of early identification on the development of deaf and hard of hearing infants and toddlers. poster presented at the american academy of audiology conference. salt lake city, 1996. 8. psarommatis im, goritsa e, douniadakis d, tsakanikos m, kontrogianni ad and apostoloulos n. hearing loss in speech-language delayed children. int j pediatr otorhi. vol 58, issue 3, may 2001 pp 205-210. 9. roizen nj. etiologies of hearing loss in children. non genetic causes. pediatr clin n am 1999 feb; 46(1):pp49-64. 10. niedzielska g, ktska e and szymula d. hearing defects in children born of mothers suffering from rubella in the first trimester of pregnancy. int j pediatr otorhi vol 54, issue, aug, 2000 pp15. 11. sadighi j, eftekhar h, and mohammad k. congenital rubella syndrome in iran. bmc infect dis. 2005; 5: 44. 12. haggard m. screening children’s hearing. brit j audiol 1992; 26: 209–215. 13. rupa v. dilemmas in auditory assessment of developmentally retarded children using behavioral observation audiometry and brainstem evoked response audiometry. j laryngol otol 1995; 109:605–609. 14. rosenhall v., sandström m, ahlsén g and gillberg c. autism and hearing loss. j autism dev disord. volume 29, number 5, 1999. publisher springer netherlands issn 0162-3257 (print) 1573-3432 (online). 15. taylor mj, rosenblatt b, linschoten l. auditory brainstem response abnormalities in autistic children. can j neurol sci 1982; 9:429-433. 16. richardson mp, reid a., tarlow m j, rudd p t. hearing loss during bacterial meningitis . arch dis child february 1997; 76:134-138. 17. koomen i, grobbee de, roord jj, donders r, schinkel aj and van furth am. hearing loss at school age in survivors of bacterial meningitis: assessment, incidence, and prediction. pediatrics. 2003; 112:1049 -1053. 18. unknown author. available at: http://www.healthnet.org.np/gsdl/collect/thesis/index/assoc/ hash0123.dir/doc.pdf 19. roizen n. hearing loss in children with down’s syndrome: a review. down syndromeroizen n. hearing loss in children with down’s syndrome: a review. down syndrome quarterly.1997. 2(4).1-4. 20. cunningham c, mcarthur k. hearing loss and treatment in young down’s syndrome children. child: care, health and development 1981. 7: 357-374. 21. robinson ro. the frequency of other handicaps in children with cerebral palsy. developmental medicine and child neurology. no. 15, 1983. pps. 305-312. 22. zafetriou di, andreou a, karasavidou k. utility of brainstem auditory evoked potentials in children with spastic cerebral palsy. acta paediatrica vol. 89 issue 2 pages 194-197, february 2000. 23. joint committee on infant hearing, american academy of audiology, american academy of pediatrics, american speech-language-hearing association, and directors of speech and hearing programs in state health and welfare agencies. position statement: principles and guidelines for early hearing detection and intervention programs. pediatrics. 2000; 106: 798– 817. 24. mehl al and thomsonv .newborn hearing screening: the great omission. pediatrics vol. 101 no.1 january 1998, p.e4. 25. kochkin s .the high cost of hearing loss. hearing journal. october 2005.available at: http:// findarticles.com/p/articles/mi_hb3496/is_200701/ai_n18863242. appendix 4. patient data collection form year case no name age sex indication right ear threshold (db) final reading left ear threshold (db) final reading referring physician (specialty) appendix 3b. p value using z-test of association 2-5 y/o >5-10 y/o difference p value conclusion mild 11.47859922 12.04819277 -0.56959355 >.05 not significant mod 16.92607004 18.6746988 -1.748628756 >.05 not significant s-p 17.3151751 13.85542169 3.459753411 >.05 not significant sp 22.95719844 21.68674699 1.270451456 >.05 not significant appendix 3a. cross tabulation of preschool and school-aged group with speech delay age group total 2-5 y/o >5-10 y/o count % within agegroup % within ears tested (right and left) count % within agegroup % within ears tested (right and left) count % within agegroup % within ears tested (right and left) 59 11.5% 74.7% 20 12.0% 25.3% 79 11.6% 100.0% ears tested (right and left) total mild mod s s-p 87 16.9% 73.7% 31 18.7% 26.3% 118 17.4% 100.0% 89 17.3% 79.5% 23 13.9% 20.5% 112 16.5% 100.0% 279 27.15% 75.4% 46 27.7% 24.6% 371 27.25% 100.0% 514 100.0% 75.6% 166 100.0% 24.4% 680 100.00% 100.0% appendix 2. 10-year average age (months) of speech delay diagnosis cases average 1996 112 45.28 1997 87 43.63 1998 166 43.1 1999 73 44.15 2000 100 49.05 2001 93 43.56 2002 94 60.66 2003 127 49.69 2004 122 44.03 2005 99 43.31 overall 1073 46.48 silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations 42 philippine journal of otolaryngology-head and neck surgery abstract objectives: to propose a simple technique to preserve, medialize and stabilize the middle turbinate through a planned medial synechiae formation using a nasal septal flap methods: a. study design: case series, surgical innovation b. setting: tertiary hospital (kumamoto university hospital, japan) c. participants, patients or population: six patients suffering from chronic sinusitis unresponsive to medication. the indication for doing this technique was unstable turbinates after removal of diseased mucosa. results: twelve weeks after surgery, the patients reported significant resolution of symptoms (headache, nasal congestion, rhinorrhea, post-nasal drip and loss of smell). ct and endoscopic findings likewise revealed clear ostio-meatal complex, drained sinuses, and complete removal of polypoid mucosa. no major side effects were noted. conclusions: this technique is especially encouraged when surgeons encounter an unstable middle turbinate after removing massive pathologic mucosal lesions. this is a preliminary report and further investigations are being carried out to validate the technique. keywords: medial synechiae, nasal septal flap, ostio-meatal complex lateral synechiae formation of the middle turbinate remains the most common complication in endoscopic sinus surgery. it results in recurrence of sinus symptoms due to blockage of the ostio-meatal complex and patient dissatisfaction. some surgeons opt to partially resect the middle turbinate to ensure post-operative patency of sinus drainage but we consider this technique quite radical and contradictory to the conservative principle of functional endoscopic sinus surgery. in untrained hands, a planned partial resection may lead to total resection and loss of anatomic landmarks essential in revision surgery. excessive middle turbinate manipulation may compromise such nasal functions as filtration, humidification and laminar flow. we propose a simple technique to preserve, medialize and stabilize the middle turbinate through a planned medial synechiae formation using a nasal septal flap. materials and methods records of patients in a tertiary hospital in japan (kumamoto university hospital) who had endoscopic sinus surgery with middle turbinate medialization using septal flap from october 2001 to may 2003 were reviewed. the indication for the septal flap technique was unstable floppy middle turbinate after removing pathologic mucosal lesions. all cases had exposed middle turbinate bone on the lateral side with a high chance of developing lateral synechiae post-operatively. only cases done by one surgeon (ey) were included in the study to avoid interoperator variability. preand post-operative symptoms (headache, nasal congestion, rhinorrhea, post-nasal drip and loss of smell) were compared on a numerical scale which patients routinely accomplished during out-patient visits prior to, and at weeks 3 and 12 after surgery. endoscopic findings and ct scan plates before, and 12 weeks after surgery were reviewed, as were intraoperative video recordings and major and minor post-operative complications. medialization and stabilization of the middle turbinate using a nasal septal flap in endoscopic sinus surgery edgardo abelardo, md, tetsuji sanuki, md, phd, eiji yumoto, md, phd department of otorhinolaryngology head and neck surgery kumamoto university hospital japan correspondence: : edgardo abelardo, md department of otorhinolaryngology head and neck surgery kumamoto university hospital 1-1-1, honjo, kumamoto city japan 860-8556 e-mail: edabelardo@yahoo.com reprints will not be available from the author. dr abelardo (ea) was a fellow of takeda science foundation during the time this paper was written. no other funding support was received for this article. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this report. philipp j otolaryngol head neck surg 2006; 21 (1,2): 43-46 c philippine society of otolaryngology – head and neck surgery, inc. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations philippine journal of otolaryngology-head and neck surgery 43 surgical technique the main indication for the medialization and stabilization technique using nasal septal flap was unstable and floppy middle turbinates after removal of diseased nasal mucosa. following uncinectomy and widening of the maxillary ostium, the middle turbinate was medialized using a freer elevator. an anteriorly-based rectangular nasal septal flap measuring 5 mm x 15 mm was drawn adjacent to the de-epithelialized margin of the middle turbinate. the lower border of the middle turbinate marked the inferior margin of the septal flap. the superior margin of the flap was 5 mm above the inferior margin. superior and inferior incisions were made with a sickle knife, subperichondrial dissection performed using a small freer elevator, and the posterior margin was cut with scissors (fig.1). the middle turbinate was medialized and the nasal flap hinged on its lateral side with the anterior border of the flap adjacent to the anterior border of the middle turbinate. the middle turbinate and flap were stabilized with fibrin glue (fig. 2) and gentle nasal packing placed lateral to the middle turbinate for 48 to 72 hours. when a bilateral medialization technique was indicated, the flaps on both sides of the septum were designed in such a way that septal cartilage was not exposed on the same level on both sides. figure 1. schematic diagram. lateral and anterior views of anteriorlybased nasal septal flap. figure 2. intra-operative endoscopic view of left nostril after medialization of middle turbinate and stabilization using nasal septal flap. results six cases of middle turbinate medialization using septal flap were reviewed. there were 4 male and 2 female patients with an average age of 49 years. the main indication for surgery was chronic sinusitis. two had pansinusitis, another two had maxillary sinusitis alone, and the remaining two had frontal sinusitis with mucoceole. four had previous nasal surgeries, with one case previously done in another hospital whose post-operative records could not be retrieved. pre-operatively, all six patients (6/6) had symptoms of mild to severe post-nasal drip, five (5/6) reported mild to severe nasal congestion, mild to severe rhinorrhea, and mild to severe loss of smell, and four (4/6) had moderate headache. endoscopy revealed pathologic nasal mucosa and obstructed ostio-meatal complex in five patients (5/6) and nasal polyps in three (3/6). these findings were confirmed by paranasal sinus ct scans. table 1 summarizes the total symptom scores pre-op and postop (5-severe, 3-moderate, 1-mild, 0-none; n = 6 patients). twelve weeks after surgery, there were significant improvements in all of the symptoms (figure 3). five patients (5/6) reported improvement figure 3. bar graph of table 1 showing pre-op and post-op symptoms and ct/endoscopic findings. (a–headache, b-nasal congestion, c–rhinorrhea, d-post-nasal drip, e-loss of smell, fobstructed omc, g-nasal polyp). table 1. total symptom scores symptoms a. headache b. nasal congestion c. rhinorrhea d. post-nasal drip e. loss of smell ct/endoscopic findings f. obstructed omc g. nasal polyp pre-op 12 15 15 18 15 15 9 (5-severe, 3-moderate, 1-mild, 0-none; n = 6 patients); omc-ostio-meatal complex). 12 weeks post-op 3 3 6 3 3 0 0 silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 surgical innovations 44 philippine journal of otolaryngology-head and neck surgery in post-nasal drip, nasal congestion, headache and olfaction while one (1/6) claimed persistence of post-nasal drip, mild headache and mild nasal blockage. severe to moderate rhinorrhea were downgraded to mild rhinorrhea in four patients (4/6). endoscopic findings showed well-defined medial synechia and a wide ostio-meatal complex in all cases (figs. 4, 5). comparison of preand post operative ct scans showed widened ostio-meatal complexes in all cases and total removal of polypoid mucosa (6/6). no major complications were noted. statistical analysis could not be done at this stage because the sample size is small. the results should also be compared to the standard sinus surgery. discussion the middle turbinate plays an important role in endoscopic sinus surgery. following extensive removal of pathologic tissue, it may be tempting to resect an unstable floppy middle turbinate to avoid lateralization and synechiae formation on the lateral wall with subsequent ostio-meatal complex obstruction and recurrence of nasal symptoms. such resection of the middle turbinate removes a very important anatomic landmark in revision surgery. several techniques in medializing the middle turbinate have been proposed. shikani advocated meatal antrostomy stents in the maxillary natural ostium for 2 weeks until re-epithelialization occured to keep the ostio-meatal complex patent1. moukarzel used a metallic clip on the head of the middle turbinate and the septum2. thorton suggested suturing of the middle turbinate and septum for stabilization3. bolger described planned medial synechiae by abrading the middle turbinate and septum using a sickle knife and stabilizing the lateral side of the middle turbinate with packing4. friedman furthered this idea, reporting excellent results using a microdebrider instead of a sickle knife5. in our opinion, ostio-meatal complex stents and turbine-septal metallic clips may cause foreign body reactions and further granulation; turbino-septal suturing seems quite a difficult and time-consuming procedure; and sickle knife or microdebrider abrasion followed by nasal pack stabilization of the middle turbinate can cause imprecise apposition of the denuded surfaces. a tight nasal pack could displace the site of planned medial synechiae. synechiae formation on the posterior segment of the middle turbinate could lateralize the anterior segment, causing ostio-meatal complex obstruction and recurrence of symptoms. excessive nasal pack pressure could also medialize and cause synechiae of the entire medial segment of middle turbinate to the nasal septum, blocking airflow to the nasal roof leading to loss of smell. the nasal flap technique allows precise determination of the site of medial synechiae. an ideal medialization of the middle turbinate is optimally stabilized by planned small synechiae at its antero-inferior region leaving enough space at its antero-superior and posterior regions. the technique we propose is an alternative to friedman’s procedure, cognizant of the fact that not all institutions have a microdebrider available. moreover, this technique does not depend on nasal packing to medialize and stabilize the middle turbinate until a synechiae is formed. instead, the planned site of medial synechiae is controlled by the surgeon through the septal flap followed by gentle nasal pack application to avoid flap displacement. we think similar results could be achieved even without nasal packs. although middle turbinate medialization may theoretically result in hyposmia due to decreased airflow in the olfactory area, friedman showed no adverse effect of medial synechiae on olfaction6. furthermore, the improvement of sense of smell in most of our patients may be attributed to the wide space in the anterior and posterior segments of the middle turbinate allowing airflow to the spheno-ethmoid recess. our proposed technique is a quick and easy alternative to medialize and stabilize the middle turbinate without a microdebrider and using minimal nasal dressing. this technique is especially encouraged when surgeons encounter unstable middle turbinate after removing massive pathologic mucosal lesions. no major side effects were noted. this is a preliminary report and further investigation is being carried out to validate the technique and allow greater documentation of its effects on nasal function. figures 4 (above) and 5 (below). right (4) and left (5) nostrils taken 3 months after surgery. note the planned medial synechiae on the antero-inferior portion of the middle turbinate. references: 1. shikani ah. a new middle meatal antrostomy stent for functional endoscopic sinus surgery. laryngoscope 1994;638-41. 2. moukarzel n, nehme a, mansour s, et al. middle turbinate medialization technique in functional endoscopic sinus surgery. j otolaryngol 2000 jun;29(3):144-7. 3. thorton rt. mt stabilization technique in endoscopic sinus surgery. arch otolaryngol head neck surg 1996;122:869-72. 4. bolger we, kuhn fa, kennedy dw. middle turbinate stabilization after functional endoscopic sinus surgery. the controlled synechiae technique. laryngoscope 1999;109:1852-3. 5. friedman m, lansberg r, tanyeri h. middle turbinate medialization and preservation in endoscopic sinus surgery. otolaryngol head neck surg 2000;123:76-80. 6. friedman m, tanyeri h, lansberg r. effects of middle turbinate medialization on olfaction. laryngoscope 1999 sep;109(9):1442-5. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 6968 philippine journal of otolaryngology-head and neck surgery under the microscope philipp j otolaryngol head neck surg 2019; 34 (1): 68-69 c philippine society of otolaryngology – head and neck surgery, inc. intracapsular carcinoma ex pleomorphic adenoma jose m. carnate jr., md1 marvin c. masalunga, md2 1department of pathology college of medicine university of the philippines manila 2department of laboratories philippine general hospital university of the philippines manila correspondence: dr. jose m. carnate, jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st. ermita, manila, 1000 philippines phone (632) 526-4450 telefax (632) 400-3638 email: jmcjpath@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. this is the case of a 37-year-old female patient presenting with a 10-year history of a gradually enlarging right infra-auricular mass. a parotidectomy was performed. the surgical pathology specimen consisted of an 18 cm diameter encapsulated nodular mass with a homogenous, cream-tan solid surface. microscopic section showed an encapsulated neoplasm with abundant chondromyxoid stroma and tubular epithelial elements characteristic of a pleomorphic adenoma. (figure 1) randomly scattered within the tumor were foci of haphazard and complex glands. (figure 2) these glands exhibited nuclear pleomorphism, luminal necrosis and mitoses compatible with an adenocarcinomatous proliferation. (figure 3) based on these features, the case was signed out as an intracapsular carcinoma ex pleomorphic adenoma. carcinoma ex pleomorphic adenoma is a carcinoma arising from a pre-existing pleomorphic adenoma. the antecedent benign tumor may either be a long-standing one often with a history measured in decades, or characterized by a protracted history of excisions and multiple recurrences.1,2 the carcinoma on the other hand is either epithelial or myoepithelial in derivation. by morphologic sub-type the most commonly reported carcinoma arising in a pleomorphic adenoma is a salivary duct carcinoma or an adenocarcinoma that is not otherwise specified (nos).1,3 residual pleomorphic adenoma tissue is identifiable either in its typical morphology, a chondromyxoid stroma, or a hyalinized sclerotic nodule.1 aside from the type of carcinoma arising from the pleomorphic adenoma, another parameter that has to be reported is the extent of involvement by the carcinomatous component. a carcinoma that is entirely limited to within the parent tumor that is still enclosed by a complete capsule is termed an “intracapsular” or “non-invasive” carcinoma ex pleomorphic creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. tumor composed of chondromyxoid stroma (asterisk), and tubular epithelial elements (arrow) surrounded by a complete fibrous capsule (double arrow) (hematoxylineosin, 40x magnification). (hematoxylin – eosin , 40x) philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 6968 philippine journal of otolaryngology-head and neck surgery under the microscope references 1. williams md, ihrler s, seethala r. carcinoma ex pleomorphic adenoma. in: el-naggar ak, chan jkc, grandis jr, takata t, slootweg pj. who classification of head and neck tumors. iarc: lyon 2017 p.176. 2. ye p, gao y, mao c, guo c, yu g, peng x. carcinoma ex pleomorphic adenoma: is it a high-grade malignancy? j. oral maxillofac. surg. 2016 oct;74(10):2093-2104. pmid: 27131030 doi https:// doi.org/10.1016/j.joms.2016.03.037. 3. mori t, kunimura t, saito k, date h, arima s, matsuo k, ochiai y, morohoshi t. three cases of noninvasive carcinoma ex pleomorphic adenoma of the parotid gland and a literature survey focusing on their clinicopathologic features. the showa university journal of medical sciences. 2010 jun;22(2):127-134. doi https://doi.org/10.15369/sujms.22.127. 4. gnepp dr, brandwein-gensler ms, el-naggar ak, nagao t. carcinoma ex pleomorphic adenoma. in: barnes l, eveson jw, reichart p, sidransky d. world health organization classification of tumours. pathology and genetics head and neck tumors. iarc: lyon 2005 p. 242. figure 2. haphazard and complex glands (asterisk) surrounded by chondromyxoid stroma (double asterisk) and tubular epithelial elements (arrow) (hematoxylin-eosin, 100x magnification). (hematoxylin – eosin , 100x) figure 3. haphazard and complex glands with luminal necrosis (thick arrow). inset shows atypical nuclei and a mitosis (thin arrow) (hematoxylin-eosin, 400x magnification). (hematoxylin – eosin , 400x) adenoma.1,2 once the carcinoma breaches the capsule and infiltrates the surrounding tissue, then it is considered invasive. if the invasion is less than 4 – 6 mm beyond the capsular border, the tumor is termed “minimally invasive”. carcinomatous elements that extend beyond this threshold is termed “widely invasive”.1 this threshold is greater than the previous threshold of 1.5 mm recommended in an earlier edition of the who classification although the present edition does state that this threshold is preliminary and requires further validation.1,2,4 it has to be pointed out though that quantifying invasion may not always be possible in tumors that have positive margins, those that are intrinsically unencapsulated such as minor salivary gland tumors, and those with complex multinodular growth patterns such as recurrent pleomorphic adenoma.1 this difficulty has to be stated in the report and what conditions preclude quantifying the degree of invasion. non-invasive carcinoma ex pleomorphic adenoma has quite a good outcome with very low reported rates of recurrence or regional metastasis. in a review of thirty cases and a report of an additional three cases, only one case showed recurrence or metastasis.3 this favorable outcome certainly contrasts with that of the widely invasive type where metastasis is reported to occur in up to 70% of cases.1 another review of ten cases showed one case developing metastasis, and recommended that non-invasive cases should thus still be followed up closely after primary treatment because regional or distant metastasis can occur.2 to the best of our knowledge, there are no published local data on the incidence of early malignant transformation of pleomorphic adenomas in the filipino population. hence, we take this opportunity to report this case. awareness of the entity and prudent liberal sampling of these tumors may help address this gap. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 17 abstract objective: to determine the prevalence rate of follow-up among infants who had a “refer” result on initial newborn hearing screening and to identify reasons for default by parents or guardians. methods: design: cross-sectional study setting: tertiary national university hospital participants: 79 parents or guardians whose newborns obtained a “refer” result on initial hearing screening were interviewed over the phone. results: among those babies who had a “refer” result on initial hearing screening, 51% followed up for repeat testing. the most common reasons for non-follow up by parents or guardians include being busy, distance from the hospital and baby’s health condition. conclusions: the follow-up rate in this study is higher compared to previous figures (27%), but is still below target. the reasons for non-follow-up obtained suggest problems may exist on all levels of the healthcare system. appropriate solutions to address these problems should be explored. keywords: neonatal screening, hearing loss, infant, newborn, hearing tests, otoacoustic emissions republic act 9709 also known as the universal newborn hearing screening and intervention act was signed into law in 2009 with the primary aim of ensuring that every newborn be given access to hearing screening examination and early intervention services.1 local published data documenting screening rates and follow-up rates in different newborn hearing screening centers in the philippines have been limited. a 3-month screening of “995 babies or 75% of all (1,327) newborns at the philippine general hospital” in 2007 yielded a 10.6% ‘refer’ result, but “of 104 babies, only 27% followed up.”2 a similar study at the st. luke’s medical center in 2004 also revealed a follow up rate of 27.7% in patients who did not pass the initial oae.3 these rates are dismal considering that in the year 2000 position statement released by the joint committee of infant hearing, the ideal return-for-follow up rate of infants should at least be 70%.4 prevalence and reasons for non-follow-up of newborns with “refer” results on initial hearing screening kimberly mae c. ong, md teresa luisa g. cruz, md, mhped precious eunice r. grullo, md, mph department of otorhinolaryngology philippine general hospital correspondence: dr. teresa luisa g. cruz department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 554 8400 local 2152 email: orl.up.pgh@yahoo.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the up-pgh department of orl descriptive case presentation, june 2, 2017. ward 10 conference room, philippine general hospital, manila. presented at the philippine society of otolaryngology – head and neck surgery descriptive research contest (2nd place). august 10, 2017. natrapharm, the patriot bldg., parañaque city. philipp j otolaryngol head neck surg 2017; 32 (2): 17-21 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles 18 philippine journal of otolaryngology-head and neck surgery low follow-up rates pose a significant barrier to proper diagnosis and are lost opportunities for potential early intervention for patients confirmed to have hearing impairment. implementation of any health program can only be considered effective if it involves a significant percentage of the population for which the program was intended. this study aims to determine the prevalence rate of follow-up among infants who had a “refer” result in initial hearing screening and to identify the reasons for non-follow-up of hearing screening by parents or guardians whose newborn was found to have a “refer” result on initial oae test at the philippine general hospital (pgh). identifying these factors can help policymakers and stakeholders revisit existing protocols and guidelines to ensure better follow up for these patients in line with the overall aim of improving implementation of the universal newborn hearing screening program. methods with institutional review board approval, this cross-sectional study considered infants who had their hearing screening performed at the pgh ear unit between november 2014 and december 2016, but did not follow up for a repeat hearing screening within 3 months after a “refer” result on initial screening. parents or guardians of the target infants were recruited and informed consent was obtained and those who did not consent to an interview, or who retracted consent anytime between the interview and writing of the manuscript were excluded. the sample size was obtained using the formula n= 1.962 p (1-p) deff/ d2, where p was the expected proportion (27%2,3), deff was the estimated design effect (1.0), and d was the desired level of absolute precision (0.1), computed at 95% confidence interval. a minimum number of 76 parents or guardians interviewed was needed (level of significance 0.05, prevalence of 50%). convenience sampling was employed. a review of records at the ear unit was performed. those who did not follow up at the ear unit within 3 months from the time of the initial screen were considered “default.” the contact numbers of their parents or guardians were obtained from their records at the ear unit. informed consent was obtained and recorded over the phone by the investigators prior to conducting interviews. the total recall call and voice note recorder version 2.0.42 (killer mobile® software llc, henderson, nv, usa), a phone application that allows users to record phone conversations was used with permission of interviewees to document consent. an open-ended questionnaire with a sample checklist of common reasons for not following up (based on our review of literature), was used as a coding guide to interview the parents or guardians. all interviews were conducted by one author (kmco). all patient information was anonymized and kept confidential. data was simultaneously encoded by two authors (kmco and perg) using microsoft excel v2013 (microsoft corp., redmond, wa, usa), and analyzed by all three authors using frequencies, percentages, chi square and content analysis. results a total of 3,517 babies were screened at the ear unit using otoacoustic emissions between november 2014 and december 2016. these included both well-babies and those that required admission at the neonatal intensive care unit. out of these, 384 (11%) babies obtained a “refer” result either unilaterally or bilaterally. fifty one percent (195/384) of these babies followed up within 3 months from initial screening. of the 49% (189/384 babies) who defaulted, only 79 (42%) parents or guardians were successfully contacted. the rest of the given contacts were either “unavailable,” “unattended or out of coverage area” or invalid. six (7.6%) of the 79 had repeat screenings elsewhere while 13 (16.5%) had repeat screenings in our institution beyond 3 months from initial screening. the rest did not have a repeat screening at the time of interview. table 1 summarizes the demographic profile of these infants as well as information on their parents or guardians. respondents showed various levels of understanding regarding the reason for needing a repeat test. some attributed the “refer” result to the baby’s incessant crying and movement. others were told that there might still be fluid in the ear that could be obstructing the ear canal or because the baby’s ear is still not fully developed. still others believed that a repeat hearing test was needed because the baby failed the initial screening, had hearing impairment, or there was a problem with the functioning of the machine. table 2 shows the reasons for failing to follow up. the most common reason given (35%) was that parents were busy or had other obligations. many of the parents who gave this reason are part of the workforce and expressed an inability to follow up either because they could not take time off work or their free time did not coincide with ear unit opening hours. under this busy cluster were parents who also had other children that needed their attention. less common reasons under this cluster involved consecutive deaths in the family, and calamity in the locale. the second most common reasons given were location and the baby’s health condition. fifteen of the 60 (25%) said that our institution was far from where they lived. interestingly, however, there was no significant association between place of residence and citing location as a reason (fisher’s probability, 2-tailed, = 0.19), such that there was an almost equal number of respondents who lived within metro manila and who lived within the luzon area (cavite, tarlac, quezon) among those who cited this as reason. only one respondent lived in mindanao, who philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 19 table 1. summary of infants and parent/guardian profiles factor category frequency (n=79) sex of infant laterality of affected ear number of siblings admission monthly income (php) age of parent place of residence educational attainment male female unilateral bilateral 0 1 2 3 or more public private <15,000 <30,000 <50,000 ≥50,000 ≤ age 21 to 25 26 to 30 31 to 35 36 to 40 ≥ 40 metro manila luzon outside luzon high school college undergraduate college graduate vocational 40 (50.6%) 39 (49.3%) 45 (57%) 34 (43%) 37 (46.8%) 21 (26.6%) 11 (13.9%) 2 (2.5%) 41 (51.9%) 37 (46.8%) 24 (30.4%) 12 (15.2%) 5 (6.3%) 7 (8.9%) 2 15 16 21 10 5 38 (48.1%) 37 (46.8%) 1 (1.3%) 13 (16.5%) 9 (11.4%) 33 (41.8%) 12 (15.2%) table 3. relationship of laterality and admission type to status of followup * level of significance =0.05 factor categories with follow up no follow up chi square p value* laterality admission unilateral bilateral public private 101 65 72 94 103 72 91 84 0.14 2.54 .71 .11 table 2. reasons for failure to follow up. categories listed are not mutually exclusive reasons for failure to follow up % (n=60) busy distance baby’s health condition unaware of results patient is not deaf lack of transportation parents forgot lack of companion pediatrician said no notified late 35 25 25 23 18 10 8 8 5 2 repeat screening (6 of 13 respondents). according to these parents, they were notified of the need to repeat the hearing test more than 3 months after the initial screening was performed, via phone short message service (sms). possible factors that could affect the decision to follow-up were analyzed using chi square test, comparing those that followed up within 3 months and those that did not, between november 2014 and september 2016. laterality of “refer” result (unilateral or bilateral) and admission to private or public services (used as a surrogate marker for financial capacity) were the factors explored. neither factor had a significant relationship with decision to follow up. (table 3) also cited distance as a reason. fifteen of the 60 (25%) also mentioned their baby’s health condition as a reason for not being able to follow up. being “sick” ranged from the relatively simple upper respiratory tract infection to more serious medical conditions requiring prolonged hospitalization such as seizure disorder, pneumonia and sepsis. in fact, 5 of the babies had already expired at the time of interview due to various serious illnesses. on the other hand, we also interviewed one parent who opted to prioritize vaccination of his prematurely born baby. fourteen (23%) of the respondents said that they were not aware of the results of their baby’s hearing exam or were not told that they had to repeat the test. distance was the most commonly given reason for not having a repeat screening at our institution among those who opted to have them done elsewhere (5 of 6 respondents). on the other hand, late notification was the most commonly given reason for the delay in discussion the prevalence rate for follow up obtained in this study was 51%. the top three most common reasons for failing to follow up include: parents were busy or had other obligations, distance and baby’s health condition. distance was the most common reason for not having a repeat screening at our institution while late notification was the most common reason for delay in repeat screening. laterality of result and financial capacity were not significantly associated with decision to follow up. the 51% follow-up rate in this study is lower than the ideal return philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles 20 philippine journal of otolaryngology-head and neck surgery for-follow up rate of infants set by the joint committee of infant hearing in 2000 which was set at a minimum of 70%.4 nevertheless, this reflects a significant increase from 20072 where only 27% followed up (x2 = 18.77, α= 0.05, p< .0001). moreover, if we were to consider including the 6 respondents who followed up elsewhere and the 13 who had repeat screenings beyond three months, the actual follow-up rate improves to 56%. a 2004 study at the st. luke’s medical center in quezon city revealed that reasons for noncompliance with repeat testing included “the patient was seen responding well to sound,” “the test was seen as an unnecessary expense,” and “some patients were transferred to another pediatrician, to another city or to another province.”3 others were also “advised by pediatricians that repeat testing was not necessary.”3 however, this study did not mention how many respondents identified each of these factors as their reasons for noncompliance. our results revealed themes similar to the aforementioned study. but in contrast, our study found other parental obligations to be the most common reason for default followed by distance and the baby’s health. the reasons for lack of follow-up may be categorized according to a four-level model of the healthcare system adapted from reid et al.5 (figure 1) the model may help us determine what level of action is required to address a problem. for example, problems at the patient or healthcare provider level might be deemed more manageable to address than problems at the environment level which require policy changes and involvement of regulatory agencies. the first two levels are self-explanatory—factors relating to the patient, his/her family and to healthcare providers. reid et al. described organization, the third level, as the one that “provides infrastructure and other complementary resources to support the work and development of care teams and microsystems.”5 it allows for the coordination of multiple care teams and the management of allocation of human, material and financial resources. it is at this level where referral systems between hearing screening units may be established and used to improve service, especially in our setting where distance between residence and hospital is a factor. finally, the priorities of the filipino family can be influenced significantly by the political and economic environment. these include “regulatory, financial and payment regimes and entities that influence the structure and performance of healthcare organizations directly and through them all other levels of the system”.5 in our setting, this involves coverage and/or reimbursement schemes by the philippine health insurance system (philhealth) and other insurance companies, as well as government policies on compensation and incentives for hearing screening. since this study delved into reasons for default as perceived by parents, it does not come as a surprise that most of the reasons elicited were more personal and may be categorized under the first two levels. however, it is also relevant to note that some factors go across levels of the healthcare system. the reason “busy” suggests that following up for repeat hearing tests would require certain sacrifices that parents or guardians were not willing to make—income, employment, time and the welfare of their other children. hearing screening does not seem to be a priority for some filipino families, and this must be addressed if follow up rates are to improve especially since this is the most commonly-cited reason for lack of follow-up—addressing this issue might require the efforts of the healthcare provider as well as higher levels of the healthcare system. interviews with the respondents have shown that some lack understanding regarding the need for newborn hearing screening as well as the need to have it repeated. this might have contributed to down-prioritizing their baby’s hearing screening. healthcare providers such as physicians (otorhinolaryngologists, pediatricians and family physicians), audiologists and staff of the ear unit giving results to parents or guardians should emphasize the importance of a repeat oae despite their busy schedule. however, there were respondents who showed adequate understanding of the need to repeat their baby’s hearing screening yet made the decision not to follow up to prioritize other obligations. in such situations, higher levels of the healthcare system might play a role since it would be difficult to expect this subset of parents to stop working even for a day. perhaps better incentives and appropriate compensation may figure 1. four-level model of the health care system adapted and reproduced with permission from building a better delivery system: a new engineering/health care partnership, 2005 by the national academy of sciences, courtesy of the national academies press, washington, dc. reasons for default categorized according to levels. factors relating to the patient or his/her family patient • busy/ other parental obligations • baby’s health condition • distance from pgh • baby is not deaf • lack of budget for transportation • lack of companion • parents forgot • number unattended • busy/ other parental obligations • unaware of results • no or delayed notification • baby is not deaf • pediatrician said no need health care provider factors relating to the health care professionals (e.g. physicians, audiologists, etc.) • distance from pgh factors relating to the infrastructure/resources (e.g. hospitals, clinics) that can support the development and work of the health care provider organization factors relating to the political and economic conditions (e.g. regulatory, financial, payment regimes), under which organizations, care providers, and patients operate environment • busy/ other parental obligation • distance from pgh philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 original articles philippine journal of otolaryngology-head and neck surgery 21 references 1. chiong cm, abes gt, reyes-quintos mrt, ricalde rr, llanes egdv, acuin jm, et al. universal newborn hearing screening and intervention act of 2009: manual of operations for republict act 9709. 2009. 2. santos-cortez rl, chiong c. cost-analysis of universal newborn hearing screening in the philippines. acta medica philippina. 2014 [cited 2016 january 12] . available fromhttp:// actamedicaphilippina.com.ph/content/cost-analysis-universal-newborn-hearing-screeningphilippines-0. 3. tan-bumanlag ra, romualdez ja. initial outcome of the universal newborn hearing screening program at st. luke’s medical center. philipp j pediatr. 2005 jan-mar. 54(1), 3137. [cited 2016 january 12]. available from: http://www.herdin.ph/index.php/component/ herdin/?view=research&cid=329. 4. joint committee on infant hearing, american academy of audiology, american academy of pediatrics, american speech-language-hearing association and directors of speech and hearing programs in state health and welfare agencies. year 2000 position statement: principles and guidelines for early hearing detection and intervention programs. pediatrics. 2000 oct; 106(4): 798-817. [cited 2016 january 12]. available from http://pediatrics.aappublications.org/ content/106/4/798..info. 5. reid pp, compton wd, grossman jh, fanjiang ga. framework for a systems approach to health care delivery. in reid pp, compton wd, grossman jh, fanjiang g (editors). building a better delivery system: a new engineering/health care partnership washington, dc, usa: national academies press.; 2005. p. 19-22. [cited 2016 january 12]. available from https://www.ncbi.nlm. nih.gov/books/nbk22878/. ensure better compliance-which is why we considered this reason under environment as well. parents and caregivers must have access to the necessary information they will need to make informed decisions regarding their baby’s hearing screening. healthcare providers must also be given access to updated information so they may be sufficiently equipped to educate patients. the reason “baby is not deaf ” might not simply be an issue of parental perception but may also reflect a lack of information given by healthcare providers. in fact, some pediatricians actually advised that hearing screening was not necessary. healthcare providers, especially physicians, are in the best position to encourage patient participation in the program as they are deemed the experts and should have developed trusting relationships with patients. communication between healthcare providers and parents/ caregivers remains vital to overall improvement of the newborn hearing screening program. distance as a reason for non-follow up may not be just an issue of transportation for the family, but may also reflect a lack of referral systems and coordination among hearing screening centers. taking into consideration that a good percentage of our participants live within and just outside metro manila, as well as the dismal traffic situation in the area, perhaps the true reason for lack of follow up might actually be the potential time wasted stuck in traffic, instead of actual distance. these issues should also be addressed, and we must recognize that for any program to be effective, it must be made convenient and efficient for the patient. a major limitation in this study was its reliance on contacting potential participants using phone numbers they disclosed during initial testing. a significant percentage of these phone numbers were unreachable which proved to be a major hindrance both for conducting the interview as well as reminding them to follow up. home visits may be done in future studies to aid in research delving on this topic and to encourage follow up. nevertheless, results of this study will greatly impact follow up protocols at the ear unit. they may also have impact on policies that can improve implementation of the universal newborn hearing screening program. further research may be done comparing follow up rates, reasons for default and factors affecting decision to follow up across multiple hearing screening centers in the country. it might also be worthwhile to compare the profiles of those who defaulted against those who followed up. another limitation is that the reasons for non-follow up were not mutually exclusive, as each participant was allowed to enumerate all possible reasons they had. however, these reasons were only tallied and analyzed as individual frequencies and percentages without accounting for overlaps. although certain trends and relationships between reasons were discussed, the data was not subjected to statistical treatment to determine presence of significant interaction between reasons. it would be interesting for future studies to examine the combinations of reasons given for default. in conclusion, the reasons for poor follow-up given by our respondents suggest problems on all levels of the healthcare system. improving implementation of the universal newborn hearing screening program will require efforts from families and healthcare providers as well as policy makers. we should explore appropriate solutions to address these problems. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 philippine journal of otolaryngology-head and neck surgery 51 surgical innovations and instrumentation philipp j otolaryngol head neck surg 2017; 32 (1): 51-54 c philippine society of otolaryngology – head and neck surgery, inc. optical myringotomy kniferozelle o. de leon, mdjay pee m. amable, md department of otorhinolaryngology head and neck surgery uerm-memorial medical center, inc. correspondence: dr. jay pee m. amable department of otorhinolaryngology head & neck surgery rm. 463, hospital service bldg., uermmmc, inc. 64 aurora blvd., quezon city 1113 philippines phone: (632) 715 0861 local 257 fax: (632) 7161789 e-mail: orlhns_uerm@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represent honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political views or beliefs, and institutional affiliations that might lead to conflict of interest. abstract objective: to describe an improvised optical myringotomy knife essential in creation of an incision in a myringotomy simulator. methods: design: instrumental innovation setting: tertiary private hospital subject: none results: the optical myringotomy knife was able to create incisions on mock membranes made up of polyethylene film (cling wrap) in a myringotomy simulator. the incisions measured approximately 2mm with sharp edges indicating that the myringotomy knife was able to penetrate the mock membrane with ease. it provided good control in performing myringotomy incisions under endoscopic visualization of the tympanic membrane. conclusion: our initial experience with this optical myringotomy knife for tympanostomy tube insertion suggests that it may greatly improve the performance of myringotomy especially among less experienced surgeons. further studies may establish its accuracy and replicability in vitro, after which formal in vivo trials can be attempted. keywords: tympanostomy, middle ear ventilation, endoscopy, instrumentation otitis media with effusion (ome) is the presence of fluid in the middle ear with no signs of infection or tympanic membrane perforation.1 ome is a very common disease affecting people of all ages worldwide though more commonly encountered in children. myringotomy with or without tympanostomy tube insertion has become the standard of care for patients with ome lasting more than three months with associated significant hearing loss and unresponsive to conservative management.2 through the years, approaches to myringotomy have evolved, recently involving microscopic, endoscopic and even laser-assisted procedures.3 with the advent of endoscopes, endoscopic myringotomy under topical anesthesia has been proven to be safe and practical.4 endoscopic myringotomy provides better visualization of the tympanic membrane and some of the middle ear structures. we describe a simple optical myringotomy knife with accuracy and precision in placement of myringotomy incisions. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 surgical innovations and instrumentation 52 philippine journal of otolaryngology-head and neck surgery methods a. endosheath fabrication a 3/10cc insulin syringe was used to create the endosheath for a 0 degree 2.7mm x 110mm rigid endoscope. (figure 1) the attached needle and flange were removed using a cutter creating a 55mm hollow tube with inner diameter of 3mm and outer diameter of 6mm with smooth edges. (figure 2) two insulin syringes were utilized in the construction to form a 110mm endosheath. (figure 3) puncturing of the tympanic membrane. the needle was then attached to the distal end of the insulin syringe using 100% ethyl cyanoacrylate exposing 5mm of the tip. this ensured that only 5mm of the needle would penetrate the tympanic membrane and the middle ear cavity. (figure 5) figure 1. 3/10cc insulin syringe figure 2. trimmed insulin syringe figure 3. two insulin syringes connected with attached needle at one end figure 4. gauge 19 needle b. improvised myringotomy knife a gauge 19 needle was flattened to create a 2mm improvised knife using pliers without violating the sharp edge of the needle. (figure 4) the pinpoint sharpness of the needle was maintained to facilitate figure 5. attachment of needle to insulin syringe figure 6. optical myringotomy knife with endoscope c. technique the optical myringotomy knife was fitted into the endoscope with just enough length to visualize the tip of the needle from the scope. the needle tip was designed to create a stab incision of 2mm in length with sharp edges. (figure 6) in a myringotomy simulator measuring 2.5 cm long x 0.7 cm wide to more or less replicate the average length and diameter of the filipino adult ear canal, polyethylene film (cling wrap) was used to create the mock membrane. (figure 7) the optical myringotomy knife with the figure 7. myringotomy simulator (anterior, lateral and posterior view) philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 philippine journal of otolaryngology-head and neck surgery 53 surgical innovations and instrumentation endoscope was advanced into the model ear canal using a one-hand technique. (figure 8) the endoscope had an advantage of allowing visualization of the entire tympanic membrane, allowing the surgeon to determine where to perform the stab incision and to direct the needle tip to that particular quadrant. once the quadrant of choice was identified and visualized, the device could be advanced using the index and middle fingers without moving the endoscope. as the needle tip punctured the mock membrane, an incision was created. (figure 9) the endoscope also allowed immediate evaluation of incision placement. several myringotomy trials using the optical myringotomy knife were conducted to verify the technique. discussion myringotomy with or without tympanostomy tube insertion is one of the most common procedures in otolaryngology. it is a relatively rapid procedure which can be performed under local or general anesthesia. generally, myringotomy entails at least two maneuvers to achieve the end result. first, myringotomy is performed using a myringotome to create a stab incision which is usually at the antero-inferior (sometimes postero-inferior) quadrant. afterwards, insertion of tympanostomy tubes can be done using applicators or alligator forceps. commercial devices like the hummingbird™ tts (tympanostomy tube system) claim to lessen maneuvers and facilitate myringotomy and tympanostomy tube insertion in one pass.5 in our setting, a novel low-cost tympanostomy tube with applicator was conceptualized which also perforated the tympanic membrane and inserted the tympanostomy tube at the same time.8 with the aid of endoscopy, one is able to perform myringotomy with better visualization and a closer view of the tympanic membrane.4 the endosheath® technology is a sterile, disposable protective barrier between the scope and the patient which works like a condom. this technology also incorporates a channel for suction, irrigation and tool passage.6 this was the inspiration for the development of this device. the insulin syringe served as the “endosheath” which snugly fits the endoscope. optical forceps have been also part of ent instrumentation ideal for foreign body removal and biopsy procedures.9 the telescope joined with the forceps provides a closeup view and allow control and visualization in biopsy or foreign body removal. this resulted in the idea for the improvised optical myringotomy knife wherein a gauge 19 needle was attached to the distal end of the syringe. the endoscope and optical myringotomy knife provided a close-up view of the tympanic membrane and allowed precise control and accurate placement of the myringotomy incision. the endoscope provides better resolution and depth perception in performing myringotomy. it has been reported that the most frequent human errors during myringotomy are failure to perform a unidirectional myringotomy incision and multiple attempts to complete the myringotomy.10 this can be eliminated with the use of an optical myringotomy knife that provides excellent visualization of the tympanic membrane and allows creation of a 2mm single stab incision sufficient for inserting tympanostomy tubes. the dimensions of the adult external auditory canal and tympanic membrane were taken into account in conceptualizing the design of this optical myringotomy knife. during the procedure, instruments would have to be maneuvered in the external auditory canal and visualize the tympanic membrane. the average length of an adult ear canal is approximately 25mm with an average diameter of 7 figure 8. endoscopic view of tympanic membrane with optical myringotomy knife at the 5 o’clock position (arrowhead) figure 9. endoscopic view of tympanic membrane with incision at the anteroinferior quadrant (arrowhead) philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 surgical innovations and instrumentation 54 philippine journal of otolaryngology-head and neck surgery references chiong cm, yang nw, almazan-aguilar na, cabungcal ac, diaz jgp, perez ab, et al. otitis media 1. with effusion in children. in: magiba-caro r, acuin jm, jose em, chiong cm, villafuerte cv, pontejos aqy, et al (editors). pso-hns clinical practice guidelines. 2006:23-30. rosenfeld rm, culpepper l, doyle kj, grundfast km, hoberman a, kenna ma, et al. 2. clinical practice guidelines: otitis media with effusion. otolaryngol head neck surg. 2004 may:130(5suppl):595-118. doi: 10.1016/j.otohns.2004.02.002; pmid: 15138413. tan kk, liang w, pham lp, huang s, gan cw, lim hy. design of a surgical device for office-based 3. myringotomy and grommet insertion for patients with otitis media with effusion. j med devices 2014 jul 21: 8(3). doi: 10.1115/1.4027247. fernando af, calavera kz. endoscopic myringotomy and ventilation tube placement: a 4. valuable otolaryngologic procedure under topical anesthesia. philipp j otolaryngol head neck surg 2012: 27(1):41-43. hummingbird tts (tympanostomy tube system). [cited 2014 sep 26]. available from http://5. www.preceptismedical.com/product/. endosheath technology. [cited 2014 sep 26]. available from http://www.visionsciences.com/6. healthcareprofessionals/productscatalog/endosheath-technology. maroonroge s, emanuel dc, letowski tr. chapter 8: basic anatomy of the hearing system. 7. [cited 2014 sep 26]. available http://www.usaarl.army.mil/publications/hmd_book09/files/ section%2015%20-%20chapter%208%20ear%20anatomy.pdf. aguila kp. self-retaining harpoon tympanostomy tube with applicator. 8. philipp j otolaryngol head neck surg. 2007: 22(1-2):27-30. optical forceps. [cited 2014 sep 26]. available from: : http://www.teleflex.com/en/usa/pdf/9. optical%20forceps%20sell%20sheet.pdf. montague ml, lee ms, hussain ss. human error identification: an analysis of myringotomy and 10. ventilation tube insertion. arch. otolaryngol head neck surg. 2004 oct 1; 130 (10): 1153-7. doi: 10.1001/archotol.130.10.1153; pmid: 15492160. to 10mm.4,7 with this in mind, we utilized a rigid endoscope with a diameter of 2.7mm to fit inside an insulin syringe with an inner diameter of 3mm and outer diameter of 6mm. this would have enough room for manipulation inside the ear canal although its shape and cross sectional dimensions change along its length.4,7 the tympanic membrane dimensions along its two major perpendicular axes are 9 to 10 mm and 8 to 9 mm with an average thickness of approximately 70 μm but can vary from approximately 30 to 120 μm7 the exposed needle tip used to puncture the tympanic membrane is approximately 5mm which would safely penetrate the usual middle ear cavity without injuring middle ear structures. this exploratory study has several limitations. due to the lack of appropriate equipment for fabrication, the ideal size and shape of the myringotomy knife was not achieved since we utilized a flattened gauge 19 needle as the knife. a customized medical grade stainless steel myringotomy knife can be fabricated to ensure sharp instrumentation, but it would definitely cost more than our fabricated instrument. difficulties in the one-hand technique were also identified such as a good hand-eye coordination, ease of advancing the endoshealth and handling the endoscope at the same time and the finesse in puncturing the tympanic membrane. the lack of formal trials by multiple operators is another limitation of our study. our initial experience with this optical myringotomy knife for tympanostomy tube insertion suggests that it may greatly improve the performance of myringotomy especially among less experienced surgeons. further studies may establish its accuracy and replicability in vitro, after which formal in vivo trials can be attempted. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 letter to the editor 62 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2012; 27 (2): 62-64 c philippine society of otolaryngology – head and neck surgery, inc. dear editor, thyroidectomy is a common surgical procedure performed by us otolaryngologists on our patients. quite often, we make our post-operative rounds on them, not knowing that the patient may have a lot of concerns regarding his or her operation that we somehow take lightly or worse, do not take seriously. i would like to share with other ear nose throat (ent) surgeons how it was to be a patient who underwent total thyroidectomy. my journey began in the mid-1990’s with an incidental finding of thyroid nodules when i underwent a magnetic resonance imaging (mri) of the cervical spine. it was then when i started medical suppression and yearly thyroid ultrasound examinations. however as the years passed, the nodules became more numerous involving both lobes and enlarging. it was last july when ultrasonography revealed that 2 of the nodules were solid and large. i then underwent ultrasound guided fine needle aspiration biopsy of the thyroid nodules for which the result was bethesda 1 (the biopsy was non-diagnostic or unsatisfactory). it was unanimously decided by the endocrinologist and my ent surgeons, dr. alfredo pontejos, jr. and dr. arsensio cabungcal, that i would undergo total thyroidectomy. i had myself admitted at the manila doctors hospital (mdh) on september 18, 2017 and underwent the surgical procedure on september 19. pre-operatively, i told the ent chief resident, dr. catherine oseña my special “bilins”: 1) that i had a cervical spine problem so i could not hyperextend the neck; 2) that i was allergic to penicillin; 3) that i had ceased antiplatelets (clopidogrel, aspirin) and fish oil omega for one week; 4) i had allergies to some non-steroidal anti-inflammatory drugs (nsaids); 5) if possible the suturing be subcuticular so that there wouldn’t be any need to remove any stitches post-op; and 6) the superior thyroid artery be ligated twice and the end of the stump sealed by harmonic scalpel. i had some anxieties regarding the surgery: losing my voice, undergoing tracheostomy for bilateral abductor paralysis since both thyroid lobes would be removed, having a malignant histopathologic result and hypocalcemia. day 0: “this is it”, i said to myself, when the nurse fetched me from my room at 6 am to be brought to the operating room (or) for my 7 am schedule. at the or everybody who saw me greeted me with phrases such as “ikaw pala ang pasyente, kaya mo yan,” “good luck” and “god bless.” here i saw one of my surgeons, dr. cabungcal enter the or suite. it was then when i saw my anesthesiologists, dr. ariel la rosa and dr. greg macasaet. the last memory i had pre-op was that of dr. la rosa inserting an intravenous (iv) line in my right wrist and that was the last thing i remembered. total thyroidectomy from a patient’s perspective cesar v. villafuerte jr., md, mha department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila correspondence: dr. cesar v. villafuerte, jr. department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 554 8467; (632) 554 8400 local 2152 email address: cvillafuertemd@gmail.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believe that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 philippine journal of otolaryngology-head and neck surgery 63 letter to the editor i woke up, already in the post-anesthesia care unit (pacu) or recovery room (rr) when i felt severe pain in my neck (surgical area). i also wanted to fix the pillow at the back of my head but i did not want to cause any strain on my anterior neck. it was also here when i was very happy to hear my own voice. it was then i said that the surgeons preserved my voice. “whataguys!” i said to my self, “thank god.” it was very painful then, i remember the pacu nurse injecting something thru my i.v. line. i felt the medication run thru the i.v. line towards my arm and throughout my body and this made me sleep again (later i found out that it was nalbuphine). i recognize seeing my wife lil, my son vinci and the ent resident, dr. dindo retreta at the pacu. the medication i was given made me sleep again. i woke up again and heard that i was being wheeled out of the pacu to be brought to my room. i only learned later that i slept about an hour after the nalbuphine was given. in my hospital room, the pain in the neck was really painful (9/10) and i had difficulty expelling the phlegm from my trachea. each time i swallowed my saliva, i could feel my trachea move up with accompanying pain. when the resident-on-duty (rod) visited, i was given n-acetylcysteine effervescent tablet bid (ed: bis in die; twice a day) that was very helpful as it made my expectoration easier. i could feel the pressure dressing over my neck which was now stiff due to dried blood. i had my first meal at around 4 pm. i remember it was a tuna sandwich and cold water which i drank using a straw from the hospital plastic cup. every bite and swallow was painful in the neck and throat. i could not detect whether the pain was coming from the throat or from the surgical site. my antibiotic was given i.v. and so was the pain reliever parecoxib, paracetamol and tranexamic acid. i still did not resume the blood thinners to prevent any post-op bleeding. i tried to get up after dinner to walk around but warm serosnguinous fluid came out of the drain soaking my hospital gown. i then had the nurse call the ent rod to change my thyroid dressing. in a few minutes, a new fluffy gauze pressure dressing was applied by the rod and my hospital gown was replaced. i had a good sleep with some pain still at the surgical site and throat. day 1: the day started with holy communion in my room, a good breakfast and my usual morning breakfast pills (thyroxine, nevibolol and folic acid). the residents came and changed the dressing. the resident “milked” the neck trying to see if there was any accumulated blood or serum at the surgical site. this was the most painful of the whole surgical experience (10/10) and it was good news that there was no hematoma in the operative site. they then mobilized the drain by a few centimeters. the dressing was still replaced with less fluffy dressing. i have allergic rhinitis, and the act of sneezing caused recurrent pain in the surgical site so i asked for an antihistamine tablet. my neck and throat were still painful on day 1 (8/10) but relieved every time the i.v. analgesic was given. in the afternoon, i had a sponge bath given by the nurse on duty with me lying in bed. i still had throat phlegm but thanks to the acetylcysteine effervescent tablet it was easier to expectorate. every time the rod made rounds, he checked for hypocalcemia- fortunately i did not have it. day 2: the day again started with holy communion and breakfast in my hospital room. my main attending surgeon, dr. pontejos made his rounds late morning and he changed the dressing and removed the drain. i was here that i realized that the superior and inferior flaps including the incision were all numb. there was no pain on drain removal as well as on tying of the standby suture to close the drain site. they were all numb. at this point, i realized that in all our patients, this removal of the drain and the tying the standby suture were painless. after a bath in the mid-afternoon before discharge, i was then feeling better but the pain was still there (7/10). on the way home, i bought some sterile gauze, plaster, mupirocin ointment and hydrogen peroxide (h2o2) for my neck wound dressing at home. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 letter to the editor 64 philippine journal of otolaryngology-head and neck surgery day 3. the pain was less (5/10) and i did not have to take any analgesic from hereon. bathing became a problem but i devised a way to bathe that i adopted for the following days. in the shower, i first shampooed by hair with my head and face facing down with my wife holding the telephone shower and focusing it where it was needed. after this i dried my head and hair with a clean towel then bathed the rest of the body in standing position with the telephone shower targeting the area needing to be rinsed. i did this method of bathing for a week until i decided that i could now bathe without my head looking down. i was at rest at home for 2 weeks. day 6: it was one of the best days of my life when the chief resident told me that the histopathologic result was multinodular goiter and no malignancy. yehey! thanks to god! god is really good! to summarize some of the things i want to share with other thyroid surgeons: 1) i didn’t realize that the post-op pain was really painful, so i can now understand my patients if they experience pain post-operatively. 2) it was difficult to expel throat phlegm and the n-acetylcysteine effervescent tablet was a big help in liquefying the phlegm. 3) the whole area is numb (superior and inferior flaps), thus the removal of the drain and sutures would not cause any pain on the patient. 4) the “milking” of the site was painful and this procedure should be gently done. 5) if the patient has nasal allergy, cover the patient with an antihistamine to prevent sneezing and unnecessary pain. 6) teach your patient the way i bathed and order a sponge bath on day 1 and 2. i hope this sharing of experience will benefit all your patients who will undergo the same procedurethyroidectomy. i would like to thank my surgeons (dr. alfredo pontejos, jr. and dr. arsenio cabungcal), the anesthesiologists (dr. ariel la rosa and dr. greg macasaet), the surgical assistants (mdh orl residents – drs. catherine elise oseña and dindo retreta), my endocrinologist dr. roberto mirasol and my cardiologist dr. rogelio tangco, for the excellent job, well done. i would like to thank my family – lil my wife, vinci, ericka and raymond for their love and support and for taking care of me. i would like to thank the mdh orl residents for taking care of me and for a job well done as well. i would also like to thank all the nursing staff at the mdh tower 1 and the or, pacu nurses for taking care of me as well. sincerely yours, cesar v. villafuerte, jr., md, mha philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 6362 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 passages robie v. zantua, md (1951-2021) anna carmina t. zantua, md other, but it was a marriage filled with love. in fact, up to the last remaining days of my dad in the icu, the family distantly celebrated our parents’ 41st wedding anniversary with cut flowers from the garden which he religiously tended. they shared the same undergraduate course— they were both b.s. pre-medicine majors in up diliman— and then later on became classmates in the up college of medicine class of 1976. their love for each other were shown in the simplest ways, and these would turn to be the finest memories with tatay. when they would do their morning strolls on bagasbas beach, they would do so holding each other’s hands. of course back then i cringed at the sight but deep inside, i hoped for the same when i became married. later in life and especially during the pandemic, my parents would complement each other’s tasks at home; my dad would lovingly prepare meals for the household and tend the garden while my mom would mainly take care of the grandchildren. my father was a homebody, a great family man, and as my mother would say, he did simple things in extraordinary ways, especially those which involved his grandkids.  when he wore his work hat, he was strict and at times difficult, especially when he was passionate about a certain topic. he could be ill-tempered and be a source of conflict, and this was because he was strong-willed, and vocal about his ideas. his boon and bane. as an ent consultant, he became active in the academe, research and established his practice in laguna and manila. he was invited by the late dr. llamas to teach in the ust college of medicine and helped establish orl as an independent department.  later on, he joined the university of perpetual help college of medicine along with dr. fita guzman. he spent the majority of his working years as an active faculty in two institutions, a laudable feat which only the hardworking ones can pull off.  he also became the president of ahnop and was very passionate in the field of head and neck surgery.  while it was very unfortunate that my father succumbed to covid and its complications, i choose to remember him as a man whose life was dedicated to us, his family. we were blessed to have him as the head of our family, we are forever grateful for the man we call tatay— the man who would tirelessly cook bicolano dishes for us, the man who would patiently and lovingly make sure we were always safe and healthy, the man who would go out of his way and put himself last just to make sure his family was well taken care of. his love was definitely felt by everyone in the family, and i sure hope he felt the same way. may his legacy live on through his children and grandchildren. we love you beyond words, tatay.  it was a challenge to write about my father without going through a mixture of emotions and memories. our father-daughter relationship was far from perfect; we had our fair share of misunderstandings—him being the disciplinarian of the family, and me being the youngest and rebellious daughter.  my father was an introvert— he would rarely say “i love you” or give us hugs growing up. rather, he would show his affection for my sister and me through his subtle but caring ways. i can still vividly remember one afternoon when we were kids, he came home from the hospital and my sister and i welcomed him home with hugs, only to be rejected by him. after seeing us with sad faces (and prodding from our mother), he had to explain the reason why he didn’t return our hugs was because he didn’t want to pass on the microbes which he may have been exposed to at the clinic. in retrospect, there were a lot of times i would misinterpret his well-meaning paternal actions. youngest in a brood of four, and born of a family of lawyers, robie zantua chose to become the first doctor among his velasco-zantua roots. while his older siblings would spend secondary school in manila, he was left in talisay, camarines norte under the care of his maternal aunt for his primary schooling. he would laughingly tell us that because he was a year younger than his classmates, his teacher had to test him before accepting him in school — he was able to read “buto” (seed) without difficulty (buto is ‘penis’ in his native dialect). in hindsight, it was probably because he grew up alone and had to do things independently at a young age that as an adult, he found it hard to ask for favors from others. on one occasion while i was still a medical clerk, he invited me to observe his emergency or (a case of foreign body impaction of a balut). when we arrived at the er, we saw that the patient was yet to be prepared for or— he was not yet even hooked to the i.v. fluid. to my surprise, he asked for i.v. needs from the er nurse and inserted the i.v. catheter himself, hooked the i.v. fluid; and on to the operating theatre we went. years later, i realised if that happened in the government hospital where i trained, it was a sure sunday duty for the er resident; but tatay did not make a fuss out of it and went to address the more important matter— performing the emergency procedure. he was ‘tubong bicol’; his original plan was to return to camarines norte after his ent residency training in pgh—a promise he made to the late dr. mariano caparas. this plan however had to change, to dr. caparas’ dismay, in order to grant my mother’s request that they build their medical practice and start a family in her hometown at santa rosa, laguna.   my mother and father became a huge part of each other’s lives. my parents were not expressive when it came to their emotions for each philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2019; 34 (1): 44-47 c philippine society of otolaryngology – head and neck surgery, inc. aggressive tuberculous otitis media in a young child laurice ann b. canta, md alfred peter justine e. dizon, md franco louie l.b. abes, md, msc department of otorhinolaryngology head and neck surgery east avenue medical center correspondence: dr. franco louie l.b. abes department of otorhinolaryngology head and neck surgery 6th floor, east avenue medical center east avenue, diliman, quezon city 1100 philippines phone: (632) 928 0611 loc. 324 fax: (632) 435 6988 email: eamc_enthns@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. abstract objective: the aim of this report is to describe an aggressive case of tuberculous otitis media in a young child and emphasize that surgical intervention and histopathologic studies can be employed to immediately arrive at a definitive diagnosis. methods: design: case report setting: tertiary government training hospital participants: one results: this is a case of a four-year-old boy who had refractory otitis media and erosive ct scan findings, mimicking aggressive csom manifestations. due to unusual intraoperative granulation tissue characteristics, it was initially considered a malignancy, necessitating surgical intervention and biopsy that resulted in a definitive diagnosis of primary middle ear tuberculosis. conclusion: this case represents the more severe end of the spectrum of tuberculous otitis media and supports the recommendation that a high index of suspicion, early detection and prompt initiation of treatment are imperative in its management, especially in children with refractory otitis media. keywords: tuberculous otitis media; tuberculosis; middle ear; otitis media; suppurative otitis media tuberculosis (tb) is a rare cause of chronic suppurative otitis media making up only 0.040.9% of chronic otitis media cases.1 its variable presentation mimics common bacterial middle ear infections such as refractory otorrhea, hearing loss and multiple tympanic membrane perforation.1-4 computerized tomography (ct) scan findings include diffuse densities in the middle ear with or without bony destruction of mastoid cavities, ossicles, semicircular canals or the tegmen.5,6 intraoperatively, the typical finding are granulation tissues characterized as pale, whitish to yellowish in color.5,6 due to its variable clinical presentation, tb otitis media is commonly misdiagnosed or undertreated. we present the case of a four-year-old boy with tuberculous otitis media with aggressive manifestations and unusual intraoperative granulation tissue characteristics. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery case reports case report a 4-year-old boy was brought to the ent outpatient clinic for evaluation of chronic right ear discharge associated with ipsilateral facial nerve paralysis. his six-month history began with watery, non-foul smelling right ear discharge associated with progressive and persistent otalgia. he had been admitted at a tertiary hospital where intravenous antibiotics and chloramphenicol otic drops were administered which allegedly resolved the symptoms. recurrence of right ear discharge was noted after 3 months, characterized as mucopurulent and associated with otalgia, occasional dizziness, headache, and post-auricular pustule formation. subsequent decreased hearing decreased activity and sudden onset of right-sided facial weakness prompted consult and subsequent admission. he had no other constitutional symptoms such as fever, cough, night sweats, body malaise or weight loss. the review of past history claimed complete immunization (based on the expanded program of immunization of the department of health), no previous surgeries, no family history of tuberculosis or tumor. he was at par with developmental age, and birth and social history were non-contributory. otoscopy revealed bilateral single, central, subtotal (80%) tympanic membrane perforations with erythematous middle ear mucosa and purulent discharge and no mass or granulation tissues. head and neck examination showed a draining pustule in the right post-auricular area (figure 1a) and ipsilateral facial asymmetry, house brackmann grade 4 (figure 1b) with no cervical lymphadenopathies palpated. there were no other neurological deficits and an essentially normal systemic examination. a chest radiograph revealed left pericardiac haziness, interpreted as pneumonia. he also had a slightly elevated white blood cell count of 14 x  109/l  with neutrophilic predominance while other blood parameters were normal. temporal bone ct scans showed cortical erosions forming a single mastoid cavity on the right with soft-tissue isodensities within. there was ossicular destruction and bony erosion of the tegmen, petrous portion of the temporal bone, sigmoid sinus and right horizontal semi-circular canal, but the cochlea was preserved and brain parenchyma was normal. (figure 2a) the left ear only showed opacification of mastoid air cells. (figure 2b) pure tone audiometry suggested moderately severe conducting hearing loss on the right and mild conductive hearing loss on the left. the initial impression was chronic suppurative otitis media with extracranial complications of facial nerve paralysis and subperiosteal abscess on the right. he was started on intravenous ceftriaxone and was scheduled for right canal wall down mastoidectomy under general anesthesia. figure 1. a. post-auricular subperiosteal abscess (arrow); b. right facial nerve paralysis, house brackmann grade iv. (photos published in full, with permission) a b a b figure 2. temporal bone ct scan a. showing erosion of tegmen, sigmoid sinus, lateral semicircular canals and absence of air cells on the right, and b. left mastoid cavity with isodense material within air cells and preservation of the ossicles and semicircular canals. intraoperatively, post-auricular subperiosteal dissection revealed irregular cortical breaks with reddish granulation tissues within. (figure 3a) the spine of henle was no longer appreciated. saucerization of the mastoid cavity by drilling further exposed granulation tissue from the tegmen tympani up to the sigmoid area. (figure 3b) attempts to dissect and remove the granulation tissues from the tegmen were unsuccessful due to their adherence and the possibility of dural sinus rupture. considering the possibility of a neoplasm, it was decided philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery case reports to obtain samples for histopathology, bacterial and acid-fast bacilli staining and culture and perform a modified meatoplasty and closure. final histopathologic results revealed chronic granulomatous inflammation highly suggestive of tuberculosis, described as granulomatous foci with multinucleated giant cells interspersed with lymphoplasmacytic cells, without evidence of malignancy. (figure 4) there were no microorganisms and acid fast bacilli seen from the tissue samples on staining and routine bacterial culture results yielded no growth (lowenstein-jensen medium was not available in our hospital). the patient was started on dose-adjusted anti-tuberculosis therapy (isoniazid, rifampicin, pyrazinamide and ethambutol) and after 2 weeks of treatment, the right ear discharge resolved. on follow-up 11 months after surgery and upon completion of 6-months anti-tuberculosis medications, both ears were dry and the facial paralysis had improved from house brackmann grade 4 to grade 3 with full eye closure but still with right lip weakness. unfortunately, they did not follow up again and post-treatment ct scans were not obtained. discussion tuberculosis is still one of the major health problems in the world especially in low and middle income countries such as the philippines. being endemic in the country, there have been numerous documentations of its varied patterns of presentation and extensive spread to extrapulmonary sites. the most common manifestation of extrapulmonary tuberculosis (eptb) is in the head and neck region, primarily in the cervical lymph nodes with only 2% involving the middle ear.4,7 according to sens et al., primary tb otitis media affects children more often than adults. it has been classically described as painless otorrhea, multiple tympanic membrane perforations and hearing loss disproportionate to otoscopic appearance.1,3,7-9 however, the clinical presentations have changed over the years and have become polymorphic and insidious. recent reports showed that otalgia is significantly present in most tb otitis media patients, such as the case presented here, and may be due to the pressure caused by granulation tissue occupying the mastoid cavity.3,6,8 tympanic membrane perforations may be multiple in the early stage and coalesce into total perforations at a later stage.6 hearing loss worsens when there is progressive erosion of the ossicles and its bony structures.8 according to sens et al., complications of tb otitis media include facial paralysis, retroauricular fistula, labyrinthitis, meningitis, tuberculous osteomyelitis, intracranial or extracranial abscesses, acute mastoiditis and cellulitis. facial nerve paresis or paralysis occurs in up to 40% of cases and more frequently in children.5,8,10,12 tuberculous otitis media mimics chronic suppurative otitis media (csom) even on ct scan presentation – soft tissue densities occupying the entire mastoid and middle ear cavities with blunting of scutum.1 in some studies, there is preservation of the mastoid air cell architecture1 while others show extensive bony destruction and sclerosis of the figure 4. histopathologic slides of mastoid antrum specimens a. granulomatous inflammation (hematoxylin-eosin, low power view); and b. granulomatous foci with multinucleated giant cells interspersed with lymphoplasmacytic cells (hematoxylin-eosin, high power view). figure 3. a. intraoperative findings of reddish, beefy granulation tissue upon exposure and b. after attempting excision (a, anterior; p, posterior; s, superior; i, inferior). b a (hematoxylin – eosin , low power view) a (hematoxylin – eosin , high power view) b philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery case reports references 1. abes gt, abes fl, jamir jc. the variable clinical presentation of tuberculosis otitis media and the importance of early detection. otol neurotol. 2011 jun; 32(4): 539-543. doi: 10.1097/ mao.0b013e3182117782. pmid: 21532520. 2. tompkins km, reimers ma, white bl, herce me. diagnosis of concurrent pulmonary tuberculosis and tuberculous otitis media confirmed by xpert mtb/rif in the united states. infect dis clin pract (baltim md). 2016 may; 24(3): 180-182. doi: 10.1097/ipc.0000000000000333; pmid: 27346926 pmcid: pmc4915369. 3. nicolau y, northrop c, eavey r. tuberculous otitis in infants: temporal bone histopathology and clinical extrapolation. otol neurotol. 2006 aug; 27 (5): 667-671. doi: 10.1097/01. mao.0000224085.08344.50; pmid: 16868514. 4. oishi m, okamoto s, teranishi y, yokota c, takano s, iguchi h. clinical study of extrapulmonary head and neck tuberculosis: a single-institute 10-year experience. int arch otorhinolaryngol. 2016 jan; 20(1): 30-33. doi: 10.1055/s-0035-1565011; pmid: 26722342 pmcid: pmc4687992. 5. gupta n, dass a, goel n, tiwari s. tuberculous otitis media leading to sequential bilateral facial nerve paralysis. iran j otorhinolaryngol. 2015 may; 27(80): 231-237. pmid: 26082906 pmcid: pmc4461848. 6. tang ip, prepageran n, ong ca, puraviappan p. diagnostic challenges in tuberculous otitis media. j laryngol otol. 2010 aug; 124(8): 913-915. doi:10.1017/s0022215110000265; pmid: 20426886. 7. akkara sa, singhania a, akkara ag, shah a, adlaja m, chauhan n. a study of manifestations of extrapulmonary tuberculosis in the ent region. indian j otolaryngol head neck surg. 2014 jan; 66(1): 46-50. doi: 10.1007/s12070-013-0661-7; pmid: 24605301 pmcid: pmc3938696. 8. sens pm, almelda ci, valle lo, costa lh, angeli ml. tuberculosis of the ear, a professional disease? braz j otorhinolaryngol. 2008 jul-aug; 74(4): 621-627. pmid: 18852993. 9. karkera gv, shah dd. silent mastoiditis-tuberculous aetiology presenting as facial nerve palsy. indian j otolaryngol head neck surg. 2006 jan; 58(1): 108-110. doi: 10.1007/bf02907762. pmid: 23120258 pmcid: pmc3450627. 10. kiminyo k, levy c, krishnan j, garro j, lucey d. tuberculous otitis media and mastoiditis. infectious diseases in clinical practice. 2001; 10:491–492. 11. choi hy, jang jh, lee km, choi ws, kim sh, yeo sg, kim ej. primary nasopharyngeal tuberculosis combined with tuberculous otomastoiditis and facial nerve palsy. iran j radiol. 2016 jan; 13(1):e30941. doi: 10.5812/iranjradiol.30941. pmid: 27127580 pmcid: pmc4841938. 12. adhikar p. tuberculous otitis media: a review of literature. the internet journal of otorhinolaryngology. 2008; 9(1):1-6. mastoid.2 in our patient, the ct scans showed soft tissue attenuation within the mastoid cavity and sclerosis of mastoid air cells. there was ossicular destruction and dehiscence of the lateral semicircular canal and tegmen and blunting of the scutum. these changes are also usually seen in csom but may represent late stages of tuberculous infection. the role of surgery in managing tuberculous otitis media is debatable. it is not essential to treatment and is only reserved for facial nerve decompression, removal of sequestra or improvement of drainage.3,8,12 however, it is important to note that surgical intervention facilitates harvesting specimens that pave the way for the definitive diagnosis of tb otitis media. intraoperatively, the most common finding is a pale, whitish to yellowish soft granulation tissue descriptive of caseous necrosis.1,5,6,11 however, there have been reports of granulation tissues adherent to mucosa with abundant dilated blood vessels that eventually led to hematoma formation that might explain the appearance of the adherent reddish soft tissue seen in our patient.3,5 the degree of bony erosion and necrosis is variable. some cases still had identifiable osssicles engulfed in granulation tissue while others had a fistula in the semicircular canals, dehiscence over the facial nerve or erosion up to the mastoid cortex.1,3,5,10 our case differs from the usual presentation in that the granulation tissue was reddish and closely adherent to the dura so much so that it could not be separated. together with the aggressive manifestations and extent of involvement, this made us consider the possibility of a soft tissue tumor or neoplastic process. histopathologic confirmation was the only way to arrive at a diagnosis. in concurrence with most reported cases of tb otitis media, histopathologic interpretation of the granulation tissue is the most reliable method, showing the presence of m. tuberculosis or epitheloid cells and multinucleated giant cells (langhans cells).4,7,8 some recommend polymerase chain reaction (pcr), bacteriologic exam and culture of the discharge, mantoux and other serologic tests to determine the immune status of the patient. unfortunately, most of these tests are non-specific and have low yield due to superimposed bacteriologic infection.2,5,10,12 the treatment of tb otitis media is primarily medical. antituberculosis medications are still the most effective management even for middle ear infection. most cases respond well, with resolution of middle ear granulations and sometimes full recovery of facial nerve paralysis. the indicator of success or failure is the time interval between onset of the infectious process and initiation of treatment.1,8,10,12 in conclusion, tuberculous otitis media remains one of the elusive causes of chronic suppurative otitis media. its diagnosis is challenging and its manifestations are evolving into a spectrum ranging from simple otitis media to tumor-like presentation. our patient represents the more severe end of that spectrum, who nonetheless responded to treatment well. this case supports previous recommendations that a high index of suspicion, early detection and prompt initiation of treatment are imperative steps in its management especially in children with refractory otitis media. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2022; 37 (2): 42-45 c philippine society of otolaryngology – head and neck surgery, inc. multifocal tuberculosis presenting as mandibular swelling in a 3-year-old boy: a case report kathleen kay k. yambot, md neil aldrine i. peñaflor, md department of otolaryngology head and neck surgery bicol medical center correspondence: dr. neil aldrine peñaflor department of otolaryngology – head and neck surgery bicol medical center concepcion pequeña, naga city, camarines sur 4400 philippines phone: (+63) 0920 915 5998 email: neil_penaflor@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest presented at the philippine society of otolaryngology head and neck surgery interesting case contest. (1st place) may 28, 2022 via zoom. abstract objective: to report a case of multifocal pediatric tuberculosis presenting with mandibular swelling and discuss its etiology, clinical findings, diagnosis, management, and outcome after treatment. methods: design: case report setting: tertiary government training hospital patient: one results: a 3-year-old boy presented with progressive non-tender, right mandibular swelling for 11 months. panoramic x-ray exhibited extensive multiple loculations with lytic changes on the mandible. ct scans revealed a peripherally enhancing hypodense mass with lytic expansion of the right mandibular angle extending across the left mandibular body with an incidental finding of right lung mass. other extrapulmonary lesions were also detected involving the scapula, pleura with lysis of the adjacent ribs at the level of t7 and t8. biopsy of the mandibular and lung mass confirmed the presence of caseating and non-caseating granulomas consistent with koch’s infection. the patient showed significant improvement by the 7th month of a 12-month course of anti-tuberculous therapy. conclusion: multifocal tb can present as simple mandibular swelling, and a thorough workup should look for other involved sites. early diagnosis in children may prevent debilitating sequelae and improve long-term treatment outcomes. keywords: tuberculosis (tb); mandible; child; multifocal; disseminated; extrapulmonary tuberculosis (tb) a granulomatous disease caused by mycobacterium tuberculosis, m. bovis and atypical mycobacteria1 that is highly curable but still ranks as the number one killer among all infectious diseases.2 the world health organization (who) estimates  1.8 million people in the western pacific region developed active tb in 2016 with 573,000 (32%) in the philippines.3 creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery case reports the majority of cases (98.9%) had pulmonary tb while 1.1% had extrapulmonary (eptb).4 tuberculous osteomyelitis of the mandible is rare and is only observed in <2% of skeletal tuberculosis.1 to our knowledge, there are two locally-reported cases of eptb involving the mandible in a 10-year-old boy5 and the temporomandibular region in a 33-year-old man.6 we report what we believe is the second locally reported case of tb of the mandible in a child, a case of multifocal pediatric tuberculosis, and discuss its clinical course, diagnosis, management and outcome after treatment.  case report a 3-year-old fully immunized boy presented with right mandibular swelling of 11 months. two months prior to consultation, episodes of low-grade fever were noted followed by gum bleeding admixed with purulent discharge. he was brought to a dentist and a panoramic x-ray revealed lytic changes encompassing the right mandibular angle extending across the left mandibular body. (figure 1) oral clindamycin was taken for 7 days with no improvement of symptoms. on the day of consult, physical examination showed an afebrile, underweight and stunted child with no developmental delay (z-score  < 2, based on who weight-for-age and height-for-age, 2-5 years old) with diffuse swelling of the right mandible and non-hyperemic, nontender overlying skin. there was purulent, bloody discharge from the crown of the right second mandibular molar with diffuse hyperemia of surrounding gingival mucosa. (figure 2) there were dental caries and multiple non-tender lymph nodes were palpated in both submandibular and submental areas. there was a family history of multiple abscesses in his maternal grandfather and three uncles that lasted for weeks during their childhood, leaving pitted scars over the thorax, knees, and thighs. unknown medications had been taken.  the boy was admitted with an impression of mandibular osteomyelitis and intravenous clindamycin at 20mg/kg and povidone iodine mouthwash were started. purified protein derivative skin test yielded a positive result of 5mm after 48 hours. chest radiographs showed hazy opacities in the right upper lobe, likely consolidation due to pneumonia or pulmonary mass with minimal fluid layering on right lateral decubitus position. the crp was elevated at 12.64 (<10) and esr was high at 70 (0-15) indicating systemic infection. peripheral blood smears revealed microcytic anemia, white blood cell counts were normal with no blast cells seen and platelets were adequate. head and neck contrast ct scans showed a peripherally enhancing hypodense mass with lytic expansion from the right angle down to the left body of the mandible. (figure 3a, b, c) there were enhancing lymph nodes along the submental, submandibular, jugular, and figure 1. panoramic radiograph showing osteolytic lesion from the right mandibular angle extending up to left mandibular body. figure 2. gingival swelling from right mandibular second molar to canine with pinpoint fistula draining purulent discharge admixed with blood. figure 3. head ct with contrast, a. axial and b. coronal bone window cuts showing peripherally enhancing hypodense mass with lytic expansion involving the right angle (+), symphysis (x), bilateral parasymphysis and bilateral mandibular body (o); c. 3d reconstruction showing lytic expansion involving the right mandibular angle, symphysis, bilateral parasymphysis and bilateral mandibular body. a c b philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery case reports panoramic x-ray showed reduction in the bony defect with progressive bone deposition. eight months post treatment, facial ct scans showed bone deposition and remodeling of the body and angle of the right mandible and longitudinal groove along the body signifying post infection changes. (figure 5 a, b) chest ct scans showed decrease in the pleural based mass to 1.74 cm x 4.69 cm x 2.10 cm still associated with lysis of the adjacent t8 rib. the previously seen right upper lobe mass now measured 2.91 cm x 3.91 cm x 4.19 cm. no lytic lesion was seen in the scapula. currently, he is compliant with follow-up, with good nutritional status (z-score of 0, based on who weight-for-age and height-forage, 2-5 years old) and regularly taking his medications to complete a 12-month course. discussion around 1 million children (<15 years) suffer from tb worldwide and more than 136,000 die each year with 75% occurring in low income countries.4 the philippines has one of the highest tb incidence rates in the region with around 554 cases per 100,000 in 2016.3 children under 5 years of age are at high risk of developing clinical tb after infection and are prone to developing severe forms of tb such as meningitis and disseminated tb particularly if not protected by bacillus calmetteguerin (bcg) vaccination.  extra pulmonary tb diagnosis is usually made based on history, clinical presentation, radiography, sputum analysis, histopathology, and serological investigations. we presented the case of a child with a slow, progressively enlarging, non-tender mass on the mandible with associated on and off low-grade fever and bloody to purulent discharge from the crown of the mandibular 2nd molar. in the two published cases of the eptb of the mandible, the 33-year-old man presented with preauricular swelling associated with trismus6 and the 10-yearold child presented with painless mandibular swelling and draining sinuses.5 laboratories revealed elevated crp, high esr, and microcytic anemia pointing to a systemic infection. gold standards for detection of tuberculosis are culture sensitivity, histology, serological testing, and tb pcr. gastric aspirate tb pcr showed very low detection for mtb, and gs/cs, koh and afb also yielded no growth. several factors may contribute to a negative result such as poor collection technique, an aerobic bacterium not isolated from the specimen or a different pathogen mimicking bacterial infection. radiologic workups exhibited an ill-defined radiolucency with sclerotic borders and osteolytic changes on panoramic x-ray, and ct scan findings of a peripherally enhancing hypodense mass with lytic figure 4. neck ct scan with contrast, axial view, with incidental finding of an enhancing mass in the right lung apex measuring 4.01 cm x 2.19 cm. figure 5. facial ct scans, 3d reconstruction. a. anterior and b. right lateral oblique views showing longitudinal groove along the body signifying post infection changes. a b posterior cervical chains with the largest measuring 2.2 cm x 1.68 cm and an incidental finding of an enhancing right upper lung mass. (figure 4) chest ct scan with contrast showed a 4.6 cm x 5.4 cm x 5.9 cm heterogenous enhancing mass in the right upper lobe and a 2.1 cm x 5.2 cm x 2.3 cm mass on the right pleura at the level of t7-t8 with lysis of adjacent ribs, and a lytic bone lesion in the right scapula. incision and punch biopsy intraoperative findings revealed granulation tissues admixed with yellowish cheesy materials. fluid samples taken for gram stain with aerobic culture sensitivity (gs/cs), koh and afb yielded negative results. histopathologic examinations of the mandible and lung specimens showed caseous and non-caseous granulomas consistent with koch’s infection. gastric aspirate sent for tb pcr yielded very low detection of mtb. he was discharged on an anti-tuberculosis regimen under direct observed treatment (dot) with instructions for monthly follow-up. chest x-rays requested for all household members were negative for tb. four months after starting treatment, there was still swelling of the mandible and intraoral pus with minimal blood. by the 7th month, he was asymptomatic, with good facial symmetry and no mandibular swelling. however, there were still hyperemic areas along the right mandibular gingival mucosa from canine to second molar. repeat philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery case reports expansion involving the right angle down to the left body of the mandible suggestive of a nonspecific osteomyelitis, with an incidental finding of a lung mass leading us to perform tissue biopsy. results showed caseating and non-caseating granuloma consistent with koch’s infection. tuberculosis infection may disseminate through direct transfer from infected sputum, regional extension of soft tissue lesion to involve the underlying bone or through hematogenous spread,7 resulting in involvement of the mandible in our case. the mandible is said to be the second most common site of tb infection.8 tuberculosis of the mandible is rare because the mandible contains less cancellous bone, and the infection is thought to begin in the cancellous portion.8 involvement of the mandible may be due to its blood supply and bone density. the mandible is a dense bone and is solely supplied by the inferior alveolar vessels. infection can cause decrease in blood supply leading to necrosis which makes it susceptible for bacteria to grow.7 tuberculosis of the mandible could present with a variety of signs, including periodontitis with horizontal bone loss, apical osteitis and widespread destructive lesions and sequestrations which were observed in our patient.9 references 1. sambyal ss, dinkar ad, jayam c, singh bp. primary tuberculous osteomyelitis of the mandible in a 3-year-old child. bmj case rep. 2016 sep 21;2016:bcr2016216854. doi: http://dx.doi.org/10.1136/bcr-2016-216854; pubmed pmid:  27655878; pubmed central pmcid: pmc5051373. 2. world health organization. tuberculosis. 14 october 2021. [cited 2022 february 27] available from https://www.who.int/news-room/fact-sheets/detail/tuberculosis. 3. snow k, yadav r, denholm j, sawyer s, graham s. tuberculosis among children, adolescents and young adults in the philippines: a surveillance report. western pac surveill response j. 2018 nov 9;9(4):16-20. doi: 10.5365/wpsar.2017.8.4.011; pubmed pmid: 30766743; pubmed central pmcid: pmc6356044. 4. kiat mo. clinical profile and treatment outcomes of childhood extra-pulmonary tuberculosis in a children’s medical center. pidsp journal. 2017 jul-dec; 18(2):3-15.  5. romualdez j, dualan m. mandibular osteomyelitis: an unusual form of tuberculosis. philipp j otolaryngol head neck surg. 1999 april-june;14(2):36-43. 6. santos jm, reala et. tuberculosis of the temporomandibular region. philipp j otolaryngol head neck surg. 2018 jul-dec;33(2):41-4. doi: https://doi.org/10.32412/pjohns.v33i2.275. 7. karjodkar f, saxena vs, maideo a, sontakke s. osteomyelitis affecting mandible in tuberculosis patients.  j clin exp dent.  2012 feb;4(1):e72–e76. doi: 10.4317/jced.50588; pubmed pmid: 24558529; pubmed central pmcid: pmc3908814. 8. towdur gn, upasi ap, veerabhadrappa uk, rai k. a rare, unusual presentation of primary tuberculosis in the temporomandibular joint.  j oral maxillofac surg. 2018 apr;76(4):806-811. doi: 10.1016/j.joms.2017.09.010; pubmed pmid: 29031528. 9. kakisi ok, kechagia as, kakisis ik, rafailidis pi, falagas me. tuberculosis of the oral cavity: a systematic review.  eur j oral sci. 2010 apr;118(2):103-109. doi:10.1111/j.16000722.2010.00725.x; pubmed pmid: 20486998. in our case, the patient was fully immunized but still developed disseminated tb. factors in developing disseminated tb include malnutrition, poor dental hygiene, and family history of unknown abscess formation. the disease may have started in the lungs as is more common and since there were dental caries, these may have been the route of infection for spread in the mandible.  our patient showed drastic improvement by the 7th month of treatment with a dot anti-tuberculosis regimen. he remains compliant with the treatment regimen which will be completed for 12 months.  in summary, tuberculosis can manifest in various ways, and diagnosing extrapulmonary tb remains a great challenge, hindering early detection. multifocal tb can present as simple mandibular swelling, and a thorough workup should look for other involved sites. early diagnosis in children may prevent debilitating sequelae and improve long-term treatment outcomes. a thorough history, complete physical examination, and appropriate diagnostics are key to diagnosis and treatment. the proper anti-tb therapeutic regimen is important and long term follow up is warranted especially in children because tb can remain inactive for years.  philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 philippine journal of otolaryngology-head and neck surgery 57 from the viewbox intracranial complications of acute sinusitis on brain ct this 35-year-old woman presented to a peripheral hospital accident and emergency department in a moribund state. she was intubated, stabilized and transferred urgently to a tertiary centre. she had attended the hospital in the prior week with a diagnosis of sinusitis. an urgent ct brain was requested by the attending a and e officer which was undertaken on the basis of her low glasgow coma scale (gcs). the paranasal sinuses were partially visualised on this investigation. correspondence: dr. ian c. bickle consultant radiologist department of radiology ripas hospital bandar seri begawan ba1710 negara brunei darussalam phone: +673 224 2424 fax: +673 224 2690 email: firbeckkona@gmail.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2017; 32 (1): 57-58 c philippine society of otolaryngology – head and neck surgery, inc. ian c. bickle, mb,bch,bao, frcr department of radiology ripas hospital bandar seri begawan brunei creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international acute bacterial rhinosinusitis is a common disease presenting to both general practitioners and ent surgeons. it is on the most part short-lived in duration responding to antibiotics and symptomatic medications. rarely it may be associated with severe life threatening complications, in the form of intra-orbital extension or even less so intracranial complications. these typically occur in the pediatric and young adult population.1 cross-sectional imaging plays an essential role in the assessment of this small sub-set of patients and is largely and almost always in the first instance with ct.2 computed tomography is broadly available even out of standard working hours and facilitates the review of potential intracranial complications and thereby guide neurosurgical management. given that a proportion of the paranasal sinuses are always visualised on a ct brain it is an important review area especially in patients with sepsis. figure 1 a. axial ct brain (non-contrast): thin bilateral subdural collections. low attenuation in the inferior right temporal lobe and external internal capsule suggestive of an acute infarct. b. axial ct brain (with contrast): enhancing bilateral subdural collections in keeping with empyemas. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 from the viewbox 58 philippine journal of otolaryngology-head and neck surgery references 1. sultész m, csákányi z, majoros t, farkas z, katona g. acute bacterial rhinosinusitis and its complications in our pediatric otolaryngological department between 1997 and 2006. int j pediatr otorhinolaryngol. 2009 nov;73(11):1507-12. doi: 10.1016/j.ijporl.2009.04.027 pmid: 19500861 2. dankbaar jw, van bemmel ajm, pameijer fa. imaging findings of the orbital and intracranial complications of acute bacterial rhinosinusitis. insights imaging. 2015 oct; 6(5): 509–518. doi: 10.1007/s13244-015-0424-y pmcid: pmc4569601 3. osborn mk, steinberg jp. subdural empyema and other suppurative complications of paranasal sinusitis. lancet infect dis. 2007 jan;7(1):62-7. doi: : 10.1016/s1473-3099(06)70688-0 pmid: 17182345 4. bickle ic. intracranial complications of acute sinusitis. case rid: 45559. created 30 may 2016 in radiopaedia.org ©2005-2017. [cited 2017 june 13] available from: https://radiopaedia.org/ cases/intracranial-complications-of-acute-sinusitis. there are a number of well recognized intracranial complications of acute rhinosinusitis which include; meningitis, cerebral abscess, subdural empyema, cavernous sinus and dural venous thrombosis.3 additional sequelae from the intracranial infection may result such as arterial territory cerebral infarction, ventriculitis and hydrocephalus. those patients in whom intracranial extension occurs often demonstrate bony destruction of the sinuses on imaging. disease involving the frontal sinus is typically associated with intracranial complications, through foci of bony dehiscence or osteomyelitis involving the floor of the anterior cranial fossa.3 in this case, the patient presented in a moribund state due to severe intracranial complications following failed treatment in the community. the initial ct imaging identified subdural collections (figure 1a and 1b) as well as pan-sinusitis (figure 2) and the suggestion of an arterial territory infarct (figure 1a). the frontal sinus however was not involved in this instance. a complete ct study of the paranasal sinuses (with a dedicated paranasal sinuses protocol) is merited including isotropic reconstructions to review the bony integrity and aid the planning of ent surgical intervention. an mri brain if available would eloquently confirm the ct findings including confirmation of the acute parietal lobe infarct.4 neurosurgical drainage of the subdural empyemas was undertaken. furthermore, functional endoscopic sinus surgery (fess) was also figure 2. axial ct brain: the ethmoid and sphenoid sinuses are opacified with fluid. no bony destruction. performed with drainage of a large volume of pus from the sphenoid, ethmoidal and right maxillary sinuses.4 this case demonstrates intracranial complications are not an entity unique to the paediatric population. when caring for patients with acute sinusitis always have a high index of suspicion for these potential complications and have a low threshold for engagement with radiology colleagues for imaging if concerned. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 president’s page greetings of peace and good health! i would like to sincerely congratulate the indefatigable editorial staff of the philippine journal of otolaryngology head and neck surgery for this latest issue of our bi-annual publication under the tutelage of our esteemed editor-in-chief, dr. jose florencio f. lapeña, jr. the philippine society of otolaryngology head and neck surgery is indebted to your tireless efforts to continue to come up with a scientific journal with academic research at par with international standards, despite what we know are more difficult circumstances brought about by a continuing global pandemic. i hope our fellows will continue to guide our training residents and fellows-in-training, in coming up with journal-worthy scientific papers. this journal would not be what it is now without the tireless efforts of our fellows in the academe and training institutions. it is my wish and hopeful prayer that the next issue will come out under more favorable and happier circumstances. let us all continue to be safe. cheers to a better year ahead. john rodolfo d. suan, jr., md, mha, fpso-hns, fpcs president philippine society of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles philippine journal of otolaryngology-head and neck surgery 19 abstract background: certain indigenous populations have been noted by the world health organization (who) to have the highest prevalence rates for chronic suppurative otitis media (csom), including the australian aborigines (28-43%), greenlanders (2-10%) and alaskan eskimos (2-10%). objectives: to determine the prevalence of common ear problems, particularly csom, among the indigenous ati or aeta community in bolabog, boracay, and to determine their hearing sensitivity using screening audiometry. methods: study design descriptive cross-sectional study. setting a small ati community in bolabog, boracay. population a total of 63 adults and children underwent medical interview and otoscopy. additionally 24 had their hearing screened by audiometry. results: about a quarter of the population participated in the study, including 41 children (40% of all children) and 22 adults (18% of all adults). forty-six percent of children and 23% of adults who were examined had previous history of ear discharge, while 22% of children and 45% of adults who were examined had history of hearing loss. seventeen percent of children had history of hearing loss in the family. csom was found in 18 (43.90%) children and 8 (36.36%) adults. impacted cerumen was found in 17.1% of children. eleven female children underwent screening audiometry. of these, eight had normal hearing and three had abnormal findings. thirteen adults were also tested, five of whom were male and had normal hearing bilaterally. four of eight female adults had abnormal hearing, of which three were unilateral. conclusions: the ati population in bolabog, boracay belongs to a group with the highest prevalence rates for csom (27.0%). a bigger sample for screening audiometry is required for proper estimation of hearing loss prevalence. both environmental and genetic factors may have increased the prevalence of csom in the ati population of boracay. keywords: hearing loss, chronic suppurative otitis media, boracay, indigenous community, ati, aeta introduction chronic suppurative otitis media (csom) is described as persistent middle ear discharge through a tympanic membrane perforation. it is a major cause of preventable hearing loss in the developing world. according to the world health organization (who), even without otoscopy, it can be assumed that any ear that continues to discharge after 2 months is already csom and that an otolaryngologist is able to diagnose csom more than 95% of the time just noting the discharge alone. the most effective means of treating csom involves the use of topical antiseptics or antibiotics for at least 2 weeks. in some cases intravenous antibiotics may be required along with surgery. in 2004, the global burden of csom involved 65 to 330 million people, 60% of whom had significant hearing loss. csom caused 28,000 deaths daily. ninety percent of csom cases are otoscopic and audiologic findings in an ati community in boracay maria rina t. reyes-quintos, md mclinaud1,2; regie lyn p. santos, md phd1,2; ma. leah c. tantoco, md mclinaud1; rodante a. roldan, md3; kathleen r. fellizar, md3; meliza anne m. dalizay-cruz, bssp, mclinaud1; generoso t. abes, md mph1,2; charlotte m. chiong, md1,2 1philippine national ear institute national institutes of health university of the philippines manila 2department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila 3department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: maria rina t. reyes -quintos, md, mclinaud philippine national ear institute, national institutes of health university of the philippines manila 2nd floor central block philippine general hospital taft avenue, ermita, manila 1000 philippines telefax: (632) 522-0946; email: info@earinstitute.org.ph reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. philipp j otolaryngol head neck surg 2007; 22 (1,2): 19-21 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles 20 philippine journal of otolaryngology-head and neck surgery found in countries in south-east asia, the western pacific region and africa and among ethnic minorities along the pacific rim. the prevalence rate of csom is classified by the who as belonging to the following groups: lowest if < 1%; low if 1-2%; high if 2-4%; and highest if >4%. the philippines is noted to have a high prevalence rate of 2-4% but the populations with the highest prevalence rates are in tanzania, india, solomon islands, and guam (>4). certain indigenous groups also belong to the group with the highest prevalence of csom such as the australian aborigines (28-43%), greenlanders (2-10%) and alaskan eskimos (2-10%).1,2 the ati is one of several indigenous populations in the philippines. they are dark-complexioned, small-framed, short in stature, often frizzyhaired people found all over the archipelago from northeastern luzon to the visayan islands and to the northeastern interior of mindanao.3 our study focused on an ati community in bolabog in the visayan island of boracay. the ati community in bolabog, boracay is composed of more than 200 individuals who belong to over 40 households. they live in wooden homes of approximately 4 meters by 5 meters clustered closely together with an average of 5 family members per household. they work as laborers either as carpenters and beach sweepers earning 125 to 150 pesos a day. they also receive private donations through the sisters of charity, st. vincent de paul. according to a volunteer pediatrician who routinely checks the children, the children are generally poorly nourished and underweight and their ears have never been evaluated medically. this study aims to determine the prevalence of common ear problems, particularly csom, among the ati in bolabog, boracay, and to determine their hearing sensitivity using screening audiometry. methods this is a descriptive cross-sectional study. initially, the community was organized through communication with the lead sister from the sisters of charity, st. vincent de paul. community consent for the study was taken. included in the study are those who consent to have their ears checked and tested, while excluded from the audiologic screening are those who cannot follow testing instructions and those with impacted cerumen and actively discharging ears due to ear infection. a questionnaire was administered by trained personnel. this contained information about name, age, occupation, present health, history of ear and hearing problems and treatment that they might have undergone. otoscopy was performed by an otolaryngologist. appearance of the ear canal and tympanic membrane and presence of ear wax/cerumen, ear discharge and ear infection were documented. cerumenolytics and antibiotic otic drops were given to those with impacted cerumen and suppurative otitis media, respectively. the medicines were left to the care of the sisters of charity who were advised on how to administer the drops and to coordinate with the local physician for patient follow-up. the hearing test was done using a screening audiometer (model mt-3a made by nagashima medical instruments company ltd, tokyo, japan) in a separate room. ambient noise was documented using a sound level meter (model tes1350a made by tes electrical electronic corp., taiwan, r.o.c.). prevalence rate of csom, other ear pathologies and hearing loss were calculated. results based on a local registry, the ati population in bolabog, boracay is composed of 222 individuals, including 119 adults and 103 children. sixty-three individuals participated in the study (28.38% of the entire population): 41 were children (40% of all children) and 22 adults (18% of all adults). otologic history majority of the participants were children and most were female (table 1). nineteen (46.3%) children and five (22.7%) adults had previous history of ear discharge, while nine (22.0%) children and ten (45.5%) adults had history of hearing loss. this makes the overall percentage of individuals with previous history of ear discharge to 38.1 and of hearing loss to 30.2. seventeen percent of children (7 of 41) had history of hearing loss in the family. table 2. otoscopic findings by age group and sex* otoscopic finding male children female children female adults impacted cerumen bilateral: 3 bilateral:1 none unilateral:1 unilateral:2 otitis media with effusion bilateral: 0 bilateral: 2 bilateral: 0 unilateral: 1 unilateral: 1 unilateral: 1 perforated eardrum, dry none bilateral: 0 bilateral: 0 unilateral: 3 unilateral: 2 perforated eardrum, wet bilateral: 3 none bilateral: 1 unilateral: 1 unilateral: 3 active discharge bilateral: 2 bilateral: 3 bilateral: 0 unilateral: 1 unilateral: 1 unilateral: 1 * only one adult male was found to have active discharge in both ears. also one adult female was found to have otomycosis in one ear. table 1. number of study participants according to age group and sex n male (%) n female (%) n total (% by age group) children* 17 (41.5) 24 (58.5) 41 (61.5) adults 7 (31.8) 15 (68.2) 22 (34.9) total 24 (38.1) 39 (61.9) 63 * includes participants below 18 years of age. otoscopic findings the otoscopic findings according to age group and gender are presented in table 2. impacted cerumen was found in 7 (17.1%) philippine journal of otolaryngology-head and neck surgery vol. 22 nos. 1 & 2 january –june; july – december 2007 original articles philippine journal of otolaryngology-head and neck surgery 21 children; otitis media with effusion in 4 (9.8%) children and 1 (4.5%) adult; perforated tympanic membrane (dry) in 3 (7.3%) children and 2 (9.1%) adults; csom and active ear discharge in 11 (26.8%) children and 6 (27.3%) adults; and otomycosis in 1 (4.5%) adult. the overall prevalence of csom among the ati participants is therefore 27.0%. impacted cerumen was also common among children, with a prevalence of 17.1% (equivalent to 11.1% of entire population tested). using otoscopy as gold standard for diagnosing chronic otitis media, history of ear discharge showed a sensitivity of 93.8% and specificity of 80.0%. audiologic findings audiologic screening was done in a relatively quiet room with background noise of 49 to 60 dba, averaging 55 dba when tested every 30 minutes. because of the high ambient noise in the room normal hearing thresholds were determined to be 40 db across frequencies (500-4000 hz). eleven female children underwent screening audiometry. eight children had normal hearing while 3 children had abnormal findings (1 unilateral). five male and 8 female adults were also tested. all the males had bilaterally normal hearing. four females had normal hearing bilaterally and 4 had abnormal hearing (3 unilateral). none of those with csom and actively discharging ears were tested. using screening audiometry as a gold standard for hearing, history taking for hearing loss alone showed a sensitivity of 20% for children and 80% for adults and a specificity of 33% for children and 80% for adults. discussion the ati in bolabog, boracay belongs to the group with the highest csom prevalence rates (27%) based on the who classification. it is much higher than the overall prevalence rate in the philippines and is approaching the prevalence rate of the australian aborigines which currently has the highest rate. this could be due to observed overcrowding in the homes, poor hygiene, poor nutrition, poor access to health care4 and possible genetic factors5 leading to predisposition to poor immune resistance. interestingly the ati community is composed of a handful of families that intermarried through generations, thus, consanguinity and increased sharing of genetic material may play a role in greater predisposition to csom. this is further strengthened by the similar environmental background and lifestyle factors that all individuals in the community are exposed to. audiologic tests were not done for all participants because many of the children were too young to follow instructions. during testing most of the adult males were at work, while many of the younger children were available for testing. also the presence of active ear discharge and failure to obtain consent precluded audiologic testing in many cases. on the other hand, the presence of drainage in the ear is highly indicative of hearing loss. only 10.8% of the population was tested with audiometry. thus the prevalence estimate of 29.2% (7 of 24) for documented hearing impairment may not be reflective of the entire community. predisposing factors such as personal history and family history of hearing loss had low sensitivity and specificity in detecting hearing loss in children, while history of hearing loss in adults is sensitive and specific. also, history of ear discharge is highly sensitive and specific in detecting presence of ear discharge in both children and adults. this means that history alone is very useful in suspecting csom, particularly in adults. for children, hearing should be tested objectively (e.g. by play audiometry) to get reliable hearing sensitivity rates. there were two children and one adult with abnormal audiometric but normal otoscopic findings. in these cases the hearing loss may be due to an inner ear problem and thus formal evaluation of these individuals is needed to determine true hearing sensitivity. the limitation of this study includes the fact that only 28% of the entire population was screened, so that the prevalence of csom in children is at least 10.7% (11/103) and 5% (6/119) if only those who participated in the study had the disease and as much as 71% (73/103) in children and 86% (103/119) in adults if all of those who did not participate had the disease! in any case, they would still have a high prevalence of csom in this population. also, although we can deduce that the hearing loss from csom would be mostly conductive in nature, we were not able to qualify the type of hearing loss in this study. it is recommended that another visit be done on the community to screen a larger sample of the population, specially the adults. evaluation of the otologic and audiologic profiles of other ati communities in the country should also be performed in order to determine possible cultural/environmental and genetic factors that predispose to ear disease. it would also be important to determine the impact of csom and hearing loss on the ati way of life.6,7 acknowledgment: we are very grateful to the sisters of charity, especially to sister vic ostan, who coordinated the hearing screening mission and acted as translator. we would also like to thank the following: dr. romeo l. villarta jr. for his invaluable input; ms. melquiadesa s. pedro, ms. melody t. francisco and ms. maureen c. tantoco for their help in gathering data. references: 1. acuin j. and child and adolescent health and development prevention of blindness and deafness. chronic suppurative otitis media: burden of illness and management options [monograph on the internet]. geneva switzerland: world health organization; 2004 [cited 2006 jul 24]. available from: http://www.who.int/entity/pbd/deafness/activities/hearing_care/ otitis_media.pdf 2. stuart, john. ear disease in aboriginal children – is prevention an option. from: conference proceedings medical option for prevention of otitis media in australian aboriginal infants. [monograph on the internet]. menzie’s school of health research and the australian doctor’s fund darwin north territory australia; 1992 [cited 2006 jul 24]. available from: www.cybrary. uq.edu.au/library.uq/gmc/images/gmc035.pdf 3. roces, ar, editor. filipino heritage: the making of a nation. vol 1. singapore: times printers sdn. blnd. 4. morris ps, leach aj, silberberg p, mellon g, wilson c, hamilton e, et al. otitis media in young aboriginal children from remote communities in northern and central australia: a crosssectional survey. bmc pediatrics. 2005 jul [cited 2006 jul 24];5(27): [about 13 p.]. available from http://www.biomedcentral.com/1471-2431/5/27 5. jassar p, murray p, wabnitz d and heldreich c. the posterior attic. an observational study of aboriginal austrians with chronic otitis meida (com) and a theory to the low incidence of cholesteatomatous otitis media versus the high rate of mucosal otitis media. int j of pediatr otorhinolaryngol. 2005 nov; 70: 1165-1167. 6. scaldwell wa. effect of otitis media upon reading scores of indian children in ontario. ann otol rhinol laryngol. 1989 mar;98(3):200-1. 7. auinger p, lanphear bp, kalkwarf h, and mansour m. trends in otitis media among children in the united states. pediatrics.2003 sept [cited 2006 july 24]; 112(3): [about 6 p.]. available from: http://www.pediatrics.aappublications.org/cgi/content/abstract/112/3/514 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery contents cover images editorial 4 the updated world association of medical editors (wame) recommendations on chatbots and generative ai in relation to scholarly publications and international committee of medical journal editors (icmje) recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals (may 2023) lapeña jff special announcement 7 chatbots, generative ai, and scholarly manuscripts wame recommendations on chatbots and generative artificial intelligence in relation to scholarly publications zielinski c, winker ma, aggarwal r, ferris le, heinemann m, lapeña jf, pai sa, ing e, citrome l, alam m, voight m, habibzadeh f. on behalf of the wame board review article 10 association of glycemic index using hba1c and sensorineural hearing loss in diabetes mellitus type 2 patients: a systematic review and meta-analysis quines mrr, gloria cec original articles 17 evaluation of the newborn hearing screening program in the university of santo tomas hospital based on the joint committee on infant hearing 2019 position statement on quality indicators for screening and confirmation of hearing loss crizaldo lpr, ramos abc 22 sinonasal anatomy variations on ct scans of a sample of filipino adults with chronic rhinosinusitis policina cp, ambrocio gmc, roldan ra, grullo per 28 high risk human papilloma virus (hpv) oropharyngeal squamous cell carcinoma in a private tertiary care setting in the philippines: prevalence, clinical characteristics and testing chang amv, santos mkd, lim wl 35 profile of patients with oral cavity cancer seen at the department of ear nose throat – head and neck surgery of the bicol medical center alvarez ad, reyes mu 39 outcomes of covid-19 positive and covid-19 negative adult patients who underwent tracheostomy for prolonged intubation in a covid-19 referral center during the pandemic yee ec, dela cruz apc, cruz tlg, villanueva cag, cruz ejm 45 delay and completion of treatment in head and neck cancer patients employing a multidisciplinary team approach: a single institution experience manaig jmn, fernando af, yu kkl case reports 50 delayed-onset unilateral facial paralysis after mastoidectomy: a case report baloco edq, orosa jb iii 54 combined cartilage graft reconstruction of the nasal tip complex after resection of nasal tip schwannoma: a case report bacalla fjp, laxamana jq practice pearls 58 intradermal hyaluronidase: the answer to treatment in softening a fibrous thick supratip skin in rhinoplasty? yap ec, porquez jm featured grand rounds 61 sinonasal mucosal melanoma: a rare intranasal tumor in an 89-year-old woman esguerra jm, ambrocio gmc, castañeda ss from the viewbox 65 fracture of the petrous carotid canal yang nw under the microscope 66 follicular thyroid adenoma with papillary architecture carnate jm captoons 68 doknet’s world billones wu “heterogenously enhancing hyperintense nasal mass” contrast mri, coronal view by jeremiah m. esguerra, md “mesenchymal component of ameloblastic fibrosarcoma” h&e slide, 400x by jose m. carnate, jr., md “screw ‘em up” canon eos 5d mark ii by rene louie gutierrez, md, mha “microlaryngeal surgery” oil on canvas 20” x 25” by mariano b. caparas, md the updated world association of medical editors (wame) recommendations on chatbots and generative ai in relation to scholarly publications and international committee of medical journal editors (icmje) recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals (may 2023) chatbots, generative ai, and scholarly manuscripts: wame recommendations on chatbots and generative artificial intelligence in relation to scholarly publications association of glycemic index using hba1c and sensorineural hearing loss in diabetes mellitus type 2 patients: a systematic review and meta-analysis evaluation of the newborn hearing screening program in the university of santo tomas hospital based on the joint committee on infant hearing 2019 position statement on quality indicators for screening and confirmation of hearing loss sinonasal anatomy variations on ct scans of a sample of filipino adults with chronic rhinosinusitis high risk human papilloma virus (hpv) oropharyngeal squamous cell carcinoma in a private tertiary care setting in the philippines: prevalence, clinical characteristics and testing profile of patients with oral cavity cancer seen at the department of ear nose throat – head and neck surgery of the bicol medical center outcomes of covid-19 positive and covid-19 negative adult patients who underwent tracheostomy for prolonged intubation in a covid-19 referral center during the pandemic delay and completion of treatment in head and neck cancer patients employing a multidisciplinary team approach: a single institution experience delayed-onset unilateral facial paralysis after mastoidectomy: a case report combined cartilage graft reconstruction of the nasal tip complex after resection of nasal tip schwannoma: a case report intradermal hyaluronidase: the answer to treatment in softening a fibrous thick supratip skin in rhinoplasty? sinonasal mucosal melanoma: a rare intranasal tumor in an 89-year-old woman fracture of the petrous carotid canal follicular thyroid adenoma with papillary architecture doknet’s world “covered” canon eos 5d mark ii by rene louie gutierrez, md, mha silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles 28 philippine journal of otolaryngology-head and neck surgery abstract objective: to determine the olfactory function and/ or dysfunction of young adults who are cigarette smokers using a locally validated smell identification test. design: cross-sectional study setting: tertiary hospital in metro manila patients: the volunteer study group was composed of 60 male and 21 female students and employees of a tertiary hospital and its affiliated medical school (both in quezon city). all subjects were young adults within the age range of 20-35 years with a mean age of 27. 58 years (±4.33). all the subjects were currently smoking cigarettes with no medical history of recent viral infection, nasal/sinus surgery, nasal/brain tumors, head trauma, radiotherapy, chronic rhinitides in exacerbation or tracheostomy. olfactory function of each subject was evaluated using the sto. tomas smell identification test (st-sit) which is a locally-validated test. results: majority of the subjects fell within the 24-27 age group with a mean age of 27.58 years (±4.33). males outnumbered females 74.1% as against 25.9%. an inverse relation between pack years and st-sit score was present indicating that there could be a dose-related effect of cigarette smoking on olfactory function. among the 81 subjects, 15 (18.5%) turned out to be anosmic, 46 (56.7%) were hyposmic and 20 (24.6%) had normal olfactory function. a mean st-sit score was computed at 81.183 (±12.58), indicating that majority of the subjects had olfactory dysfunction, meaning they were hyposmic. conclusion: smoking cigarettes has become part of the lifestyle of a lot of people in spite of its hazards to health. in the present study, a majority of supposedly healthy young adults who currently smoked cigarettes were proven to suffer from olfactory impairment based on the scores of a locally-validated smell identification test. an inverse relation between st-sit scores and pack years was also noted which may indicate a dose-related effect of smoking on olfactory function. keywords: olfaction, smoking,, hyposmia, anosmia there is a dearth of information on the influence of smoking on the ability to smell. several studies have shown the adverse effect of cigarette smoking on smell function while others found no correlation between smoking and smell function7, 8. to the best of our knowledge, there are no locally-published studies on the topic. olfactory problems can have a significant impact on our lives. a person with a faulty sense of smell and taste is deprived of an early warning system that most of us take for granted3. smell and taste alert us to fires, poisonous fumes, leaking gas, and spoiled foods. loss of the sense of smell a cross-sectional study on olfactory function among young adult smokers maria cristina c. da silva, md, windolyn d. panganiban, md department of otolaryngology head and neck surgery, st. luke’s medical center correspondence: maria cristina c. da silva, md department of otolaryngology head and neck surgery st. luke’s medical center 279 e. rodriquez ave, quezon city 1102 philippines telefax: (632) 727 5543 e-mail: peachiemd@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this study. presented at the descriptive research contest (3rd place), philippine society of otolaryngology head and neck surgery 49th annual convention, westin philippine plaza hotel, manila, december 1, 2005 philipp j otolaryngol head neck surg 2006; 21 (1,2): 28-30 c philippine society of otolaryngology – head and neck surgery, inc. silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles philippine journal of otolaryngology-head and neck surgery 29 may also be a sign of sinus disease, growths in the nasal passages or, in rare circumstances, brain tumors. because an intact sense of smell and taste is required in some professions, chefs and firemen, among others, may be subject to serious handicaps. in addition, this sense provides aesthetic pleasure, as shown by our predilection for the smell of such objects such as flowers, condiments and scented consumer products. recent statistics from the who have shown that there has been a decline of tobacco use in the developed world while a rise is seen in developing countries, with asia having the highest smoking rate. in the philippines, 60% of men smoke, with women catching up fast. nearly all of them began smoking in their teens, even before reaching the peak of olfactory function. despite these statistics, little is known regarding the effect of cigarette smoking on the olfactory function in the local setting. given the contrasting results in studies relating olfactory function and smoking and paucity of related literature in the local setting, we table 1 age, sex and pack years distribution in relation to olfactory function normal n=20 13 65.0% 7 35.0% 4 20.0% 14 70.0% 2 10.0% 0 0.0% 18 90.0% 2 10.0% 0 0.0% 0 0.0% sex male female age group 20 – 23 24 – 27 28 – 31 > 31 pack years 5 and below 6 10 years 11 15 years more than 15 anosmia n=15 11 73.3% 4 26.7% 4 26.7% 0 0.0% 3 20.0% 8 53.3% 4 26.7% 7 46.7% 3 20.0% 1 6.7% hyposmia n=46 36 78.3% 10 21.7% 10 21.7% 12 26.1% 13 28.3% 11 23.9% 35 76.1% 6 13.0% 3 6.5% 2 4.3% table 2 measures of central tendencies and dispersion in relation to olfactory function normal 25.10 1.80 25.00 22 29 95.28 3.22 94.75 91 104 3.02 1.88 2.75 1.0 6.0 age (years) mean sd median range sit score mean sd median range pack years mean sd median range anosmia 29.93 5.63 32.00 20 – 35 60.97 5.75 60.00 50 68.75 8.44 5.46 7.50 2 – 22 hyposmia 27.89 4.17 28.00 22 – 35 81.65 6.47 84.00 71 – 90 5.05 4.48 3.10 1.25 20.0 attempted this study in the hope of providing local information on the effects of smoking on the much-neglected sense of smell. this study aims to determine the olfactory function and/or dysfunction of young adult smokers using a locally-validated smell identification test. materials and methods subjects: the volunteer study group was composed of 60 male and 21 female students and employees of a tertiary hospital and its affiliated medical school. these subjects were acquired within a designated 1month period. all subjects were young adults within the age range of 20-35 years with a mean age of 27. 58 years. a written consent was accomplished by all the subjects prior to the procedure. a complete medical history was obtained and a physical examination with emphasis on nasal endoscopy performed on all subjects to rule out other entities that could impair the function of smell. all subjects must have been between 20-35 years old, currently smoking cigarettes and did not meet the following exclusion criteria: medical history of recent viral infection, nasal/sinus surgery, nasal/brain tumors, head trauma, radiotherapy, chronic rhinitides in exacerbation or tracheostomy. data collection: olfactory function was assessed using the sto. tomas smell identification test (st-sit), a standardized, validated test9. this test uses 45 odorants each enclosed in an opaque polyethylene squeeze bottle. this test is able to qualify whether a person is anosmic, hyposmic or has normal olfactory function. each odorant is smelled by the subject and identified from a written list of choices. the odorant has a corresponding score and the summation of these scores serve to discriminate those with normal olfactory function from those with olfaction problems9. data analysis: study variables included subjects’ age, sex, number of sticks per day and number of years smoking. cigarette dose was calculated in pack years by multiplying the number of packs per day with the number of years smoking. confounders were controlled by eliminating subjects who fulfilled even one of the exclusion criteria. all data was processed and analyzed using epi-info version 6.04 statistical software (anova and kruskal-wallis one way anova) (cdc: freeware) and tabulated using excel (microsoft). results majority of the subjects fell within the 24-27 age group with a mean age of 27.58 (±4.33) years. males outnumbered females 74.1% as against 25.9%. the subjects had mean pack years of 5.18 (±4.53). out of the 81 subjects, 49 were members of the hospital staff and 32 were students. among the 81 subjects, 15 (18.5%) turned out to be anosmic, 46 (56.7%) were hyposmic and 20 (24.6%) had normal olfactory function. mean st-sit score for all the subjects was 81.18 (±12.58), indicating that majority of the subjects had olfactory dysfunction, meaning they were hyposmic. 75.2% of the subjects had olfactory dysfunction based on st-sit score. table 1 summarizes the distribution of age, sex, and pack years in relation to olfactory function. table 2 summarizes the different measures of central tendencies silver anniversary issue vol. 21 nos. 1 & 2 january –june; july – december 2006 original articles 30 philippine journal of otolaryngology-head and neck surgery and dispersion in relation to olfactory function. the age and number of pack years smoked in relation to the olfactory status grouping (normal, hyposmic, anosmic) were found to be statistically significant with p-values: 0.0196 0.0013 for age and pack years respectively using kruskal-wallis one way anova. correlation coefficient (r= -0.43) between the number of pack years and st-sit scores was found to have an inverse relationship which may indicate that the effect of smoking on olfactory function is dose-related. the higher the number of pack years, the lower the st-sit score. no statistically significant differences were noted in st-sit scores between sex (p-value 0.345) or number of pack years between males and females (p-value 0.0634). discussion the results of this study show that smoking has an effect on olfactory function. majority (56.7%) of the subjects were found out to be hyposmic while 18.5% were anosmic. a total of 75.2% of subjects had an olfactory deficit based on the scores gathered from the st-sit. the 20-35 age group was chosen to eliminate the effect for age since the average ability to identify odors reaches a peak between 20-40 years and begins to decline after this time3. the authors also eliminated any confounders--medical conditions such as recent viral infection, nasal/ sinus surgery, nasal/brain tumors, head trauma, radiotherapy, chronic rhinitides in exacerbation and tracheostomy, which could decrease stsit score. persons who smoke are nearly twice as likely to have an olfactory deficit than persons who have never smoked1. the inverse relation between pack years and st-sit scores strengthens the findings of frye et.al.1 that there is a clear adverse effect of cigarette smoking on olfactory function that is dose-related. however, this effect is reversible to some degree. the reversibility is dependent on the duration of cessation from smoking and the amount of prior smoking activity. the same study showed that restoration of smell function to the level observed in non-smokers requires approximately the same duration as the number of years smoked. the statistically significant difference between olfactory groups and age seen could be explained by the fact that as a person ages, the number of cigarettes consumed is also increased cumulatively. the agerelated olfactory degeneration is a confounder which was eliminated by choosing young adult subjects (25-35 years old). certain chemicals in tobacco smoke such as acrolein, acetaldehyde, ammonia and formaldehyde damage olfactory receptor cells in the nose which in turn cause olfactory deficits4. animal studies done postulate that smell is mediated by olfactory sensory neurons (osns) exposed to the nasal airway making them vulnerable to environmental injury and death2. damaged or dead osns are replaced to maintain sufficient numbers of neurons. the disruption of this homeostasis has been proven to cause a clinical loss of smell. the death of osns, aptly called apoptosis (programmed cell death) was noted to occur after exposure to tobacco smoke2. tobacco smoke causes a disruption of homeostasis in the olfactory epithelium by increasing apoptotic activity of cells resulting in the net loss of osns over time. as a consequence, the regenerative capacity of the epithelium is overwhelmed causing decreased smell acuity. although smoking has been proven to damage olfactory cells causing olfaction problems, all is not lost for cigarette smokers. some studies show that there is no significant difference between smokers who had quit and non-smokers by subjective olfactometry2. in addition, it has been found that there is no elevated risk of olfactory dysfunction for previous smokers when compared with persons who never smoked1. these findings support the theory that smoking-related olfactory effects are reversible and that the olfactory epithelium is able to recover after smoking cessation. however, the regenerative process is slow, stressing the importance of quitting as early as possible not only to avoid or curtail the health hazards of cigarette smoking but to regain normal olfactory function as well. smoking cigarettes has become part of the lifestyle of a lot of people in spite of its hazards to health. in our initial study, a majority of seemingly healthy young adults who currently smoked cigarettes were proven to suffer from olfactory impairment based on the scores of a locally-validated smell identification test. an inverse relation between st-sit scores and pack years also noted may indicate a dose-related effect of smoking on olfactory function. a case-control comparison, the inclusion of older age groups, and a larger study population can further strengthen the association between smoking and olfactory dysfunction. acknowledgements: we thank dr. anthony calibo for help with statistical analysis, dr. joyce castillo and the group 2 medical interns of st. luke’s medical center batch 2006 for their technical help. references: 1. frye r, schwartz b, doty r. dose-related effects of cigarette smoking on olfactory function. jama. 1990;263(9):1233-6. 2. vent j, robinson a, gentry-nielsen m, conley d, hallworth r, leopold d et al. pathology of the olfactory epithelium: smoking and ethanol exposure. laryngoscope. 2004; 114(8):1383-8. 3. doty r, shaman p, applebaum s, giberson r, siksorski l, rosenberg l. smell-identification ability: changes with age. science. 1984;226:1441-3. 4. fackelmann ka. smokers suffer from impaired smell. science news online. mar. 3, 1990. available from http://www.sciencenews.org/ 5. deems d. smell and taste disorders, a study of 750 patients from the university of pennsylvania smell and taste center . arch otolaryngol head neck surg. 1991;117(5):519-28. 6. bramerson a, johansson l, lars e, nordin s, bende m. prevalence of olfactory dysfunction: the skovde population-based study. laryngoscope. 2004;114(4):733-7. 7. mclean a. paradoxical association between smoking and olfactory identification in psychosis versus controls. aust new z j psychiatry. 2004; 38(1-2):81-3. 8. rupp e. reduced olfactory sensitivity discrimination & identification in patients with alcohol dependence. alcohol clin exp res. 2003; 27(3):432-9. 9. david, j, campomanes b, dalupang j, loberiza f. smell identification test. philipp j otolaryngol head neck surg. 1994;62-8. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 24 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of fnab in detecting parotid malignancies in our institution. methods: design: retrospective chart review setting: tertiary government hospital participants: postoperative records of seventy six (76) patients with tumors of the parotid gland preoperatively diagnosed by fnab. results: the sensitivity of fnab was 46%. the specificity and positive predictive value were both 100% and negative predictive value was 90%. overall accuracy in diagnosing malignant parotid tumor was 91%. conclusion: fnab in this institution is a poor predictor of malignancy, having a sensitivity rate of only 46%. while this may serve as a basis for not recommending pre-operative fnab for patients with parotid tumors in the interim, other factors should also be considered, including concerns with the actual performance and interpretion of fnab in our institution. keywords: parotid neoplasm, cancer of the parotid, fine needle aspiration biopsy, sensitivity, specificity, accuracy the role of fine needle aspiration biopsy (fnab) in the workup of salivary gland tumors has been debated. in the 2016 national comprehensive cancer network (nccn) guideline,1 and in our institution, fnab is a required diagnostic procedure to determine treatment and management of parotid gland tumors. however, some clinicians question its value.2 supporters of the procedure noted that it offers helpful information for planning surgery and counselling patients regarding expectations from the surgery and its after care.3 detractors, however, state that the management does not change regardless of the result of fnab, believe that it may not be cost effective in routine cytology workup in every patient, and may do no more than increase the cost of healthcare.2 this paper aims to determine the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of fnab in detecting parotid malignancies in our institution. accuracy of fine needle aspiration biopsy in diagnosing parotid gland malignancy kathleen joy b. santiago, md rodante a. roldan, md samantha s. castañeda, md department of otorhinolaryngology head and neck surgery rizal medical center correspondence: dr. kathleen joy b. santiago department of otorhinolaryngology head and neck surgery rizal medical center pasig boulevard barangay pineda, pasig city 1603 philippines phone: (632) 871 6269/ (0917) 880 1082 email: ent.hns_rmc@yahoo.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery analytical research contest. october 23, 2014. unilab bayanihan center, pasig city. philipp j otolaryngol head neck surg 2016; 31 (2): 24-26 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles philippine journal of otolaryngology-head and neck surgery 25 methods with irb approval, a retrospective review of medical records of patients who underwent parotidectomy in the department of otolaryngology-head and neck surgery and the department of surgery of a single tertiary government hospital from january 2008 to august 2014 was done. records of all parotid surgeries performed during this period were screened for those that had both fnab and surgical histopathology performed in this institution. an inflammatory result, records of cases where fnab was performed in other institutions and where surgical histopathology results were unavailable were excluded. only records with fnab results of benign or malignant were included in the study. non-diagnostic fnab results were excluded. in our institution, the standard procedure for fine needle aspiration biopsy was performed routinely by second year residents who had undergone training in the department of pathology, and results were interpreted by board-certified pathologists, who also interpreted final histopathologic results. initial fnab interpretation and final histopathologic interpretation were not usually performed by the same pathologist. the final histopathology results were compared with the preoperative cytologic interpretation of the fnab specimens. sensitivity, specificity, positive predictive value (ppv ), negative predictive value (npv ), and overall accuracy of fnab to differentiate between benign and malignant disease were determined using the galen and gambino method.4 the following parameters were analyzed: sensitivity – the proportion of patients with malignant 1. cytopathology and surgical histopathology results. specificity – the proportion of patients with benign 2. cytopathology and surgical histopathology results. positive predictive value (ppv) – the probability of having 3. a malignant surgical histopathology and malignant cytopathology findings. negative predictive value (npv) – the probability of having 4. a benign surgical histopathology with benign cytopathology findings. accuracy –the proportion of correct results (true positive and 5. true negative) in relation to all cases studied. results a total of 94 records of patients who underwent parotidectomy in our institution were reviewed, and 76 records that had both final histopathologic results and preoperative fnab performed in our institution were included. eighteen records were excluded, either due to unavailable final histopathologic results or where fnab had been performed elsewhere. of the 76 records that satisfied inclusion criteria, six (6) were reported malignant after fnab and confirmed malignant on surgical histopathology (true positive). no cases were reported malignant on fnab and later found to be benign on surgical histopathology (false positive). there were seven (7) cases that were reported benign on fnab but were later found to be malignant on surgical histopathology (false negative). there were 63 cases that were reported benign on fnab and confirmed benign on surgical histopathology (true negative). (table 1) table 1. comparison of fna and surgical histopathology findings fna surgical histopathology malignant benign total malignant benign total 6 7 13 0 63 63 6 70 76 there was a 46% sensitivity, 100% specificity, 100% positive predictive value, 90% negative predictive value, and 91% overall accuracy for fnab in diagnosing parotid tumors in our sample. discussion the objective of this paper was to evaluate the accuracy of fine needle aspiration biopsy as a screening tool for parotid gland malignancies in terms of sensitivity, specificity, positive predictive value and negative predictive value. in this series, the probability that a tumor found to be malignant on fnab would be malignant on surgical histopathology was 100% and the probability that a tumor found to be benign on fnab would be benign on surgical histopathology was 90%. these findings are similar with previous studies, with sensitivities and specificities ranging from 64% to 95% and 86% to 99%, respectively.5-8 benign diseases were accurately diagnosed by fnab with very low false positive rates as seen in this study. the most commonly diagnosed histology type was pleomorphic adenoma followed by warthin’s tumor. the low sensitivity (46%) result in this study can be attributed to its high false negative rate for the diagnosis of malignancy, as malignant tumors were falsely classified as benign. these results were also seen in the study of fakhry et al. with 8% to 46% of cases.9 the implication philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 26 philippine journal of otolaryngology-head and neck surgery original articles of this result is that if fnab had been used as a screening tool, 54% of malignant lesions would have been missed. many clinicians believe this could be related to technical factors and expertise of the cytopathologist.10 most of the studies reviewed attribute false negative rates to sampling errors.10-12 according to a 2005 review,13 the malignant neoplasm cases of salivary gland with the highest false negative rates were mucoepidermoid carcinoma, acinic cell carcinoma, and adenoid cystic carcinoma. these were the seven malignancies that were falsely diagnosed to be benign by fnab in this study, with four (4) cases of mucoepidermoid carcinoma and one (1) case of acinic cell carcinoma diagnosed as pleomorphic adenoma and two (2) cases of adenoid cystic carcinoma diagnosed as trichoblastoma and pleomorphic adenoma respectively. possible reasons for the discrepancies include the wide variability of benign and malignant tumors having similar cytologic features with differences in some cases being quantitative rather than qualitative; and the nature of fnab, which is focused on cytology instead of histology. the morphologic patterns of salivary gland tumors contrast with the small size of the needle aspiration references 1. network ncc. nccn clinical practice guidelines in oncology. 2016 [updated 2016 may 6; cited 2016 oct 7]; 1.2016: available from: https://www.nccn.org/store/login/login. aspx?returnurl=https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf. 2. batsakis jg, sneige n, el-naggar ak. fine-needle aspiration of salivary glands: its utility and tissue effects. ann otol rhinol laryngol. 1992;101(2 pt 1):185-8. epub 1992/02/01. pubmed pmid: 1739267. 3. nguansangiam s, jesdapatarakul s, dhanarak n, sosrisakorn k. accuracy of fine needle aspiration cytology of salivary gland lesions: routine diagnostic experience in bangkok, thailand. asian pac j cancer prev. 2012;13(4):1583–1588. pubmed pmid: 22799371. 4. galen rs, gambino sr. beyond normality-the predictive value and efficiency of medical diagnosis. new york: ny:wiley; 1975. p. 10-40. 5. ali ns, akhtar s, juanid m, awan s, aftab k. diagnostic accuracy of fine needle aspiration cytology in parotid lesions. srn surg. 2011 may;2011:721525. doi: 10.5402/2011/721525. pubmed pmid: 22084773. pubmed central pmcid: pmc3200214. 6. tan lg, khoo ml. accuracy of fine needle aspiration cytology and frozen section histopathology for lesions of the major salivary glands. ann acad med singapore. 2006 apr;35(4):242-8. pubmed pmid: 16710494. 7. awan ms, ahmad z. diagnostic value of fine needle aspiration cytology in parotid tumors. j pak med assoc. 2004 dec;54(12):617–9. pubmed pmid: 16104489. 8. cruz rm. the accuracy of fine needle aspiration biopsy in diagnosing malignancy of major salivary gland tumors. philipp j otolaryngol head and neck surg. 2004 jul-dec;19(3-4):132–136. 9. fakhry n, antonini f, michel j, penicaud m, mancini j, lagier a, et al. fine-needle aspiration cytology in the management of parotid masses: evaluation of 249 patients. eur ann otorhinolaryngol head neck dis. 2012 jun;129(3):131-135. doi: 10.1016/j.anorl.2011.10.008. pubmed pmid: 22626640. 10. cohen eg, patel sg, lin o, boyle jo, kraus dh, singh b, et al. fine – needle aspiration biopsy of salivary gland lesions in a selected patient population. arch otolaryngol head neck surg. 2004 jun;130(6):773–778. doi: 10.1001/archotol.130.6.773. pubmed pmid: 15210562. 11. zurrida s, alasio l, tradati n, bartoli c, chiesa f, pilotti s. fine-needle aspiration of parotid masses. cancer. 1993 oct 15;72(8):2306–2311. pubmed pmid: 8402443. 12. tryggvason t, gailey mp, hulstein sl, karnell lh, hoffman ht, funk gf, et al. accuracy of fineneedle aspiration and imaging in the preoperative workup of salivary gland mass lesions treated surgically. laryngoscope. 2013 jan;123(1):158–163. doi: 10.1002/lary.23613. pubmed pmid: 22991236. 13. hughes jh, volk ee, wilbur dc. pitfalls in salivary gland fine-needle aspiration cytology: lessons from the college of american pathologists interlaboratory comparison program in nongynecologic cytology. arch pathol lab med. 2005;129(1):26-31. epub 2005/01/05. doi: 10.1043/1543-2165(2005)129<26.pisgfc>2.0.co;2. pubmed pmid: 15628905. sample, which may not be representative of the entire mass.6,10 it is important to be able to characterize the tumor preoperatively in order to correctly inform the patient about the type of surgery that will be performed, the need for lymph node dissection, and the possibility of nerve sacrifice7 as well as for psychological and medicolegal purposes.5,7 however, although fnab in this institution can accurately diagnose benign parotid tumors with a specificity rate of 100%, it does not exclude malignancy because of a 54% false negative rate, and is a poor predictor of malignancy, having a sensitivity rate of only 46%. although this study is limited by small sample size and incomplete data, it may serve as a basis for recommending discontinuation of routine preoperative fnab for parotid tumors in the interim, while other factors are considered, including concerns with the actual performance and interpretion of fnab in our institution. the possible variability in levels of expertise both in obtaining specimens, and in fnab interpretation should be addressed, and investigation into, and improvement of both fnab specimen collection and interpretation may be in order. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2022; 37 (2): 16-19 c philippine society of otolaryngology – head and neck surgery, inc. the complete and two-turn cochlear duct length among filipinos raiza michaella a. kasilag, md kathrina aquino-diaz, md department of otorhinolaryngology head and neck surgery ospital ng maynila medical center correspondence: dr. kathrina aquino-diaz department of otorhinolaryngology head and neck surgery ospital ng maynila medical center quirino ave. cor. roxas blvd, malate, manila 1004 philippines phone: (+632) 8524 6061 local 220 email: ommc_enthns@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology – head and neck surgery descriptive research contest (2nd place) november 8, 2021 creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international abstract objective: this study aims to measure the complete and two-turn cochlear duct lengths in a filipino population using archived ct scan images. methods: design: retrospective review of records setting: tertiary government training hospital participants: ct scan images of 255 patients cochlear images of patients who underwent cranial, facial, orbital, paranasal sinus and temporal bone ct scans from january 2019 to december 2019 were analyzed. coronal oblique images from 3d multiplanar reconstructions were obtained and a single linear measurement (‘a’ value) was used as the spiral coefficient to calculate the complete cochlear duct length (cdl) and twoturn length (2tl). results: a total of 510 cochlear images were obtained from the ct scan images of 255 subjects (143 males, 112 females aged 1 to 81 years; mean age = 47 years). the mean ‘a’ value was 8.81 mm (sd = 0.20). the mean complete cochlear duct length was 32.68 mm (31.01 mm – 35.50 mm; sd = 0.834) while the mean two-turn cochlear duct length was 29.61 mm (28.14 mm – 32.08 mm; sd = 0.732). the complete and two-turn cochlear duct lengths in males were found to be significantly longer than in females (p = .001). no significant difference was found between cochlear measurements for left and right ears. conclusion: the mean complete cochlear duct length among filipinos in our study measures 32.68 mm while the mean two-turn cochlear duct length measures 29.61mm. both complete and two-turn cochlear duct lengths were longer among filipino males than among females. keywords: cochlea; cochlear duct length; two-turn length; high-resolution computed tomography (hrct ) cochlear duct length is defined as the length of the scala media obtained by measuring the distance from the middle of the round window to the helicotrema.1,2 knowledge of the cochlear duct length measured pre-operatively is valuable for the cochlear implant surgeon for precise intracochlear electrode array placement. with variable electrode implant lengths available, cochlear duct length plays a significant role in the depth of insertion and the success of hearing improvement as well as hearing preservation. 2,3 previous studies have established philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery original articles the cochlear duct length among various populations in north america, europe and australia,4-7 while subsequent studies in asian populations showed significantly shorter values.2,8-10 a search of the english medical literature on herdin plus, the asean citation index (aci), the who global health library – western pacific region index medicus (gimwprim), directory of open access journals (doaj), medline (pubmed and pmc) and google scholar using the search terms “filipino cochlear duct length,” “filipino cdl values,” “normative filipino cochlear duct measurements,” and “cochlear implant,” yielded no previous studies on the cdl among a filipino population. since the numbers of cochlear implantation surgeries being done in the philippines continues to increase at a steady rate, it is important to establish normative cdl values among the filipino population. the cochlear duct length has been previously measured using 4 major techniques: 1) direct method, involving microscopic evaluation of histologic sections using a micrometer;11-13 2) indirect method, which measures cdl using landmarks from plastic casts or histologic sections;14 3) 3d reconstruction of the cochlea using 3d coordinate;15-17 and 4) by using linear measurements on imaging and representing the cochlea as a mathematical spiral function.5-10 three-dimensional (3d) reconstruction from histologic sections is said to be the most accurate method in measuring cochlear dimensions. however, the amount of time needed to make such measurements make this method difficult to use. making singular linear measurements on high-resolution ct scans of the temporal bone, however, allows accurate measurements of cochlear dimensions in less time, making the spiral coefficients method the more popular choice in recent studies. 2,3 in addition to finding the complete cochlear duct length, there is a growing interest in the two-turn (2tl) cochlear duct length in an attempt to mitigate the anatomical variations between cochleae. with previous studies noting that such variations exist only in the apical turn, calculating the 2tl (basal and middle turn) decreases the variations in computed cochlear duct lengths, and as a corollary. better correlation was demonstrated by multiple studies among 2tl than complete cochlear duct length.11,14,18 this study aims to establish normative cochlear duct length values using archived ct scan images, specifically the mean complete and two-turn cochlear duct length in a filipino population. methods with institutional review board approval from the san juan de dios educational foundation institutional review board (sjirb-2021-0004), this retrospective review of records obtained archived cochlear images of patients who underwent cranial, facial, orbital, paranasal sinus and temporal bone computed tomography scans for various indications from january 2019 to december 2019 at the ospital ng maynila medical center. the minimum number of patients was determined at 95% level of confidence, power = 80%, detectable mean difference of 0.1, and standard deviation of 0.4. the computed minimum sample size for this study was 252 patients, calculated using open source epidemiologic statistics for public health (openepi version 3.01 updated 20103/0004/06) available from https://openepi.com/samplesize/ ssmean.htm. all included scans were obtained using the same single 24 detector-row brivo ct385 helical ct (ge medical systems inc., wi, usa), employing 0.625mm section thickness, 120kv tube voltage, 54 ma tube current, 1.5s revolution time, 512 x 512 matrix resolution, 0.9375 pitch factor, and 70mm field of view parameters. computed tomography scans that were found to have either congenital or acquired cochlear or inner ear pathologies based on the official reading of a board-certified radiologist were excluded from the study. in compliance with the provisions of the hospital’s ethics review board, temporal bone image isolation was done on all computed tomography scans meeting the above-mentioned criteria. the scans were processed using radiant dicom viewer version 5.5.1 (medixant, poznan, poland) with a 4000 window width and 1000 window level. since a view of the entire basal turn of the cochlea (showing one full 360-degree turn from the round window onwards) was not possible using a single 2-dimensional plane, a multiplanar reconstruction using minimum intensity projection was made. by aligning the multiplanar reconstruction axes parallel to the basal turn on axial (figure 1a) and sagittal (figure 1b) planes, multiplanar reconstruction of the inner ear was done to produce a coronal oblique (figure 1c) image of the cochlea. the resulting coronal oblique image was able to show the entire basal turn of the cochlea, round window, oval window and anterior parts of the superior and lateral semicircular canals. the largest distance from the middle of the round window, passing through the modiolus to the opposing lateral wall of the cochlea was obtained as the ‘a’ value.5 for this distance, two separate measurements were individually obtained by each author, and the average was taken as the final measurement for the ‘a’ value. measurements were obtained for both ears of all patients. the obtained ‘a’ value was the spiral coefficient used to calculate the complete cochlear duct length (cdl) and two-turn length (2tl). cochlear duct length was calculated as cdl = 4.16a−3.98 while the 2 turn length was computed using the equation 2tl = 3.65 (a-0.7).18 demographic and clinical characteristics of patients were recorded in microsoft excel version 16.16.27 (microsoft corporation, redmond, wa, usa). categorical data were presented as frequencies and percentages while numerical data were summarized using mean and standard deviation with its minimum and maximum values. interval estimates for mean were reported using a 95% confidence interval and were compared to reported values in literatures. group means of numerical variables (for example left versus right cdl) were computed then compared using independent sample t-test. all tests were performed at 5% level of significance (α). philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery original articles results a total of 510 cochlear images were obtained from the ct scan images of 255 patients (143 males and 112 females; aged 1 to 81 years; mean age = 47 years) and reconstructed for further analysis. the ‘a’ value (largest distance from the middle of the round window, passing through the modiolus, to the opposing lateral wall of the cochlea) ranged from 8.41 mm to 9.49 mm (m = 8.81 mm; sd = 0.20). the mean complete cochlear duct length was 32.68 mm (31.01 mm – 35.50 mm; sd = 0.83) while the mean two-turn cochlear duct length was 29.61 mm (28.14 mm – 32.08 mm; sd = 0.73). the mean complete cdl of the 143 males (m = 32.85, sd = 0.87) compared to the mean complete cdl of the 112 females in the study (m = 32.49, sd = 0.75) were significantly longer, t(253) = 3.48, p = .001. likewise, the mean two-turn cdl values among males (m = 32.49, sd = 0.75) were also noted to be significantly longer, t(253) = 3.50, p = .001 than the mean two-turn cochlear duct length among females (m = 29.44, sd = 0.66). the mean complete cochlear duct length on the right ear of all subjects was 32.67 mm (32.57 mm – 32.78 mm; sd = 0.83) while that of the left ear was 32.69 mm (32.59 mm – 32.79 mm; sd = 0.84). the mean two-turn cochlear duct length of the right and left ears were 29.61mm (29.52 mm – 29.70 mm; sd = 0.73) and 29.62 mm (29.53 mm – 29.71 mm; sd = 0.73), respectively. discussion our present study found the mean ‘a’ value for the filipino cochlea was 8.81 mm, which when used as a spiral coefficient would lead to a mean complete cochlear duct length value of 32.68 mm while the mean two-turn cochlear duct length was 29.61 mm. in addition, significantly longer values (p = .001) for both the complete and two-turn cochlear duct length among filipino males were found than that for filipino females. since the advent of cochlear implantation, increasing interest in cochlear dimensions and how they affect electrode design and insertion has been observed.1-4 cadaveric examinations of human cochlea were time-consuming and did not allow real time physiologic correlation.5,6,18 although 3d reconstruction is the most accurate method of determining cochlear duct length, the spiral coefficient method allows surgeons to use a single linear measurement on pre-operative ct scans to approximate cochlear duct lengths. since considerable inter-population variations in cochlear duct length has been proven,4-10 the need to produce electrodes accordingly is increasing in order to improve postoperative outcomes.1 compared to previous methods historically employed in measuring cochlear duct length, escudé et al.5 provided a single value ‘a’ measured by the surgeon on high-resolution ct images of the temporal bone that predicted electrode placement during surgery. this value ‘a’ is the largest distance from the round window to the lateral wall, passing through the mid-modiolar axis. in their study, incorporating value ‘a’ into a basic spiral function allowed prediction of the cochlear duct length.5 alexiades et al. deem that the two-turn cdl strikes the balance between achieving adequate cochlear coverage and decreasing insertional trauma to the apical region. ‘a’ values of 7.3, 8.4, and 9.2mm equate to 2tl values of 24-, 28-, and 31-mm lengths, respectively, aiding the surgeon in pre-operative selection of electrode array.18 one variation also notable in previous studies was the zero reference angle – the location in which the measurement of the ‘a’ value began. measurements in some studies started at the inferior edge of the round window, while others used the middle portion of the round window as the starting point.19 to address this difference, a consensus panel on a cochlear coordinate system in 2010 established the zero reference angle as the center of the round window.20 similar to other studies,8,9,11,13 significant differences between both the complete and two-turn cochlear duct lengths of males and females were found in this study. cochlear duct length among males has been found to be significantly longer than among females using the various methods for cdl measurement. it was first hypothesized by sato et al.13 that the significant cdl differences consistently observed between sexes but not between various age groups is a function of sexual dimorphism instead of continued cochlear growth as a person ages. it was further hypothesized in their study that similar function is figure 1. temporal bone ct bone window images of the left ear showing the basal turn of the cochlea: a. plain axial; b. plain sagittal cuts; and c. coronal oblique image obtained from multiplanar reconstruction of the same axial and sagittal cuts showing measurement for ‘a’ value a c b philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery original articles noted for the same percentage distance along the basilar membrane despite differences in cochlear duct length among sexes, suggesting that longer latency is required for cochlear transduction in males than females – evidenced by a significantly longer latency of wave i in auditory brainstem responses in males.13 compared with measurements made in the reported literature worldwide which also employed spiral coefficients, the mean complete cochlear duct length of filipinos found in our present study was shorter than that of northern american and european populations. a study among north americans by skinner et al. found a mean complete cdl of 34.62mm (sd = 1.2).7 a similar study by escudé et al. among europeans found a mean complete cdl of 34.4 mm (sd = 2.2).5 both studies showed mean cdl values that were significantly longer than those of our filipino population (p = .001). comparisons with published mean cdl values among other asian populations however, showed similar or shorter values than those found for filipinos in our present study. the mean complete cdl of filipinos in our present study is significantly longer (p < .001) than that of the saudi arabian population (m = 31.882; sd = 2.65).9 interestingly, there was no significant difference in the complete cdl (mean = 32.45; sd = 1.31) among an indonesian population in the study by zahara et al.10 compared to the complete cdl of filipinos (p = .127). the similarity between the complete cdl among filipinos and indonesians in these studies may reflect our partial indo-malay ancestry. while previously identified differences among acknowledgements we would like to thank dr. manolo c. maglonzo, md, fpcr for his inputs to improve the research methodology, mr. ruben mendoza for sharing his technical expertise in ct imaging and dicom software use and mr. roy alvin malenab for his assistance in statistical analysis. references 1. erixon e, rask-andersen h. how to predict cochlear length before cochlear implantation surgery. acta otolaryngol. 2013 dec;133(12):1258–65. doi:  10.3109/00016489.2013.831475; pubmed pmid: 24053486. 2. grover m, sharma s, singh sn, kataria t, lakhawat rs, sharma mp. measuring cochlear duct length in asian population: worth giving a thought!. eur arch otorhinolaryngol. 2018 mar;275(3):725-728. doi: 10.1007/s00405-018-4868-9; pubmed pmid: 29332169. 3. koch r, ladak hf, elfarnawany m, agrawal sk. measuring cochlear duct length – a historical analysis of methods and results. j otolaryngol head neck surg. 2017 mar; 46(1):19. doi: 10.1186/ s40463-017-0194-2; pubmed pmid: 28270200; pubmed central pmcid: pmc5341452. 4. ketten dr, skinner mw, wang g, vannier mw, gates ga, neely jg. in vivo measures of cochlear length and insertion depth of nucleus cochlear implant electrode arrays. ann otol rhinol laryngol suppl. 1998 nov;175:1–16. pubmed pmid: 9826942. 5. escudé b, james c, deguine o, cochard n, eter e, fraysse b. the size of the cochlea and predictions of insertion depth angles for cochlear implant electrodes. audiol neurotol. 2006;11 suppl 1:27–33. doi: 10.1159/000095611; pubmed pmid: 17063008. 6. kawano a, seldon hl, clark gm. computer-aided three-dimensional reconstruction in human cochlear maps: measurement of the lengths of organ of corti, outer wall, inner wall, and rosenthal’s canal. ann otol rhinol laryngol. 1996 sep;105(9):701–9. doi: 10.1177/000348949610500906; pubmed pmid: 8800056. 7. skinner mw, ketten dr, holden lk, harding gw, smith pg, gates ga, et al. ct-derived estimation of cochlear morphology and electrode array position in relation to word recognition in nucleus-22 recipients. j assoc res otolaryngol. 2002 sep;3(3):332–50. doi:  10.1007/ s101620020013; pubmed pmid: 12382107. 8. thong j, low d, tham a, liew c, tan t, yuen h. cochlear duct length–one size fits all? am j otolaryngol. 2017 mar-apr;38(2):218-221. doi:  10.1016/j.amjoto.2017.01.015; pubmed pmid: 28139318. 9. alanazi a, alzhrani f. comparison of cochlear duct length between the saudi and non-saudi populations. ann saudi med. 2018 mar-apr; 38(2):125-129. north american and european versus asian cochlear duct lengths may be related to larger head sizes for the former, further investigations are needed as the previously published literature and our present study have not measured and correlated racial head sizes to cochlear duct length. this study is not without its limitations. ct images with incidental findings of congenital and acquired inner ear malformations were excluded, so there were no associations made with pathologic findings. in addition since data collected were computed tomography scans from a single institution, findings may not have included variations, if any, for cdl measurements in other regional populations in the country. it is recommended that future studies incorporate ct data from multiple institutions in different regions in the philippines and to also incorporate patient age and audiometric data in further investigations. in conclusion, the mean complete cochlear duct length among the filipinos in our study measured 32.68 mm while the mean two-turn cochlear duct length measured 29.61mm. both complete and twoturn cochlear duct lengths were longer in filipino males than females. although existing variations in the cochlea necessitate the need for individual pre-operative ct measurements, trends are apparent between sexes as well as among different races, with asian cdl measurements (including those of filipinos) being shorter than those in north american and european populations. doi:  10.5144/0256-4947.2018.125; pubmed pmid:  29620546; pubmed central pmcid: pmc6074369. 10. zahara, d., dewi, r. d., aboet, a., putranto, f. m., lubis, n. d., & ashar, t. variations in cochlear size of cochlear implant candidates. int arch otorhinolaryngol. 2019 apr;23(2):184–190 doi: 10.1055/s-0038-1661360; pubmed pmid: 30956703; pubmed central pmcid: pmc6449142 11. hardy m. the length of the organ of corti in man. american journal of anatomy. 1938 jan;62(2):291–311. doi: 10.1002/aja.1000620204. 12. úlehlová l, voldřich l, janisch r. correlative study of sensory cell density and cochlear length in humans. hear res. 1987;28(2-3):149–51. doi:  10.1016/0378-5955(87)90045-1; pubmed pmid: 3654386. 13. sato h, sando i, takahashi h. sexual dimorphism and development of the human cochlea. computer 3-d measurement. acta otolaryngol. 1991;111(6):1037–40. doi: 10.3109/00016489109100753; pubmed pmid: 1763623. 14. erixon e, högstorp h, wadin k, rask-andersen h. variational anatomy of the human cochlea: implications for cochlear implantation. otol neurotol. 2009 jan;30(1):14-22. doi:  10.1097/ mao.0b013e31818a08e8; pubmed pmid: 18833017. 15. meng j, li s, zhang f, li y, qin z. cochlear size and shape variability and implications in cochlear implantation surgery. otol neurotol. 2016 oct;37(9):1307–13. doi:  10.1097/ mao.0000000000001189; pubmed pmid: 27579839. 16. takagi a, sando i. computer-aided three-dimensional reconstruction: a method of measuring temporal bone structures including the length of the cochlea. ann otol rhinol laryngol. 1989 jul;98(7 pt 1):515-522. doi: 10.1177/000348948909800705; pubmed pmid: 2751211. 17. shin kj, lee jy, kim jn, yoo jy, shin c, song wc, et al. quantitative analysis of the cochlea using three dimensional reconstruction based on microcomputed tomographic images. anat rec (hoboken). 2013 jul;296(7):1083-8. doi: 10.1002/ar.22714; pubmed pmid: 23670819. 18. alexiades g, dhanasingh a, jolly c. method to estimate the complete and two-turn cochlear duct length. otol neurotol. 2015 jun;36(5):904-7. doi: 10.1097/mao.0000000000000620; pubmed pmid: 25299827. 19. dimopoulos p, muren c. anatomic variations of the cochlea and relations to other temporal bone structures. acta radiol. 1990 sep;31(5):439–44. pubmed pmid: 2261286. 20. verbist bm, skinner mw, cohen lt, leake pa, james c, boëx c, et al. consensus panel on a cochlear coordinate system applicable in histologic, physiologic, and radiologic studies of the human cochlea. otol neurotol. 2010 jul;31(5):722–30. doi:  10.1097/mao.0b013e3181d279e0; pubmed pmid: 20147866; pubmed central pmcid: pmc2945386. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles philippine journal of otolaryngology-head and neck surgery 13 abstract objective: to compare the incidence of acute otitis media among children aged 2 to 6 months old in sampaloc, manila who were previously given 3 doses of pneumococcal conjugate vaccine (non-typeable haemophilus influenzae (nthi) protein d, diphtheria or tetanus toxoid conjugates) and those who did not receive the vaccine over a period of one year. methods: design: cohort study setting: primary health center in sampaloc, manila, philippines participants: medical records of well children aged 2 to 6 months were reviewed for inclusion. participants were categorized into vaccinated and unvaccinated groups. both groups underwent baseline history and physical examination including otoscopy and any signs and symptoms of active ear infection were noted. subjects were followed up for a period of one year on a monthly basis for signs or symptoms of acute otitis media. results: a total of 176 subjects participated in the study. the overall incidence of aom among participants was 5.11% (9 out of 176). an aom incidence of 3.75% (3 out of 80) and 6.25% (6 out of 96) was found among the exposed and unexposed groups, respectively. fisher’s exact test (one-tailed) p value =.34, relative risk (rr) .6 (95% ci 0.155, 2.323). conclusion: the results of this study showed no difference in the development of aom in the two groups. however, based on the relative risk, pneumococcal conjugate vaccine is still beneficial in preventing aom in children. keywords: pneumococcal conjugate vaccine; acute otitis media acute otitis media (aom) is a common diagnosis among pediatric patients. in the philippine general hospital (pgh), acute otitis media constitutes 0.9% of otorhinolaryngology out-patient department consults.1 by three years of age, 75–80% of children will have had at least one episode, with the peak incidence occurring before the age of two years.2 aom is clinically defined as an inflammation of the middle ear with rapid onset of signs and symptoms of less than 3 weeks duration.1 the most common causative bacteria in aom are streptococcus pneumoniae, haemophilus influenzae, and moraxella catarrhalis, with streptococcus pyogenes and staphylococcus pneumococcal conjugate vaccine (non-typeable haemophilus influenzae (nthi) protein d, diphtheria or tetanus toxoid conjugates) in prevention of acute otitis media in children: a cohort study trixy g. chu, md1 daniel rafael r. cachola iii, md2 mary agnes s. regal, md1 agnes cecille g. llamas, md1 norberto v. martinez, md2 wilfredo r. santos, md1 1department of pediatrics university of santo tomas hospital 2department of otorhinolaryngology head and neck surgery university of santo tomas hospital correspondence: dr. daniel rafael r. cachola iii department of otorhinolaryngology head and neck surgery university of santo tomas hospital españa blvd., sampaloc, manila 1015 philippines phone: (632) 731 3001 local 2411 email: archangel_00011@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. this study was exhibited as a poster presentation during the 51st annual convention of the philippine pediatric society, manila, philippines, april 6, 2014 and the 32nd meeting of the european society of paediatric infectious diseases, dublin, ireland may 8, 2014. presented at the philippine society of otolaryngology head and neck surgery analytical research contest. october 23, 2014. unilab bayanihan center, pasig city. philipp j otolaryngol head neck surg 2016; 31 (2): 13-15 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles 14 philippine journal of otolaryngology-head and neck surgery aureus also reported in some cases. streptococcus pneumoniae can be isolated from up to 50% of aom effusions and is the most common cause of complications.2 since heptavalent pneumococcal conjugate vaccine (pcv-7) was incorporated into the routine immunization schedule in the united states by mid 2000 several studies have demonstrated a dramatic decrease in invasive pneumococcal disease.3 in march 2009, a pneumococcal vaccine containing 10 serotype-specific polysaccharides conjugated to haemophilus influenzae protein d, tetanus toxoid, and diphtheria toxoid as the carrier proteins was developed (phidcv10) was licensed in the european union (synflorix, glaxosmithkline vaccines, rixensart, belgium). vaccines have been used to prevent pneumococcal disease for more than 30 years. in the united states, seven pneumococcal serotypes cause approximately 80% of invasive disease and represent approximately 60% of middle-ear isolates in children younger than age 2 years.4 antibacterial treatment has shown good activity against pneumococcal aom, but with the recent advent of antibiotic-resistant pneumococcal strains there is an increasing risk for serious and fatal infections. preventive immunization against pneumococcal disease, especially in individuals at risk, may be preferred to treatment of existing infections.4 we hypothesized (h1) that a population vaccinated with pneumococcal conjugate vaccine (non-typeable haemophilus influenzae (nthi) protein d, diphtheria or tetanus toxoid conjugates) would have a lower incidence of acute otitis media compared to an unvaccinated group of children. we conducted this study to compare the incidence of acute otitis media among children aged 2 months to 6 months old in sampaloc, manila who were previously vaccinated with 3 doses of pneumococcal conjugate vaccine (non-typeable haemophilus influenzae (nthi) protein d, diphtheria or tetanus toxoid conjugates) and those who were not vaccinated with the vaccine over a period of one year. methods study design: cohort study setting: local health center in earnshaw, sampaloc, manila consisting of 30 barangays with approximately 600-700 inhabitants per barangay, approximately one-fourth of whom were 0-71 months old. the area was bounded by a. lacson, fajardo, valencia and earnshaw streets on the outskirts of the university of santo tomas hospital. subjects with institutional review and ethics committee approval, 188 children meeting inclusion criteria from the selected local health center in earnshaw, sampaloc, manila were considered for this study. the target sample size computed using openepi version 3.01 (open source epidemiologic statistics for public health, www.openepi.com, updated 2013/04/06) was 188 using an alpha of 0.95 and power of 80%. inclusion criteria for the vaccinated and unvaccinated groups were well children born term (>37 weeks-42 weeks) who were or were not previously vaccinated with pneumococcal conjugate vaccine (non-typeable haemophilus influenzae (nthi) protein d, diphtheria or tetanus toxoid conjugates) between 2 to 6 months of age, respectively. excluded were children who were born preterm or post-term, children with weight z scores of <2 or >2, length z scores of <2 or >2, weight for length of <2 or >2, children suffering from chronic illness (including chronic heart, lung, kidney, or liver disease; brain or spinal fluid leaks), those with weakened immune system (cancer, organ or bone marrow transplantation, children under chemotherapy or radiation treatment, long term steroids), suffering from sickle cell disease, with disorders of the spleen or those who underwent splenectomy. procedure the investigators obtained permission to access medical records of the pediatric subjects aged 0-71 months from the local health officer. all available medical records were reviewed by an independent third party. barangay health workers personally visited potential subjects in their homes and requested them to come to the local health center to be seen by the investigators. study details were discussed with the parents or guardians of each child prior to study enlistment and written informed consent was obtained. subjects who met the inclusion criteria and participated in the study were categorized by an independent third party to the vaccinated group and the unvaccinated group. both groups underwent history and physical examination including otoscopy by the investigators at the initial visit to the local health center. any sign and symptom of active ear infection was noted. the investigators were blinded to the vaccinated and unvaccinated groups. the diagnosis of acute otitis media was based on predefined clinical criteria,1 requiring 1) a history of acute onset of signs and symptoms, and 2) signs and symptoms of middle ear inflammation. elements of the definition of acute otitis media were: 1) recent (within a time frame of less than three weeks), usually abrupt onset of signs and symptoms of middle ear inflammation; 2) any one of the following otoscopic findings: markedly retracted tympanic membrane, distinct erythema of the tympanic membrane, bulging of the tympanic membrane, limited or absent mobility of the tympanic membrane, air-fluid level or air bubbles behind the tympanic membrane, perforation with otorrhea; and 3) any one of the following: fever, distinct otalgia (discomfort clearly referable to the ears) that results in interference with or precludes normal activity or sleep).1 participating subjects were required to be brought to the local health center and were actively monitored through clinical examination including otoscopy by the investigators for a period of one year on a monthly basis. the parents or guardians were also given a list of symptoms to record and were asked to bring their children to the study clinic for symptoms suggestive of acute otitis media. subjects who were unable to come to the local health center were personally visited at home by the investigators. statistical analysis the overall incidence of acute otitis media as well as incidence of aom among the vaccinated and unvaccinated groups was computed. the philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles philippine journal of otolaryngology-head and neck surger 15 1-sided fischer’s exact test was computed using the simple interactive statistical analysis (sisa) fischer exact test calculator (quantitative skills consultancy for research and statistics, the netherlands) to compare the vaccinated and unvaccinated groups. the risk ratio was also computed using medcalc® (medcalc software, belgium). results a total of 188 subjects were included in the study, aged between 2 months and 6 months at the time of enrolment. of these, 176 participants completed the study while 12 participants were lost to follow-up. out of the 176 participants, 80 were categorized to the vaccinated group and 96 were categorized to the unvaccinated group. the vaccinated group had 45 males and 35 females while the unvaccinated group had 42 males and 54 females. the mean age was 4.5 months in the vaccinated group and 5.7 months in the unvaccinated group. the overall incidence of acute otitis media among all participants was 5.11% (9 out of 176), with incidences of 3.75% (3 out of 80) and 6.25% (6 out of 96) among the vaccinated and unvaccinated groups, respectively. the one-sided fisher’s exact test p value = .34. relative risk (rr) was .6 (95% ci 0.155, 2.323). discussion after the introduction of pcv-7 in the us, non-typeable h. influenza nthi became the most common pathogen for a period of time, but an increase in non-pcv-7 s. pneumoniae was also noted.5 in a study by parra et al., among bacterial etiology for aom, 64% of samples were culture positive for bacterial pathogens with h. influenzae and s. pneumoniae as the leading causes of bacterial aom, detected in 34% and 29% of aom episodes, respectively.5 the most commonly isolated s. pneumoniae serotypes were 19a, 19f and 23f. all h. influenzae isolates were identified as non-typeable.5 based on epidemiologic data from the health protection agency (hpa), 35.9% of aom cases were assumed to have been attributable to s. pneumoniae and 32.3% to nthi. phid-cv is a 10-valent conjugate vaccine that includes an additional 3 serotypes (1, 5, and 7f) and uses a carrier protein derived from nontypable h influenzae (nthi) for 8 of the 10 serotypes included.6 by virtue of using protein d from nthi as a carrier protein, phid-cv may offer additional protection against nthi, an important cause of aom in children.6 in another study, a seven valent conjugate vaccine was found to be more immunogenic than the polysaccharide pneumococcal vaccines and was 80–100% effective against vaccine-type invasive disease and 50–60% effective against vaccine-type pneumococcal otitis media.3 routine immunization with pneumococcal conjugate vaccines should substantially reduce the morbidity, mortality, and costs associated with pneumococcal disease in children.3 this study showed no statistically significant difference in the incidence of acute otitis media between the vaccinated and unvaccinated groups. similar results were seen in a cohort study among australian aboriginal children, wherein the introduction of pneumococcal vaccination was not associated with significant changes in prevalence or age of onset of different otitis media outcomes or the incidence of acute otitis media or tympanic membrane perforation.7 in comparison to the study by eskola et al., the vaccine reduced the number of episodes of acute otitis media from any cause by 6%, cultureconfirmed pneumococcal episodes by 34%, and the number of episodes due to the serotypes contained in the vaccine by 57%.8 the number of episodes attributed to serotypes that were cross-reactive with those in the vaccine was reduced by 51%, whereas the number of episodes due to all other serotypes increased by 33%.8 based on the relative risk in this study, pneumococcal conjugate vaccination is still beneficial in preventing aom in children, comparable to the previous study. this study only focused on one subset of the population and may not be representative of the entire population. moreover, this study did not account for risk factors in developing acute otitis media such as socioeconomic status, number of household members, overcrowding, and housing conditions. because this study diagnosed aom clinically and did not use other methods such as tympanostomy with culture and sensitivity; it was unable to identify organisms that may have caused the disease. the observation period was limited only to one year, and some subjects may have developed aom after the conclusion of this study. we recommend a more diverse population with a larger sample size and a longer observation period be considered by future studies. although the results of this study showed no difference in the incidence of aom among the two groups, based on the relative risk, pneumococcal conjugate vaccine may still be beneficial in preventing aom in children. references 1. magiba-caro r, acuin j, jose e, chiong c, villafuerte c, pontejos a, nolasco f. clinical practice guidelines on acute otitis media in children. philippine society of otolaryngology head and neck surgery, inc. 2006. 2. grevers g. challenges in reducing the burden of otitis media disease: an ent perspective. int jpediatr otorhinolaryngol. 2010 jun; 74(6):572-577. doi: 10.1016/j.ijporl.2010.03.049. pubmed pmid: 20409595. 3. poehling ka, szilagyi pg, grijalva cg, martin sw, lafleur b, mitchel e, griffin m, et al. reduction of frequent otitis media and pressure-equalizing tube insertions in children after introduction of pneumococcal conjugate vaccine. pediatrics. 2007 apr; 119(4): 707-715. doi:10.1542/ peds.2006-2138. pubmed pmid: 17403841. erratum in pediatrics. 2007 june; 119(6): 1270. doi:10.1542/peds.2007-1030. 4. o’brien kl, santosham m. potential impact of conjugate pneumococcal vaccines on pediatric pneumococcal diseases. am jepidemiol. 2004 apr 1; 159 (7): 634-644. doi: 10.1093/aje/kwh082. pubmed pmid: 15033641. 5. parra mm, aguilar gm, echaniz aviles g, rionda rg, estrada mde l, cervantes y, hausdorff wp, et al. bacterial etiology and serotypes of acute otitis media in mexican children. vaccine. 2011 jul 26; 29(33): 5544-5549. doi: 10.1016/j.vaccine.2011.04.128. pubmed pmid: 21596081. 6. de wals p, black s, borrow r, pearce d. modeling the impact of a new vaccine on pneumococcal and nontypable haemophilus influenzae diseases: a new simulation model. clinical therapeutics. 2009 oct; 31(10): 2152-2169. doi: 10.1016/j.clinthera.2009.10.014. pubmed pmid:19922887. 7. mackenzie ga, carapetis jr, leach aj, morris ps. pneumococcal vaccination and otitis media in australian aboriginal infants: comparison of two birth cohorts before and after introduction of vaccination. bmc pediatr. 2009 feb 19; 9:14. doi: 10.1186/1471-2431-9-14. pubmed pmid: 19228431. pubmedcentral pmcid: pmc2656498. 8. eskola j, kilpi t, palmu a, jokinen j, haapakoski j, herva e, makela ph, et al. efficacy of a pneumococcal conjugate vaccine against acute otitis media. n engl j med. 2001 feb 8; 344(6):403-409. doi: 10.1056/nejm200102083440602. pubmed pmid: 11172176. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery case reports abstract objective: to discuss the case of a 36-year-old man who presented with left unilateral facial paralysis 11 days after mastoidectomy. methods: design: case report setting: tertiary government training hospital patient: one results: a 36-year-old man with recurrent left ear discharge of 30 years duration underwent left canal wall-down mastoidectomy and was discharged well after 3 days. on follow up after 8 more days, he was noted to have house-brackmann iv left facial paralysis. following 5 days methylprednisolone, neurologic evaluation and physical therapy rehabilitation, facial paralysis improved in the ensuing weeks until house-brackmann i was achieved at week 12. conclusion: delayed-onset facial palsy (dfp) following tympanomastoid surgery may be approached conservatively, including steroids, acyclovir, and, if with a history of herpes or varicella infection, immunization can be given. prognosis for dfp is good especially when the facial nerve is identified intraoperatively during otologic surgeries. keywords: facial nerve; mastoidectomy; otologic surgeries, unilateral facial paralysis, viral reactivation a thorough knowledge of the intricate, convoluted course of the facial nerve and its anatomic relationship to other vital structures in the temporal bone is essential to the otologic surgeon.1 proper identification of the facial nerve intraoperatively is crucial for preventing facial paralysis. what if the complication was not present after surgery, but developed over a week later? we discuss one such case. delayed-onset unilateral facial paralysis after mastoidectomy: a case report elbert digger q. baloco, md jose b. orosa iii, md department of otorhinolaryngology head and neck surgery mariano marcos memorial hospital and medical center correspondence: dr. jose b. orosa iii department of otorhinolaryngology head and neck surgery mariano marcos memorial hospital and medical center 3h65+5m6, brgy, 6, ilocos norte 2906 philippines phone: +63 77 600 8000 local 2205 email: elbertdiggerbaloco@gmail.com docjune1968@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2023; 38 (1): 50-53 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery case reports case report a 36-year-old man with recurrent left ear discharge of 30 years duration underwent an uneventful left canal wall-down mastoidectomy for chronic ototympanomastoiditis with cholesteatoma. he was discharged well after 3 days on oral antibiotics and a pain reliever. on follow up after 8 days, he had a house-brackmann iv unilateral facial paralysis drooling when he would drink liquids and being unable to close his left upper eyelid or puff his left cheek. (figure 1) a review of the past medical history yielded childhood varicella infection but no other viral exanthems, no other drug intake or history of stroke. he was started on methylprednisolone 16 mg tab for 5 days and was referred to a neurologist and physical therapy for rehabilitation. no nerve conduction studies were done, but he was on weekly follow up with monitoring of his muscles of facial expression. (figure 1) facial paralysis improved week after week until he achieved house-brackmann ii iii on his 5th week and house-brackmann i by the 12th week and beyond. (figure 2) discussion facial nerve paralysis as a complication of middle ear surgery is dreadful for the otologic surgeon. usually caused by surgical trauma or local anesthetic use, it is uncommon to see onset of facial nerve palsy more than 72 hours following the surgery.2 in a meta-analysis of 14 patients by bae and kwak et al., the overall incidence of delayed facial palsy following middle ear surgery was 0.65% but had multiple etiologies and differed depending on the type of surgery.3 the mean time onset of facial palsy was 8.47± 3.98 days after surgery, and 95.3% of the patients completely recovered.3 facial palsy that occurs immediately after middle ear surgery (stapedectomy, stapedotomy, and tympanoplasty) can be a consequence of local anesthetics and regresses completely within a few hours, while delayed facial palsy occurs several days or even weeks after uneventful surgery.4 the mechanism of the neural dysfunction is not readily defined. surgical stress, intraoperative trauma, or laceration of the chorda tympani nerve with resultant retrograde facial nerve edema can all be provoking etiological factors.4 our patient underwent mastoidectomy before the delayed-onset complication after eight days. several studies identify tympanomastoidectomy as a high-risk factor due to the invasiveness and extent of the procedure.4,5,6 a 2019 review by eckermann et al. of 10 studies involving 12,161 patients stated that the incidence of dfp after middle ear surgeries varies between 0.2 and 1.9%.5 in comparison, bell’s palsy occurs with an incidence of 0.02–0.03%.7 in eckermann’s review, the influence of the type of surgical technique on the incidence of dfp was included. figure 1. house-brackmann iv facial nerve function during the first 3 follow-up visits. top row, initial presentation 15 days after surgery; second, and third rows, after 19 and 21 days, respectively (photos published in full, with permission). figure 2. progressive improvement in facial nerve function to house brackmann ii-iii at 5 weeks (35 days) follow-up (top row), becoming house – brackmann i at 12 weeks and beyond (middle and bottom row). (photos published in full, with permission). philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery case reports a comparison showed that the incidence of dfp was lowest in stapedectomy and stapedotomy with 0.43% in mean value and highest in tympanomastoid surgery with 1.18 in mean value. for the surgical technique of simple tympanoplasty, the mean incidence was 0.72% on average.5 revesz et al. reported that out of 149 ktp laser stapedotomies performed at their department since 2006, 2 cases (0.01%) of delayed facial paralysis occurred.4 the first was a 52-year-old woman who had an uneventful postoperative period and was discharged 3 days after explorative tympanotomy, only to have house-brackmann grade ii facial palsy on the operated side 8 days postoperatively. the second was a 45-year-old man who also underwent an uneventful ktp laser stapedotomy who developed a house-brackmann grade iii facial palsy on the operated side 13 days post-operation.4 neither patient had any active ear infections during their facial paralysis and both were managed with methyprednisolone and acyclovir, completely recovering (house-brackmann grade i) several weeks after onset of facial palsy.4 in a study by mills,6 the temperature in the facial canal was examined during stapedectomy using a laser or microdrill and a mean temperature elevation by 6.2 °c in the facial canal was observed when lasers were used.6 thermal stress is assumed to be a possible factor for viral reactivation or edema. the use of lasers during middle ear surgery increases the risk of dfp.6 since our patient had a history of childhood varicella, viral reactivation could be considered as another etiology. de stefano et al. reported the case of a patient who had facial paralysis 11 days after a successful canal wall down mastoidectomy concluded that when an ipsilateral facial nerve palsy appears more than 72 hours after an uneventful middle ear procedure without symptoms of any infection, viral reactivation should be suspected.2 bonkowsky8 focused on viral reactivation and attempted to confirm this theory through various tests, identifying hsv-1 and vzv as two main representatives of viral reactivation. furuta and others9,10 were able to detect the latent viral infection caused by hsv-1 and vzv in investigations of deceased patients who had an idiopathic acute facial paralysis, proving the site of origin of reactivation of latent viral infection in the geniculate ganglion on autopsy. bonkowsky8 opined that the viral reactivation due to surgical stress leads to an immune reaction, which can be responsible for the development of dfp. according to gianoli et al., dna detection by pcr should be sought if virus reactivation is suspected.11 althaus12 cited the occurrence of neuronal edema as another reason for the development of dfp. in the examined articles, edema was postulated as a reason for the development of dfp in approximately 17% of the performed stapedectomies.12 these occurred intraor immediately postoperatively. the causes were probably surgical stress and small injuries to the tissue.12 edemas are caused by restricted venous drainage, vascular thrombosis, vasospasm, meningitis or fluid retention.12 neuronal edema compresses the nerve and disrupts its supply because the facial nerve is located in a confined space.12 as a result, delayed paralysis of the nerve develops. neuronal edema reaches its greatest extent on the 5th day, then subsides again, and is almost completely receded on the 14th day.13 althaus12 cites manipulation or separation of the chorda tympani as another triggering cause for the development of neuronal edema. the resulting traumas develop edema that spread retrogradely and thus compress the facial nerve.12 this hypothesis of retrograde edema was also discussed by blatt and freeman.14 patients with dehiscence of the facial canal have a significantly higher probability for a delayed facial palsy.5 xu15 referred to a bony anomaly in his article wherein he cited facial canal dehiscence for the development of dfp. in his study, 9 of 15 patients with dfp (60%) had dehiscence of the facial canal. in comparison, 20% of patients who underwent surgery had dehiscence without dfp.15 dehiscence, therefore, increases the risk of developing dfp by the open nerve canal and exposed nerve in the case of our patient, no facial canal dehiscence was evident on his ct findings. moreano et al.16 also recorded this problem in their study, where 1000 petrous bones were examined. of the 1000 facial canals, 560 were dehiscent. the most common location of dehiscence was at the oval window, accounting for 73.5%.16 the recommended therapy of dfp based on the data of the therapy of bell’s palsy, consists of steroid administration.5 for patients with a history of previous viral infections, antiviral prophylaxis is recommended.5 the meta-analysis of bae et al.3 compared different therapeutic options for dfp after middle ear surgeries, finding no significant differences between steroids, antivirals, steroids plus antivirals, and no therapy. glass et al.17 summarized the results of current reviews, meta-analyses and larger randomized trials dealing with bell’s palsy therapy. an early steroid administration was recommended, with antiviral therapy only for patients with positive viral serology or anamnesis.17 patients with igm or igg antibodies against hsv-1 or vzv for example, are treated with an antiviral such as acyclovir.17 in the study by de stefano and colleagues,2 patients were treated with 2400 mg of acyclovir per day in addition to steroids if the viral serology was positive for 10 days. acyclovir can also be administered prophylactically to prevent dfp if the patient had a positive viral anamnesis.2 another prophylactic therapy is vaccination of high-risk patients; immunosuppressed patients in particular have an increased risk of herpes virus reactivation.18 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery case reports references 1. nelson rf, gubbels sp, gantz bj. intratemporal facial nerve surgery. in: flint p, francis hw, haughhey bh, lesperance mm, lund vj robbins k, et al., (editors). cumming’s otolaryngology head and neck surgery, 7th edition. philadelphia, pa: elsevier inc.; 2021. p. 2598-2599. 2. de stefano a, neri g, kulamarva g. delayed facial nerve paralysis post middle ear surgery: herpes simplex virus activation. b-ent. 2009;5(1):47-50. pubmed pmid: 19456000. 3. bae sh, kwak sh, nam gs, jung j. meta-analysis of delayed facial palsy following middle ear surgery. otol neurotol. 2019 sep; 40(8);1109-1115. doi:  10.1097/mao.0000000000002318; pubmed pmid: 31356488. 4. révész p, piski z, burián a, harmat k, gerlinger i. delayed facial paralysis following uneventful ktp laser stapedotomy: two case reports and a review of the literature. case rep med. 2014;2014:971362. doi: 10.1155/2014/971362. epub 2014 nov 11. pubmed pmid: 25435882; pubmed central pmcid: pmc4243476. 5. eckermann j, meyer je, guenzel t. etiology and therapy of delayed facial paralysis after middle ear surgery. eur arch otorhinolaryngol. 2020 apr;277(4):965-974. doi:  10.1007/s00405-02005825-y; pubmed pmid: 32008076. 6. mills r, szymanski m, abel e. delayed facial palsy following laser stapedectomy: in vitro study of facial nerve temperature. clin otolaryngol allied sci. 2003 jun;28(3):211–214. doi: 10.1046/j.1365-2273.2003.00691.x; pubmed pmid: 12755758. 7. baxter a. dehiscence of the fallopian canal. an anatomical study. j laryngol otol. 1971 jun;85(6):587–594. doi: 10.1017/s0022215100073849; pubmed pmid: 5581361. 8. bonkowsky v, kochanowski b, strutz j, pere p, hosemann w, arnold w. delayed facial palsy following uneventful middle ear surgery: a herpes simplex virus type 1 reactivation? ann otol rhinol laryngol. 1998 nov;107(11 pt 1):901-5. doi:  10.1177/000348949810701101; pubmed pmid: 9823837. 9. furuta y, fukuda s, suzuki s, takasu t, inuyama y, nagashima k. detection of varicella-zoster virus dna in patients with acute peripheral facial palsy by the polymerase chain reaction, and its use for early diagnosis of zoster sine herpete. j med virol. 1997 jul;52(3):316-319.pubmed pmid: 9210042. 10. furuta y, takasu t, sato kc, fukuda s, inuyama y, nagashima k. latent herpes simplex virus type 1 in human geniculate ganglia. acta neuropathol. 1992;84(1):39-44. doi: 10.1007/bf00427213; pubmed pmid: 1323906. 11. gianoli gj. viral titers and delayed facial palsy after acoustic neuroma surgery. otolaryngol head neck surg. 2002 nov;127(5):427-431. doi: 10.1067/mhn.2002.129817; pubmed pmid: 12447236. 12. althaus sr, house hp. delayed post-stapedectomy facial paralysis: a report of fve cases. laryngoscope. 1973 aug;83(8):1234–1240. doi: 10.1288/00005537-197308000-00007; pubmed pmid: 4758126. 13. vrabec jt. delayed facial palsy after tympanomastoid surgery. am j otol. 1999 jan;20(1):26-30. pubmed pmid: 9918167. 14. blatt im, freeman ja. bell’s palsy 3 further observations on the pathogenesis of bell’s palsy and the results of chorda tympani neurectomy. trans am acad ophthalmol otolaryngol. 1969 mayjun;73(3):420–438. pubmed pmid: 5791365. 15. xu p, liu w, zuo w, wang d, wang h delayed facial palsy after tympanomastoid surgery: a report of 15 cases. am j otolaryngol. 2015 nov-dec;36(6):805–807. doi: 10.1016/j.amjoto.2015.07.004; pubmed pmid: 26545475. 16. moreano eh, paparella mm, zelterman d, goycoolea mv. prevalence of facial canal dehiscence and of persistent stapedial artery in the human middle ear: a report of 1000 temporal bones. laryngoscope. 1994 mar;104(3 pt 1):309–320. doi:  10.1288/00005537-199403000-00012; pubmed pmid: 8127188. 17. glass ge, tzafetta k. bell’s palsy: a summary of current evidence and referral algorithm. fam pract. 2014 dec;31(6):631–642. doi: 10.1093/fampra/cmu058; pubmed pmid: 25208543. 18. florian p, matthias p, ulf ml, andreas s. januskinase-inhibitoren: therapie mit wermutsreopfen: reaktivierung von herpes zoster. deutsches ärzteblatt. 2019;116(35–36):1540–1542. 19. hardillo jau, lopa rab, crisostomo-tan gu, gonzales re, del rosario ra, caparas mb. an unusual case of facial paralysis. philipp j otolaryngol head neck surg 1994:93-97. [cited 2023 april 28] available from: https://pjohns.pso-hns.org/index.php/pjohns/issue/view/81/29. overall, dfp has a very good prognosis, with 95% healed completely following appropriate therapy.5 a review of the medical records of otologic surgeries in our hospital for the past 10 years (2010 to 2019) including interviews with otolaryngologists revealed several mastoid surgeries done but without any complication of delayed-onset facial paralysis on follow up. only one case was documented to have unilateral facial paralysis which the patient already had even before the surgery for mastoidectomy. after a search of herdin plus and the asean citation index (aci), we found no locally published case of delayed-onset facial paralysis after otologic surgery; a study by hardillo et al. of an unusual case of facial paralysis occurred with a pre-existing right sided paralysis and an ipsilateral infraauricular mass with ear discharge.19 our experience in this case teaches us that delayed-onset facial palsy (dfp) following tympanomastoid surgery may be approached conservatively, including steroids, acyclovir, and, if with a history of herpes or varicella infection, immunization can be given. it affirms the literature that the prognosis for dfp is good especially when the facial nerve is identified intraoperatively during otologic surgeries. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 6 philippine journal of otolaryngology-head and neck surgery commentary social media is the new avenue for creating connections and sharing of information. through social media, one can reach a global community. in recent years, we have seen how social media has changed the way we do things. social media has been extensively utilized for health education and promotion, proving itself to be an invaluable tool for public health, professional networking and patient care benefit. the challenge has been to use the power afforded by social media responsibly, and to define the line between use and abuse. while there may be laws, implementation proves to be a challenge in the digital age. therefore, self-regulation and institutional policy remain a critical part. it is therefore urged that hospitals and health care facilities adopt their own social media use policy appropriate for the institution. below are proposed rules that could guide institutions in developing their own policy for social media use: sec. 1. declaration of policy. the health facility recognizes that the exercise of the freedom of expression comes with a responsibility and a duty to respect the rights of others. the health facility likewise acknowledges the fundamental right to privacy of every individual. this policy shall provide rules for responsible social media use. sec. 2. definition. for purposes of this policy, the following definitions shall be used: a. social media refers to electronic communication, websites or applications through which users connect, interact or share information or other content with other individuals, collectively part of an online community. this includes facebook, twitter, google+, instagram, linkedin, pinterest, blogs, social networking sites. b. health facility shall refer to the hospital or other health care facilities, including training and educational institutions. c. individual shall refer to physicians, employees, other health facility staff, residents, or students to which this policy would apply. sec. 3. applicability. this policy shall apply to all physicians, health professionals, employees and other health facility staff, including students or residents in training, practicing their profession, working, or fulfilling academic and clinical requirements within the health facility, whether temporary or permanent. recommendations for social media use in hospitals and health care facilities ivy d. patdu, md, jd national privacy commission republic of the philippines correspondence: dr. ivy d. patdu deputy commissioner national privacy commission philippines phone: (632) 804 2784 email: ivypatdu@protonmail.com the author declares that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2016; 31 (1): 6-9 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 7 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 commentary sec. 4. general principles. social media use shall be guided by the following principles: a. in using social media, an individual should always be mindful of his or her duties to the patient and community, his profession and his colleagues. b. the individual should always be conscious of his or her online image and how it impacts his or her profession, or the institution where he or she is professionally employed, affiliated or otherwise connected. c. responsible social media use also requires the individual to ensure that in his or her social media activity, there is no law violated, including copyright, libel and cybercrime laws. at all times, the individual shall respect the right of privacy of others. d. use of social media requires a personal commitment to uphold the ethical standards required of those providing health services, upon which patient trust is built. sec. 5. social media for health education or promotion a. the individual using social media for health education or promotion must be well-informed of the matter subject of the social media post, comment or other activity. the individual shall refrain from any activity which spreads or tends to spread misinformation. b. an article written by an individual and posted in social media must be evidence-based and disclose connections with pharmaceutical or health product companies or other sources of possible conflict of interest. c. social media shall not be used to dispense specific medical diagnosis, advice, treatment or projection but shall consist of general opinions only. use of social media should include statements that a person should not rely on the advice given online, and that medical concerns are best addressed in the appropriate setting. d. the individual shall be careful in posting or publishing his or her opinion and shall ensure that such opinion will not propagate misinformation or constitute a misrepresentation. the individual shall not make any misrepresentations in his or her social media activity relating to content, his or her employment or credentials, and any other information that may be misconstrued or taken out of context. sec. 6. professionalism in social media use a. individuals are discouraged from using a single account for both professional and private use. be mindful that an electronic mail address used professionally may readily be linked to a social media site used privately. b. the individual shall conduct himself or herself in social media or online the same way that he would in the public, mindful of acting in a manner befitting his profession, or that would inspire trust in the service he or she provides, especially if the individual has not separated his or her professional and personal accounts in social media. c. the individual shall likewise refrain from using the name, logo or other symbol of an institution without prior authority in his or her social media activity. an individual shall not identify himself or herself as a representative of an institution in social media without being authorized to do so. d. individuals shall not accept former or current patients as friends or contacts in their personal accounts, unless there is justification to do so, such as a pre-existing relationship or when unavoidable for patient care. in case of online interaction with patients, this should be limited to matters related to the patient’s treatment and management, and which could be properly disclosed. e. informal and personal information concerning a patient, colleague or the health facility shall not be posted, shared or otherwise used in social media. f. social media shall not be used to establish inappropriate relationships with patients or colleagues, and shall not be used to obtain information that would negatively impact on the provision of services and professional management of the patient. g. an individual shall refrain from posting, sharing or otherwise using photos or videos taken within the health facility, which would give the impression of unprofessionalism, show parts of the health facility where there is an expectation of privacy, or those which includes colleagues, employees, other health facility staff, or patients without their express consent. the consent requirement shall apply even if the other individuals included are not readily identifiable. sec. 7. responsible social media activity a. in using social media, the individual shall respect the dignity, personality, privacy and peace of mind of another. b. the individual shall not post, share or otherwise use social media with the intent of damaging the reputation of any other individual or institution, especially if the subject is identified or identifiable. c. derogatory comments about patients, colleagues, employers and institutions or companies should be avoided. an individual may “like” a defamatory post but he or she must use caution philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 commentary 8 philippine journal of otolaryngology-head and neck surgery when sharing, retweeting or contributing anything that might be construed as a new defamatory statement. a post, comment or other social media activity is considered defamatory if: 1) the activity imputes a discreditable act or condition to another; 2) the activity is viewed or seen by any other person; 3) the person or institution defamed is identified or readily identifiable; 4) there is malice or intent to damage the reputation of another. d. he or she shall be careful of sharing posts or other contents that are unverified, particularly if it discredits another person or institution, or imputes the commission of a crime or violation of law even before trial and judgment, and violates the privacy of another. fair and true reporting on matters of public concern shall be allowed provided that the content was obtained lawfully and with due respect for the right of privacy. e. an individual shall not use copyrighted materials other than for fair use where there is proper citation of source and author. use of copyrighted material for purpose of criticism, comment, news, reporting, teaching, scholarship, research, and similar purposes is compatible with fair use. f. an individual is prohibited from: 1) social media activities that defame, harass, stalk, or bully another person or institution. 2) the use or access of personal social media accounts of others without authority. 3) posting, sharing or otherwise using any information intended to be private or obtained through access to electronic data messages or documents. 4) posting, sharing or otherwise using recorded conversations between doctors, individuals or patients, when such recording, whether audio or video, was obtained without consent of all the parties to the conversation g. individuals should use conservative privacy settings in their social media account used professionally. the individual should also practice due diligence in keeping their social media accounts safe such as through regular password change and logging out after social media use. sec. 8. health information privacy a. the individual shall respect the right to privacy of others and shall not collect, use, access or disclose information, pictures and other personal or sensitive information without obtaining consent from the individual concerned. physicians, health facility employees and other health staff shall have the duty of protecting patient confidentiality in their social media activity. b. personal health information, including photos or videos of patients, shall not be posted, shared or otherwise used in social media without consent of patient. consent shall be obtained after explaining to the patient the purpose of the intended collection, use, access and disclosure. consent for use of personal health information shall be written or evidenced by electronic means. c. an individual shall not post, share or otherwise use any information which could be used to identify patients without their consent, including patient’s location, room numbers, and photographs or videos of patients or their body parts, including code names referring to patients. d. the individual shall not post, share or otherwise use any other information acquired in attending to a patient in a professional capacity, and which would blacken the reputation of the patient. the duty of maintaining patient confidentiality remains even after patient’s death. e. an individual shall not post, share or otherwise use any information relating to the identity, status and personal details of persons with hiv, those who have undergone drug rehabilitation, and victims of domestic violence, rape and child abuse. sec. 9. compliance and reporting. a. an individual shall strive to develop, support and maintain a privacy culture in the health facility. he or she shall abide by the social media use policy of the institution. b. an individual who becomes aware of unprofessional behavior, misinformation or privacy violations in social media shall report the matter to the hospital’s privacy officer or the proper office or authority within the facility. c. health facilities shall in so far as practicable monitor the social media activity of all physicians, employees and other health facility staff, including students or residents in training, practicing their profession, working, or fulfilling academic and clinical requirements within the health facility, whether temporary or permanent. sec. 10. penalty. a violation of this policy may constitute a violation of the code of ethics of physicians and other professions, and other applicable laws. a. health professionals, employees and other health facility staff. any person found violating this policy will be considered in philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 commentary philippine journal of otolaryngology-head and neck surgery 9 violation of health facility rules and regulations, and shall be subjected to health facility administrative proceedings, which after notice and hearing, and depending on the severity of the violation, could result to termination of service or withdrawal of privileges. a lighter penalty may likewise be imposed. in determining the severity of the violation, the following factors may be considered: previous violation, if any, the nature of the violation, and the extent of injury or damage. the penalty imposed by the health facility shall be without prejudice to the filing of a complaint before the civil service references 1987 constitution of the republic of the philippines, article iii, section 3(1) (1987). 1. an act to ordain and institute the civil code of the philippines, republic act no. 386, article 2. 26 (1950). an act providing for the recognition and use of electronic commercial and non-commercial 3. transactions and documents, penalties for unlawful use thereof and for other purposes, (electronic commerce act of 2000), republic act no. 8792, §§ 5, 7, 31-33 (2000). an act protecting individual personal information in information and communications 4. systems in the government and the private sector, creating for this purpose a national privacy commission, and for other purposes (data privacy act of 2012), republic act no. 10173, (2012). an act to prohibit and penalize wire tapping and other related violations of the privacy of 5. communication, and for other purposes, (anti wire-tapping law), republic act no. 4200, §§ 1-2 (1965). an act prescribing the intellectual property code and establishing the intellectual property 6. office, providing for its powers and functions, and for other purposes, (intellectual property code of the philippines), republic act no. 8293, (1998). an act promulgating policies and prescribing measures for the prevention and control of 7. hiv/aids in the philippines, instituting a nationwide hiv/aids information and educational program, establishing a comprehensive hiv/aids monitoring system, strengthening the philippine national aids council, and for other purposes, (philippine aids prevention and control act of 1998), republic act no. 8504, (1998). an act instituting the comprehensive dangerous drugs act of 2002, repealing republic act 8. no. 6425, otherwise known as the dangerous drugs act of 1972, as amended, providing funds therefor, and for other purposes, (comprehensive dangerous act of 2002), republic act no. 9165, (2002). an act providing assistance and protection for rape victims, establishing for the purpose a 9. rape crisis center in every province and city, authorizing the appropriation of funds therefor, and for other purposes, (rape victim assistance and protection act of 1998), republic act no. 8505, (1998). revised rules on evidence, rules of court, rule 130, section 24(c).10. hippocratic oath, available at https://www.philippinemedicalassociation.org/downloads/11. pma-codes/hippocratic-oath.pdf (last accessed may, 26, 2016). code of ethics of the philippine medical association at https://www.philippinemedicalassociation.12. org/downloads/pma-codes/final-pma-codeofethics2008.pdf (last accessed may, 26, 2016). special committee on ethics and professionalism. (2012, april). model guidelines for the 13. appropriate use of social media and social networking in medical practice., at https://www. fsmb.org/media/default/pdf/fsmb/advocacy/pub-social-media-guidelines.pdf (last accessed may 25, 2016). bristish medical association. using social media: practical and ethical guidance for doctors 14. and medical students at http://bma.org.uk/-/media/files/pdfs/practical advice at work/ethics/ socialmediaguidance.pdf (last accessed may 25, 2016). federation of state medical boards. social media guidelines. at from www.fsmb.org/pdf/pub-15. social-media-guidelines.pdf (last accessed may 25, 2016). patdu-calaquian, i. d. (2015, december 1). “16. to click or not to click: social media and the md” (legal & ethical issues for doctors using social media). lecture presented at 59th philippine society of otolaryngology-head and neck surgery annual convention in manila marriott hotel. patdu-calaquian, i. d. (2014, may 6). 17. “facebook for doctors: use, abuse, misuse... confused?”. lecture presented at 44th annual pcp convention in smx convention center. commission, the professional regulations commission, the office of the prosecutor or ombudsman, or proper courts. b. students. in case of students, they shall be reported to the college wherein they are enrolled and shall be subjected to disciplinary proceedings, which could result to expulsion, depending on the severity of the violation, and in accordance with the applicable university and respective college rules. a lighter penalty may likewise be imposed. the disciplinary proceedings shall be without prejudice to other applicable legal remedies. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 67 passages tierry f. garcia, md (1919-2016) “the most good for the most people” charlotte m. chiong, md, phd dr. tierry garcia was born december 20, 1919 as one of nine children of dr. silverio f. garcia from bocaue, bulacan (upcm 1912) and elisea trijo ballesteros (up pharmacy) from sorsogon. he was married to amanda, wife of 63 years, and the couple was blessed with three children: tierry, jr., sofia garcia – buder, m.d. (a third generation upcm graduate) and angela. according to sofia he “led a life of service to god and to his fellowmen, both professionally and personally. his greatest professional legacies for posterity include being among the founding fathers and past chairman of the department of ear, nose and throat at the up-pgh; the philippine society of otorhinolaryngology; and the manila doctors hospital. he was the last of the small group of pioneers over six decades ago who helped pave the way for the delivery of modern day ent care to the filipino people whom he loved.” she continues: “like his father before him, a former surgeon and governor of sorsogon,” he “strived towards doing ‘the most good for the most people’.” on a personal note, his father used to play tennis with my grandfather col. antonio martinez, a bicolano who was philippine constabulary officer in sorsogon at that time. because of this, a special bond was formed between dr. tierry and my father. here are the thoughts and recollections of my father dr. armando t. chiong on this great man: “i first met dr. tierry garcia in 1960. i was 30 years old and he was 40. my first impression of dr. garcia was that he was a visionary leader with strong intellect. when he talked in meetings and conferences everybody listened. he was well-respected such that he was able to establish the first separate department of otolaryngology from ophthalmology at manila doctors hospital in 1956 in spite of much objections. he established his clinic beside famous physicians with the likes of dr. ambrocio tangco, founder of department of orthopedics at the philippine general hospital; benjamin barrera, then dean of up college of medicine; dr. gonzalo austria, former dean of ue college of medicine; dr. constantino manahan, world renowned ob-gynecologist; and dr. carlos sevilla, famous eent specialist who was among the 14 of his co-founders of manila doctors hospital. most importantly, he also founded the philippine society of otolaryngology and bronchoesophagology in 1956.” “when he left for the united states in 1972, i took over his clinic and practice. all his medical instruments that he left with me are still intact and i have them in our hospital in malolos, bulacan. as for my last impression of dr. garcia, he was a generous and kind person. he helped in my first appointment to the department of otolaryngology at up college of medicine in 1964 apart from giving me his clinic at the manila doctors hospital.” he graduated from upcm at the top 10 of his class in 1942 and ranked in the top 10 of the physician’s licensure board exams followed by a three-year residency training in surgery at pgh then another residency in the u.s. finishing as chief resident in otolaryngology at columbia presbyterian. this prepared him well for the trail blazing and pioneering work. his bold, and inspiring spirit proved a great influence to succeeding generations of what he had ascribed as the “best and the brightest” otolaryngologist fellows of psohns now numbering 694 from the original heroic nine that rallied to establish a separate society 60 years ago in the midst of great opposition. he firmly believed that serving others was the “true path to happiness” as gleaned from one of my own conversations with him after a pgh grand rounds he attended. as proof, he established a pgh patient endowment fund in orl to help indigent patients undergo much needed surgeries with meager financial resources. we have been most fortunate indeed that he was able to join us in the 2015 annual congress last december and on the 60th anniversary of the philippine society of otolaryngology-head and neck surgery last february. proof perhaps that not all “the good die young.” he has bequeathed to us a most precious legacy, a specialty we have chosen as careers and where we have all found some of life’s most important rewards. in his own words, a meaningful life that can only be measured by what he thought constitutes “true happiness” – a life lived in the service of our god and country, while enjoying a journey filled to the brim by love of family, friends and fellowmen. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 special announcement geneva, 11 october 2021 the philippine journal of otolaryngology head and neck surgery joined more than 300 organizations representing at least 45 million nurses, doctors and health professionals worldwide – about three quarters of the global health workforce – and signed an open letter to the 197 government leaders and national delegations ahead of the un climate conference (cop26) in glasgow, uk, warning that the climate crisis is the single biggest health threat facing humanity, and calling on world leaders to deliver on climate action.1 the letter’s publication coincided with the october 11, 2021 release of a new report by the world health organization (who), which argues that countries can only ensure a long-term recovery from the pandemic by implementing ambitious climate commitments. the report delivers ten high-level recommendations, backed up by action points, resources and case studies, including the need to place health and social justice at the heart of the un climate talks.2 the letter states: “wherever we deliver care, in our hospitals, clinics and communities around the world, we are already responding to the health harms caused by climate change.” it further says “those people and nations who have benefited most from the activities that caused the climate crisis, especially fossil fuel extraction and use, have a great responsibility to do everything possible to help those who are now most at risk.” global health community calls for climate action ahead of cop26 to avert “biggest health threat facing humanity” who report calls for ambitious climate commitments as the only path to long-term recovery from pandemic josé florencio lapeña, editor-in-chief of the philippine journal of otolaryngology head and neck surgery echoed the statement: “wildfires, flooding, heatwaves and droughts impacting people’s health have been on the rise around the world, compounding other health challenges such as the pandemic. in the philippines, we are already seeing heightened el niño and la niña phenomena, with flooding and rising sea levels. by integrating health and equity into climate policy, the philippines has the opportunity to protect peoples’ health, maximize returns on investments, and build public support for the urgently needed responses from governments to the climate crisis.”   both the letter and the report argue that health and equity must be at the center of climate change response; while the letter calls for action, the report provides the blueprint for delivering climate action that will protect the health of people around the world. the letter, which has been signed by diverse medical organizations and high profile individuals, such as who directorgeneral dr. tedros adhanom ghebreyesus, the world medical association, the international council of nurses and doctors for philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 special announcement extinction rebellion switzerland, calls on all governments to update their national climate commitments under the paris agreement, in line with their fair share of limiting warming to 1.5°c. a recent report by un climate change (unfccc) found that countries’ collective climate commitments are falling far short of this goal, and would lead to a global temperature rise of at least 2.7°c by the end of the century.3,4 the 45 million health professionals represented in the letter are demanding a rapid and just transition away from fossil fuels; for high income countries to provide the promised transfer of climate funds; for investments in resilient and low carbon health systems; and for pandemic recovery investments to support climate action and reduce social and health inequities.  the signatories of the open letter represent every region of the world, and include the international council of nurses, the world medical association, the international federation of medical students associations, the international confederation of midwives, the international pediatrics association as well as the philippine journal of otolaryngology head and neck surgery. see full list of signatories at: https://healthyclimateletter.net/signatories/ end notes: 1. more information on the #healthyclimate prescription letter is available at: https://healthyclimateletter.net 2. the who report “the health argument for climate action” is available at: https://www.who.int/health-topics/climate-change. as part of key climate action, the report recommends to: o place health and social justice at the heart of the un climate talks, prioritizing those climate interventions with the largest health-, social and economic gains; o guide a rapid transition to renewable energy, to save lives from air pollution, particularly from coal combustion, ensuring energy security for health care facilities, and end energy poverty; o promote sustainable, healthy urban design and transport systems, with improved land-use, access to public space, and priority for walking, cycling and public transport; o promote sustainable food supply chains and more nutritious diets that deliver on both climate and health outcomes; o finance a transition towards a wellbeing economy; o mobilize and support the health community on climate action. https:// www.who.int/health-topics/climate-change  3. climate action tracker, fair share: https://climateactiontracker.org/ methodology/cat-rating-methodology/fair-share/ 4. unfccc, nationally determined contributions under the paris agreement, 17 september 2021, https://unfccc.int/sites/default/files/resource/cma2021_08_ adv_1.pdf contacts: joey lapeña, editor-in-chief, philippine journal of otolaryngology head and neck surgery, lapenajf@upm.edu.ph dave walsh, communications advisor, global climate and health alliance, +34 691 826 764 (europe) press@climateandhealthalliance.org is checked regularly. ceridwen johnson, world health organization johnsonc@who.int  arthur wyns, world health organization wynsa@who.int philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial twelve years have passed since my first editorial for the philippine journal of otolaryngology head and neck surgery, on the occasion of the silver anniversary of our journal and the golden anniversary of the philippine society of otolaryngology – head and neck surgery (pso-hns).1 special editorials have similarly marked our thirtieth (pearl)2 and thirty-fifth (coral or jade)3 journal anniversaries, punctuating editorials on a variety of themes in between. whether they were a commentary on issues and events in the pso-hns or philippine society, or on matters pertaining to medical research and writing, publication and peer review, i have often wondered whether my words fell on deaf ears. but write, must i-despite my writer’s doubt. what then, do a dozen years symbolize? as a baby boomer, i am all too familiar with what “cheaper by the dozen” meant in daily life, outwardly displayed in the matching attire my siblings and i wore on special occasions -such as yuletide when we would sing the carol “twelve days of christmas.”4 we read the comedy “twelfth night”5 in school, although i admittedly enjoyed “the dirty dozen”6 more than shakespeare. college rotc introduced me to the “daily dozen” and the grueling navy count1,2,3, one! one, two, three, two! (one, two, three, four! i love the marine corps!) and that is as far as my list of memorable dozens goes, covering five dozen years of life. of these, one fifth or 20% of my life has been devoted to our journal. from that perspective, i cannot help but wonder whether, or how it mattered. after 12 years, the day-to-day routine has hardly changed; neither have the periodic problems that precede the birth of each issue. i still find it difficult to solicit and follow-up reviews, and i still burn the midnight oil on weekends and holidays, patiently guiding authors in revising their manuscripts. nevertheless, our journal has come a long way from where it was when we started (although it has not reached as far and as quickly as i would have wanted it to). much depends on our authors and the caliber of their contributions, and our reviewers and the quality and timeliness of their reviews. however, despite our efforts to conduct education and training sessions on medical writing and peer review, the new batch of submissions and reviews each year evinces the need to repeat these regularly. in this regard, the increasing response-ability of our associate editors and continuing support of our society are needed to ensure our progress. this year, we welcome dr. eris llanes as our new managing editor as we thank and congratulate dr. tony chua (who retains his position as associate editor) for serving in that role for the past 12 years. we have finally migrated from our previous platform to the public knowledge platform open journal systems (pkp-ojs) available from https://pjohns.pso-hns.org/index.php/pjohns/ index. the pso-hns has become a member of the publishers international linking association correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 554 8467 telefax: (632) 524 4455 email: lapenajf@upm.edu.ph , jflapena@up.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines a dozen years, a dozen roses philipp j otolaryngol head neck surg 2018; 33 (2): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial (pila), which manages and maintains, deposits and retrieves, metadata and digital identifiers inclusive of associated software and know-how. this will enable us to register digital object identifiers (dois) for all our content using the crossref® system (https://www.crossref.org/about/), making our “research outputs easy to find, cite, link, and assess.”7 we are also subscribing to the crossref® similarity check plagiarism detection software service powered by ithenticate® (https://www.crossref. org/services/similarity-check/)7 and are exploring ways and means of converting all our articles to extensible markup language (xml) format. these steps reflect our continuing efforts to comply with the requirements for indexing in the directory of open access journals (doaj)8 and our re-application for indexing in scopus®.9 these steps would not have been possible without the full support of the psohns board of trustees under the leadership of our president, dr. aggie remulla, for which we are truly grateful. but these steps are just the beginning of a new journey, marking the next stage in the evolution of our journal. now that we have embarked on it, we cannot stop to rest. full activation of our crossref® similarity check plagiarism detection software service is contingent upon migrating all our content from 1981 to the new system and generating dois for each and every published article. converting each article to xml format entails time, effort, and expertise. all these require that adequate resources be allocated to ensure that the migration and conversion not only starts as soon as possible, but continues in a regular, uninterrupted, and timely manner. our efforts to teach authors to engage in relevant research and report these in writing, train reviewers to constructively critique manuscripts and uphold the soundness of the science, and tutor editors and mentors to oversee the publication process and produce a references 1. lapeña jf. silver and gold: looking back, looking ahead. philipp j otolaryngol head neck surg 2006 dec; 21(1&2):4. 2. lapeña jf. creative concretions, pearls and publication: the philippine journal of otolaryngology head and neck surgery on its thirtieth year. philipp j otolaryngol head neck surg 2011 jul-dec; 26 (2):4. 3. lapeña jf. “blood and foliage: coral red and jade green” philipp j otolaryngol head neck surg 2016 jan-jun; 31(1):4-5. 4. the twelve days of christmas [music]: traditional / arranged by frederic austin (1872-1952). printed 1909 london: novello, 11p. [cited 31 october 2018] available from: https://trove.nla. gov.au/work/10813839. 5. shakespeare w. twelfth night. complete works of william shakespeare. [public domain] created by jeremy hylton [cited 31 october 2018] available from: http://shakespeare.mit.edu/ twelfth_night/index.html. 6. the dirty dozen [motion picture]: directed by robert aldrich. uk/usa: m.k.h. productions, metro-goldwyn-mayer, 1967. [cited 31 october 2018] catalogued at: https://catalog.afi.com/ catalog/moviedetailsprintview/23682. 7. crossref®. [cited 30 october 2018] available from: https://www.crossref.org. 8. directory of open access journals. [cited 30 october 2018] available from: https://doaj.org. 9. scopus®. [cited 30 october 2018] available from: https://www.elsevier.com/solutions/scopus. 10. “with every blessing, there’s a cross.” [music and lyrics]: jose florencio f. lapeña, jr., 1983 (unpublished). journal worth sharing, should be matched measure for measure by the management processes required for the journal to be securely indexed and widely disseminated on multiple platforms. these processes must be assured by the pso-hns as publisher of our journal. like it or not, our journal, and the contents we publish will long outlive us and our society. nay, the pjohns will ensure that we who are published, and our pso-hns, will live on in the minds and hearts of our present and future readers – generations of medical students, residents and fellows, clinicians and academicians, scientists and researchers, public servants and policy-makers -and through their healing hands, in the lives of their patients and publics. cycles in perpetuity-this is why we engage in relentless pursuit of excellence in publishing our journal, why we unceasingly strive for inclusion in doaj and scopus, scie and medline (pubmed), and why we plead for your continuing support: to perpetuate your work that others may be informed of what has transpired, that by being inspired, they may transform others and the world they live in. indeed, the past 12 years may represent a complete cycle (such as 12 hours on a clock, or months in a year, or 12 signs of the zodiac), the first steps in the rebirth of our journal. although they may not count among the “memorable dozens” of my life, each of these years may be likened to a rose (with its attendant thorns) – a bouquet of a dozen roses that i offer to all of you. “for there’s no rose without a thorn, no night without the morn, no gain without some meaningful loss …”10 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles 14 philippine journal of otolaryngology-head and neck surgery abstract objective: to determine the association of arnica montana and blood loss, surgical field bleeding and operative time in endoscopic sinus surgery among adults with chronic rhinosinusitis with nasal polyposis. methods: design: single-blinded randomized controlled trial setting: tertiary government hospital participants: forty-one (41) adults aged 19-76 years old with chronic rhinosinusitis with nasal polyposis and meeting inclusion criteria were randomly divided into two groups, arnica and control. the former took 5 sublingual boiron® arnica montana 30c pellets, 12 hours then 1 hour prior to surgery; the latter did not. both groups had routine oxymetazoline and lidocaine-epinephrine decongestion. intraoperative blood loss, surgical field bleeding quality and operative time were assessed by blinded surgeons and anesthesiologists. results: mean estimated blood loss was 187ml (sd 100.14) for controls versus 72ml (sd 12.59) for the arnica group; (p < 0.05). mean operative time was 3.55 hours (sd 1.25) for controls and 3.44 hours (sd 1.57) for the arnica group; (p=0.9). surgical field bleeding was graded slight with 75% needing occasional suctioning (grade 2) and 25% needing frequent suctioning (grade 3) in the arnica group, versus moderate bleeding with more frequent suctioning (grade 4) in 71% and slight bleeding but needing frequent suctioning (grade 3) in 29% of controls. conclusion: in this randomized clinical trial, arnica montana was associated with less blood loss and less surgical field bleeding compared to controls, but there was no difference in mean operative times. arnica montana may be effective in reducing blood loss and improving surgical field quality during endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis. keywords: arnica montana, hemostasis, surgical endoscopic sinus surgery (ess) is one of the most common operative ent procedures, including for chronic rhinosinusitis with nasal polyposis. visualization of the nasal anatomy is vital to the procedure, allowing complete dissection, and lessening complications. bleeding from the nasal mucosa during ess interferes with the surgical field, prolongs operative time, and increases the incidence of incomplete surgery. hence, most surgeons agree that hemostasis is important.1 several clinical trials have demonstrated different ways of controlling bleeding operatively during ess using oxymetazoline, preoperative oral steroids, and tranexamic acid.2,3,4 arnica montana is a homeopathic medicine used by plastic and cosmetic surgeons to lessen postoperative edema and ecchymosis in rhinoplasty,5 but studies are limited and none deal with ess. we hypothesized that administering arnica montana preoperatively to adult patients with chronic rhinosinusitis with nasal polyps may decrease blood loss, improve surgical field bleeding arnica montana and blood loss, surgical field bleeding and operative time in endoscopic sinus surgery: a randomized-controlled trial michael luke t. salinas, md charmagne ross e. bato, md department of otorhinolaryngology head and neck surgery ospital ng makati correspondence: dr. michael luke t. salinas department of otorhinolaryngology-head and neck surgery 5th floor, ospital ng makati sampaguita st. corner gumamela st. pembo, makati city 1218 philippines telefax: (632) 882 6316 local 309 email: mlsalinasmd@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2016; 31 (1): 14-16 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 15 quality and lessen operative time during endoscopic sinus surgery. the aim of this trial is to determine the association of sublingual arnica montana on estimated blood loss, surgical field bleeding and operative time in endoscopic sinus surgery among adults with chronic rhinosinusitis with nasal polyposis. methods this single blind randomized controlled clinical trial was approved by our institutional ethics committee and conducted in a tertiary government hospital from january 2013 to july 2014. with written informed consent, all participants were recruited from the ent-hns outpatient department of our institution. the sample size of 40 was computed based on the institution out-patient department yearly census of endoscopic sinus surgery with a type 1 error of 0.05 and type 2 error of 95%. inclusion criteria were adults aged 19 and above who satisfied the operational definition of grade 2 or 3 nasal polyposis with or without chronic rhinosinusitis undergoing functional endoscopic sinus surgery as defined by the pso-hns clinical practice guidelines.4. in addition, evidence of sinus mucosal disease and nasal polyps had to be demonstrated on sinus ct imaging and nasal endoscopy. patients with a history of hypersensitivity to arnica montana, lactose intolerance, deranged bleeding parameters, cardiac and hematologic problems, and intake of aspirin, warfarin or other anti-coagulant medications were excluded from the study. a total of 41 patients meeting inclusion criteria were recruited and informed consent was obtained. subjects were randomly divided into 2 groups, the control and arnica group, using simple randomization technique. fish bowl method was used to classify “odd” and “even,” with “odd” assigned to the control group and “even” to the arnica group, resulting in a total of 21 controls and 20 in the arnica group. intervention after a history was obtained and otorhinolaryngological physical examination performed, all participants had their bleeding parameters (prothrombin and partial thromboplastin time) checked pre-operatively. patients more than 34 years old underwent medical risk assessment. the arnica group received 5 boiron® arnica montana 30c pellets (boiron, newtown square, pa, usa) administered sublingually, 12 hours then 1 hour prior to procedure by the physician – investigator while the control group did not receive any. all surgeons and anaesthesiologists were blinded to the study. all procedures were performed under inhalational general endotracheal anaesthesia using sevoflurane and intravenous lactated ringer’s solution. intraoperative mean arterial pressure was maintained at 60mmhg. topical oxymetazoline 0.05% solution (pt schering-plough, indonesia) and 2% lidocaine hcl + 1:100,000 epinephrine injection (hospira, il, usa) were used prior to surgery. four different surgeons performed ess by rotation using the messerklinger technique. different anaesthesiologists used the same anesthesia protocol for each patient. cutting and grasping blakesley (karl storz gmbh & co., germany) and takahashi (karl storz gmbh & co., germany) nasal forceps were used for all procedures. no microdebrider was used. outcome measures the amount of estimated blood loss in milliliters was estimated by the anesthesiologist at the end of each procedure, by subtracting the total volume collected from the 500ml graded suction canister plus the volume per number of nasal strips used intraoperatively from the total volume of saline irrigation used intraoperatively. after the procedure the surgeon answered the boezart6 grading scale for scoring surgical field bleeding to grade the quality of the surgical field. operative time was recorded in minutes. data analysis data was encoded on microsoft excel 2013 version 15.0 (office 2013, microsoft corporation, redmond, wa, usa) spreadsheets and analyzed. data was presented in means and percentages. statistical analysis used a two-tailed student t test and chi square test were used to compare the control and arnica group with a confidence interval of 95% and level of significance set at p<0.05. results a total of 41 participants, 19 males and 22 females aged 16 – 73 years old (mean, 42 years) participated in the study. demographic analysis of age, gender, and polyp grade showed no significant differences between arnica and control groups (p>0.05). all patients underwent surgery uneventfully without complications such as bleeding and hypertension. the mean estimated blood loss for the control group was 187ml (sd 100.14) versus 72ml (sd 12.59) for the arnica group; the difference was statistically significant (p < 0.05). the mean operative time for the control group was 3.55 hours (sd 1.25) versus 3.44 (sd 1.57) for the arnica group, although the difference was not statistically significant (p=0.91). in terms of the grading scale for scoring of surgical field bleeding, surgeons reported slight bleeding in the arnica group wherein 75% needed occasional suctioning (grade 2) and 25% needed frequent suctioning (grade 3). on the other hand, surgeons reported that 71% of controls had moderate bleeding with more frequent suctioning (grade 4) and 29% had slight bleeding but needed frequent suctioning (grade 3). outcome measures are summarized in table 1. discussion this study showed a significant decrease in the mean estimated blood loss and good surgical field bleeding quality during functional endoscopic sinus surgery in the arnica montana group versus controls. the anti-inflammatory property of arnica montana, sesquiterpene lactones, may have played a role in minimizing blood loss. kawakami7 et al. demonstrated in vivo decrease in histamine release causing decrease capillary permeability and an increase in diameter of lymphatic vessels causing less swelling using arnica montana. moreover, they philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles 16 philippine journal of otolaryngology-head and neck surgery concluded that the anti-inflammatory property of arnica montana and dexamethasone was generally comparable. arnica montana is part of the compositae plant family.1 its active ingredients sesquiterpene lactones, such as helenalin and dihydrohelenaline extracted from its disk flower and stem are responsible for its anti-inflammatory properties. it has anti-coagulation, anti-inflammatory, and analgesic effects.8 this is supported by the in vivo findings of kawakami7 et al. that pre-treatment with arnica montana in rats showed significant anti-edematous effect with less intense mass cell degranulation and greater diameter average of lymphatic vessels, however there was no significant difference in the cell infiltrate of polymorphonuclear and mononuclear cells seen in acute inflammation. thus, there was no selective modulation of leukocytes but only vascular regulations. despite limited clinical trials on the efficacy of arnica montana and its anti-inflammatory property, plastic and cosmetic surgeons use the drug. intravenous dexamethesone and oral arnica montana were compared in the clinical trial of totonchi and guyuron5 in grading postoperative edema and ecchymosis after rhinoplasty. arnica montana demonstrated good results in reducing edema but did not show any decrease in the intensity of ecchymosis as seen in dexamethasone. moreover, significant results of both drugs were seen in the first 2-3 days postoperatively and eventually became insignificant. arnica montana is considered a generally safe homeopathic medication. kawakami7 established its peak onset of action to start at 30-180 mins after ingestion. boiron arnica montana 30c is available in pellets and is an over-the-counter drug for swelling, bruises, and muscle pains. cosmetic and plastic surgeons use arnica montana pellets to lessen postoperative edema and ecchymosis.5 the limited studies did not establish pharmacodynamic and pharmacokinetic properties nor did they address preclinical safety. moreover, its safety for pregnant and breast feeding patients, adverse reactions and drug interactions have not been established. because research on the efficacy, drug action, and safety profile of arnica montana is still limited, further studies are recommended. additional limitations of this study include surgeon and anesthesiologist variations. post-operative outcomes such as presence of residual or incomplete dissection and post-operative pain may also vary. our study had no comparator or placebo and comparing arnica montana with tranexamic acid and/or corticosteroids may be considered for future studies. in addition, this study did not include bleeding parameters as part of the outcome measures because the study of baillargeon1 already showed no statistically significant effect on pt, ptt, platelet count, and procoagulant factor viii after arnica montana treatment. in this randomized clinical trial, arnica montana was associated with less blood loss and less surgical field bleeding during endoscopic sinus surgery compared to controls, but there was no difference in mean operative times. arnica montana may be preoperatively effective in reducing estimated blood loss and improving surgical field quality during endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis. acknowledgements we would like to thank the anesthesiologists and co-resident ent surgeons, dr. michelle angelica cruz-daylo, waynn destriza, elaine lagura, and khrsitine girado for participating in our study. references 1. baillargeon l, drouin j, desjardins l, leroux d, audet d. the effects of arnica montana on blood coagulation. randomized controlled trial. can fam physician. 1993 nov; 39: 2362-2367. (corrected in can fam physician 1994 february; 40: 225). 2. zhen h, gao q, cui y, hua x, li h, feng j. the use of oxymetazoline in nasal endoscopic sinus surgery. j clin otorhinolaryngol. 2003 may;17(5):281-282. 3. sieskiewicz a, olszewska e, rogowski m, grycz e. preoperative corticosteroid oral therapy and intraoperative bleeding during functional endoscopic sinus surgery in patients with severe nasal polyposis: a preliminary investigation. annals of otology rhinology and laryngology. 2006 jul; 115(7):490-494. 4. alimian m, mohseni m. the effect of intravenous tranexamic acid on blood loss and surgical field quality during endoscopic sinus surgery: a placebo-controlled clinical trial. j clin anesth. 2011 dec; 23(8): 611-615. 5. totonchi a, guyuron b. a randomized, controlled comparison between arnica and steroids in the management of post rhinoplasty ecchymosis and edema. plast reconstr surg. 2007 jul; 120(1): 271-274. 6. boezaart ap, van der merwe j, coetzee a. comparison of sodium nitroprussideand esmololinduced controlled hypotension for functional endoscopic sinus surgery. can j anesth. 1995 may; 42(5 pt 1): 373-6. 7. kawakami ap, sato c, cardoso tn, bonamin lv. inflammatory process modulation by homeopathic arnica montana 6ch: the role of individual variation. evid based complement alternat med. 2011; 2011: 917541. 8. perry nb, burgess ej, rodriguez guitian ma, romero franco r, lopez mosquera e, smallfield bm, et al. sesquiterpene lactones in arnica montana: helenalin and dihydrohelenalin chemotypes in spain. planta med. 2009 may;75(6): 660-6. table 1. outcome measurements in two groups control group n=21 arnica group n=20 p-value age gender (male) nasal polyp grade grade 2 grade 3 estimated blood loss (ml) operative time (hrs) bleeding score (n: %) 0 1 2 3 4 5 40 9 11 10 187 3.5 0 0 0 6 (29%) 15 (71%) 0 44 10 8 12 72 3.5 0 0 15 (75%) 5 (25%) 0 0 0.412 0.646 0.631 5.31 0.25 philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to compare the efficacy of clarithromycin versus methylprednisolone in the treatment of non-eosinophilic and eosinophilic nasal polyposis. methods: design: randomized controlled trial setting: tertiary government training hospital participants: forty two (42) patients with chronic rhinosinusitis with nasal polyps (crswnp) were grouped into non-eosinophilic and eosinophilic groups after biopsy determination of eosinophil count. both groups were further randomized into a treatment arm given clarithromycin (cla) 500 mg/ day and another arm given methylprednisolone (meth) 32 mg/ day tapering to 8 mg/ day for 15 days. all participants underwent pre– and post–treatment evaluation via anterior rhinoscopy, sino-nasal outcome test (snot-22) and endoscopic appearance (ea) scoring. data were encoded and subjected to statistical analysis using mannwhitney u test. results: for the 9 participants in the non-eosinophilic group, 4 were given cla and 5 were given meth. the cla arm showed significant improvement in snot-22 scores by the 15th day (p= .007). the meth arm did not demonstrate significant improvement by the 7th (p= .44) or 15th day (p= .22). comparison of the improvement in snot-22 scores between the two arms showed that on both 7th and 15th days, cla outperformed meth (p= .026 and p= .004, respectively). for the ea scoring, both the cla and meth groups significantly improved by the 7th (p= .027 and p= 0.017, respectively), and 15th day (p= .013 and p= .027, respectively). comparison of the improvement in ea scores between the two arms showed significant difference on the 15th day (p= .01) with the cla performing better than meth. overall, the results suggest that the cla arm performed significantly better than the meth arm in the treatment of non-eosinophilic patients. of the 33 eosinophilic patients, 17 were given cla and 16 were given meth. the cla arm showed significant improvement in snot-22 scores by the 15th day (p < .001) while the meth arm on both 7th (p= .033) and 15th day (p< .001). comparison of the improvement in snot-22 results between the two arms showed no significant differences (7th day p= .494; 15th day p= .587). for the ea scoring, both treatment groups showed significant improvement by the 7th and 15th day (p< .001). comparison of the improvement in ea scores between the two arms showed significant differences (p< .001) on both 7th and 15th day, suggesting that meth was more effective efficacy of clarithromycin versus methylprednisolone in the treatment of non-eosinophilic and eosinophilic nasal polyposis: a randomized controlled trial jemilyn c. gammad, md1 antonio h. chua, md1 charmaine s. templonuevo-flores, md2 1department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center 2department of pathology jose r. reyes memorial medical center correspondence: dr. antonio h. chua department of otorhinolaryngology head and neck surgery 4th floor, jose r. reyes memorial medical center rizal avenue, sta. cruz, manila 1003 philippines phone: (+632) 711 9491 local 320 email: entjrrmmc@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the 10th international symposium on recent advances in rhinosinusitis and nasal polyps, and 61st annual convention of the philippine society of otolaryngology head and neck surgery, philippine academy of rhinology “cesar f. villafuerte, sr. research contest“ (1st place) november 30, 2017, “antonio l. roxas international research contest” (finalist) december 1, 2017, at the manila hotel, manila. philipp j otolaryngol head neck surg 2018; 33 (2): 6-13 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery original articles than cla. overall, the results showed that both cla and meth were effective in the treatment of eosinophilic nasal polyps. however, meth was significantly better than cla in terms of superior ea scores. conclusion: in terms of improving symptoms and well-being, as well as decreasing nasal polyp size and reducing discharge and edema as reflected in superior snot-22 and ea scores, clarithromycin was significantly more effective than methylprednisolone in the treatment of non-eosinophilic nasal polyps. while both clarithromycin and methylprednisolone were shown to be effective in the treatment of eosinophilic nasal polyps, methylprednisolone was significantly better than clarithromycin in terms of superior ea scores. a biopsy for tissue eosinophil cell count prior to treatment is recommended to establish the predominant inflammatory cell in nasal polyps in order to provide appropriate targeted treatment, i.e. clarithromycin for non-eosinophilic nasal polyps and methylprednisolone for eosinophilic polyps. keywords: macrolides, clarithromycin, methylprednisolone, nasal polyps, eosinophils macrolides are known for their immunomodulatory properties. laboratory and clinical studies have shown that macrolides inhibit mucus hypersecretion, enhance mucociliary activity, reduce mucus secretion and suppress cytokine/chemokine production.1-4 they have been used as alternative treatment for a host of inflammatory diseases including chronic rhinosinusitis (crs) with and without polyps.1-4 roxithromycin and clarithromycin administered for at least 8 weeks resulted in marked shrinkage of polyps.5,6 the ability of macrolides to down-regulate neutrophilic activity has been believed to account for its immunomodulatory effect in crs.7-9 a significant correlation between decreased nasal lavage levels of il-8, a potent neutrophil chemotactic factor, and the clinical effect of macrolides on the size of the nasal polyps have been reported.10 the therapeutic efficacy of macrolides in improving subjective symptoms decreases in patients with high eosinophil counts in the blood, nasal secretions and nasal mucosa or high serum ige levels.9,11,12 while multiple etiopathogeneses have been proposed for crs in general, nasal polyposis is believed to be primarily ige-mediated, characterized by th2 inflammation, local immunoglobulin production and eosinophil infiltration driven by il-5 and eotaxin.13 in such socalled eosinophilic patients, corticosteroids have been recommended as first-line management choice. having been known to suppress the chemotaxis and activation of eosinophils, t cells and mast cells, corticosteroids have also shown beneficial effects in reduction of polyp size, improvement of nasal symptoms and nasal airflow. in conjunction with oral therapy, topical corticosteroids are considered well-tolerated for long term use.12 while numerous articles have suggested that macrolides and corticosteroids modulate non-eosinophilic and eosinophilic inflammation, respectively, controversies still exist regarding the use of macrolides in the treatment of crs.1-3 reduction of nasal polyps is often observed but the response is variable and often seen only in smaller polyps. studies suggest that low dose macrolides provide benefit only when used as an adjunct to topical corticosteroids.1 a major limitation of these studies was the lack of pretreatment classification based on eosinophilic predominance of nasal polyps which may explain the conflicting responses. furthermore, an explant model study showed clarithromycin and dexamethasone exhibiting similar anti-inflammatory effects on different phenotypes of crs.3 these findings have yet to be conclusively reflected outside of the laboratory setting. at present, evidence is still insufficient to warrant concrete recommendations for the use of macrolide therapy in crs with polyp phenotype.1 this clinical study aimed to further investigate the potential beneficial effects of macrolides on both non-eosinophilic and eosinophilic nasal polyps by comparing the efficacy of clarithromycin against methylprednisolone. outcome measures included sinonasal outcome test (snot-22)14 and endoscopic appearance (ea)14,15 scoring. methods with institutional review board approval, this randomized controlled trial was conducted at the out-patient department of a tertiary government training hospital from august 2016 to december 2016. all patients newly diagnosed as having chronic rhinosinusitis with nasal polyps (crswnp) according to the 2016 philippine clinical practice guidelines on chronic rhinosinusitis14 were screened for the study. (figure 1) excluded were patients with unilateral polyps, pregnant patients, immunocompromised patients, those with known hypersensitivity to either macrolides or corticosteroids and patients not amenable to biopsy. diagnosis was established via physical examination, anterior rhinoscopy and nasal endoscopy. patients were asked to evaluate their symptoms using the sino-nasal outcome test (snot-22, washington university, st. louis, missouri).14 polyps were evaluated using the endoscopic appearance (ea) score14,15 as shown below. ea scoring was done separately for the right and left nasal cavity of each subject, and each side was treated as a separate item for analysis (number of patients multiplied by 2 sides): philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery original articles informed consent was obtained for inclusion in the study and for biopsy of nasal polyps under local anesthesia. specimens were sent to pathology for eosinophil count. patients were classified into two groups: non-eosinophilic and eosinophilic, based on the number of eosinophils/ high power field (hpf ) at 400x magnification (average of 10 scan fields) as recommended by the 2016 philippine clinical practice guidelines on chronic rhinosinusitis.14 presence of <5 eosinophils/hpf was classified as non-eosinophilic while eosinophilic polyps were those with >5 eosinophils/hpf by a blinded resident pathologist (co-author). after biopsy, all patients were given intranasal fluticasone propionate aqueous nasal spray (50mcg/spray), administered twice daily until such time that the cell count results were released. thereafter, patients in both groups were randomized via lottery sampling/ fishbowl technique to either treatment 1 or treatment 2. treatment 1 arm was given clarithromycin 500mg/day for 15 days. treatment 2 arm was given methylprednisolone 32mg/day for 5 days, 16mg/day for the next 5 days and 8mg/day for the last 5 days. treatment regimen was based on the recommendations of the 2016 philippine clinical practice guidelines on chronic rhinosinusitis.14 assessors of the nasal polyps before and after treatment were blinded. patients were not blinded to treatment. patients were reevaluated using the snot-22 and the ea scores on 7th and 15th day of treatment. endoscopic evaluation of the nasal polyps was done via review of video recordings by 2 senior residents who did not perform the endoscopies and submitted as a consensus report. outcome measure data were encoded and snot-22 and ea scores were subjected to statistical analysis using mann-whitney u test (spss version 20, ibm corp., armonk, ny, usa). patients were informed that should nasal polyps fail to respond to the assigned treatment, they would be shifted to the standard medical treatment for nasal polyposis (oral corticosteroid combined with topical nasal corticosteroid). patients were also informed of the possible signs and symptoms of the above treatment and were advised that should any adverse drug reaction be experienced during the course of therapy, treatment would be discontinued immediately. appropriate therapy would be administered and researchers would see to it that patients received appropriate medical attention. * discharge: 0 – no discharge; 1 – clear, thin discharge; 2 – thick, purulent discharge edema: 0 – absent; 1 – mild; 2 – severe polyp: 0 – absence of polyps 1 – polyps in the middle meatus only 2 – polyps beyond middle meatus but not blocking the nose completely 3 – polyps completely obstructing the nose characteristic* pre-test 7th day 15th day discharge, right (0,1,2) edema, right (0,1,2) polyp, right (0,1,2,3) characteristic pre-test 7th day 15th day discharge, left (0,1,2) edema, left (0,1,2) polyp, left (0,1,2,3) confirmation of nasal polyps via physical examination snot-22 and endoscopic appearance scores non-eosinophilic (<5/ hpf ) evaluation: day 7 snot22/ ea scores evaluation: day 15 snot-22/ ea scores evaluation: day 7 snot-22/ ea scores eosinophilic (>5/ hpf ) clarithromycin improvement standard treatment standard treatment continue treatment until 15 days no yesyes no improvement clarithromycinmethylprednisolone methylprednisolone biopsy for eosinophil count (with informed consent) figure 1. methodology flowchart philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery original articles results 42 patients participated in the study. 20 were females (47%) and 22 were males (52%) with mean age of 45.25. nine (21%) were found to be non-eosinophilic and 33 (79%) were classified as eosinophilic. for the non-eosinophilic patients, the meth group mean age was slightly younger than that of the cla group. however, a t-test for two independent samples revealed that the difference was not significant (p= .566). gender across the groups was also fairly distributed with no significant difference based on chi-square test (p= .764). pretreatment baseline examination scores were also fairly comparable between both groups. a mann-whitney u test on the snot-22 scores revealed no significant difference pre-treatment (u= 32.5, z= -0.696, p= .486 and r= .515). a mann-whitney u test on the ea scores also showed no significant difference pre-treatment (u= 4.5, z= -1.37, p= .171 and r = .190). ( table 1) figure 2. mann-whitney u test comparison of snot-22 scores for non-eosinophilic nasal polyps: cla (clarithromycin); meth (methylprednisolone); median in white bar (pre-treatment); median in gray bar (7th day); median in black bar (15th day); small dashed line (p-value of pre-treatment versus 7th day); big dashed line (p-value of pre-treatment versus 15th day); s (significant); ns (nonsignificant) demographic profile cla=4 mean meansd sd meth=5 age gender: male female pre-treatment evaluation: snot-22 ea 45.25 freq 2 2 median 2.5 3.4 9.18 % 50.0 50.0 mean rank 8.56 6.38 40.8 freq 2 3 median 3.5 2.8 12.19 % 40.0 60.0 mean rank 10.25 3.9 table 1. demographics of patients with non-eosinophilic polyps demographic profile cla=17 mean meansd sd meth=16 age gender: male female pre-treatment evaluation: snot-22 ea 42 freq 10 7 median 3 3.2 10.012 % 58.8 41.2 mean rank 34.32 17.47 43.81 freq 8 8 median 3 3 12.59 % 50.0 50.0 mean rank 32.68 16.5 table 2. demographics of patients with eosinophilic polyps for the eosinophilic patients, the meth group mean age was slightly older than that of the cla group. however, a t-test for two independent samples revealed that the difference was not significant (p= .649). likewise, gender was fairly distributed between both groups as computed on chi-square test (p= .611). pre-treatment examination scores were also fairly similar between both groups. a mann-whitney u test on the snot-22 scores showed no significant difference pretreatment (u= 517.5, z= -0.354, p= .723 and r= .727). a mann-whitney u test on the ea scores revealed no significant pre-treatment difference either (u= 128, z= -0.294, p=.769 and r= .790). (table 2) non-eosinophilic polyps for the 9 participants in the non-eosinophilic group, 4 were given clarithromycin (cla) and 5 were given methylprednisolone (meth). a. snot-22 of pre-treatment versus 7th day and versus 15th day (figure 2) a1. clarithromycin medians of pre-treatment and 7th day were 2.5 and 1, respectively, with no significant difference (mean ranks were 10.56 and 6.44, respectively; u= 15.5, z= -1.8, p= .072 and r= .083). the medians of pre-treatment and 15th day were 2.5 and 1, respectively. there was a significant difference by the 15th day (mean ranks were 11.5 and 5.5, respectively; u = 8, z = -2.677, p= .007 and r = .010) suggesting a significant effect of clarithromycin on the 15th day. a2. methylprednisolone the medians of pre-treatment and 7th day were 3.5 and 2.5, respectively, with no significant difference (mean ranks were 11.45 and philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery original articles 9.55, respectively; u= 40.5,z= -0.772, p= .44 and r= .481). medians of pretreatment and 15th day were 3.5 and 2.5, respectively, with no significant difference (the mean ranks were 12.05 and 8.95, respectively; u = 34.5, z = -1.226, p = .22 and r = .247) suggesting there was no improvement with methylprednisolone on both days. b. ea score of pre-treatment versus 7th day and versus 15th day (figure 3) c. clarithromycin versus methylprednisolone improvement in snot-22 and ea scores on the 7th and 15th day c1. snot-22 for the 7th day, medians of treatment arm 1 (cla) and treatment 2 (meth) were 1 and 2.5, respectively, with a significant difference (the mean ranks were 6.5 and 11.9, respectively; u= 16, z= -2.221, p= .026 and r= .034). for the 15th day, medians of treatment arm 1 (cla) and treatment 2 (meth) were 1 and 2.5, respectively, with a significant difference (the mean ranks were 5.63 and 12.6, respectively; u= 9, z= -2.902, p= .004 and r= .004) showing that on both 7th and 15th days, cla outperformed meth. c2. ea score for the 7th day, medians of treatment arm 1 (cla) and treatment 2 (meth) were 2.2 and 2.6, respectively, with no significant difference (the mean ranks were 4.25 and 5.6, respectively; u= 7, z= -0.786, p= .432 and r= .556). for 15th day, medians of treatment arm 1 (cla) and treatment 2 (meth) were 1.6 and 2, respectively, with a significant difference on the 15th day (the mean ranks were 2.5 and 7, respectively; u= 0, z= -2.582, p= .01 and r= .016) suggesting the cla arm results were better than the meth arm on the 15th day. overall, the results suggest that the cla arm performed significantly better than the meth arm in the treatment of non-eosinophilic patients. eosinophilic polyps of the 33 eosinophilic patients, 17 were given clarithromycin (cla) and 16 were given methylprednisolone (meth). a. snot-22 of pre-treatment versus 7th day, and versus 15th day (figure 4) a1. clarithromycin medians of pre-treatment and 7th day were 3 and 2, respectively. a mann-whitney u test revealed no significant difference (the mean ranks were 39.15 and 27.85, respectively; u= 517.5, z= -0.352, p= .723 and r= .727). the medians of pre-treatment and 15th day were 3 and 2, respectively, with a significant difference (the mean ranks were 44.36 and 22.64, respectively; u= 186, z= -4.793, p< .001 and r< .001) suggesting there was significant improvement on the 15th day. a2. methylprednisolone the medians of pre-treatment and 7th day were 3 and 2, respectively, with a significant difference (mean ranks were 38.36 and 28.64, figure 3. mann-whitney u test comparison of ea scores for non-eosinophilic nasal polyps: cla (clarithromycin); meth (methylprednisolone); median in white bar (pre-treatment); median in gray bar (7th day); median in black bar (15th day); small dashed line (p-value of pre-treatment versus 7th day); big dashed line (p-value of pre-treatment versus 15th day); s (significant); ns (nonsignificant) b1. clarithromycin the medians of pre-treatment and 7th day were 3.4 and 2.2, respectively, with a significant difference (the mean ranks were 6.38 and 2.63, respectively; u= 0.5, z= -2.205, p= .027 and r= .029). the medians of pre-treatment and 15th day were 3.4 and 1.6, respectively, with a significant difference (the mean ranks were 6.5 and 2.5, respectively; u= 0, z= -2.477, p= .013 and r= .029) suggesting there was significant improvement with clarithromycin on both the 7th and 15th days. b2. methylprednisolone the medians of pre-treatment and 7th day were 2.8 and 2.6, respectively, with a significant difference (mean ranks were 7.7 and 3.3, respectively; u= 1.5, z= -2.386, p= 0.017 and r= 0.016). medians of pretreatment and 15th day were 2.8 and 2, respectively, with a significant difference (mean ranks were 6.38 and 2.63, respectively; u= .5, z= -2.205, p= .027 and r= .029) suggesting there was improvement by the 7th and 15th day. philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery original articles respectively; u= 384, z= -2.133, p= 0.033 and r= 0.033). medians of pre-treatment and 15th day were 3 and 2, respectively, with a significant difference (mean ranks were 42.88 and 24.12, respectively; u= 235, z= -4.152, p< .001 and r< .001) suggesting there was significant improvement on both the 7th and 15th day. b. ea score of pre-treatment versus 7th day, and versus 15th day (figure 5) b1. clarithromycin the medians of pre-treatment and 7th day were 3.2 and 2.4, respectively, with a significant difference (mean ranks were 24.35 and 10.65, respectively; u= 28, z= -4.083, p< .001 and r< .001). medians of pre-treatment and 15th day were 3.2 and 2, respectively, with a significant difference (mean ranks were 25.82 and 9.18, respectively; u= 3, z= -4.922, p< .001 and r< .001) suggesting a significant improvement with clarithromycin on both the 7th and 15th day. b2. methylprednisolone the medians of pre-treatment and 7th day were 3 and 2, respectively. a mann-whitney u test showed a significant difference (the mean ranks were 24.47 and 8.53, respectively; u= 0.5, z= -4.856, p< .001 and r< .001). medians of pre-treatment and 15th day were 3 and 1.4 respectively, showing a significant difference (the mean ranks were 24.5 and 8.5, respectively; u= 0, z= -4.858, p< .001 and r< .001). there was significant improvement on 7th and 15th day respectively with methylprednisolone showing more improvement on the 15th day. c. clarithromycin versus methylprednisolone improvement in snot-22 and ea scores on the 7th and 15th day c1. snot-22 for 7th day, medians of treatment arm 1 (cla) and treatment 2 (meth) were 2 and 2, respectively. there was no significant difference (the mean ranks were 35.03 and 31.97, respectively; u= 494, z= -0.684, p= .494 and r= .503). for the 15th day, medians of treatment arm 1 (cla) and treatment 2 (meth) were 2 and 2, respectively, also with no significant difference (the mean ranks were 34.65 and 32.35, respectively; u= 506.5, z= -0.544, p= .587 and r= .607). both treatments were found to be equally effective in improving snot-22 scores. c2. ea score for the 7th day, medians of treatment arm 1 (cla) and treatment 2 (meth) were 2.4 and 2, respectively, with a significant difference (the mean ranks were 23.29 and 10.31, respectively; u= 29, z= -3.933, p< .001 and r< .001). for the 15th day, medians of treatment arm 1 (cla) and treatment 2 (meth) were 2 and 1.4, respectively, also with a significant difference (the mean ranks were 23.26 and 10.34, respectively; u= 29.5, z= -3.894, p< .001 and r< .001) suggesting that methylprednisolone performed better than clarithromycin. overall, the results showed that both clarithromycin and methylprednisolone were effective in the treatment of eosinophilic nasal polyps. however, methylprednisolone was significantly better than clarithromycin in terms of superior ea scores. figure 4. mann-whitney u test comparison of snot-22 scores for eosinophilic nasal polyps: cla (clarithromycin); meth (methylprednisolone); median in white bar (pre-treatment); median in gray bar (7th day); median in black bar (15th day); small dashed line (p-value of pre-treatment versus 7th day); big dashed line (p-value of pre-treatment versus 15th day); s (significant); ns (nonsignificant) figure 5. mann-whitney u test comparison of ea scores for eosinophilic nasal polyps: cla (clarithromycin); meth (methylprednisolone); median in white bar (pre-treatment); median in gray bar (7th day); median in black bar (15th day); small dashed line (p-value of pre-treatment versus 7th day); big dashed line (p-value of pre-treatment versus 15th day); s (significant); ns (nonsignificant) philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery original articles discussion in this study, clarithromycin performed better than methylprednisolone in the treatment of non-eosinophilic nasal polyps. this is in congruence with most studies comparing macrolides and corticosteroids in the treatment of nasal polyps, suggesting that corticosteroids perform poorly in the absence of eosinophilic predominance.5,6,10,16 in an investigation comparing responses of neutrophil-positive and neutrophil-negative nasal polyps to oral prednisone treatment, wen and colleagues noted that neutrophilmediated inflammation negatively affected the efficacy of oral corticosteroid therapy.16 the result of this study was further supported by a double-blind study by wallwork et al. in which patients treated with roxithromycin (compared to placebo) who demonstrated significant improvement in both subjective and objective outcome measures exhibited low levels of ige, suggesting that low levels of eosinophils in nasal polyps may respond better to macrolide treatment.6 by the same token, a study done by haruna et al. noted that poor responders to macrolide therapy had a statistically significant increase in the percentage of eosinophils in the sampled polyp tissue, further emphasizing the preferential response to therapy of both nasal polyp phenotypes.9 macrolides are better known for their capacity to inhibit neutrophilic rather than eosinophilic function. reduced numbers of neutrophils and inhibition of neutrophilic function lead to lower concentrations of neutrophil elastase and il-8, and ultimately to a decrease in tissue injury.7 however, some studies revealed macrolides also contribute to eosinophil reduction. a study done by fan et al. revealed clarithromycin decreased both il-8 and il-5 concentrations in nasal discharges, implying its effect in both neutrophil and eosinophil mediated inflammation.17 an in vitro study done by lin et al. revealed macrolide azithromycin can down regulate il-5 production suggesting effectivity in other eosinophil mediated diseases such as asthma.17 in our study, clarithromycin was as effective as methylprednisolone in improving snot-22 and ea scores of eosinophilic patients although statistically significant difference was only noted in the ea scores. these results were similar to an explant study by zeng et al. which found that clarithromycin and dexamethasone exerted similar anti-inflammatory effects on both non-eosinophilic and eosinophilic polyp tissues which had distinctly different inflammatory pathways.3 both clarithromycin and dexamethasone up-regulated the production of anti-inflammatory mediators and down-regulated the production of th2 response and eosinophilia promoting molecules, th1 response and neutrophiliapromoting molecules.3 while the effect of macrolides on eosinophils has been less commonly investigated, these findings indicate that th2 cytokines are more frequently reduced than th1 cytokines, suggesting that the role of macrolides in eosinophilic inflammatory disease should not be ignored.7 most trials and reviews promoted long-term, low dose macrolide therapy for chronic rhinosinusitis.4-6,8-10,16,18-20 nakamura et al. advocated the use of low dose macrolide therapy for up to 6 months to allow regeneration and persistence of healthy mucosa even after discontinuation of treatment.8 his investigation revealed that treatment of macrolides for 3 months still did not allow full recovery of nasal mucosa and submucosal glands, however, long term administration of macrolide for up to 9 months improved ciliary clearance causing decrease in mucus gland secretions allowing restoration of healthy mucosa.8 wallwork et al. noted that significant clinical improvement was seen by the 12th week of macrolide treatment.9 however, this prolonged course of treatment can lead to emergence of resistance and potential adverse drug effects. wong et al. noted that longer courses of clarithromycin were associated with more cardiovascular events.21 the increased risk may persist well beyond even after clarithromycin is stopped. while long term, low dose macrolide treatment has been suggested, effects of long term macrolide therapy such as antibiotic resistance and cardiac events should not be ignored. in our study, clarithromycin was given at 500mg once daily for 15 days to closely simulate the standard duration of oral steroid therapy, in contrast to the suggested 250mg/day for at least 8 weeks. two weeks course of macrolides have been reported to show significant reduction in eosinophils, macrophages, il-6, il-8 and tnf-alpha, which however, lasted only for two weeks after discontinuation of treatment.4 a more recent study done by fan et al. noted that short-term, high-dose macrolide was effective in the treatment of chronic rhinosinusitis.17 endoscopic appearance and snot-20 scores, as well as inflammatory markers (il-5 and il-8), decreased by the 7th day of clarithromycin 500 mg twice daily, suggesting that dosage, rather that duration of treatment, offers greater importance in the treatment of nasal polyps.17 however, the question of how long lasting the improvement observed in just 2 weeks of clarithromycin treatment remains unclear. the value of determining polyp tissue eosinophil count should also be highlighted. as numerous studies reflect the different responses to either macrolide or oral corticosteroid, determination of nasal polyp phenotype can prove to be cost effective and safe for the patient. since clarithromycin performed better than methylprednisolone in the treatment of non-eosinophilic polyps, establishing the low eosinophil count prior to treatment would spare the patient unnecessary corticosteroid medication. pretreatment cell count will also decrease philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery original articles references lasso a, masoudian p, quinn jg, cowan j, labajian v, bonaparte jp, et al. long-term low-dose 1. macrolides for chronic rhinosinusitis in adults a systematic review of the literature. clin otolaryngol. 2017 jun;42(3):637-650. doi:10.1111/coa.12787; pmid: 27809411. oakley gm, harvey rj, lund vj. the role of macrolides in chronic rhinosinusitis (crssnp and 2. crswnp). curr allergy asthma rep. 2017 may;17(5):30. doi:10.1007/s1882-017-0696-z; pmid: 28429305. zeng m, li zy, ma j, cao pp, wang h, cui yh, et al. clarithromycin and dexamethasone show 3. similar anti-inflammatory effects on distinct phenotypic chronic rhinosinusitis: an explant model study. bmc immunol. 2015 jun 6; 16:37. doi:10.1186/s12865-015-0096-x; pmid: 26047816 pmcid: pmc4456709. cervin a, wallwork b. macrolide therapy of chronic rhinosinusitis. rhinology 2007 dec; 45(4): 4. 259-267. pmid:18085018. ichimura k, shimazaki y, ishibashi t, higo r. effect of new macrolide roxithromycin upon nasal 5. polyps associated with chronic sinusitis. auris nasus larynx. 1996; 23(1): 48-56. doi:10.1016/ s0385-8146(96)80008-3. wallwork b, coman w, mackay-sim a, greiff l, cervin a. a double-blind, randomized, placebo-6. controlled trial of macrolide in the treatment of chronic rhinosinusitis. laryngoscope. 2006 feb; 116(2): 189-93. doi: 10.1097/01.mlg.0000191560.53555.08; pmid: 16467702. zimmerman p, ziesenitz vc, curtis n, ritz n. the immunomodulatory effects of macrolides: a 7. systematic review of underlying mechanisms. front immunol. 2018 mar; 9:302. doi:10.3389/ fimmu.2018.00302. nakamura y, suzuki m, yokota m, ozaki s, ohno n, hamajima y, et al. optimal duration of 8. macrolide treatment for chronic sinusitis after endoscopic sinus surgery. auris nasus larynx. 2013 aug; 40(4):366-72. doi:10.1016/j.anl.2012.09.009. pmid: 23107100. haruna s, shimada c, ozawa m, fukami s, moriyama h. a study of poor responders for long-9. term, low-dose macrolide administration for chronic sinusitis. rhinology 2009 mar;47(1):66-71. pmid:19382498. yamada t, fujieda s, mori s, yamamoto h, saito h. macrolide treatment decreased the size 10. of nasal polyps and il-8 levels in nasal lavage. am j rhinol. 2000 may-jun; 14(3):143–148. pmid:10887619. suzuki h, ikeda k, honma r, gotoh s, oshima t, furukawa m, et al. prognostic factors of chronic 11. rhinosinusitis under long-term low-dose macrolide therapy. orl j otorhinolaryngol relat spec. 2000 may-jun; 62(3): 121-127. doi:10.1159/000027731; pmid: 10810255. bachert c, zhang l, gevaert p. current and future treatment options for adult chronic 12. rhinosinusitis: focus on nasal polyposis. j allergy clin immunol. 2015 dec; 136(6): 1431-1440. doi:10.1016/j.jaci.2015.10.010. pmid: 26654192. chen jb, james lk, davies am, wu yb, rimmer j, lund vj, et al. antibodies and superantibodies 13. in patients with chronic rhinosinusitis with nasal polyps. j allergy clin immunol. 2017 apr; 139(4): 1195-1204. doi:10.1016/j.jaci.2016.06.066; pmid: 27658758 pmcid: pmc5380656. hernandez jg, jarin jp, enecilla mlb, timbungco nbv, campomanes bsa, chua ah, et al. clinical 14. practice guidelines: chronic rhinosinusitis in adults. philippine society of otorhinolaryngologyhead and neck surgery, philippine academy of rhinology. 2016 dec. available from: https:// pso-hns.org/clinical-practice-guidelines-psohns2016/. lund vj, kennedy dw. quantification for staging sinusitis. the staging and therapy group. 15. ann otol rhinol laryngol suppl. 1995 oct;167: 17-21. pmid:7574265. wen w, liu w, zhang l, bai j, fan y, xia w, et al. increased neutrophilia in nasal polyps reduces 16. the response to oral corticosteroid therapy. j allergy clin immunol. 2012; 129(6): 1522-8. doi:10.1016/j.jaci.2012.01.079. pmid: 22460066. fan y, xu r, hong h, luo q, xia w, ding m, et al. high and low doses of clarithromycin treatment 17. are associated with different clinical efficacies and immunomodulatory properties in chronic rhinosinusitis. j laryngol otol. 2014 mar; 128(3): 236-41. doi:10.1017/s0022215114000279. pmid: 24555753. lin sj, lee wj, liang yw, yan dc, cheng pj, kuo ml. azithromycin inhibits il-5 production of 18. t helper type 2 cells from asthmatic children. int arch allergy immunol. 2011;156 (2): 179–86. doi:10.1159/000322872. pmid: 21597298. fokkens wj, lund vj, mullol j, bachert c, alobid i, baroody f, et al. european position paper on 19. rhinosinusitis and nasal polyps 2012. rhinol suppl. 2012 mar; 23:3 preceding table of contents, 1-298. pmid:22764607. shimizu t, suzaki h. past, present, and future therapy of macrolide therapy for chronic 20. rhinosinusitis in japan. auris nasus larynx. 2016 apr; 43(2): 131-6. doi:10.1016.j.anl.2015.08.014. pmid: 26441370. wong ay, root a, douglas ij, chui csl, chan ew, ghebremichael-weldeselassie y, et al. 21. cardiovascular outcomes associated with use of clarithromycin: population based study. bmj. 2016 jan 14; 352: h6926. doi:10.1136/bmj.h6926; pmid: 26768836. mahdavinia m, suh la, carter rg, stevens ww, norton je, kato a, et al. increased non-22. eosinophilic nasal polyps in chronic rhinosinusitis in us second generation asians suggests genetic regulation of eosinophilia. j allergy clin immunol. 2015 feb; 135(2):576-579. doi:10.1016/j.jaci.2014.08.031; pmid: 25312761 pmcid: pmc4323954. kim sj, lee kh, kim sw, cho js, park yk, shin sy. changes in histological features of nasal polyps 23. in a korean population over a 17-year period. otolaryngol head neck surg. 2013 sep; 149(3): 431-437. doi:10.1177/0194599813495363; pmid: 23812744. wang et, zheng y, liu pf, guo lj. eosinophilic chronic rhinosinusitis in east asians. 24. world j clin cases. 2014 dec 16; 2(12): 873-82. doi:10.12998/wjcc.v2.i12.873; pmid: 25516863 pmcid: pmc4266836. cao pp, li hb, wang bf, wang sb, you xj, cui yh, et al. distinct immunopathologic characteristics 25. of various types of chronic rhinosinusitis in adult chinese. j allergy clin immunol. 2009 sep; 124(3): 478-484, 484. e1-2. doi:10.1016/j.jaci.2009.05.017; pmid: 19541359. incidence of resistance hence we recommend initial nasal polyp biopsy in order to provide a more targeted treatment. further studies may be done to address cost-effectiveness and safety issues. an interesting side note in this study was that our study population predominantly exhibited the eosinophilic phenotype (79%). eosinophilic inflammation has been considered a cardinal feature of crswnp in caucasians, and in contrast, around half of asians present with eosinophilic inflammation, indicating a more heterogeneous feature of crswnp in asians.21-25 our findings closely mirrors the study of wen et al. wherein the sample chinese population was determined to be predominantly eosinophilic (76%).16 we acknowledge the limitations of our study in terms of sample size and follow-up period. a multi-institutional study involving a larger sample size and a longer follow-up is currently under development. a larger sample size would mean larger subset population of noneosinophilic polyps. a longer duration of follow-up would determine how long the improvement will last with only 2 weeks of treatment. blinding of patients might also help diminish research bias. in summary, our study showed that in terms of improving symptoms and well-being, as well as decreasing nasal polyp size and reducing discharge and edema as reflected in superior snot-22 and ea scores, clarithromycin performed better than methylprednisolone in the treatment of non-eosinophilic nasal polyps. while both clarithromycin and methylprednisolone were shown to be effective in the treatment of eosinophilic nasal polyps, methylprednisolone was significantly better than clarithromycin in terms of superior ea scores. a biopsy for tissue eosinophil cell count prior to treatment is recommended to establish the predominant inflammatory cell in nasal polyps in order to provide appropriate targeted treatment, i.e. clarithromycin for noneosinophilic nasal polyps and methylprednisolone for eosinophilic polyps. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2023; 38 (1): 22-27 c philippine society of otolaryngology – head and neck surgery, inc. sinonasal anatomy variations on ct scans of a sample of filipino adults with chronic rhinosinusitis catherine p. policina, md giancarla marie c. ambrocio, md rodante a. roldan, md, mha precious eunice r. grullo, md, mph, msc department of otorhinolaryngology head and neck surgery rizal medical center correspondence: dr. giancarla marie c. ambrocio department of otorhinolaryngology head and neck surgery rizal medical center, pasig blvd, pasig 1600 philippines phone: +63 998 550 5409 email: giancarlamarie.ambrocio@rmc.doh.gov.ph the authors declared that this represents original material, that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosure: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. abstract objective: to determine the prevalence of sinonasal anatomic variations seen on paranasal sinus (pns) ct scans of a sample of filipino adults with chronic rhinosinusitis. methods: design: cross-sectional study setting: tertiary government training hospital participants: the pns ct scans of 51 filipino patients with chronic rhinosinusitis with and without nasal polyposis diagnosed at our outpatient department of otorhinolaryngology-head and neck surgery between october 2015 to december 2020 were reviewed for the presence of sinonasal anatomic variants. the prevalence of the identified variants was calculated. results: the ct scans of 51 patients, 41 (80.4%) men and 10 (19.6%) women, were included. the median age was 48 years (q25: 35, q75: 56, iqr:21). the median lund mackay score (lms) was 15 (q25: 12, q75: 20, iqr:8). majority (94%) had an lms of ≥5. the most common anatomic variant in the study population was agger nasi (n=46/51, 90.2% present bilaterally) followed by uncinate process attachment to the lamina papyracea (n=90/102, 88.24%). the third to sixth most common findings were keros type ii classification (n=76/102, 74.51%), nasal septal deviation (n=35/51, 68.62%), optic nerve canal type 1 (n=67/102, 65.69%) and anterior ethmoid artery grade 1 (n=46/102, 45.1%), respectively. less common variants were onodi cell (n=13/51, 25.49% unilateral and n=10/51, 19.61% bilateral), haller cell (n=8/51, 15.69% unilateral and n=1/51, 1.96% bilateral), supraorbital cell (n=4/51, 7.84% unilateral and n=4/51, 7.84% bilateral), middle turbinate concha bullosa (n=3/51, 5.88% unilateral and n=6/51, 11.76% bilateral), superior turbinate concha bullosa (n=2/51, 3.92% unilateral and n=1/51, 1.96% bilateral), pneumatized crista galli (n=2/51, 3.92%) and optic nerve dehiscence (n=1/51, 1.96% bilateral). conclusion: in the adult filipino population with crs sampled in this study, the six most common sinonasal anatomic variants were agger nasi, superior attachment of the uncinate process to the lamina papyracea, keros type ii classification, septal deviation, optic nerve canal type 1 and anterior ethmoid artery grade 1. pre-operatively, the pns ct scan of every patient must be meticulously evaluated for the sinonasal anatomic variants to avoid surgical complications. keywords: chronic rhinosinusitis; paranasal sinus ct; anatomic variants creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles the management for chronic rhinosinusitis (crs) includes medical treatment. however, those who have failed medical therapy will subsequently undergo surgery.1 according to the european position paper (epos) on rhinosinusitis and nasal polyps 2020, a paranasal sinus (pns) computed tomography (ct) scan is required prior to undergoing endoscopic sinus surgery (ess) to determine both the extent of the disease and the sinonasal anatomic variants that may increase the risk of surgical complications.2 thus, knowledge of these radiologic anatomic variants is important especially because they differ individually and between ethnic groups. a local study that included pns ct scans of 45 patients with presumably sinonasal symptoms found out that the most common anatomic variation was the agger nasi cell.3 in 2018, the group of espinosa determined the prevalence of six anatomic variations, namely agger nasi (an), haller cell, septal deviation, concha bullosa, everted uncinate process and paradoxical middle turbinate, of the nasal cavity and paranasal sinuses in patients with chronic rhinosinusitis.4 acosta and vicente, on the other hand, described other sinonasal variants such as asymmetric ethmoid roof, deep olfactory fossa, onodi cells and dehiscent lamina papyracea in patients with nasal polyposis only.5 a search in pubmed central, medline, google scholar, and herdin revealed a lack of published local data that investigates all the other possible sinonasal anatomic variants in crs patients with or without nasal polyposis such as uncinate process attachment, anterior ethmoid artery grading types, presence or absence of frontal cells, turbinate pneumatization, carotid artery and optic nerve dehiscence, which can have an impact in the surgical management. hence, this study aimed to identify the prevalence of radiologic sinonasal anatomic variants in the pns ct scans of a sample of adult filipino patients with crs with and without nasal polyposis. it is important for the surgeon to determine all the anatomic variants because failure to do such may lead to complications (i.e. injury to critical structures such as the orbit, skull base, internal carotid artery and optic nerve). as part of describing the pns ct scans, this study also determined the severity of crs radiologically using the lund-mackay staging system. methods with rizal medical center institutional review board approval (2021-orl-#020-rp-1.iv), this cross-sectional study considered for inclusion all ct scans of adult filipino patients with crs with and without nasal polyposis, as defined by the criteria in the clinical practice guidelines of the philippine society of otolaryngology – head and neck surgery.1 patients were those diagnosed at the outpatient department of otorhinolaryngology head and neck surgery (orl-hns) from october 2015 to december 2020 whose ct scans were available at the department of radiology, section of computed tomography. scans of those with prior sinus surgery or craniofacial anomalies were excluded. the pns ct scan images were taken using the ct scan machines ge healthcare revolution act with slice thickness of 1.25mm and philips mx 16-slice with slice thickness of 2mm, and were hosted in the pacs system of the department of radiology. the slice thickness of images was set at ≤2 mm intervals. a single number code was assigned to each ct scan dicom file to anonymize the patient’s identity. all ct scans were independently evaluated and interpreted by each author. the multiplanar views (axial, coronal and sagittal planes) of the imaging studies were evaluated in bone window (width 2000, level 350)6 using horos or radiant dicom medical image viewer. the authors used their laptops to evaluate the ct scans. the laptops satisfied the display requirements for clinical review work, which means that the viewing and interpretation of images were carried out to influence clinical management and not to generate a formal radiology report.7 the lund-mackay ct score (lms) was first obtained by scoring the 1); opacification of 5 bilateral sinuses (frontal, maxillary, anterior ethmoid, posterior ethmoid, sphenoid); and 2) obstruction of the ostiomeatal complex. possible range of total lund-mackay score was between 0 and 24. the presence or absence of the anatomic variants were identified in each imaging study: keros classification (i, ii, iii) – height of the lamella or depth of the olfactory fossa;8 frontal sinus cells (k1, k2, k3, k4);9 frontal sinus outflow tract obstruction; hypoplastic frontal sinus; interfrontal sinus septal cell; agger nasi cell; supraorbital ethmoidal cell; suprabullar cell; infraorbital ethmoidal cell or haller cell; sphenoethmoidal cell or onodi cell; dehiscence of lamina papyracea (lp); pneumatized crista galli, pneumatization of superior/middle/inferior turbinate, nasal septum; paradoxic middle turbinate; nasal septal deviation (measured by drawing a line from the superior insertion of the nasal septum at the crista galli to the inferior insertion at the level of the anterior nasal spine) classified as absent (nasoseptal angle 4 degrees and below) or present (nasoseptal angle 5 degrees and above);10 septal spur; uncinate process attachment; sinus lateralis; grading of anterior ethmoid artery (aea): (grade 1 – aea courses within skull base, grade 2 – aea adjacent but inferior to, described as prominent from, inferior surface of the skull base, grade 3 – aea courses freely inferior to skull base);11 types of sphenoid sinus pneumatization: conchal (region below sella completely ossified and consists of a solid block of bone with no air cavity), presellar (air cavity does not penetrate beyond a vertical plane parallel to anterior sellar wall), incomplete sella (sinus is well developed, and pneumatization extends beyond tuberculum sella below the sella and sometimes with bulging of sellar floor into sinus cavity), complete philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles sella (air cavity extends into body of sphenoid, continues beyond posterior margin of dorsum sella into clivus bone);12 sphenoid sinus wall dehiscence in relation to optic nerve and internal carotid artery; and types of optic nerve canals (onc): type 1 (canal superolateral to sphenoid sinus without indentation on sinus wall on coronal ct sections), type 2 (indentation on sphenoid sinus contour with less than 50% protrusion of nerve circumference on coronal view), type 3 (optic nerve traversing through sphenoid sinus with coronal view showing more than 50% protrusion of nerve circumference into sinus), type 4 (canal adjacent to sphenoid and posterior ethmoid sinuses/presence of onodi cell).13 the sample size was calculated using the formula n = n*x / (x + n – 1), where, x = z α/2 2 *p*(1-p) / moe 2, and z α/2 is the critical value of the normal distribution at α/2, moe is the margin of error, p is the sample proportion, and n is the population size. using a margin of error of 5%, confidence level at 99.1%, population set at 1000 and sample proportion of 98% based on a study by shpilberg,14 the minimum sample size calculated was 51 ct scan images. the results were recorded using a data collection form. in case of disagreements in interpretation, the authors convened, and the decision was made by consensus (i.e. at least 3 out of the 4 authors agreed). if consensus was not reached, the interpretation of the most senior (and most experienced) rhinologist (rar) was deemed final. all collected data were tabulated in microsoft excel version 16.71 (microsoft corp., redmond, wa, usa). the frequencies or proportions were summarized in appropriately labeled tables. the median, 1st quartile, 3rd quartile and interquartile range (iqr) were reported for age and lms because of non-normal distribution of age and the ordinal nature of lms data. for statistical analysis, python version 3.11.0 (python software foundation, beaverton, or, usa) was used. results out of 53 pns ct scans initially retrieved, 2 were excluded (1 with craniofacial anomaly, 1 with previous sinus surgery), and the ct scans of 51 patients, 41 (80.4%) men and 10 (19.6%) women, were finally included in this study. the median age was 48 years (q25: 35, q75: 56, iqr:21). the lund mackay scores (lms) ranged from 0 to 24 with a median score of 15 (q25: 12, q75: 20, iqr:8). among the participants, 94% had an lms of ≥5. table 1 shows the distribution of sinonasal anatomic variants from the right and left side of each patient’s nasal cavity (n=102), while table 2 shows the anatomic variations that were either present unilaterally or bilaterally (n=51). the most common anatomic variant in this study was an (n=46/51, 90.2% present bilaterally and n=1/51, 1.96% present unilaterally). the second most common variant was uncinate process attachment to the lamina papyracea (n=90/102, 88.24%). keros type ii classification (n=76/102, 74.51%) was the third most common variant noted, followed by nasal septal deviation (n=35/51, 68.62%), optic nerve canal type 1 (n=67/102, 65.69%) and anterior ethmoid artery grade 1 (n=46/102, 45.1%). less common variants were onodi cell (n=13/51, 25.49% unilateral and n=10/51, 19.61% bilateral), haller cell (n=8/51, 15.69% unilateral and n=1/51, 1.96% bilateral), supraorbital cell (n=4/51, 7.84% unilateral and n=4/51, 7.84% bilateral) and middle turbinate concha bullosa (n=3/51, 5.88% unilateral and n=6/51, 11.76% bilateral). some anatomic variants were rarely seen in this study. only three patients had superior turbinate concha bullosa (n=2/51, 3.92% unilateral and n=1/51, 1.96% bilateral). two patients had pneumatized crista galli (n=2/51, 3.92%), and only one had optic nerve dehiscence (n=1/51, 1.96% present bilaterally). none had lamina papyracea dehiscence, carotid artery dehiscence, paradoxic middle turbinate, inferior turbinate concha bullosa and pneumatized nasal septum. discussion our study found that the majority (94%) of patients had a lundmackay score (lms) of ≥5. this score has an excellent positive predictive value, which strongly indicates true disease in patients according to epos 2020.2 it is interesting to note that 6% had an lms of less than 5. this finding of having a low lms in crs patients is supported by the study of dietz de loos et al.2 in their investigation, 26% (n=107) of patients who were diagnosed with crs based on nasal symptoms only had an lms of 1 to 3 in their ct scans.2 they also found out that lms can be 0 in 50% (n=107) of crs patients.2 overall, an was the most common anatomic variation, which was present bilaterally in 90.2% (n=46) patients and unilaterally in 1.96% (n=1) patient. similarly, in the other three studies on filipino patients, an was also the most common variant detected with a prevalence of 86% (n=88), 62% (n=28) and 78% (n=47), respectively.3,4,15 the presence of this variant helps the surgeon to access the frontal recess faster. however, its pneumatization must be carefully evaluated. a wellpneumatized an may be mistaken for the frontal recess.13 removal of an extensively pneumatized an in a patient with a thin lacrimal bone may increase the risk of orbital injury.13 in the case of an overly pneumatized an displacing the middle turbinate more medially, resection must be executed with caution to prevent destabilization of the middle turbinate.13 more important than determining the presence of the an is the thorough assessment of its relationship to the surrounding critical structures to prevent complications. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles complications like cerebrospinal fluid (csf) leak. the third most prevalent variant was the presence of a type ii keros classification (n=76/102, 74.51%). this was in contrast with the local study done by paber et al. where the most common identified classification was type i keros (n=165, 81.6%), and only 17.9% (n=52) had type ii keros.17 this varying distribution among filipinos means that surgeons must be attentive to each patient’s depth of olfactory fossa in each side to avoid skull base and intracranial injuries. it was also notable that keros type iii was the least prevalent in this study which was found in only 1.96% (n=2) patients. this very low prevalence was consistent with the local study of paber17 and other studies conducted among the saudi, indian and egyptian populations18,19 suggesting that although it was the most dangerous classification, it was uncommon. table 1. distribution of right and left sinonasal anatomic variants classificationanatomic variant right n=51 n (%) left n=51 n (%) total n=102 for 2 sides n (%) keros classification frontal (kuhn) cell uncinate process attachment anterior ethmoid artery sphenoid sinus pneumatization optic nerve canal septal deviation septal spur type i type ii type iii none k1 k2 k3 k4 lamina papyracea middle turbinate skull base grade 1 grade 2 grade 3 conchal presellar incomplete complete type 1 type 2 type 3 type 4 present present 12 (23.5) 39 (76.4) 0 37 (72.55) 4 (7.84) 0 5 (9.8) 5 (9.8) 44 (86.27) 7 (13.73) 0 23 (45.1) 8 (15.69) 20 (39.22) 3 (5.88) 14 (27.45) 23 (45.1) 11 (21.57) 34 (66.67) 1 (1.96) 1 (1.96) 15 (29.41) 30 (58.82) 7 (13.73) 12 (23.53) 37 (72.55) 2 (3.92) 34 (66.67) 7 (13.73) 0 7 (13.73) 3 (5.88) 46 (90.2) 5 (9.8) 0 23 (45.1) 4 (7.84) 24 (47.06) 4 (7.84) 10 (19.61) 21 (41.18) 16 (31.37) 33 (64.71) 3 (5.88) 3 (5.88) 12 (23.53) 5 (9.8) 0 24 (23.53) 76 (74.51) 2 (1.96) 71 (69.61) 11 (10.78) 0 14 (13.73) 8 (7.84) 90 (88.24) 12 (11.76) 0 46 (45.1) 12 (11.76) 44 (43.14) 7 (6.86) 24 (23.53) 44 (43.14) 27 (26.47) 67 (65.69) 4 (3.92) 4 (3.92) 27 (26.47) n=51 n (%) 35 (68.62) 7 (13.73) next to agger nasi in terms of prevalence was the uncinate process (up) superior attachment to the lamina papyracea (n=90/102, 88.24%). this finding was consistent with the study by tuli et al. wherein 79.8% (n=67) of the study participants had the up attached to the lamina papyracea.16 in this study, none of the up was attached to the skull base, while the rest was noted to have superior attachment to the middle turbinate (n=12/102, 11.76%). this was in contrast to the study of tuli et al. where the least common attachment was to the middle turbinate (n=3, 3.57%).16 these findings suggest that careful uncinectomy must be done to avoid inadvertent injury to the lamina papyracea where it most commonly attaches to. however infrequent, the attachment of the uncinate to the skull base and middle turbinate must still be identified pre-operatively to prevent iatrogenic damage that can cause table 2. distribution of unilateral or bilateral sinonasal anatomic variants frontal sinus frontal sinus outflow tract obstruction interfrontal sinus septal cell hypoplastic frontal sinus ethmoid sinus and related anatomy haller cell supraorbital cell agger nasi suprabullar cell sinus lateralis onodi cell lamina papyracea dehiscence sphenoid sinus and related anatomy intersphenoid septa carotid dehiscence optic nerve dehiscence turbinates paradoxic middle turbinate superior turbinate pneumatization middle turbinate pneumatization inferior turbinate pneumatization crista galli pneumatized crista galli nasal septum pneumatized septum 13 (25.49) 6 (11.76) 7 (13.73) 8 (15.69) 4 (7.84) 1 (1.96) 13 (25.49) 8 (15.69) 13 (25.49) 0 13 (25.49) 0 0 0 2 (3.92) 3 (5.88) 0 28 (54.9) 0 1 (1.96) 1 (1.96) 4 (7.84) 46 (90.2) 16 (31.37) 19 (37.25) 10 (19.61) 0 1 (1.96) 0 1 (1.96) 0 1 (1.96) 6 (11.76) 0 present 2 (3.92) present 0 anatomic variant unilateral n (%) bilateral n (%) philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles next, the fourth most frequently seen variant in this study was septal deviation, which was present in 68.62% (n=35, more commonly found in the right side n=30). this was in contrast to the findings of other anatomic studies.14,20 kaygusuz et al. reported that in the turkish population, the most common anatomic variant was nasal septal deviation (72.7%, n=72).20 in addition, shpilberg et al. reported that among the population in new york in their investigation, nasal septal deviation was also the most common variant with a prevalence of 98.4% (n=189).14 the slightly lower prevalence among filipinos may mean that challenging surgical exposure in endoscopic sinus surgeries secondary to an obstructing deviated septum may be a less likely problem. septal spur may also cause obstruction, but it was not that common in our study population (n=7, 13.73%). type 1 optic nerve canal was the fifth most common anatomic variant. among the other types of optic nerve canal, the second most common was type 4 (n=27, 26.47%). only one patient had optic nerve dehiscence. onodi cells were present in 23 patients (n=13, 25.49% unilateral and n=10, 19.61% bilateral). this study reported a higher prevalence of onodi cells compared to other studies involving filipino participants where the prevalence ranged from 8.2%-8.8%.3,5 the presence of these variants warrants vigilance when approaching the posterior ethmoid and sphenoid sinuses to prevent damage to the optic nerve, which can ultimately cause blindness. the sixth most common variant was grade 1 anterior ethmoid artery (aea). in this study, grade 1 and grade 3 aea had close prevalence, 45.1% (n=46) and 43.14% (n=44), respectively. the symmetry of the grading on each patient’s side did not largely deviate from each other. these results were similar to the study of taha et al. wherein 45% of the patients had grade 1 aea, and another 45% of the patients had grade 3 aea, with the prevalence of the right and left side not far from each other.21 from these findings, the aea can commonly hang below the skull base, hence, extra caution when performing ethmoidectomy is recommended. inability to recognize the aea particularly when it travels freely from the skull base can cause unintentional transection of the artery. its subsequent retraction to the orbit can lead to retroorbital hemorrhage, which may progress to optic nerve compression and blindness. other anatomic variants had lower prevalence in this study. only 9 patients (17%) had haller cells. in the local studies available, the prevalence of haller cells was higher ranging from 28% to 41.6%.3,4,15 from the analysis of badia, which tabulated results of 10 studies including asian and caucasian populations, the prevalence of haller cells ranged from 3% to 46%.22 another infrequent variant in our study was the supraorbital cell (n=8, 15.6%). none of the local publications described its prevalence among filipinos. from shpilberg et al.14 and gouripur et al.,23 supraorbital cells were present in 28.1% and 26% of patients, respectively. regardless of the lower prevalence observed in this study, the presence of haller cells and supraorbital cells should be noted prior to the surgery as they can increase the risk of injury to the orbit. a retained haller cell may also have an impact on the drainage of the maxillary sinus. dehiscence in the lamina papyracea (lp) and bone through which the carotid artery runs in relation to the sphenoid sinus are other important variants to evaluate. further violation of a dehisced lp can lead to prolapse of or damage to the orbital contents. aggressive clearance of secretions from the sphenoid sinus may result in massive hemorrhage for patients with carotid canal dehiscence. likewise, sphenoid sinus septations that are connected to the bone overlying the carotid may increase the risk for bleeding during removal. in this present study, none of the subjects had a dehiscence in the lp or bony canal of the carotid artery. meanwhile, in the study of santos and jarin, 37% (n=18) of the filipino participants had lp dehiscence.15 lastly, pneumatization of the nasal turbinates is also important to assess. the presence of such can either be a contributing factor to the pathophysiology of chronic rhinosinusitis or may affect the field exposure in sinus surgeries. in this analysis, middle turbinate concha bullosa was present in nine patients (17.6%). this prevalence was similar to the study of santos et al. (n=9, 20%).3 interestingly, badia et al. cited a study where the prevalence of concha bullosa among caucasians was as high as 53%.22 superior turbinate pneumatization was rare in this present study, only presenting in three patients (n=2, 3.92% unilateral and n=1, 1.96% bilateral). none of the patients had a pneumatized inferior turbinate. to date, this study has the most number of sinonasal anatomic variants evaluated from the pns ct scans of filipinos with crs. however, it also has several limitations. first, the windowing used in this review was fixed to one setting only. second, the readers only used laptops instead of primary diagnostic workstations. these factors could have affected the visibility of some anatomic variants and interrater variability. the use of different bone window levels and diagnostic display monitors is suggested in the future. further multicenter studies with a larger sample size is another recommendation to increase the generalizability of the results. the different ethnicities of filipinos (e.g., chinese, malay, caucasoid and combinations) can also be captured and analyzed. in the filipino sample included in this study, the six most common sinonasal anatomic variants were agger nasi, superior attachment of the uncinate process to the lamina papyracea, keros type ii classification, septal deviation, optic nerve canal type 1 and anterior ethmoid artery grade 1. the prevalence of some anatomic variants differ among philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles references 1. caro r, acuin j, villegas m, llanes eg, calaquian c, dumlao kj. clinical practice guidelines on chronic rhinosinusitis in adults. philippine society of otolaryngology – head and neck surgery. 2016. [cited 2021 jan 10] retrieved from https://pso-hns.org/clinical-practice-guidelines-v2/. 2. fokkens wj, lund vj, hopkins c, hellings pw, kern r, reitsma s. et al. european position paper on rhinosinusitis and nasal polyps 2020. rhinology. 2020 feb 20;58(suppl s29):1-464. doi: 10.4193/rhin20.600; pubmed pmid: 32077450. 3. santos dr, fragante re, espina cs, hernandez jg. a descriptive study of anatomic variants of ethmoid sinus: agger nassi cell, haller cell, onodi cell, concha bullosa, and paradoxic middle turbinate as seen on ct scans of paranasal sinuses in filipino subjects. radiology journal. 2009 jul;3(1):47-51. 4. espinosa w, genito r, ramos rz. anatomic variations of the nasal cavity and paranasal sinus and their correlation with chronic rhinosinusitis using harvard staging system. j otolaryngol ent res. 2018 jul 6;10(4):190-193. doi: 10.15406/joentr.2018.10.00343. 5. acosta er, vicente g. risk areas in endoscopic sinus surgery: a review of 175 computed tomography scans of the sinuses among patients with nasal polyposis. philipp j otolaryngol head neck surg. 2001;16(3):118-125. [cited 2021 jan 10] available from: https://pjohns.pso-hns. org/index.php/pjohns/issue/view/61. 6. cebula m, danielak-nowak m, modlinska s. impact of window computed tomography (ct) parameters on measurement of inflammatory changes in paranasal sinuses. pol j radiol. 2017 oct 20;82:567-570. doi:  10.12659/pjr.901939; pubmed pmid:  29662587; pubmed central pmcid; pmc5894057. 7. radiology informatics committee. picture archiving and communication systems (pacs) and guidelines on diagnostic display devices third edition. the royal college of radiologists. 2019 february. [cited 2022 jan 17] available from: https://www.rcr.ac.uk/publication/picturearchiving-and-communication-systems-pacs-and-guidelines-diagnostic-display-0. 8. babu ac, nair mrpb, kuriakose am. olfactory fossa depth: ct analysis of 1200 patients. indian j radiol imaging. 2018 oct-dec;28(4):395-400. doi:  10.4103/ijri.ijri_119_18; pubmed pmid: 30662198 pubmed central pmcid: pmc6319094. 9. lal d, stankiewicz j. primary sinus surgery in flint p, francis h, haughey b, lesperance m, lund v, robbins k, thomas j. cummings otolaryngology head and neck surgery. 7th edition, philadelphia; elsevier, 2020. pp 677-710. 10. periyasamy v, bhat s, sree ram mn. classification of naso septal deviation angle and its clinical implications: a ct scan imaging study of palakkad population, india.  indian j otolaryngol head neck surg. 2019 nov;71(suppl 3):2004-2010. doi:  10.1007/s12070-018-1425-1; pubmed pmid: 31763284; pubmed central pmcid: pmc6848586. 11. taha ma, hall ca, zylics he, westbrook mb, barham wt, stevenson mm, et al. variability of the anterior ethmoid artery in endoscopic sinus surgery. ear nose throat j. 2022 may;101(4):268273. doi: 10.1177/0145561320950488; pubmed pmid: 32845806. 12. famurewa oc, ibitoye bo, ameye sa, asaleye cm, ayoola oo, onigbinde os. sphenoid sinus pneumatization, septation, and the internal carotid artery: a computed tomography study.  niger med j. 2018 jan-feb;59(1):7-18. doi: 10.4103/nmj.nmj_138_18; pubmed pmid: 31198272; pubmed central pmcid: pmc6561078. 13. yanagisawa e, joe jk. the surgical significance of the agger nasi cell. ear nose throat j. 1999 may;78(5):328-30. pubmed central pmid: 10355191. 14. shpilberg ka, daniel sc, doshi ah, lawson w, som pm. ct of anatomic variants of the paranasal sinuses and nasal cavity: poor correlation with radiologically significant rhinosinusitis but importance in surgical planning. ajr am j roentgenol. 2015 jun;204(6):1255-60. doi: 10.2214/ ajr.14.13762; pubmed pmid: 26001236. 15. santos c, jarin ps. computed tomographic analysis of paranasal sinus anatomic variations among filipinos. philipp j otolaryngol head neck surg. 2004;19(3-4):155-160. [cited 2021 jan 10] available from: https://pjohns.pso-hns.org/index.php/pjohns/issue/view/53/3. 16. tuli ip, sengupta s, munjal s, kesari sp, chakraborty s. anatomical variations of uncinate process observed in chronic sinusitis.  indian j otolaryngol head neck surg. 2012 dec 25;65(2):157-161. doi: 10.1007/s12070-012-0612-8; pubmed pmid: 24427557; pubmed central pmcid: pmc3649035. 17. paber jel, cabato ms, villarta r, hernandez j. radiographic analysis of the ethmoid roof based on keros classification among filipinos. philipp j otolaryngol head neck surg. 2008 janjun;23(1):15–19. doi: 10.32412/pjohns.v23i1.763. 18. lmushayti z a, almutairi a n, almushayti m a, et al. 2022. evaluation of the keros classification of olfactory fossa by ct scan in qassim region. cureus. 2022 feb 19;14(2):e22378. doi: 10.7759/ cureus.22378; pubmed pmid: 35321069; pubmed central pmcid: pmc8935634. 19. murthy va, santosh b. a study of clinical significance of the depth of olfactory fossa in patients undergoing endoscopic sinus surgery.  indian j otolaryngol head neck surg. 2017 dec;69(4):514-522. doi:  10.1007/s12070-017-1229-8; pubmed pmid:  29238684; pubmed central pmcid: pmc5714917. 20. kaygusuz a, haksever m, akduman d, aslan s, sayar z. sinonasal anatomical variations: their relationship with chronic rhinosinusitis and effect on the severity of disease—a computerized tomography assisted anatomical and clinical study. indian j otolaryngol head neck surg. 2014 sep;66(3):260-6. doi:  10.1007/s12070-013-0678-y; pubmed pmid:  25032111; pubmed central pmcid: pmc4071417. 21. taha ma, hall ca, zylicz he, westbrook mb, barham wt, stevenson mm, et al. variability of the anterior ethmoid artery in endoscopic sinus surgery. ear nose throat j. 2022 may;101(4):268– 273. doi: 10.1177/0145561320950488; pubmed pmid: 32845806. 22. badia l, lund vj, wei w, ho wk. 2005. ethnic variation in sinonasal anatomy on ct scanning. rhinology. 2005 sep;43(3):210-4. pubmed central pmid: 16218515. 23. gouripur k, kumar u, janagond ab, elangovan s, srinivasa v. incidence of sinonasal anatomical variations associated with chronic sinusitis by ct scan in karaikal, south india. int j otorhinolaryngol head neck surg. 2017 jul;3(3):576-580. doi: http://dx.doi.org/10.18203/ issn.2454-5929.ijohns20172291. different ethnicities and even among studies including the same ethnicity. therefore, the pns ct scan of each patient who will undergo sinus surgery must be meticulously analyzed. every possible anatomic variant mentioned in this study should be noted to avoid inadvertent injuries to the critical structures during ess. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 joseph anthony r. rivera, md (1980-2016) january e. gelera, md it is an honor to write this tribute to dr. joseph anthony ‘otep’ rivera (1980-2016) – a friend, colleague, teacher, brother, uncle and son. how do you describe a person, a friend, who led an extraordinary life, that the loss of his companionship and example defies measurement? can his life be measured by his accomplishments in his field of work, patients’ illnesses dispelled and injuries healed? perhaps. as important as his labor was though, as certain and measurable his accomplishments are, what remains of otep in our memories will be his warmth and humanity. otep and i were batch mates and anyone familiar with the circumstances of this unique relationship knows there can be no small degree of friction and quarreling on occasion. we had our share but he would drop any issue of contention to help me in times of need. otep had a relaxed approach to problem solving, displaying initiative and ingenuity in organizing the resources needed to solve any challenge. his passion for community service was recognized by his colleagues and deeply appreciated by the people he helped. he had a charismatic personality that drew people to him. people listened to him, followed him. what made him special was his love for people, all people. this was apparent by the work he chose. yes, he was a doctor. yes, he trained to be an ear, nose and throat specialist. however, this was not enough for him. he devoted his extra time working as an emergency medical technician, responding to emergency calls. he also found time to be a firefighter during his days off. i don’t know how he found the time. given his other responsibilities, it simply defies the laws of physics. after residency, aside from establishing his private practice, he taught clinical ent to medical students at our lady of fatima medical university. he also worked as the chief medical officer of the municipality of apalit, pampanga. his work as a rural health provider left the people of apalit not only with better medical care but also with the awareness they now had a new friend. during residency, we remember otep as a dependable, resourceful, committed friend who loved life and all it offered. his passion for cars was legendary. if you had car trouble, you asked otep. if you want to trade or buy cars, you asked otep. you could ask otep, even if you were stuck in traffic (he had a solution for everything). in addition, he was fun to work with, always ready to tell an anecdote or two to lift one’s spirit and make the workplace atmosphere enjoyable. his life may have been cut short by an incurable illness but to me it was a life well lived. otep was a cherished friend to many, an awesome brother and uncle and a loving son—he will be missed but never forgotten by those who are fortunate enough to have known him. philippine journal of otolaryngology-head and neck surgery 65 passages philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery president’s page greetings to all! congratulations for another successful publication of the philippine journal of otolaryngology-head and neck surgery. this year marks the 42nd publication and i would like to commend the editorial team, spearheaded by dr. josé florencio f. lapeña jr., and all the authors for their hard work and outstanding performance in this journal. as we transition to a new normal after the pandemic, we cannot deny that it has brought changes into our lives including the way we approach research. but why do we even need to conduct research? we faced seemingly insurmountable limitations and obstacles during the past 3 years and coming up with a research topic and writing a research paper should have been the last thing on our minds, yet we continued. we continued to further our knowledge about the topics that we know and love. we continued to seek answers to the questions that we had. and finally, we continued to encourage and motivate the younger generation to be inquisitive and to keep the love of learning burning. the pjohns embodies the passion and the drive to learn more about orl-hns. the various case studies, descriptive researches, and analytical researches present in this journal, represent the commitment of the editor-in-chief and editorial staff, and the dedication of the authors to our field. i hope that everyone that reads this journal will find it helpful in furthering their knowledge about the field of orl-hns. as you go through the pages of this journal, i hope it ignites your thirst for knowledge once again and renews your passion in otorhinolaryngology. enjoy reading! ricardo l. ramirez jr., md, fpso-hns president philippine society of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 (hematoxylin – eosin , 100x) philippine journal of otolaryngology-head and neck surgery 59 under the microscope philipp j otolaryngol head neck surg 2017; 32 (1): 59-60 c philippine society of otolaryngology – head and neck surgery, inc. middle ear paragangliomajose m. carnate, jr., md 1 vincent g. te, md2 michelle anne m. encinas-latoy, md1 1department of pathology, college of medicine university of the philippines manila 2department of laboratories, university of the philippines manila philippine general hospital correspondence: dr. jose m. carnate, jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st. ermita, manila 1000 philippines phone (632) 526-4450 telefax (632) 400-3638 email: jmcjpath@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. a 51-year-old woman underwent mastoidectomy with labyrinthectomy on the right for a polypoid external auditory canal mass accompanied by tinnitus and ear discharge. she was reported to have undergone mastoidectomy on the same site seven years prior to the present consult. the material from this prior surgery was not made available to us. the submitted specimen from this surgery consisted of several dark brown irregular tissue fragments with an aggregate diameter of 4.2 centimeters. histologic sections show tumor cells arranged in “ball-like” clusters that are surrounded by a network of sinusoidal channels. the cells are round to oval with round, uniform nuclei that have finely granular chromatin and moderate amounts of eosinophilic to amphophilic cytoplasm. (figure 1) mitoses, nuclear pleomorphism and hyperchromasia are not observed. immunohistochemical studies show diffuse cytoplasmic positivity for synaptophysin and chromogranin. (figure 2) the s100 stain highlights a peripheral layer of cells taking up the stain around the cell clusters. (figure 3) based on these features, we diagnosed the case as a paraganglioma likely a recurrence. paragangliomas are neuroendocrine neoplasms that arise from paraganglia found in various anatomic locations.1 in the middle ear, they arise from paraganglia found in the adventitia of the jugular bulb – hence, the old synonym “glomus jugulare” and “glomus tympanicum.” other sites where they can develop include paraganglia of the carotid artery bifurcation (“chemodectoma”), the larynx and the vagal trunk (“glomus vagale”). the world health organization has simplified the nomenclature of these tumors by calling all of them simply “paraganglioma” and specifying the site involved.1 in our case, it is likely a middle ear paraganglioma borne out by the history, clinical picture, and the morphology. head and neck paragangliomas occur in adults from the 5th – 6th decade, more commonly in females, and present mostly with mass-related symptoms.2,3 creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. tumor cells arranged in “ball-like” clusters surrounded by vascular channels (hematoxylin-eosin, 100x magnification). high power (inset) shows round to oval cells with round uniform nuclei and finely granular chromatin (hematoxylin-eosin, 400x magnification). philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 (horseradish peroxidase, 100x) (horseradish peroxidase, 400x) under the microscope 60 philippine journal of otolaryngology-head and neck surgery references 1. kimura n, capella c, gill a, lam aky, tischler as, williams md. paraganglion tumours. in: elnaggar ak, chan jkc, grandis jr, takata t, slootweg pj. world health organization classification of head and neck tumors. lyon: iarc press. 2017. p. 276-284. 2. stelow eb, mills se. biopsy interpretation of the upper aerodigestive tract and ear. 2nd ed. philadelphia: lippincott williams and wilkins. 2013. p. 163-165. the morphology of paragangliomas in all head and neck locations is similar. hematoxylin-eosin sections show cells arranged in organoid groups (“cell-ball”, “zellballen”) surrounded by a vascular network. there are two cell types encountered: the chief cells which comprise the bulk of the cell nests and have abundant eosinophilic cytoplasm and the sustentacular cells which are spindly and located at the periphery of the nests. neuroendocrine immunohistochemical stains (e.g. synaptophysin, chromogranin, cd56) highlight the chief cells while s100 and glial fibrillary acidic protein (gfap) highlight the sustentacular cells. cytokeratin is typically non-reactive and distinguishes this tumor from neuroendocrine tumors (i.e. carcinoid, neuroendocrine carcinoma) and middle ear adenoma.1,3 there are no consistent histologic features that can discriminate between benign and malignant cases, nor are there criteria that can predict aggressive behavior and metastasis.1,2,3 head and neck paragangliomas are slow-growing tumors and surgery is the most common treatment option. radiotherapy is an option, especially for vagal paragangliomas where severe vagal nerve deficits occur in surgically treated cases.1 recurrence after surgery is reported to be less than 10% for carotid and up to 17% in laryngeal cases.1 metastasis on the other hand occur in 4 – 6 % of carotid, 2% of middle ear and laryngeal, and 16% of vagal tumors.3 the world health organization nomenclature states that “all paragangliomas have some potential for metastasis (albeit variable).”1 thus, long-term follow-up may be prudent for all cases. figure 2. diffuse cytoplasmic positivity on synaptophysin and chromogranin immunohistochemistry (horseradish peroxidase method, 100x magnification). (horseradish peroxidase, 100x) figure 3. peripheral positivity highlighting a layer of sustentacular cells around the cell clusters on s100 immunohistochemistry, (horseradish peroxidase method, 400x magnification). (horseradish peroxidase, 400x) 3. williams md. paragangliomas of the head and neck: an overview from diagnosis to genetics. head neck pathol. 2017 march 20. [epub ahead of print] doi: 10.1007/s12105-017-0803-4. pmid: 28321772. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 6 philippine journal of otolaryngology-head and neck surgery special announcement we, the participants in the joint meeting of the asia pacific association of medical journal editors (apame), the index medicus of the south east asia region (imsear), and the western pacific region index medicus (wprim) held in manila from 24 to 26 august 2015, in conjunction with the cohred global forum on research and innovation for health held in manila from 24-27 august 2015, drawing on the preforum discussions on hifa from 20 july to 24 august 2015 “meeting the information needs of researchers and users of health research in lowand middle-income countries” available at http://www.hifa2015.org/meetingthe-information-needs-of-researchers-and-users-of-health-research-2/ and the bmj blogs 20 july 2015 “how can we improve the availability and use of health research in developing countries?” available at http://blogs. bmj.com/bmj/2015/07/20/how-can-we-improve-the-availability-anduse-of-health-research-in-developing-countries/: considering that the who constitution “enshrines the highest attainable standard of health as a fundamental right of every human being;” and that “the right to health includes access to timely, acceptable, and affordable healthcare of appropriate quality in tandem with “the underlying determinants of health,” including “access to health-related education and information;” that increasing the availability of quality health research information is fundamental to the successful attainment of global health and progressive realization of the right to health; and that all healthcare stakeholders (individuals, researchers, providers, professionals, leaders and policymakers) need seamless access to peer-reviewed research and information that are relevant to their respective contexts, and presented in a language they can understand; that despite a growing momentum towards free and open access to research literature, and important initiatives, such as hinari access to research in health programme and iris institutional repository manila declaration on the availability and use of health research information in and for low-and middle-income countries in the asia pacific region for information sharing, that have helped to improve the availability of research in lowand middle-income countries, there continue to be many challenges, limitations and exclusions that prevent health research information from becoming freely and openly available to those who need it; that the global health library (ghl), index medicus of the south east asia region (imsear), western pacific region index medicus (wprim), and asia pacific association of medical journal editors (apame) are important collaborative initiatives that can promote and uphold the availability and use of health research information especially in and for lowand middle-income countries in the asia pacific region; confirm our commitment to champion and advocate for the increased availability, accessibility and visibility of health research information from and to lowand middle-income developing countries through our journals, our respective national associations of medical editors, and apame; our commitment to make research information freely and openly available in the right language to producers and users of health research in lowand middle-income countries through imsear, wprim, the asia pacific medical journal articles central archives (apamed central) and other platforms; our commitment to improve availability, accessibility and interoperability of the different formats of health information suitable to different users in their respective contexts including through both conventional and alternative channels of research dissemination such as new and social media, mobile and disruptive technologies, blogging and microblogging tools and communities, and communities of practice; philippine journal of otolaryngology-head and neck surgery 7 this declaration was launched at the 2015 convention of the asia pacific association of medical journal editors (apame) held in manila from 24 to 26 august 2015. it is concurrently published by journals linked to apame and listed in the index medicus of the south east asia region (imsear) and the western pacific region index medicus (wprim). philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 special announcement 26 august 2015, manila copyright © apame. www.wpro.who.int/apame apame@wpro.who.int call on member states of and governments in the south east asia and western pacific regions, in collaboration with stakeholders from the non-government and private sectors to formulate and implement policies and certification schemes such as the cohred fairness index™ (cfi) that promote free and open availability of health 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and practices that would improve the quality, availability and accessibility of scientific writing and publications in the asia pacific region and the world; bibliographic, citation and full-text databases such as pubmed, global health database (cab direct), the directory of open access journals (doaj), embase, scielo citation index, scopus, and the web of science to review their policies and processes for indexing journals from lowand middle-income countries, as well as making health research information freely and openly available to users in these countries who cannot afford to pay for it; commit ourselves and our journals to publishing innovative and solutionfocused research in all healthcare and related fields such as health promotion, public health, medicine, nursing, dentistry, pharmacy, other health professions, health services and health systems, particularly health research applicable to lowand middle-income countries; ourselves and our publishers to disseminating scientific, healthcare and medical knowledge fairly and impartially by developing and using bibliographic indices, citation databases, full-text databases and open data systems including, but not limited to, such regional indexes of the global health library as imsear, wprim and apamed central; our organization, apame, to building collaborative networks, convening meaningful conferences, and organizing participative events to educate and empower editors, peer reviewers, authors, librarians and publishers to achieve real impact, and not just impact factor, as we advance free and open access to health information and publication that improves global health-related quality of life. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery wealthy nations must step up support for africa and vulnerable countries in addressing past, present and future impacts of climate change the 2022 report of the intergovernmental panel on climate change (ipcc) paints a dark picture of the future of life on earth, characterised by ecosystem collapse, species extinction, and climate hazards such as heatwaves and floods.1 these are all linked to physical and mental health problems, with direct and indirect consequences of increased morbidity and mortality. to avoid these catastrophic health effects across all regions of the globe, there is broad agreement— as 231 health journals argued together in 2021—that the rise in global temperature must be limited to less than 1.5oc compared with pre-industrial levels. while the paris agreement of 2015 outlines a global action framework that incorporates providing climate finance to developing countries, this support has yet to materialise.2 cop27 is the fifth conference of the parties (cop) to be organised in africa since its inception in 1995. ahead of this meeting, we—as health journal editors from across the continent—call for urgent action to ensure it is the cop that finally delivers climate justice for africa and vulnerable countries. this is essential not just for the health of those countries, but for the health of the whole world. africa has suffered disproportionately although it has done little to cause the crisis the climate crisis has had an impact on the environmental and social determinants of health across africa, leading to devastating health effects.3 impacts on health can result directly from environmental shocks and indirectly through socially mediated effects.4 climate change-related risks in africa include flooding, drought, heatwaves, reduced food production, and reduced labour productivity.5  droughts in sub-saharan africa have tripled between 1970-79 and 2010-2019.6 in 2018, devastating cyclones impacted 2.2 million people in malawi, mozambique and zimbabwe.6 in west and central africa, severe flooding resulted in mortality and forced migration from loss of shelter, cultivated land, and livestock.7 changes in vector ecology brought about by floods and damage to environmental hygiene has led to increases in diseases across sub-saharan africa, with rises in malaria, dengue fever, lassa fever, rift valley fever, lyme disease, ebola virus, west nile virus and other infections.8,9 rising sea levels reduce water quality, leading to water-borne diseases, including diarrhoeal diseases, a leading cause of mortality in africa.8 extreme weather damages water and food supply, increasing food insecurity and malnutrition, which causes 1.7 million deaths annually in africa.10 according to the food and agriculture organization of the united nations, malnutrition has increased by almost 50% since 2012, owing to the central role agriculture plays in african economies.11 environmental shocks and their knock-on effects also cause severe harm to mental health.12 in all, it is estimated that the climate crisis has destroyed a fifth of the gross domestic product (gdp) of the countries most vulnerable to climate shocks.13 the damage to africa should be of supreme concern to all nations. this is partly for moral reasons. it is highly unjust that the most impacted nations have contributed the least to global correspondence: chris zielinski centre for global health, university of winchester sparkford road winchester hampshire so22 4nr united kingdom phone: +44 (0) 1962 841515 fax: +44 (0) 1962 842280 email: chris.zielinski@ukhealthalliance.org disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. disclaimer: this comment is being published simultaneously in multiple journals. for the full list of journals see: https://www.bmj.com/content/full-listauthors-and-signatories-climate -emergency-editorialoctober-2022 lukoye atwoli,1 gregory e. erhabor,2 aiah a. gbakima,3 abraham haileamlak,4 jean-marie kayembe ntumba,5 james kigera,6 laurie laybourn-langton,7 robert mash,8 joy muhia,9 fhumulani mavis mulaudzi,10 david ofori-adjei,11 friday okonofua,12 arash rashidian,13 maha el-adawy,14 siaka sidibé,15 abdelmadjid snouber,16 james tumwine,17 mohammad sahar yassien,18 paul yonga,19 lilia zakhama,20 chris zielinski21 1editor-in-chief, east african medical journal 2editor-in-chief, west african journal of medicine 3editor-in-chief, sierra leone journal of biomedical research 4editor-in-chief, ethiopian journal of health sciences 5chief editor, annales africaines de medecine 6editor-in-chief, annals of african surgery 7university of exeter 8editor-in-chief, african journal of primary health care & family medicine 9london school of medicine and tropical hygiene 10editor-in-chief, curationis 11editor-in-chief, ghana medical journal 12editor-in-chief, african journal of reproductive health 13executive editor, and 14director of health promotion, eastern mediterranean health journal 15director of publication, mali médical 16managing editor, journal de la faculté de médecine d’oran 17editor-in-chief, african health sciences 18editor-in-chief, evidence-based nursing research 19managing editor, east african medical journal 20editor-in-chief, la tunisie médicale 21university of winchester cop27 climate change conference: urgent action needed for africa and the world creative commons (cc-by 4.0) attribution 4.0 international philipp j otolaryngol head neck surg 2022; 37 (2): 4-5 guest editorial philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery cumulative emissions, which are driving the climate crisis and its increasingly severe effects. north america and europe have contributed 62% of carbon dioxide emissions since the industrial revolution, whereas africa has contributed only 3%.14 the fight against the climate crisis needs all hands on deck yet it is not just for moral reasons that all nations should be concerned for africa. the acute and chronic impacts of the climate crisis create problems like poverty, infectious disease, forced migration, and conflict that spread through globalised systems.6,15 these knock-on impacts affect all nations. covid-19 served as a wake-up call to these global dynamics and it is no coincidence that health professionals have been active in identifying and responding to the consequences of growing systemic risks to health. but the lessons of the covid-19 pandemic should not be limited to pandemic risk.16,17 instead, it is imperative that the suffering of frontline nations, including those in africa, be the core consideration at cop27: in an interconnected world, leaving countries to the mercy of environmental shocks creates instability that has severe consequences for all nations.  the primary focus of climate summits remains to rapidly reduce emissions so that global temperature rises are kept to below 1.5 °c. this will limit the harm. but, for africa and other vulnerable regions, this harm is already severe. achieving the promised target of providing $100bn of climate finance a year is now globally critical if we are to forestall the systemic risks of leaving societies in crisis. this can be done by ensuring these resources focus on increasing resilience to the existing and inevitable future impacts of the climate crisis, as well as on supporting vulnerable nations to reduce their greenhouse gas emissions: a parity of esteem between adaptation and mitigation. these resources should come through grants not loans, and be urgently scaled up before the current review period of 2025. they must put health system resilience at the forefront, as the compounding crises caused by the climate crisis often manifest in acute health problems. financing adaptation will be more cost-effective than relying on disaster relief. some progress has been made on adaptation in africa and around the world, including early warning systems and infrastructure to defend against extremes. but frontline nations are not compensated for impacts from a crisis they did not cause. this is not only unfair, but also drives the spiral of global destabilisation, as nations pour money into responding to disasters, but can no longer afford to pay for greater resilience or to reduce the root problem through emissions reductions. a financing facility for loss and damage must now be introduced, providing additional resources beyond those given for mitigation and adaptation. this must go beyond the failures of cop26 where the suggestion of such a facility was downgraded to “a dialogue”.18  the climate crisis is a product of global inaction, and comes at great cost not only to disproportionately impacted african countries, but to the whole world. africa is united with other frontline regions in urging wealthy nations to finally step up, if for no other reason than that the crises in africa will sooner rather than later spread and engulf all corners of the globe, by which time it may be too late to effectively respond. if so far they have failed to be persuaded by moral arguments, then hopefully their self-interest will now prevail. references 1. ipcc. climate change 2022: impacts, adaptation and vulnerability. working group ii contribution to the ipcc sixth assessment report; 2022. available from: https://www.ipcc.ch/ report/sixth-assessment-report-working-group-ii/ 2. un. the paris agreement: united nations; 2022 [cited 2022 sep 12] available from: https:// www.un.org/en/climatechange/paris-agreement. 3. climate change and health in sub-saharan africa: the case of uganda. climate investment funds; 2020. available from: https://www.climateinvestmentfunds.org/sites/cif_enc/files/ knowledge-documents/final_chasa_report_19may2020.pdf 4. who. strengthening health resilience to climate change 2016. available from: https://www. afro.who.int/publications/strengthening-health-resilience-climate-change 5. trisos ch, adelekan io, totin e, ayanlade a, efitre j, gemeda a, et al. africa. in: climate change 2022: impacts, adaptation, and vulnerability. 2022 [cited 2022 sep 26] available from: https:// www.ipcc.ch/report/ar6/wg2/. 6. climate change adaptation and economic transformation in sub-saharan africa. world bank; 2021. available from: https://openknowledge.worldbank.org/bitstream/ handle/10986/36332/9781464818059.pdf 7. opoku sk, leal filho w, hubert f, adejumo o. climate change and health preparedness in africa: analysing trends in six african countries. int j environ res public health. 2021;18(9):4672. doi: 10.3390/ijerph18094672 pubmed pmid: 33925753 pubmed central pmcid: pmc8124714 8. evans m, munslow b. climate change, health, and conflict in africa’s arc of instability. perspect public health. 2021;141(6):338-41.  doi: 10.1177/17579139211058299 pubmed pmid: 34787038 pubmed central pmcid: pmc8649415 9. anugwom ee. reflections on climate change and public health in africa in an era of global pandemic. in: stawicki sp, papadimos tj, galwankar sc, miller ac, firstenberg ms (editors). contemporary developments and perspectives in international health security. 2: intechopen; 2021. doi: 10.5772/intechopen.97201 available from: https://www.intechopen.com/ chapters/76312 10. climate change and health in africa: issues and options: african climate policy centre 2013 [cited 2022 sep 12] available from: https://archive.uneca.org/sites/default/files/ publicationfiles/policy_brief_12_climate_change_and_health_in_africa_issues_and_options. pdf. 11. climate change is an increasing threat to africa2020. [cited 2022 sep 12] available from: https:// unfccc.int/news/climate-change-is-an-increasing-threat-to-africa. 12. atwoli l, muhia j, merali z. mental health and climate change in africa. bjpsych international. 2022:1-4 [cited 2022 sep 26] available from: https://www.cambridge.org/core/journals/ bjpsych-international/article/mental-health-and-climate-change-in-africa/65a414598ba1d62 0f4208a9177eed94b . 13. climate vulnerable economies loss report. switzerland: vulnerable twenty group; 2020. available from: https://www.v-20.org/resources/publications/climate-vulnerable-economiesloss-report 14. ritchie h. who has contributed most to global co2 emissions? our world in data. [cited 2022 sep 12] available from: https://ourworldindata.org/contributed-most-global-co2. 15. bilotta n, botti f. paving the way for greener central banks. current trends and future developments around the globe. rome: edizioni nuova cultura for istituto affari internazionali (iai); 2022. available from: https://www.iai.it/sites/default/files/iairs_8.pdf 16. who. cop26 special report on climate change and health: the health argument for climate action. .geneva: world health organization; 2021. available from: https://www.who.int/ publications/i/item/9789240036727 17. al-mandhari a; al-yousfi a; malkawi m; el-adawy m. “our planet, our health”: saving lives, promoting health and attaining well-being by protecting the planet – the eastern mediterranean perspectives. east mediterr health j. 2022;28(4):247−248. [cited 2022 sep 26] available from: https://doi.org/10.26719/2022.28.4.247  doi: 10.26719/2022.28.4.247 pubmed pmid: 35545904 18. evans s, gabbatiss j, mcsweeney r, chandrasekhar a, tandon a, viglione g, et al. cop26: key outcomes agreed at the un climate talks in glasgow. carbon brief [internet]. 2021.[cited 2022 sep 12] available from: https://www.carbonbrief.org/cop26-key-outcomes-agreed-at-the-unclimate-talks-in-glasgow/. guest editorial philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 case reports philippine journal of otolaryngology-head and neck surgery 47 philipp j otolaryngol head neck surg 2017; 32 (2): 47-50 c philippine society of otolaryngology – head and neck surgery, inc. late-onset anterolateral thigh free flap failure in buccal carcinoma reconstruction daniel jose c. mendoza, md cristina s. nieves, md samantha s. castañeda, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. cristina s. nieves department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 743 6921; (632) 711 9491 local 320 email: chienieves_md@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. abstract objective: to report a case of late-onset anterolateral thigh free flap failure in reconstruction of a defect from excision of buccal carcinoma. methods: design: case report setting: tertiary government training hospital patient: one results: a 57-year-old man with well-differentiated buccal squamous cell carcinoma underwent wide excision with segmental mandibulectomy, bilateral neck dissection and anterolateral thigh free flap reconstruction. complete failure of the anterolateral thigh free flap was documented on the 29th post-operative day. conclusion: late-onset flap failure is mainly non-vascular in etiology. however, flap failure is more likely multifactorial. frequent follow-up after hospital discharge is recommended to monitor flap viability. keywords: free flap, anterolateral thigh flap, flap failure, microvascular surgery, head and neck reconstruction free tissue transfer has become the gold standard in reconstruction of many head and neck defects.1 success rates are more than 90%.2-3 however, failures and complications still occur. lateonset flap failure is defined as failure occurring 7 days post-operatively or on follow-up visits after hospital discharge.4 we present a case of a 57-year-old man with a complete, late-onset anterolateral thigh (alt) free flap failure in reconstructing the defect from excision of a buccal carcinoma. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 figure 1. squamous cell carcinoma of left buccal mucosa with extension to the lower alveolar ridge, hard and soft palate, and retromolar trigone figure 2. a. actual defect after excision of mass; and b. mandibular reconstruction using titanium plates and screws; a. body of mandible; b. hard palate; and c. tongue a b 48 philippine journal of otolaryngology-head and neck surgery case reports case report a 57-year-old man was seen at the outpatient department with an enlarging left buccal mass for six months which started as ulcers, now accompanied by pain and occasional bleeding. (figure 1) he did not complain of dysphagia, dyspnea, trismus or weight loss. he was a 37pack-year smoker and consumed 1 bottle of beer 3-4 times per week. he did not have hypertension, diabetes mellitus or radiation exposure and denied any heredofamilial diseases such as cancer. physical examination showed an ulcerated mass over the buccal mucosa extending to adjacent structures such as the left soft palate, retromolar trigone and mandibular alveolar ridge. a 1 x 1cm level 1b lymph node was palpable on the left. contrast computerized tomography scan of the oral cavity showed the buccal mass encasing the ramus of the left mandible with osteolytic changes and necrotic changes in the left masticator space. biopsy revealed well-differentiated squamous cell carcinoma. chest radiograph and liver ultrasonogram were unremarkable. he was staged t4an1m0, stage iva based on the american joint committee on cancer (ajcc) staging, 7th edition for oral cavity cancer. he underwent tracheostomy, modified radical neck dissection on the left, selective neck dissection (levels i-iii) on the right, wide excision with segmental mandibulectomy from left body to left ascending ramus via lip-split approach, and reconstruction using alt flap under general anesthesia. (figures 2 and 3) the left alt fasciocutaneous flap measuring 18 x 6 cm was harvested by elevating the medial portion down to the subfascial layer by cutting the tensor fascia above the rectus femoris muscle. two musculocutaneous perforators passing through the vastus lateralis and emerging from the pedicle, the descending branch of the lateral circumflex femoral artery (lcfa) and 2 venae comitantes, were identified and dissected. the lateral portion of the flap was cut to complete dissection of the flap. recipient vessels in the neck were first identified before dividing the pedicle and harvesting the alt flap. partial flap inset with horizontal mattress suturing using absorbable polygalactin suture was done. using an operating microscope, microvascular anastomosis was done to reestablish perfusion of the flap using nylon 9-0 sutures. the descending branch of the lcfa was anastomosed to the left facial artery and the venae comitantes were anastomosed to tributaries of the left external jugular vein. after anastomosis, there was immediate perfusion of the flap evidenced by presence of bright-red bleeding of the flap edges. complete flap inset, lip and neck closure and primary closure of the donor site were done. blood loss was 1500 ml and 2 units of fresh whole blood were transfused. surgery lasted 17.25 hours. flap monitoring using visual inspection and pin prick was done hourly for the first 48 hours, every 4 hours from the 3rd to 5th postoperative days, and once daily thereafter while admitted. there were no post-operative complications and he was decannulated after 1 week. he was discharged after 10-hospital days without flap dehiscence or discoloration such as bluish or pale flap color. follow-up was on a weekly basis. on the 17th post-operative day, minimal salivary discharge was noticed from the neck incision site. conservative management with acetic acid gargle thrice a day was started. partial dehiscence of the flap was noted on the 24th postoperative day and removal of necrotic tissue and resuturing were done. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 figure 4. complete flap necrosis on 29th post-operative day. a. alt flap, b. hard and soft palate, c. buccal mucosa, and d. tongue. philippine journal of otolaryngology-head and neck surgery 49 case reports complete flap failure was seen on the 29th post-operative day and removal was done under local anesthesia. (figure 4) granulation and mucosa formation was seen on the bed of the recipient site without plate exposure. the neck fistula spontaneously closed and no additional surgery was done. adjuvant chemotherapy and radiation were advised but he was not able to comply. recurrence in the buccal area was seen a year after surgery. discussion the alt flap is an extremely versatile flap for head and neck reconstruction providing excellent tissue quality and quantity as well as low donor site morbidity.5 the large tissue defect created after removal of buccal carcinoma in our patient was the main reason for choosing an alt flap over other available free flaps. vascular occlusion remains the primary reason for flap loss with venous thrombosis being more common than arterial occlusion and majority of flap failures occur within the first 48 hours.1 rarely do flaps fail in the late post-operative period. it is not well understood why free flaps can fail after 7 post-operative days.4 wax and rosenthal reported median time of necrosis at 21 (range 7-90) days.4 however, none of the 13 patients reported had an alt free flap. flap necrosis in our patient was within range but was longer compared to the median time on the 29th post-operative day. late flap failures were most often due to infection or mechanical stress around anastomosis rather than technical or vascular etiology.1,4,6 in head and neck reconstruction, wound infection is usually caused by fistula formation or wound dehiscence 4 or 5 days after surgery.6 kubo et al. found that disruption of anastomosed vessels can occur with high frequency after infection ranging from 3-14 days post-operatively and salivary fistula formation is one of the causes of infection reported.7 small intraoral dehiscence exposes the vascular pedicle of the flap and can cause saliva to leak into the neck where the anastomosis site is located. saliva carries potential pathogens which may not be part of the normal oral flora.7 wound infection causes edema and necrosis promoting thrombus formation.6 it is one of the possible causes of flap failure in our patient. however, huang et al. showed that postoperative salivary fistulas do not appear to be strongly associated with flap failure in head and neck reconstruction.8 the condition and quality of the recipient site also play a large role in flap survival. young demonstrated that neovascularization develops within 7 to 10 days.9 however, the flap edges lose contact with skin edges and base of recipient site once fistula or wound dehiscence occurs, delaying revascularization.6 thus, wound infection due to salivary fistula may damage anastomosed vessels and delay revascularization leading to flap failure.6-7 blood loss and transfusion may indirectly contribute to flap failure of our patient. although flap survival was not significantly different comparing patients who were transfused and not transfused with blood, wound dehiscence was significantly increased in patients with transfusion. fistula formation and wound infection tended to be higher in transfused patients.10 the blood loss of our patient was 1500ml, which was 3 times more than their findings(499.41+/-163.64),10 requiring blood transfusion. animal studies indicate that transfusion figure 4. complete flap necrosis on 29th post-operative day. a. alt flap, b. hard and soft palate, c. buccal mucosa, and d. tongue. figure 3. a. left alt flap design measuring 18 x 6 cm; and b. flap inset a b philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 case reports 50 philippine journal of otolaryngology-head and neck surgery references 1. novakovic d, patel rs, goldstein dp, gullane pj. salvage of failed free flaps used in head and neck reconstruction. head neck oncol. 2009 aug 21; 1:33. doi: 10.1186/1758-3284-1-33; pmid: 19698095 pmcid: pmc2749848. 2. klosterman t, siu e, tatum s. free flap reconstruction experience and outcomes at a lowvolume institution over 20 years. otolaryngol head neck surg. 2015 may;152(5):832-7. doi: 10.1177/0194599815573726; pmid: 25953911. 3. disa jj, hu qy, hidalgo da. retrospective review of 400 consecutive free flap reconstructions for oncologic surgical defects. ann surg oncol. 1997 dec;4(8):663-9. pmid: 9416415. 4. wax mk, rosenthal e. etiology of late free flap failures occurring after hospital discharge. laryngoscope. 2007 nov;117(11):1961-3. doi:10.1097/mlg.0b013e31812e017a; pmid: 17828052. 5. park cw, miles ba. the expanding role of the anterolateral thigh free flap in head and neck reconstruction. curr opin head neck surg. 2011 aug.;19(4):263-8. doi: 10.1097/ moo.0b013e328347f845; pmid: 21900855. 6. kadota h, sakuraba m, kimata y, yano t, hayashi r. analysis of thrombosis on postoperative day 5 or later after microvascular reconstruction for head and neck cancers. head neck. 2009 may;31(5):635-41. doi:10.1002/hed.21021; pmid: 19260134. 7. kubo t, matsuda k, kiya k, hosokawa k. behavior of anastomozed vessels and transferred flaps after anastomosed site infection in head and neck microsurgical reconstruction. microsurgery. 2016 nov; 36(8): 658-663. doi:10.1002/micr.30025; pmid: 26790991. 8. huang ry, sercarz ja, smith j, blackwell ke. effect of salivary fistulas on free flap failure: a laboratory and clinical investigation. laryngoscope. 2005 mar;115(3):517-21. doi: 10.1097/01. mlg.0000157827.92884.c5; pmid: 15744169. 9. young cm. the revascularization of pedicle skin flaps in pigs: a functional and morphologic study. plast reconstr surg. 1982 oct;70(4):455-64. pmid: 6287512. 10. puram sv, yarlagadda bb, sethi r, muralidhar v, chambers kj, emerick ks, et al. transfusion in head and neck free flap patients: practice patterns and a comparative analysis by flap type. otolaryngol head neck surg. 2015 mar;152(3):449-57. doi:10.1177/0194599814567107; pmid: 25628368. 11. okano t, ohwada s, sato y, sato m, toyama y, nakanose y, et al. blood transfusions impair anastomotic wound healing, reduce luminol-dependent chemiluminescence, and increase interleukin-8. hepatogastroenterology. 2001 nov-dec;48(42):1669-74. pmid: 11813598. triggers release of inflammatory cytokines such as interleukin-8 which impair wound healing. 11 this may have affected normal wound healing of our patient causing fistula formation and poor revascularization of the alt flap. our patient presented with late-onset alt fasciocutaneous free flap failure on the 29th post-operative day. wound dehiscence causing salivary fistula may be the cause of flap failure. it may have damaged the anastomosed vessels and delayed revascularization of the flap. blood loss and transfusion may also have contributed to poor wound healing. possibly, free flap failure in this case was multifactorial and not due to a single cause. in conclusion, late-onset flap failures are mostly non-vascular in origin. the presence of a salivary fistula should alert surgeons to the possibility of flap failure. extensive pre-operative planning, meticulous intraoperative dissection and hemostasis, and timely intervention are necessary to prevent and minimize free flap loss. it is also important to reiterate the importance of frequent follow-up to monitor flap viability and status even after hospital discharge, among patients who undergo free flap reconstruction. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 passages joselito b. buluran, md (1962-2021) rene c. lacanilao, md interns. one day i saw him in the ent chair at the opd and asked him what he was doing. he answered that he was testing the interns if they know how to actually remove cerumen and he was in the chair because he was the patient. it was also when he was intern’s monitor that he met the love of his life. suddenly, his world changed. from a happy-go-lucky guy with a ready smile he suddenly became serious. so serious in fact that he approached me one night and confronted me if i was showing interest in the same person he was interested in. i’m kind of smiling because i still remember that night. that was totally not in character for jb. i assured him that he had nothing to fear because i had no interest, and the girl was his. he courted her and in the end they got married. we parted ways when we graduated, and we barely saw each other even during conventions. he moved back to norzagaray where he established his practice. i always thought he would be using his mle but he never did. once when we were somewhere in bulacan near norzagaray, my wife needed a phone and i thought since we were in buluran territory why not try to find him. he was easy to find because the people we asked pointed us to where he lived. and so it is with sadness that i heard of his passing. maybe it’s ironic that he had a very fine heart but in the end it was his heart that did him in. if you took your temporal bone course at the eamc, then jb has touched your lives. he was the one who made those dissection bowls you used. the first time i saw doctor joselito buluran or jb as he was fondly called, was when we were oriented before we began our preresidency. he was shy and most of the time quiet when in the presence of people he was not familiar with. he always had a ready smile and laughed just as easily. sometimes you felt he was the kid in school who was bullied and made fun of. he was easy to get along with and probably had no enemies. he was very unassuming. unknown to most of us he was in fact chinese by blood who grew up locally; he was the youngest in the family (born when his mother was in her 60’s). it was sometimes funny that given that fact and the way he looked, one may think he could be retarded. now that was funny because he was in fact quite intelligent. now imagine that and combine that with his study habits you had a powerhouse of a resident who would be prepared for the weekly grand rounds or the subspecialty hour. the night before the grand rounds you would see him pouring over cummings and you would still see him reading when you woke up the next day. he was always studying. it was therefore no surprise that he readily passed the usmle when he took it in our 2nd year of residency. jb was not athletic. but that did not stop him from participating in the pso-hns sportsfests. and even if he did not know how to play and looked like a duck out of water, he gamely joined the tennis tournament between residents thought up by another co-resident. he was easy to get along with and seemed like he never got angry. in fact, of all the residents, he may have been the subject and target of more jokes and practical jokes than anyone else. he made sure he did what was assigned to him. as an intern’s monitor, a position he reveled in, he was constantly teaching the philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2018; 33 (1): 39-42 c philippine society of otolaryngology – head and neck surgery, inc. extranasopharyngeal angiofibroma: a diagnostic dilemma nitin gupta, ms arjun dass, ms vaibhav saini, ms shashikant anil pol, ms lovekesh mittal, mbbs department of ear nose throat govt medical college and hospital sector-32 chandigarh, india correspondence: dr. nitin gupta associate professor department of e.n.t. govt medical college and hospital sector-32 chandigarh 160030 india phone: +91 9646121704 email: nitinent123@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. abstract objective: to report two cases of extranasopharyngeal angiofibroma, highlighting the diagnostic challenges involved. methods: design: case report setting: tertiary teaching hospital and medical school patients: two results: a 13-year-old boy who presented with epistaxis and a vascular mass on the posterior nasal septum that enhanced on contrast-enhanced computed tomography (cect), and a 3-year-old boy who presented with dysphagia and mild respiratory difficulty, with a large nasooropharyngeal mass arising from the soft palate on physical and x-ray examination that could not be corroborated because stridor developed during sedation for cect, both underwent endoscopic tumor excision. conclusion: as illustrated in these cases, atypical presentations of extranasopharyngeal angiofibromas can pose a considerable diagnostic and surgical challenge for clinicians. keywords: angiofibroma: classification; diagnosis; diagnostic imaging; extranasopharyngeal angiofibromas are vascular tumors that are frequently observed in adolescent males and are the most common benign tumors of the nasopharynx.1 extranasopharyngeal angiofibromas are very rare tumors2 that can present in either sex, different age groups and varying locations compared to classical angiofibromas.3,4 it has been suggested that extranasopharyngeal angiofibroma be considered as a separate entity2 or that tumors with different characteristics from those of classical angiofibroma be referred to as ‘atypical angiofibroma’.5 further to a previous report of two cases,6 we present two more such cases. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery case reports case reports case 1 a 13-year-old boy presented in hospital with the chief complaint of acute-onset, profuse, intermittent, spontaneously resolving bleeding from the right nasal cavity for the past 3 days. there was no history of trauma, fall or deranged coagulopathy. he had a total of 3 episodes of such bleeding before consult. he had pallor on general physical examination. anterior rhinoscopy revealed blood clots in the anterior right nasal cavity with a polypoidal mass in the posterior part. blood stains were also visualized over the posterior pharyngeal wall. he was admitted for diagnostic nasal endoscopy under general anaesthesia. routine investigations prior to procedure revealed low hemoglobin of 7.6 gm % for which 3 units of cross-matched packed red blood cells were transfused. plain computed tomography showed a mass in nasopharynx with a normal sphenopalatine area while contrast computed tomography revealed an enhancing lesion in the posterior part of the septum. (figure 1) with a differential diagnosis of bleeding polyps of the septum and extranasopharyngeal juvenile angiofibroma, endoscopic excision was planned. intraoperative findings revealed a 1.5 × 1 cm polypoidal mass which was attached to posterior part of the right septum. (figure 2) the mass was completely excised and the site of origin cauterized. histopathological examination revealed a tumor composed of abundant thin-walled variably sized blood vessels lined by a single figure 1. plain ct showed a normal sphenopalatine area while contrast ct revealed an enhancing lesion in the posterior septum on the right. layer of endothelium. (figure 3) he was discharged on the third postoperative day and has remained disease-free on regular follow-up for 6 months. case 2 a 3-year-old boy presented in hospital with the chief complaint of acute-onset difficulty swallowing both solids and liquids that persisted for the last 15 days with no aggravating or relieving factors. there was also mouth-breathing and intermittent noisy breathing. examination of the oral cavity revealed a single, smooth, pinkish, non-pulsatile, ovoid-polypoidal mass of approximately 4 ×3 cm which seemed to arise from the nasopharynx. a soft tissue neck lateral x-ray of the neck was suggestive of an homogenous mass arising from the nasopharynx reaching up to the oropharynx. (figure 4) as he was being sedated for contrast enhanced computed tomography, he started having difficulty in breathing and was intubated. he was transferred to the operating theatre under bag and mask ventilation for emergent surgery. intraoperative findings were suggestive of a nasopharyngeal mass pushing the uvula into the oropharynx. (figure 5) the mass actually arose from the posterior part of the soft palate and uvula. it was completely excised and delivered perorally. histopathological examination revealed blood vessels lined by a single layer of endothelial cells. no stromal atypia was seen. (figure 6) he was discharged on the fifth post-operative day. philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery case reports discussion angiofibroma is the most common tumor in the nasopharynx, making up 0.5% of all head and neck tumors and is typically found in young males in the first two decades.1,7 more recently, the term extranasopharyngeal angiofibroma has been applied to vascular, fibrous nodules occurring outside the nasopharynx that do not arise from the vicinity of the sphenopalatine foramen or pterygoid plates.2,5 compared to those with nasopharyngeal angiofibromas, patients with extra-nasopharyngeal angiofibroma differ in presentation. these patients are older, both sexes can be affected, symptoms develop more quickly and hypervascularity is less common.4 angiofibromas presenting with at least one of the following criteria such as origin or location other than nasopharynx, presenting complaints other than nasal obstruction or epistaxis, age younger than seven or older than 25, female sex, atypical histopathology and multifocality were considered figure 5. intraoperative photo showing the mass pushing the uvula and extending to the oropharynx. figure 6. histopathological examination (hematoxylin – eosin, 400 x), revealed blood vessels lined by single layer of endothelial cells with no stromal atypia. (hematoxylin – eosin, 400x) figure 3. histopathological examination (hematoxylin – eosin, 400 x), revealed tumor composed of abundant thin-walled variably sized blood vessels lined by a single layer of endothelium. (hematoxylin – eosin , 400x) figure 4. soft tissue lateral neck x-ray suggestive of an homogenous mass arising from the nasopharynx reaching down to the oropharynx. figure 2. intraoperative findings of a 1.5 × 1 cm polypoidal mass attached to the posterior right side of the septum. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery case reports references 1. windfuhr jp, remmert s. extranasoparyngeal angiofibroma: etiology, incidence and management. acta otolaryngol 2004 oct; 124(8): 880-9. doi: 10.1080/00016480310015948; pmid: 15513521. 2. de vincentiis g, pinelli v. rhinopharyngeal angiofibroma in the pediatric age group. clinical –statistical contribution. int j pediatr ororhinolaryngol. 1980 jun; 2(2):99-122. pmid: 6323331. 3. akbas y, anadolu y. extranasopharyngeal angiofibroma of the head and neck in women. am j otolaryngol. 2003 nov-dec; 24(6):413-4. pmid: 14608576. 4. peloquin l, klossec jm, basso-brusa f, gougeon jm, toffel ph, fontanel jp. a rare case of nasopharyngeal angiofibroma in a pregnant woman. otolaryngol head neck surg, 1997 dec;117(6), pp. s111-4. doi: 10.1016/s0194-59989770074-3 pmid: 9419120. 5. celik b, erisen l, saraydaroglu o, coskun h. atypical angiofibroma: a report of four cases. int j pediat otorhinolaryngol 2005 mar; 69(3): 415-421. doi: 10.1016/j.ijporl.2004.10.007; pmid: 15733604. 6. singhal sk, gupta n, verma h, dass a, kaur a. extranasopharyngeal angiofibroma: report of two cases. egyptian journal of ear, nose, throat and allied sciences. 2014 mar; 15(1):73-76.https:// doi.org/10.1016/j.ejenta.2013.12.002. 7. nomura k, shimomura a, awataguchi t, murakami k, kobayashi t. a case of angiofibroma originating from the inferior nasal turbinate. auris nasus larynx 2006 jun; 33(2):191-3. doi: 10.1016/j.anl.2005.09.004; pmid: 16310998. 8. trinidad caj, david mjc, chua ah. extranasopharyngeal angiofibroma of the larynx. philipp j otolaryngol head neck surg. 2010 jan-jun; 25(1): 23-25. 9. mehmet a, orhan s, supni m. juvenile nasopharyngeal agiofibroma : radiological evaluation & preoperative embolization. kbb forum. 2006; 5(1): 58-61. 10. suhick b, kahle g. radiological findings in angiofibroma. acta radiol. 2000 nov; 41(6):585-93. pmid: 11092480. 11. maroldi r, berlucchi m, farina d, tomenzoli d, borghesi a, pianta l. benign neoplasm and tumor-like lesions. in: maroldi r, nicolai p (editors). imaging in treatment planning for sinonasal diseases. 2005. berlin, heidelberg, new york: springer verlag. p. 107-58. 12. alvi a, myssiorek d, fuchs a. extranasopharyngeal angiofibroma. j otolaryngol. 1996 oct; 25(5):346-8. pmid: 8902697. 13. harrison df. the natural history, pathogenesis, and treatment of juvenile angiofibroma. personal experience with 44 patients. arch otolaryngol head neck surg. 1987 sep; 113 (9):93642. pmid: 3038146. 14. hazarika p, nayak dr, balakrishnan r, raj g, pillai s. endoscopic and ktp laser-assisted surgery for juvenile nasopharyngeal angiofibroma. am j otololaryngol. 2002 sep-oct; 23(5): 282-286. pmid: 12239693. as ‘atypical’.5 the mean age of presentation of the tumor in extranasopharyngeal sites is 22 years and the male to female ratio is roughly 3:1.1,6 in contrast, nasopharyngeal angiofibroma presents almost exclusively in adolescent males with a mean age range between 14 and 17 years and female presentation is very rare.4 it is unclear why this discrepancy in the age of presentation and sex predilection exists between the two different types of angiofibromas. unlike previous reports,5 our patients were 13 and 3 years old. our 2 previously reported cases had patients who were 28 and 12 years old, respectively.6 extra-nasopharyngeal angiofibromas most commonly take their origin from maxillary sinus.7 other primary extra-nasopharyngeal sites reported are ethmoid and sphenoid sinuses, nasal septum, frontal recess, middle and inferior turbinates, tonsil, parapharyngeal space, ear, trachea, larynx, middle cranial fossa, infratemporal fossa, tonsil, retromolar region and conjunctiva.8 trinidad et al. have reported a case of extranasal angiofibroma arising from the vocal cord.8 in our cases the mass was seen arising from the posterior septum and oropharynx, respectively. to the best of our knowledge, based on a search of the english literature in medline(pubmed), embase, scopus and google scholar using the keywords “angiofibroma,” “extranasopharyngeal angiofibroma,” “juvenile angiofibroma,” “atypical angiofibroma,” we could not find no other reports of an angiofibroma arising from the soft palate and uvula. contrast enhanced ct scan (cect) and magnetic resonance imaging (mri) are the key investigations to determine tumor site and extension, with special attention being focused on skull base involvement, intracranial spread and relationship to important vascular and neurologic structures.9 while bone erosion can be more easily revealed by ct scan, mri is adequate in demonstrating cortical erosion and cancellous replacement by tumour.9,10 t1-weighted mri show a typical “salt and pepper” appearance caused by the increased vascularity of the tumour.10,11 alvi et al. considered ct scan to be sufficient for the diagnosis of extranasopharyngeal angiofibroma, as it clearly delineates and identifies the tumour.12 extreme caution should be exercised while performing ct scan in patients with an already compromised airway. this caution is even more imperative in paediatric patients as sedating the child can further precipitate respiratory embarrassment in narrow airways of children, as was seen in our case. an intubation and resuscitation trolley should always kept on standby in such cases. surgical excision of the mass is the treatment of choice and recurrence rate is generally low. both of our cases were operated endoscopically. the decision to perform jna resection endoscopically should be based on the experience and skill of the surgeon as well as the extent of the tumour (i.e. the lateral extent of the tumour must be accessible endoscopically).13 tumours extending to the lateral wall of frontal sinuses, intracranially or reaching up to skin are not suitable candidates for endoscopic excision.5,14 the surgeon must also be willing and capable to convert to an open approach if necessary.14 it has been suggested that tumours involving the ethmoid, maxillary, or sphenoid sinus, the sphenopalatine foramen, nasopharynx, or pterygomaxillary fossa and having limited extension into the infratemporal fossa are amenable to endoscopic resection.14 complete excision is therefore undertaken for both therapeutic and diagnostic purposes.14 in closing, our review of the literature and experience with previously reported cases, teach us that although extranasopharyngeal angiofibroma is a rare entity, it should be kept in mind as a differential diagnosis of a nasal mass irrespective of the status of the vascularity, age or sex of the patient until histopathologically proven. extranasopharyngeal sites should be regarded as potential, though exceptional, places of origin for these neoplasms. as illustrated in these cases, atypical presentations of extranasopharyngeal angiofibromas can pose a considerable diagnostic and surgical challenge for clinicians. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial on january 20, 2023, the world association of medical editors published a policy statement on chatbots, chatgpt, and scholarly manuscripts: wame recommendations on chatgpt and chatbots in relation to scholarly publications.1 there were four recommendations, namely: 1. chatbots cannot be authors; 2. authors should be transparent when chatbots are used and provide information about how they were used; 3. authors are responsible for the work performed by a chatbot in their paper (including the accuracy of what is presented, and the absence of plagiarism) and for appropriate attribution of all sources (including for material produced by the chatbot); and 4. editors need appropriate tools to help them detect content generated or altered by ai and these tools must be available regardless of their ability to pay.1 this statement was spurred in part by some journals beginning to publish papers in which chatbots such as chatgpt were listed as co-authors.2 first, only humans can be authors. chatbots cannot be authors because they cannot meet authorship requirements “as they cannot understand the role of authors or take responsibility for the paper.”1 in particular, they cannot meet the third and fourth icmje criteria for authorship, namely “final approval of the version to be published” and “agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.”1,3 moreover, “a chatbot cannot understand a conflict of interest statement, or have the legal standing to sign (such a) statement,” nor can they “hold copyright.”1 because authors submitting a manuscript must ensure that all those named as authors meet icmje authorship criteria, chatbots clearly should not be included as authors.1 correspondence: prof. dr. josé florencio f. lapeña, jr. department of otolaryngology head and neck surgery ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 telefax: (632) 8524 4455 email: lapenajf@upm.edu.ph jflapena@up.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr., ma, md department of otolaryngology head and neck surgery college of medicine, university of the philippines manila department of otorhinolaryngology head and neck surgery east avenue medical center, diliman, quezon city the updated world association of medical editors (wame) recommendations on chatbots and generative ai in relation to scholarly publications and international committee of medical journal editors (icmje) recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals (may 2023) c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philipp j otolaryngol head neck surg 2023; 38 (1): 4-6 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial second, authors should acknowledge the sources of their materials. when chatbots are used, authors “should declare this fact and provide full technical specifications of the chatbot used (name, version, model, source) and method of application in the paper they are submitting (query structure, syntax),” “consistent with the icmje recommendation of acknowledging writing assistance.”1,4 third, authors must take public responsibility for their work; “human authors of articles written with the help of a chatbot are responsible for the contributions made by chatbots, including their accuracy,” and “must be able to assert that there is no plagiarism in their paper, including in text produced by the chatbot.”1 consequently, authors must “ensure … appropriate attribution of all quoted material, including full citations,” “seek and cite the sources that support,” as well as oppose (since chatbots can be designed to omit counterviews), the chatbot’s statements.1 fourth, to facilitate all this, medical journal editors (who “use manuscript evaluation approaches from the 20th century”) “need appropriate (digital) tools … that will help them evaluate … 21st century … content (generated or altered by ai) efficiently and accurately.”1 the “proliferation of chatbots and their expanding use in scholarly publishing over the last few months, as well as emerging concerns regarding lack of authenticity of content when using chatbots” prompted the issuance in may 2023 of a revised policy statement: chatbots, generative ai, and scholarly manuscripts: wame recommendations on chatbots and generative artificial intelligence in relation to scholarly publications.5 a new recommendation has been added to the four original principal recommendations: editors and reviewers should specify, to authors and each other, any use of chatbots in evaluation of the manuscript and generation of reviews and correspondence. if they use chatbots in their communications with authors and each other, they should explain how they were used.5 journal “editors and reviewers are responsible for any content and citations generated by a chatbot, and should be aware that chatbots retain the prompts fed to them, including manuscript content, and supplying an author’s manuscript to a chatbot breaches confidentiality of the submitted manuscript.”5 in addition, the second recommendation (authors should be transparent when chatbots are used and provide information about how they were used) has been expanded, with two sub-headings: 2.1. authors submitting a paper in which a chatbot/ai was used to draft new text should note such use in the acknowledgment; all prompts used to generate new text, or to convert text or text prompts into tables or illustrations, should be specified; and 2.2: when an ai tool such as a chatbot is used to carry out or generate analytical work, help report results (e.g., generating tables or figures), or write computer codes, this should be stated in the body of the paper, in both the abstract and the methods section. in the interests of enabling scientific scrutiny, including replication and identifying falsification, the full prompt used to generate the research results, the time and date of query, and the ai tool used and its version, should be provided.5 the revised wame recommendations also reflec t the m ay 2023 updated icmje recommendations that added a new sec tion (ii.a.4) and revised other sec tions (ii.c.3, iii.d.2, iv.a.3.g) to provide guidance on how wor k conduc ted with the assistance of ai technology (including chatgpt ) should and should not be ack nowledged. 6 these updated recommendations have also been incor porated in the revised i nstruc tions to authors (https://pjohns.pso-hns.org/index.php/pjohns/libraryfiles/downloadpublic/121) and author forms (https://pjohns.pso-hns.org/index.php/pjohns/libraryfiles/downloadpublic/123) of the philippine journal of otolaryngology head and neck surgery.6 in particular, the sections on requirements for authorship, acknowledgements, and references reflect the may 2023 icmje recommendations.6,7 insofar as authorship is concerned,   the icmje revised criterion #2 from “drafting the work or revising it critically for important intellectual content” to “drafting the work or reviewing it critically for important intellectual content”.6 the icmje made this change “because some authors may interpret ‘revising’ to indicate the requirement to make changes to earlier versions of the manuscript (in order to qualify for authorship) even if authors agree with the content,” believing that “this new change more accurately captures the original intent of the criterion -which is that all authors must at a minimum review the manuscript critically for important intellectual content and have the opportunity to make changes if warranted.”6 in our context, this particularly calls out (mostly ‘senior’) co-authors who relegate the tasks of drafting and philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery editorial references 1. zielinski c, winker m, aggarwal r, ferris l, heinemann m, lapeña jf, pai s, ing e, citrome l on behalf of the wame board. chatbots, chatgpt, and scholarly manuscripts: wame recommendations on chatgpt and chatbots in relation to scholarly publications. january 20, 2023. world association of medical editors. available from: https://wame.org/page3.php?id=110; republished as: zielinski c, winker m, aggarwal r, ferris l, heinemann m, lapeña, jr jf, pai s, ing e, citrome l. chatbots, chatgpt, and scholarly manuscripts: wame recommendations on chatgpt and chatbots in relation to scholarly publications. open access maced j med sci. 2023 jan. 30;11(a):83-6. available from: https://oamjms.eu/index.php/mjms/article/view/11502. 2. stokel-walker c. chatgpt listed as author on research papers: many scientists disapprove. nature 2023 january 18; 613:620-621. doi: 10.1038/d41586-023-00107-z; pubmed pmid: 36653617. 3. international committee of medical journal editors (icmje). recommendations  for the conduct, reporting, editing, and publication of scholarly work in medical journals. updated may 2022. who is an author? defining the role of authors and contributors. [cited 2023 january 18] available from: https://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html. 4. i n t e r n a t i o n a l c o m m i t t e e o f m e d i c a l j o u r n a l e d i t o r s ( i c m j e ) . r e c o m m e n d a t i o n s  f o r t h e c o n d u c t , r e p o r t i n g , e d i t i n g , a n d p u b l i c a t i o n o f s c h o l a r l y w o r k i n m e d i c a l j o u r n a l s . u p d a t e d m a y 2 0 2 2 . n o n a u t h o r c o n t r i b u t o r s , d e f i n i n g t h e r o l e o f a u t h o r s a n d c o n t r i b u t o r s . [ c i t e d 2 0 2 3 j a n u a r y 1 8 ] av a i l a b l e f r o m : https://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html. 5. zielinski c, winker ma, aggarwal r, ferris le, heinemann m, lapeña jf, pai s, ing e, citrome l, alam m, voight m, habibzadeh f. on behalf of the wame board. chatbots, generative ai, and scholarly manuscripts: wame recommendations on chatbots and generative artificial intelligence in relation to scholarly publications. world association of medical editors. may 31, 2023. available from:  https://wame.org/page3.php?id=106. 6. international committee of medical journal editors (icmje) [homepage on the internet]. recommendations  for the conduct, reporting, editing, and publication of scholarly work in medical journals. updated may 2023. [cited 2023 may 29]. available from: https://www.icmje.org/news-and-editorials/icmje-recommendations_annotated_may23.pdf. 7. philipp j otolaryngol head neck surg. official publication of the philippine society of otolaryngology head and neck surgery. [homepage on the internet; accessed 2023 may 29]. available from: https://pjohns.pso-hns.org/index.php/pjohns. 8. lapeña jf. truth and transparency, compromise and climate change. philipp j otolaryngol head neck surg. 2022 nov. 15;37(2):4-5. doi: 10.32412/pjohns.v37i2.2015. 9. heidari s, babor tf, de castro p, tort s, curno m. sex and gender equity in research: rationale for the sager guidelines and recommended use. res integr peer rev. 2016 may 3;1:2. doi: 10.1186/ s41073-016-0007-6 pubmed pmid: 29451543 pubmed central pmcid: pmc5793986. revising the manuscript to the first (usually ‘junior’) author, failing to even review the manuscript as it undergoes revisions based on editor and reviewer comments, corrections, and recommendations. insofar as the peer review process is concerned, the icmje has replaced the terms “blinded” with “anonymized.”6 this is not new to us, as the philipp j otolaryngol head neck surg already made this transition in 2022.8 in addition, the icmje now encourages authors “to refer to the sager guidelines for reporting of sex and gender information in study design, data analyses, results, and interpretation of findings.9 without officially adapting sager guidelines, the pjohns has long considered sex as pertaining to biological and gender as pertaining to psycho-socio-cultural differences between men, women, boys, girls, and gender-diverse people. the bulk of changes in the new icmje recommendations concern the use of ai technology (including chatgpt). these recommendations have all been incorporated in our journal. requirements for authorship now state: “artificial intelligence (ai)assisted technologies (such as large language models [llms], chatbots or image creators) should not be listed or be cited as authors, because they cannot be responsible for the accuracy, integrity, and originality of the work, and these responsibilities are required for authorship.”7 acknowledgements now include: “authors must disclose whether they used artificial intelligence (ai)-assisted technologies (such as large language models [llms], chatbots or image creators) in the production of submitted work. authors who use such technology should describe, in both the cover letter and the submitted work, how they used it. humans are responsible for any submitted material that included the use of ai-assisted technologies. authors should carefully review and edit the manuscript because ai can generate authoritative-sounding output that can be incorrect, incomplete or biased.”7 references now instruct: “do not cite references listing ai as an author, because ai cannot fulfill authorship criteria. authors should be able to assert that there is no plagiarism in their paper, including in text and images produced by the ai. humans must ensure there is appropriate attribution of all quoted material including full citations.”7 the wame recommendations on chatbots and generative ai (including chatgpt) in relation to scholarly publications will continue to be modified as the software and its applications develop,5 and we can expect the icmje recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals6 to be continuously updated also. as a journal of a wame member editor (https://wame.org/journals-whose editors-belong-to -wame#m-r) and o n e s t a t i n g t h a t i t f o l l o w s t h e i c m j e r e c o m m e n d a t i o n s (https://www.icmje.org/journals-following-the-icmje-recommendations/#p), the philippine journal of otolaryngology head and neck surgery will update its policies and practice as well. philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery case reports abstract objective: to report a case of lethal midline granuloma and discuss the diagnostic and treatment dilemma and management. methods: design: case report setting: tertiary government hospital patient: one results: a 15-year-old girl under treatment for pulmonary tuberculosis presented to the emergency room for epistaxis and a nasopalatine lesion. she was managed as a case of nasopalatine osteomyelitis for one month and discharged on antibiotics. she returned due to bleeding after being lost to follow up for 3 more months. hemostasis, debridement and biopsy yielded atypical cells, possibly lymphoma. immunohistochemistry confirmed the diagnosis of nk-cell lymphoma. unfortunately, she expired prior to initiation of chemotherapy. conclusion: clinicians must have a high index of suspicion for lethal midline granuloma in chronic, non-healing midline lesions. multiple biopsies confirm the diagnosis and earlier initiation of treatment may improve prognosis. keywords: granuloma, lethal midline; lymphoma, extranodal nk-t-cell lethal midline granuloma is a rare clinical entity1 that usually occurs among middle-aged men in the southeast asian and south american region2 with only a few documented cases in the philippines.3 with informed consent from her parents and her assent, we report its presentation in a young girl and discuss the diagnostic and treatment dilemma and management involved. case report a 15-year-old girl presented to the ear, nose, throat (ent) emergency room (er) of the northern mindanao medical center with a chief complaint of epistaxis and a nasopalatine lesion. nine months prior to admission, she noted nasal pruritus and occasional discomfort of the hard palate. no consultations were made and no medications were taken. two months before admission, she was brought to a local health center for nonproductive cough associated with undocumented fever and weight loss. direct sputum smear microscopy lethal midline granuloma in a 15-year-old girl: a diagnostic dilemma ian christian a. gonzales, md cagayan de oro consortium of otorhinolaryngology head and neck surgery northern mindanao medical center correspondence: dr. ian christian a. gonzales cagayan de oro consortium of otorhinolaryngology head and neck surgery northern mindanao medical center capitol compound, cagayan de oro city 9000 philippines phone: (6388) 726362 local 636 email: ianchristiangonzales@gmail.com the author declares that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2018; 33 (2): 37-40 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery case reports figure 1. intraoral view upon initial presentation. figure 3. intraoral view 3 months after initial presentation. she was anemic (rbc 2.46 x106/ul, hemoglobin 5.5 g/dl, hematocrit 17.4%) with leukocytosis (wbc 15.93 x103/ul), neutrophilia (89%) and lymphocytopenia (7.1%). contrast-enhanced computed tomography (ct) scan showed central, lobulated, soft tissue densities in both nasal cavities with partial lysis of the septum, hard palate and turbinates. (figure 2 a, b) initial aerobic wound culture showed light growth of pseudomonas putida, sensitive to multiple antibiotics. blood cultures were negative. nasopalatine swab was negative for acid-fast bacilli (afb) and potassium hydroxide (koh) stain. sputum afb, genexpert and tb culture were negative. the patient was initially managed as a case of nasopalatine osteomyelitis. clindamycin was started, anti-tb meds were continued, and she was co-managed by the pediatric infectious disease service. repeat wound culture a month later showed heavy growth of stenotrophomonas maltophilia, sensitive to trimethoprim/ sulfamethoxazole. repeat blood cultures were negative. repeat was positive for acid-fast bacilli and category i anti-tuberculosis (tb) treatment was started using the directly observed treatment-short course (dots) protocol with good compliance. she did not reveal that she already had a nasopalatine lesion at this time. she developed increasing nasal congestion over the next month and had epistaxis the day before, prompting consult and subsequent admission. she had no previous hospitalization or surgery and no history of any heredofamilial disease. baseline vital signs were within normal limits. she was asthenic with a bmi of 11.41 kg/m2. clinical examination revealed an extensively ulcerated and necrotic lesion on the hard and soft palate with a perforation that communicated with the nasal cavity. (figure 1) diagnostic nasal endoscopy revealed a perforation of the inferior to midnasal septum with erosion and ulceration of the nasal floor and inferior turbinate and minimal purulent discharge. the rest of the physical exam findings were unremarkable. figure 2. initial ct scan, axial view, a. bone window (left), showing the septal mass extending to the left intranasal area, and b. soft tissue window (right), showing the septal mass extending to the left intranasal area. a b figure 4. readmission ct scan, axial view, a. bone window (left), showing destruction of the nasal and philtrum soft tissue, hard palate, alveoli, and dental structures; b. soft tissue window (right), showing destruction of the nasal septum, and extension of the mass to the nasopharynx, and bilateral maxillary sinusitis. a b philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery case reports histopathology of the intraoperative biopsy specimens showed atypical cells, suggestive of lymphoma. (figure 6a) immunohistochemical stains (cd3, cd20, cytokeratin, synaptophysin, chromogranin) were negative except for cd56, confirming diagnosis of nk-cell lymphoma. (figure 6b) she was referred to family and community medicine for counseling and supportive care and to pediatric oncology for chemotherapy but expired due to sepsis and bleeding. discussion lethal midline granuloma is a rare clinical entity.1 mcbride first described the term in 1897, after which it was also known as stewart’s granuloma and polymorphic reticulosis.1 these previous terminologies were generic and confusing because the entity described is actually a heterogeneous group of disorders.2 hence, it was subsequently recommended that the label ‘lethal midline granuloma’ be used as a descriptive designation until a specific diagnosis is obtained.1 ishi et al. first recognized the presence of tumor cells expressing cd3 and termed the disease ‘nasal t-cell lymphoma.’3 however, suzumiya et al. noted that tumor cells in nasal lymphoma stained positive with cytoplasmic cd3 and cd56, but not t-cell receptors, suggesting an nkcell origin.4 the combined term ‘extranodal nk/t-cell lymphoma’ was adopted to take this into account.1 the differential diagnosis includes squamous cell carcinoma, other lymphomas, wegener granulomatosis, infections or idiopathic which is then labeled as idiopathic midline destructive disease.5 the nk/t-cell lymphoma type of lethal midline granuloma is strongly associated with epstein-barr virus infection with a higher prevalence in figure 5. intraoral view after debridement. figure 6a. hematoxylin and eosin stained slide showing atypical cells (arrows), suggestive of lymphoma, high power view, 40x magnification. nasopalatine swab was also negative for afb but positive for budding cells and pseudohyphae. a biopsy only showed granulation tissue with focal mild acute and chronic inflammation and necrosis. after three weeks, a more extensive biopsy with debridement and sequestrectomy under general anesthesia also showed chronic inflammation on histopathology. she was discharged on antibiotics and was subsequently lost to follow-up. after 3 months, she presented at the er for bleeding. the lesion had progressed anteriorly with necrosis and loss of the philtrum, columella, inferior and middle turbinates and nasal septum. (figure 3, 4 a, b) she underwent emergency debridement and ligation of bleeders with pre and post-operative blood transfusions. (figure 5) (hematoxylin – eosin , 40x) a figure 6b. hcd-56 immunohistochemical stained slide showing the nk-cells (yellow arrows), high power view, 40x magnification. (hematoxylin – eosin , 40x) b philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery case reports acknowledgements the author acknowledges the assistance of drs. maximo saavedra and edel vivas of the department of pathology, northern mindanao medical center; and dr. alessandra mallari of the department of pathology, perpetual succour hospital with technical aspects of this report; and the consultants, residents and staff of the department of otolaryngology – head and neck surgery and the department of pediatrics, for their contributions to patient care. references 1. metgud rs, doshi jj, gaurkhede s, dongre r, karle r. extranodal nk/t-cell lymphoma, nasal type (angiocentric t-cell lymphoma): a review about terminology. j oral maxillofac pathol. 2011 jan; 15(1):96-100. doi: 10.4103/0973-029x.80016; pmid: 21731288 pmcid: pmc3125667. 2. tlholoe mm, kotu m, khammissa ra, bida m, lemmer j, feller l. extranodal natural killer/t-cell lymphoma, nasal type: ‘midline lethal granuloma.’ a case report. head face med. 2013 jan 17; 9:4. doi: 10.1186/1746-160x-9-4; pmid: 23327615 pmcid: pmc3564726. 3. ishii y, yamanaka n, ogawa k, yoshida y, takami t, matsuura a, et al. nasal t-cell lymphoma as a type of so-called “lethal midline granuloma.” cancer. 1982 dec 1; 50(11):2336–44. pmid: 6754065. 4. suzumiya j, takeshita m, kimura n, kikuchi m, uchida t, hisano s, et al. expression of adult and fetal natural killer cell markers in sinonasal lymphomas. blood. 1994 apr 15; 83(8):2255–60. pmid: 8161791. 5. rodrigo jp, suarez c, rinaldo a, devaney k, carbone a, barnes l, et al. idiopathic midline destructive disease: fact or fiction. oral oncology. 2004 oct; 41:340-348. doi: 10.1016/j. oraloncology.2004.10.007; pmid: 15792605. 6. chavez r. lethal midline granuloma [unpublished case report]. philippines: northern mindanao medical center; 2012. 7. gourin cg, johnson jt, selvaggi k. nasal t-cell lymphoma: case report and review of diagnostic features. ear nose throat j. 2001 jul; 80(7): 458-60. pmid: 11480303. 8. alzubaidee a, ahmed sa. midline lethal granuloma: case report and review of literature. zanco j med sci. 2015; 19(1): 935-937. in press. 9. mallya v, singh a, pahwa m. lethal midline granuloma. indian dermatol online j. 2013 jan; 4(1): 37-39. doi: 10.4103/2229-5178.105469; pmid: 23440011 pmcid: pmc3573451. 10. yamaguchi m, kwong yl, kim ws, maeda y, hashimoto c, suh c, et al. phase ii study of smile chemotherapy for newly diagnosed stage iv, relapsed, or refractory extranodal natural killer nk/t-cell lymphoma, nasal type: the nk-cell tumor study group study. j clin oncol. 2011 nov 20; 29(33):4410-4416. doi: 10.1200/jco.2011.35.6287; pmid: 21990393. 11. jaccard a, gachard n, marin b, rogez s, audrain m, suarez f, et al. efficacy of l-asparaginase with methotrexate and dexamethasone (aspametdex regimen) in patients with refractory or relapsing extranodal nk/t-cell lymphoma, a phase ii study. blood. 2011 feb 10; 117(6):18341839. doi: 10.1182/blood-2010-09-307454; pmid: 21123825. 12. tse e, kwong yl. how i treat nk/t-cell lymphomas. blood. 2013 jun 20; 121(25):4997-5005. doi: 10.1182/blood-2013-01-453233; pmid: 23652805. 13. tababi s, kharrat s, sellami m, mamy j, zainine r, beltaief n, et al. extranodal nk/t-cell lymphoma, nasal type: report of 15 cases. eur ann otorhinolaryngol head neck dis. 2012 jun; 129(3):141-7. doi: 10.1016/j.anorl.2011.08.004; pmid: 22321911.` south-east asia, central and south america, and it commonly occurs in middle-aged persons and affects males more frequently.2 due to its rarity, exact incidence is unknown. at the northern mindanao medical center, this is only the second documented case.6 according to gourin,7 the patient will initially present with nasal congestion, epistaxis and pain. as the disease progresses, necrosis, tissue loss and bleeding are noted. secondary infection with bone sequestration is frequent, thus purulent discharge is expected. systemic symptoms such as fever and weight loss are present only in advanced stages.7 the working impression for this case was osteomyelitis vs. tb due to the patient’s history of an ongoing tb infection along with the clinical appearance of the lesion on initial presentation. exhaustive diagnostics for tb as well as other cultures and preliminary biopsies were either negative or inconclusive. due to lack of clinical improvement, repeated biopsies were needed with more tissue from multiple sites and a greater portion of clinically normal-looking tissue. however, the patient was lost to follow-up for three months. even when adequate biopsy specimens had been obtained, the unavailability of immunostaining in our institution and the expense of sending the specimens to another institution caused additional delays in clinching the diagnosis. definitive diagnosis requires some combination of histopathological, immunohistochemical, and molecular studies, often only after repetitive biopsies have been obtained.3 histologically, nk-cell lymphoma is characterized by polymorphic inflammatory infiltrates.5 necrosis favors the entrance of infectious processes that can lead to sepsis.8 on immunostaining, the malignant tumor cells express cd2, cytoplasmic cd3 and cd56. in some instances, they may also express cytotoxic granular-associated proteins, granzyme b, perforin and t cell-restricted intracellular antigen (tia-1).2 nasal nk/t cell lymphoma has a long natural history with an average of 29 months reported in all races.8 it has a very high mortality reaching almost 100% if untreated due to sepsis, hemorrhage or intracranial spread.9 it is usually responds to radiation and chemotherapy with the best clinical outcomes achieved when treatment is started early in the course of the disease. the chemotherapeutic regimens used in published case reports are chop (cyclophosphomide, doxorubicin, vincristine, and prednisone), smile (steroid [dexamethasone], methotrexate ifosfamide, l-asparaginase and etoposide)10 and aspametdex (l-asparaginase, methotrexate and dexamethasone).11 other treatment options include autologous or allogenic hematopoietic stem-cell transplantation (hsct) for advanced cases when remission is achieved.12 local recurrence occurs in 50% of cases and overall prognosis is poor, with a 5-year survival rate of 10% to 45% depending on the series.13 our unfortunate experience taught us that clinicians must have a high index of suspicion for chronic, non-healing midface lesions as they are often incorrectly diagnosed as infection. repeat biopsies must be done with access to advanced diagnostics such as immunohistochemical staining in order to clinch the diagnosis. the patient’s financial situation is a serious consideration in the diagnostic delay, therefore we must advocate for better health care access and universal coverage. although the prognosis is poor, aggressive treatment of secondary infections and subsequent chemoradiotherapy give the best possible chance of survival. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery from the viewbox pulsatile tinnitus due to a sigmoid sinus diverticulum and/or dehiscence in 2009, a 52-year-old man presented with a two-year history of intermittent right-sided pulse-synchronous tinnitus. he noted that the tinnitus worsened when his blood pressure was elevated. otologic exam was unremarkable with no obvious middle ear fluid or mass. there was no neck bruit and the tinnitus diminished on manual compression of the ipsilateral internal jugular vein. in keeping with the recommendations for clinical imaging at that time, a non-contrast ct of the temporal bone was performed. this was to evaluate for conditions such as: a middle ear glomus, an aberrant internal carotid artery, a jugular bulb variant (e.g. a highriding jugular bulb), otosclerosis, superior semicircular canal dehiscence syndrome, a persistent stapedial artery, or a hemangioma of the temporal bone.1 no evidence of these conditions was found. an mri of the brain, with mr angiography and venography of the intracranial vasculature also performed to evaluate for conditions such as: idiopathic intracranial hypertension, a dural arteriovenous fistula, an arteriovenous malformation, vascular loop syndrome and dural sinus stenosis or thrombosis.2 all of these conditions were excluded. as no definite pathology was identified, no firm treatment recommendations were initiallly made. in 2011, eisenman reported on a series of 13 patients with pulsatile tinnitus due to a sigmoid sinus diverticulum and/or dehiscence who were successfully treated surgically via an extraluminal transmastoid approach.3 this was the first relatively large series published in the otologic literature. this publication likewise reported on the subtle radiologic signs that signify the presence of a sigmoid sinus diverticulum and/or dehiscence such as an irregularity of the normal semicircular contour of the bony sinus wall, focal thinning of the calvarial cortex overlying the adjacent sinus wall, absence of the normal thin layer of cortical bone overlying the sinus and the “air-on-sinus” sign where mastoid air cells directly contact the sinus wall without overlying bone.3 in light of this new information, the patient’s imaging studies were re-evaluated and evidence of a right-sided sigmoid sinus diverticulum and/or dehiscence was identified. the images below show the findings on an axial slice of the patient’s temporal bone ct study. correspondence: dr. nathaniel w. yang department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 526 4360 fax: (632) 525 5444 email: nathaniel.w.yang@gmail.com the author declared that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2018; 33 (2): 60-61 c philippine society of otolaryngology – head and neck surgery, inc. nathaniel w. yang, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila department of otolaryngology head and neck surgery feu-nrmf institute of medicine creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery from the viewbox references 1. mattox de, hudgins p. algorithm for evaluation of pulsatile tinnitus. acta oto-laryngologica 2008; 128: 427-431. 2. shin ej, lalwani ak, dowd cf. role of angiography in the evaluation of patients with pulsatile tinnitus. laryngoscope 2000; 110:1916-1920. 3. eisenman dj. sinus wall reconstruction for sigmoid sinus diverticulum and dehiscence: a standardized surgical procedure for a range of radiographic findings. otol neurotol 2011; 32: 1116-9. 4. schoeff s, nicholas b, mukherjee s, et al. imaging prevalence of sigmoid sinus dehiscence among patients with and without pulsatile tinnitus. otolaryngol head neck surg 2014; 150: 84146. figure 1. axial ct image of the temporal bone at the level of the horizontal semicircular canals : absence of the normal thin layer of cortical bone overlying the right sigmoid sinus (white arrow) compared to the left sigmoid sinus figure 3. magnified view of figure 1 showing the “air-on-sinus” sign, where the mastoid air cell directly contacts the sinus wall, without any overlying bone (white arrow) figure 2. axial ct of the temporal bones: the location of the sigmoid sinus outlined with the red dotted line, illustrating the irregularity in the normal semicircular contour of the bony sinus wall. a portion of the sigmoid sinus can be seen extending beyond the seeming border of the sigmoid sinus. how significant is this condition ? sigmoid sinus diverticulum and/ or dehiscence is being increasingly recognized as a common cause of pulsatile tinnitus. in fact, a recent study by schoeff et al. found its prevalence to be 23% in patients with pulsatile tinnitus.4 as such, the identification of this condition is highly relevant particularly because effective surgical management is available for its alleviation. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports philippine journal of otolaryngology-head and neck surgery 23 abstract objective: to report a case of primary non-hodgkin’s t-cell lymphoma in the temporal bone in a pediatric patient, discussing clinical presentation and course, diagnostic evaluation and management in the light of published literature. methods: design: case report setting: private tertiary university hospital patient: one results: an 8-year-old female with a 10-month history of otalgia and ipsilateral headache developed facial paralysis, unresponsive to topical otic drops and oral antibiotics. imaging revealed mastoid sclerosis, tegmental and ossicular erosions, and an attico-antral mass which was excised through exploratory tympanomastoidectomy. final histopath following immunohistochemical corroboration was t-cell lymphoma. conclusion: primary malignant lymphoma of the temporal bone may initially present with otalgia and headache unresponsive to conventional medical management. ominous signs like facial paralysis should heighten the suspicion of malignancy warranting prompt imaging of the temporal bone. histopathologic evaluation of all mastoidectomy specimens should be mandatory especially in children, and special stains performed as needed. patients with t cell nhl should undergo chemotherapy and may warrant closer follow up for tumor recurrence and disease progression. key words: non-hodgkin’s lymphoma, temporal bone primary malignant lymphoma of the temporal bone has not been reported locally and most internationally documented cases allude to mainly secondary involvement from distant sites. we report the case of an 8-year-old female with a primary t-cell lymphoma of the temporal bone. primary lymphoma of the temporal bone: the first locally reported case julie ann g. uy, md jose carlos z. jugo, md jose m. acuin, md, msc department of otorhinolaryngology head and neck surgery de la salle health sciences institute de la salle university medical center philipp j otolaryngol head neck surg 2008; 23 (2): 23-27 c philippine society of otolaryngology – head and neck surgery, inc. correspondence: julie ann g. uy, md department of otorhinolaryngology head and neck surgery de la salle university medical center pasong lawin, dasmarinas, cavite 4114 philippines phone: (046) 416 0226 local 183 email: july28_md@yahoo.com reprints will not be available from the author. no funding support was received for this study. the authors signed a disclosure that they have no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this report. presented at the inter-hospital grand rounds, philippine society of otolaryngology – head and neck surgery, university of the east –ramon magsaysay memorial hospital, september 4, 2007 de la salle university center annual residents’ research contest “case report category,” (1st place) dlsmc-dasmarinas cavite, november 28, 2007. interesting case contest (2nd place) philippine society of otolaryngology – head and neck surgery midyear convention, pryce plaza hotel, cagayan de oro city, may 2, 2008. philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports 24 philippine journal of otolaryngology-head and neck surgery case report an eight-year-old girl with a 10-month history of left sided intermittent otalgia and progressively worsening ipsilateral temporal headache developed left sided facial paralysis. admitted for bells’ palsy and acute otitis media, her symptoms were unrelieved by topical otic drops and oral antibiotics, and she was eventually referred to our institution for further work-up and management. she presented with a house-brackmann 5/6 facial paralysis on the left (figure 1). a sagging postero-superior external auditory canal wall prevented otoscopic visualization of the tympanic membrane. the rest of the examination was unremarkable, and complete blood count showed leukocytosis with predominance of segmenters. initial diagnosis was left facial paralysis secondary to otomastoiditis with cholesteatoma. computed tomography revealed a well-delineated soft tissue lesion in the left middle ear extending to the external auditory canal and pinna (figures 2 a, b), sclerosis of mastoid air cells with cortical erosion of the tegmen tympani and ossicular erosion. the left temporal bone appeared thickened and irregular. the right temporal bone was unremarkable. a hyperdense lesion was also seen in the contiguous brain parenchyma, dorsal to the tegmen tympani and anterior to the petromastoid bone (figure 3), initially read as an abscess but interpreted as cerebritis by a neurosurgeon. magnetic resonance imaging study was not obtained due to financial constraints. exploratory mastoidectomy and facial nerve decompression yielded a fleshy, grayish-white soft tissue mass from the superior and posterior wall of the external auditory canal. the tegmen was granular and the mastoid segment of the facial nerve near the facial ridge was dehiscent. the long process of the malleus, incus, incudostapedial joint, and stapes capitulum were eroded and encased by yellowishwhite soft tissue invading the attic and antrum. the attico-antral and external auditory canal wall soft tissue lesions were excised and a type iva tympanoplasty was performed. partial recovery of facial nerve function to house-brackmann 3/6 was achieved on the 3rd day post-operative day. a post-operative cranial ct scan revealed an extra-axial mass lesion anterior and superior to the left temporal bone measuring 2.1x2.1 cm (figure 4 a, b). histopathologic evaluation of the attico-antral mass revealed only acute suppurative inflammation while the postero-superior canal wall mass showed surface epithelial erosion with fibrosis accompanied by acute and chronic inflammatory cells. below the epithelium were neoplastic cells seen invading the fibrous stroma (figure 5 a, b). these cells were generally small, having round, ovoid to irregularlyshaped, hyperchromatic nuclei with fine to coarse chromatin pattern and inconspicuous nucleoli. cytoplasm was scant and ill-defined; mitosis, rare. this was consistent with a small round cell tumor with the following considerations: lymphoma, peripheral neuroectodermal tumor, neuroblastoma and rhabdomyosarcoma. immunohistochemical analysis using cd20 and cd3stains was negative for cd20, ruling out lymphoma of b cell origin, with 60% of the tumor cells positive for cd3, indicating t cell origin. additional terminal deoxynucleotidyl transferase or terminal transferase (tdt) stain was negative, indicating involvement of mature t cells. diagnosis was diffuse large cell non-hodgkin’s lymphoma of the tcell type, and she underwent four courses of induction chemotherapy with vincristine, granisetron, doxorubicin, l-asparaginase, methotrexate, prednisone, g-csf, and epoietin and recovered facial nerve function to house brackmann 2/6 (figure 6). magnetic resonance imaging revealed marked decrease in size of the left temporal extra-axial mass to 11 x 6 mm. it was hypodense in all sequences but showed slight inhomogenous enhancement in the contrast phase, and right signals were again seen in the left mastoid air cells indicative of mastoid disease. all other laboratories to identify disease elsewhere were negative. at the time of this writing, our patient was on her 8th month regular follow up. she had completed the 1st of the 5 courses of consolidation chemotherapy and recovered complete facial nerve function to housebrackmann 1/6. discussion malignancies of the temporal bone occur rarely, accounting for approximately less than 0.2% of all head and neck tumors. these include those arising primarily from the skin of the pinna, primary tumors of the external auditory canal, middle ear, mastoid, or petrous apex and metastatic lesions to the temporal bone from distant sites.1 the most common malignancy involving the temporal bone is squamous cell carcinoma. other less common types identified are adenocarcinoma, melanoma, histiocytosis x, rhabdomyosarcoma, osteosarcoma, lymphoma, adenoid cystic carcinoma and acinic cell carcinoma.2 the first case of anaplastic carcinoma occurring in the temporal bone was reported locally by penaflor et al in 1999.3 lymphoid neoplasms account for the majority of non-epithelial malignancies in the head and neck.4 an electronic search conducted with the search words “temporal bone” and “lymphoma” revealed only 20 reported cases in international literature.* a similar electronic search of the available local database herdin collection from 1914 to 2006 revealed no published case report. inquiries made for unpublished case reports of temporal bone lymphoma in two academic referral hospitals, the philippine general hospital and university of santo tomas hospital, found none published locally or reported in scientific conferences. primary lymphoma originating in the temporal bone particularly affects the middle ear, mastoid, internal auditory canal and the external auditory canal. of these sites the middle ear and the mastoid appear to be the most common. 6 ogawa et al7 reviewed 18 case reports of primary lymphoma of the temporal bone=: 1 arose from the external auditory canal with no bone destruction, 2 originated from mastoid air cells, and the rest had unidentified sites of origin. ten patients were elderly adults. the 8 philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports philippine journal of otolaryngology-head and neck surgery 25 figure 1. patient’s picture showing incomplete eye closure (during the performance of schirmer’s test) (with permission). figure 2. plain ct scan of the mastoid. a and b. soft tissue density in the left middle ear extending out to the external auditory canal as well as the pinna. pediatric cases were all males with an age range of 5 to 16 years old. five of these 8 patients who underwent immunophenotypic analysis, 1 was of t cell origin and 4 were of b cell origin. 7 our patient varied from ogawa’s series in that: (1) she was within the pediatric age group, (2) was female, and (3) had a t cell type of non-hodgkin’s lymphoma. the initial presentation of progressively worsening unilateral otalgia unresponsive to medical management, temporal headache, and facial paresis with bulging of the postero-superior wall of the external auditory canal prompted the initial impression of chronic middle ear infection, a highly prevalent condition in the philippines. the facial paresis was then thought to be a complication of a long-standing inadequately treated figure 3. ct scan of the mastoid (plain). hyperdense lesion in the contiguous brain parenchyma, dorsal to the tegmen tympani and anterior to the petromastoid bone. chemotherapy and may warrant closer follow up for tumor recurrence and disease progression. * 18 cases were included in ogawa’s series and the other 2 cases were from hersch and nicolaides = these cases were collected over 30 years from 1976-2006 from different countries. chronic otomastoiditis. these features were consistent with the initial signs, symptoms, and clinical diagnoses of patients with temporal bone lymphoma.5,7,9 other initial symptoms reported in the literature include decreased hearing, headache, loss of balance, fever and mass in the external auditory canal.7 the ct scan findings of this patient are also consistent with other reports.5,7,9 koral et al noted bone erosion and epidural mass in a 15-year-old male with nhl9. bockmuhl et al found opacification of mastoid air cells on conventional radiographic schuller’s view in a 2year-old male.5 ogawa reported an enhanced mass spreading through both sides of the temporal bone with involvement of the mastoid air cells and the middle ear. mri of the head was further requested which revealed a destructive mass lesion in the temporal bone.7 in the reported case of a primary nhl of the temporal bone in a 2year-old-male with the same clinical presentation as that of the patient, an exploratory mastoidectomy was also performed. this revealed a fleshy soft tissue in the mastoid air cells involving the midvertical portion of the facial nerve. immunophenotypic analysis revealed a b cell type of nhl and co-expression of other cell surface molecules like ebv-coded lmp (latent membrane protein) and cd30 molecule further labeled it as a highly malignant type of lymphoma. additional staging work-ups were also performed and adjunctive chemotherapy which consisted of 4 cycles of cyclophosphamide, adriamycin & vincristine was given to the patient. this patient had no tumor recurrence in a 12 month follow-up period and recovery of facial nerve function was also observed after chemotherapy.5 on the other hand, both the pediatric patient and adult patients of tucci only received chemotherapy but also showed recovery of facial nerve function.8 (table 1) ogawa’s tabulated review of related literature of the 8 pediatric cases of temporal bone lymphoma reported similar therapeutic interventions. a combination of surgery and chemotherapy was given two patients who both survived. chemotherapy alone was given to four patients where three survived. on the other hand, one of the two patients who did not survive received a combination of chemotherapy and radiotherapy and this patient was the only one with the t cell type of nhl (among the five with immunophenotypic analysis). surgery was the sole intervention on the one patient who experienced relapse and was lost to follow up. although the above observations may suggest that chemotherapy with or without surgery is effective therapy for temporal bone lymphoma, findings suggestive of infection and inconclusive for malignancy may justify exploratory mastoidectomy. primary malignant lymphoma of the temporal bone may initially present with otalgia and headache unresponsive to conventional medical management. ominous signs like facial paralysis should heighten the suspicion of malignancy warranting prompt imaging of the temporal bone. histopathologic evaluation of all mastoidectomy specimens should be mandatory especially in children and special stains performed as needed. patients with t cell nhl should undergo philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports 26 philippine journal of otolaryngology-head and neck surgery figure 6. patient’s picture. recovery of facial nerve function graded as house-brackmann 2/6 on the left side (with permission). figure 4. post-operative ct scan of the mastoid. homogenously enhancing extra-axial hyperdense lesion anterior and superior to the left temporal bone (a) plain, (b) with contrast figure 5. photomicrograph of the specimen removed from the canal wall revealing a small round cell tumor. (a) low power view, and (b) high power view acknowledgements we would like to express our heartfelt appreciation to the consultant staff of the dlsumc department of ent for their ideas and contributions during the preparation of this paper. references 1. lim lh, goh yh, chan ym. malignancy of the temporal bone and external auditory canal. otolaryngol head neck surg. 2000 jun;122(6):882-6. 2. zhang b, tu g, xu g. squamous cell carcinoma of temporal bone: reported on 33 patients. otolaryngol head neck surg. 1999 aug; 21(5):461-6. 3. penaflor n, jugo jcz, abes gt. anaplastic cancer of the temporal bone presenting as chronic otitis media. philipp j otolaryngol head neck surg. 1999;14(4): 26-32. 4. paparella mm,el-ficky fm. ear involvement in malignant lymphoma. ann otol rhinol laryngol. 1972;81:356-63. 5. bockmuhl u, et al. primary non-hodgkin’s lymphoma of the temporal bone. eur arch otorhinolaryngol. 1995; 252:376-378. 6. hersh d. primary b cell lymphoma of the external auditory canal. ear, nose, throat j. 2006 sept; 85(9):597-9. 7. shoko ogawa, isao tawara, satoshi ueno, miho kimura, kana miyazaki, hiroyoshi nishikawa, et al. de novo cd5-positive diffuse large b-cell lymphoma of the temporal bone presenting with an external auditory canal tumor. intern. med. 2006; 45:733-737. 8. tucci dl, lambert pr, innes dj jr. primary lymphoma of the temporal bone. auris nasus larynx. 1992; 19(1):28-35. 9. koral k, curran jg, thompson a. primary non-hodgkin’s lymphoma of the temporal bone: ct findings. auris nasus larynx; 1994; 21(1): 1-7. 10. house jw, brackmann de. facial nerve grading system. otolaryngol head neck surg. 1985; 93:146. appendix a house – brackmann grading system10 grade i. normal ii.mild dysfunction iii. moderate dysfunction iv. moderately severe dysfunction v.severe dysfunction vi.total paralysis characteristics normal facial function in all areas gross · slight weakness noticeable on close inspection · may have slight synkinesis · at rest, normal symmetry and tone motion · forehead moderate-to-good function · eye complete closure with minimal effort · mouth slight asymmetry gross · obvious but not disfiguring difference between the two sides · noticeable but not severe synkinesis, contracture, or hemifacial spasm · at rest, normal symmetry and tone motion · forehead slight-to-moderate movement · eye complete closure with effort · mouth slightly weak with maximum effort gross · obvious weakness and/or disfiguring asymmetry · at rest, normal symmetry and tone motion · forehead none · eye incomplete closure · mouth asymmetric with maximum effort gross · only barely perceptible motion · at rest, asymmetry motion · forehead none · eye incomplete closure · mouth slight movement no movement table 1. summary of the therapeutic intervention and outcome of primary temporal bone lymphoma cases author blockmuhl (1995) tucci (1992) age/gener 2/m 5/m 66/m immunophenotype b cell (-) (-) therapy mastoidectomy & adjunctive chemotherapy chemotherapy chemotherapy outcome recovery of facial nerve function disease free (12 month follow up) recovery of facial nerve function recovery of facial nerve function philippine journal of otolaryngology-head and neck surgery vol. 23 no. 2 july – december 2008 case reports philippine journal of otolaryngology-head and neck surgery 27 philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 philippine journal of otolaryngology-head and neck surgery 55 featured grand rounds when evaluating patients with a non-traumatic auricular deformity that presents like a soft tissue infection unresponsive to antibiotic therapy and progressively resembles a tumor, immediate biopsy and imaging should be instituted to obtain an accurate diagnosis and avoid unnecessary procedures. after all, not all head and neck masses are managed with surgery. case report a 64-year-old diabetic man with a 30-pack/year smoking history presented with progressive diffuse swelling of the right auricule with exudative yellow non-foul smelling discharge. initially diagnosed with auricular cellulitis by an ent specialist, there was no response to oral and topical antibiotic treatment as the swelling developed into a large cauliflower-like deformity. incisional biopsy only revealed fibrocollagenous tissue with chronic inflammation without evident granuloma. with the progressively enlarging right auricular mass unresponsive to medical treatment for over six months, the man underwent a series of multi-disciplinary consultations in our institution. also noted were left tragal enlargement without ulceration or bleeding, palpable level ii-iii cervical lymph nodes (measuring 2.5 cm in widest diameter), but no palpable skin lesions, other signs or associated symptoms. (figure 1) otoscopy was normal with normal hearing thresholds on the right and mild conductive hearing loss on the left on pure tone audiometry. the rest of the physical examination and blood laboratory tests were unremarkable. a temporal bone ct scan (to determine mass extent and the best site for repeat incisional biopsy) showed an intensely enhancing external ear mass extending to the outer cartilaginous portion of the auditory canal with multiple sub-centimeter enhancing nodules in the right parotid gland. (figure 2) an excision biopsy between the junction of the mass and grossly normal-looking tissue of the right helix revealed atypical round cell tumor, subsequently diagnosed as t-cell lymphoma after strongly staining with cd3 and ki67 immunohistochemistry studies. after unremarkable repeat chest x-ray and abdominal ct findings, the patient underwent six cycles of chemotherapy using the chop (doxorubicin, vincristine, cyclophosphamide, prednisone) protocol for peripheral t-cell lymphoma, not otherwise specified (ptcl-nos), stage ii. significant decrease in size of the auricular mass was noted from the second cycle until no mass was evident after completion of the regimen. no recurrence was noted during a 48-month followup period. (figure 3) peripheral t-cell lymphoma presenting as an auricle mass correspondence: dr. adrian f. fernando department of otorhinolaryngology head and neck surgery university of santo tomas hospital españa boulevard, manila 1108 philippines phone: (632) 731 3001 local 2478 email: ianfernando_md@yahoo.com the authors declared that this represents original material, that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the 2nd international congress free paper presentation for medical sciences, january 16, 2016. st. paul university, tugegarao city, philippines. institutional review board approval and written informed consent for publication were obtained for this case report. veronica marie m. mendoza, md juan ramon v. perez de tagle, md adrian f. fernando, md department of otorhinolaryngology head and neck surgery university of santo tomas hospital philipp j otolaryngol head neck surg 2017; 32 (1): 55-56 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. external ears on presentation a. right nodular, non-tender auricular mass almost completely occupying the entire pinna and anterior cartilaginous portion of the external auditory canal (asterisk*); and b. enlarged left tragus (arrow). philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 featured grand rounds 56 philippine journal of otolaryngology-head and neck surgery and deformities such as squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, mucoepidermoid carcinoma, basal cell carcinoma and rhabdomyosarcoma, must be ruled out.3,4 these conditions have distinct presentations and may arise from the external ear, middle ear or temporal bone before affecting the external auditory canal.5 the literature on extra-nodal lymphomas is scarce, with bcell origin more commonly reported. on the other hand, peripheral t-cell lymphomas (ptcl) represent only 10-15% of non-hodgkin lymphoma, categorized as nodal, extra nodal or leukemic.6 a subtype of ptcl that do not correspond to any of the specifically defined t-cell entities in the world health organization (who) classification are defined as not otherwise specified pctl (ptcl-nos).7,8 however, based on a search of pubmed and herdin using the search terms “peripheral t-cell lymphoma,” “auricle,” and “external ear,” to the best of our knowledge, ptcl-nos has not been locally reported as primarily affecting the external ear.6,8 the clinical presentation of primary lymphomas of the eac is nonspecific and they can be easily misdiagnosed and treated as infectious or inflammatory conditions of the external ear. as with other conditions, early and accurate diagnosis based on good clinical correlation with imaging studies must be achieved to allow early and specific treatment. for ptcl-nos, the ann arbor staging system still applies although it was originally designed for hodgkin lymphoma.7 surgical management has been reported for isolated auricular lymphomas but disseminated disease or involvement of complex structures such as the external ear warrant chemotherapy as the primary and definitive treatment.2 external beam radiation has likewise been reported as an option but may not be applicable in this particular case where structural preservation of the auricle is considered.2 to date, no therapeutic guidelines have been established due to the paucity of cases. this case of ptcl-nos of the auricle, just like other reported cases of lymphoma arising from the external auditory canal, appear to respond well with the standard chop regimen. the favorable resolution in our case suggests that surgical resection of the auricle should be reserved for non-response to standard treatment for lymphoma. figure 2. temporal bone and neck contrast ct imaging a. axial view showing intensely-enhancing right auricular mass with ill-defined borders extending to surrounding soft tissues (asterisk*); b. coronal view showing enhancing right auricular mass extending to peri-parotid region with multiple enlarged right intra-parotid and cervical lymph nodes (arrow). figure 3. response to chop treatment a. right auricle before chemotherapy b. after 2nd cycle c. after 6th cycle d. left ear before chemotherapy e. after 6th cycle of chemotherapy. references kindem s, traves v, requena c, alcalá r, llombart b, serra-guillén c, et al. bilateral cauliflower 1. ear as the presenting sign of b-cell chronic lymphocytic leukemia. j cutan pathol. 2014 feb; 41(2): 73–77. doi: 10.1111/cup.12290; pmid: 24460879. bruschini l, de vito a, fortunato s, pelosini m, cervetti g, petrini m, et al. a case of primary non-2. hodgkin’s lymphoma of the external auditory canal. case rep otolaryngol. 2013; 2013: 138397. doi:10.1155/2013/138397; pmid: 23984144; pmcid: pmc3747615 merkus p, copper mp, van oers mh, schouwenburg pf. lymphoma in the ear. 3. orl j otorhinolaryngol relat spec. 2000 sep-oct; 62(5): 274–77. doi: 27759; pmid: 10965264. gonzález delgado a, argudo marco f, sánchez martínez n, sprekelsen gassó c. t cell non 4. hodgkin’s lymphoma of the external auditory canal. acta otorrinolaringol esp. 2008 apr; 59(4):200–201. pmid: 18447981. national cancer institute [internet]. cancer facts. head and neck cancer: questions and answers. 5. [cited 2017 feb 4]. available from: http://www.cancer.gov/cancertopics/factsheet/sites-types/ head-and-neck/. shuto j, ueyama t, suzuki m, mogi g. primary lymphoma of bilateral external auditory 6. canals. am j otolaryngol. 2002 jan-feb; 23(1):49-52. pmid: 11791249. lister ta, crowther d, sutcliffe sb, glatstein e, canellos gp, young rc, et al. report of a 7. committee convened to discuss the evaluation and staging of patients with hodgkin’s disease: cotswolds meeting. j clin oncol. 1989 nov; 7(11): 1630–6. doi: 10.1200/jco.1989.7.11.1630; pmid: 2809679. peripheral t-cell lymphoma facts [internet]. white plains, ny: leukemia and lymphoma society.8. [revised 2014 jul; cited 2017 feb 4]. available from: http://www.cancer.gov/cancertopics/ factsheet/sites-types/head-and-neck/. discussion because the external ear and auditory canal can be affected by various organisms especially in elderly, diabetic, and immunocompromised individuals, aggressive medical treatment is often warranted. a neoplastic etiology should be suspected when rapidly progressive ear deformities arise in cases of perichondritis and other non-infectious inflammatory conditions that are nonresponsive even to culture-guided therapy. in the absence of trauma, such other causes of ear deformity as sarcoidosis, perniosis, polychondritis and auricular pseudocyst must be carefully investigated by adequate biopsies and histopathologic studies to rule out malignant processes.1,2 lymphomas represent approximately 2.5% of head and neck malignancies, and the majority present with cervical lymph node involvement.2 while 40% of head and neck lymphomas occur in such extranodal sites as the nasopharynx, lacrimal sac, temporal bone, or salivary glands, they rarely involve the auricle and external auditory canal.2 more common malignancies that may lead to auricular masses philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 editorial 4 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 5 the old guards are fading as we take their place. many of us are ourselves in golden years, with more of our lives behind than before us. but all around us, many lives much younger than ours are being violently and unjustly terminated on a daily basis. in our very homes and communities, “man’s inhumanity to man makes countless thousands mourn.”2 as the morning of our life slowly fades and twilight shadows lengthen, this realization should stir us to “rage against the dying of the light”1 – not so much for ourselves, but on behalf of these countless thousands. whether we accomplished little, or much in our lifetime, the promises we once made will ultimately be measured against our own passage. many of these pledges were uttered in our springtime, when dawn was breaking on our seemingly endless day. over our lifetime, we may have kept some oaths, and broken others—in matters large or small. many of these are personal matters that do not involve the rest of us. but there is one vow that we professed in common, and that concerns all of us-the physician’s oath.3 at the time of being admitted as a member of the medical profession: correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 554 8467 telefax: (632) 524 4455 email: lapenajf@upm.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines the physician’s pledge: promises at dawn, passages in darkness philipp j otolaryngol head neck surg 2016; 31 (2): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international “do not go gentle into that good night.”1 dylan thomas i solemnly pledge to consecrate my life to the service of humanity; i will give to my teachers the respect and gratitude that is their due; i will practise my profession with conscience and dignity; the health of my patient will be my first consideration; i will respect the secrets that are confided in me, even after the patient has died; i will maintain by all the means in my power, the honour and the noble traditions of the medical profession; my colleagues will be my sisters and brothers; i will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient; i will maintain the utmost respect for human life; i will not use my medical knowledge to violate human rights and civil liber ties, even under threat; i make these promises solemnly, freely and upon my honour. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 4 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 5 editorial the promises we made in this oath now confront us with urgency and timeliness. how much longer can we turn a blind eye or a deaf ear when scores are slaughtered daily? how much longer shall we remain silent? is omission less evil than commission? the honorable mariott brosius of lancaster, pennsylvania on “the medical profession and the state” reminds us: 4 he should not be lulled to repose by the delusion that he does no harm who takes no part in public affairs. he should know that bad men need no better opportunity than when good men look on and do nothing. he should stand to his principles even if leaders go wrong. darkness is creeping upon us, and we too must pass on. in the deafening silence, the song rings in our ears: “in the evening of my life i shall look to the sunset, at a moment in my life when the night is due. and the question i shall ask only i can answer. was i brave and strong and true?”5 it is not too late to “conduct a pre-mortem on your life” to answer this question, unless you “would rather wait until someone else conducts the post-mortem on you.”6 we have solemnly pledged “to consecrate” our lives “to the service of humanity,” and “maintain the utmost respect for human life.”3 our patients are our brethren whose “health” – wellness and wholeness – should be our “first consideration.”3 we promised that we “will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between (our) duty and (our) patient.”3 we must not break this promise. “the woods are lovely, dark and deep, but i have promises to keep, and miles to go before i sleep, and miles to go before i sleep.” 7 robert frost references 1. thomas dm. “do not go gentle into that good night” in country sleep and other poems. new york: new directions, 1952. p. 18. 2. burns r. “man was made to mourn: a dirge” in the poems and songs of robert burns. eliot cw (editor). the harvard classics volume 6. new york: p.f. collier & son, 1909-14; bartleby.com, 2001. [cited 29 october 2016.] available at: http://www.bartleby.com/6/54.html. 3. the world medical association declaration of geneva. adopted by the 2nd general assembly of the world medical association, geneva, switzerland, september 1948; amended by the 22nd world medical assembly, sydney, australia, august 1968, the 35th world medical assembly, venice, italy, october 1983 and the 46th wma general assembly, stockholm, sweden, september 1994; editorially revised by the 170th council session, divonne-les-bains, france, may 2005 and the 173rd council session, divonne-les-bains, france, may 2006. [cited 29 october 2016.] available from: http://www.wma.net/en/30publications/10policies/g1/. 4. brosius m. the medical profession and the state [alumni oration]. the medical bulletin: a monthly journal of medicine and surgery. 1895 june;17:201-203. [cited 29 october 2016.] available from: http://quoteinvestigator.com/2010/12/04/good-men-do/#note-1664-6. 5. bricusse l (music), rattigan t (lyrics). “fill the world with love”. from the musical “goodbye, mr. chips” peter o’toole, petula clark (original artists). metro-goldwyn-mayer, 1969. 6. lapeña jf. from here and now to infinity and eternity: a message to new medical doctors. mens sana monogr. 2014 jan-dec; 12(1):153-160. doi: 10.4103/0973-1229.130328 pmcid: pmc4037894 pmid: 24891804. 7. frost r. “stopping by woods on a snowy evening” from the poetry of robert frost. lathem ec (editor) ©1923, © 1969 henry holt and company, inc., renewed 1951, by robert frost. [cited 29 october 2016.] available from: https://www.poetryfoundation.org/poems-and-poets/poems/ detail/42891. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery featured grand rounds keywords: streptococcus suis; meningitis; hearing loss streptococcus suis is a bacterial pathogen causing a wide range of infections including meningitis, lung infections, arthritis, sepsis and endocarditis.1 over the years, an increasing number of cases have been reported among humans especially in countries in southeast asia specifically in vietnam and thailand where pig-rearing is common.2 one of the prominent symptoms of s. suis infection is hearing loss that may be present during the onset or a few days after.1 we report two cases of adult s. suis meningitis presenting with bilateral hearing loss. case report our first patient was a 57-year-old man who presented with a one day history of generalized weakness initially unaccompanied by any other symptoms. the previous day, he was still able to walk but was generally weak, and preferred to stay in bed. that evening, he developed high grade fever (40ºc) that was temporarily relieved by paracetamol. there were two episodes of vomiting previously ingested food but no headache. by late evening, he was noted to have increased sleeping time, opening eyes spontaneously, responding mostly with yes or no, and following commands but drowsing back to sleep. on the day of admission, he could sustain spontaneous eye opening with no regard and groaned in response to questions without following commands. high grade fever persisted and he was rushed to the emergency room. on examination, he was febrile at 40.5ºc, hypertensive at 160/80mmhg, tachycardic at 109 with a glasgow coma scale (gcs) of 9/15 (e4v1m6), and was given o2 support at 1lpm by nasal cannula. he presented with spontaneous eye opening, no regard and did not follow commands. he had meningeal signsnuchal rigidity but no kernig’s sign. cranial ct scans showed no acute territorial infarct or intracranial hemorrhage, and a stable chronic lacunar infarct versus prominent perivascular space in the left lentiform nucleus. a covid rt-pcr test was negative. complete blood count showed leukocyte count of 5,220/mm3 with 72% neutrophils and a platelet count of 57,800/mm3. bleeding parameters showed prothrombin time of 14.4 seconds, inr of 1.23 and an elevated ptt of 45.3. he was started on meropenem and vancomycin and admitted to the neurological critical care unit while awaiting clearance for lumbar puncture (being on anti-coagulants). our second patient was his wife, a 51-year-old professional singer with no known co-morbidities who was also admitted due to fever and headache. at the time her husband was admitted, she had febrile episodes as high as 40ºc associated with pressure-like headache over both occipital hearing loss from s. suis meningitis in a middle-aged couple correspondence: dr. norberto v. martinez department of otolaryngologyhead and neck surgery st. luke’s medical center bonifacio global city, taguig 1634 philippines phone: (+632) 8723 0101 local 5543 email: nvmartinez@stlukes.com.ph the authors declare that this represents original material. that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. reprints will not be available from the author presented at the philippine society of otolaryngology head and neck surgery virtual interesting case contest. june 23, 2021. norberto v. martinez, md michiko s. hosojima, md department of otorhinolaryngology head and neck surgery st. luke’s medical center philipp j otolaryngol head neck surg 2022; 37 (2): 50-52 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery featured grand rounds areas (rated ps 7/10) as well as joint pain and nape pain. there were no associated cough, colds, dysuria, otalgia or otorrhea. paracetamol afforded temporary relief but fever intermittently recurred the next day and she was admitted for further evaluation and management even though her covid rt-pcr test was negative. on initial examination at the er, she was still febrile at 38.5c. she was awake, coherent and oriented to 3 spheres. complete blood count showed leukocytosis, while c reactive protein and erythrocyte sedimentation rate were elevated. magnetic resonance imaging (mri) showed diffuse flair hyperintensities along bilateral cerebral sulci and cerebellar interfoliar spaces with associated leptomeningeal enhancement. there was also enhancement along the ventral surface of the brain stem. a cns infection was suspected and lumbar puncture was performed. her csf showed gram positive cocci in pairs and chains with a possible streptococcus infection, but no fungal elements or acid fast bacilli. both csf and blood culture and sensitivity specimens tested positive for streptococcus suis sensitive to penicillin. she and her husband were started on intravenous penicillin. both patients had improvement in headache and nape pain over the next two days. however, they both reported persistent, progressive dizziness and bilateral hearing loss, and showed signs of vestibular dysfunction. the vestibular dysfunction was so severe that both patients were bed-bound and needed assistance in ambulating throughout their hospital stay. their hearing was described as distorted, with a sensation of being underwater. hearing tests revealed profound sensorineural hearing loss on the right and moderate sensorineural hearing loss on the left for the husband, and severe sensorineural hearing loss on the right and moderate sensorineural hearing loss on the left, downsloping at 6000 to 8000 hz in both ears for the wife. both patients were started on intravenous dexamethasone, which they completed (together with penicillin) over the course of 16 days. they were also given betahistine tablets for dizziness, metoclopramide for nausea and vitamin b complex. repeat cranial mri showed significant interval regression in the diffuse flair hyperintensities and associated leptomeningeal enhancement along bilateral cerebral sulci and cerebellar interfoliar spaces. repeat lumbar punctures showed no growth of any pathogen and resolution of s. suis infection. serial hearing tests showed stable hearing loss for both patients. after 2 months from the onset of infection, both patients continued to experience dizziness, vestibular dysfunction and hearing loss. although both were now able to ambulate, they still needed assistance in daily activities including driving. they still could not tolerate sudden head movements; even nodding and turning the head from side-toside elicited dizziness. the wife’s singing was greatly affected as the right ear had persistent severe hearing loss. sounds were perceived as distorted, described as ‘scratches;’ her right ear would hear higher frequencies, while the left ear heard lower frequencies. the perceived imbalance in frequencies posed a challenge to singing the right tune, but she continues to perform and sing professionally despite her hearing condition. she adapted through repetition, practicing until she achieved muscle memory in getting the right tone. they were offered several options for managing the residual symptoms including rehabilitation, hearing aids and early cochlear implantation. it was subsequently determined that they both ate at a korean barbecue restaurant days before the onset of symptoms. however, they ordered chicken barbeque and did not eat any pork dishes. discussion streptococcus suis is a gram positive bacteria isolated from the upper respiratory tract, genitourinary tract and gastrointestinal tract of infected pigs.1 though primarily inoculated from the swine population, increased in human transmission and cases have been observed in asian populations.2 it is believed that the s. suis pathogen may be classified into 35 serotypes, with the type 2 (ss2) mainly implicated for the human s. suis infection.1,2 huong et al. listed common risk factors for acquiring this infection, including occupational hazard (pig breeders), skin injury exposure, or ingestion of contaminated food.3 since both of our patients had no direct contact with pigs/livestock, what was the possible source of bacterial meningitis? a recent study by nhung et al. discussed possible colonization of s. suis in poultry flocks, reporting approximately 34% prevalence of the pathogen in chickens.4 this raises the possibility that poultry may have been one of the reservoirs in our patients’ case, having had korean chicken barbeque for dinner a few days before onset of symptoms. boonyong et al. also mentioned the possibility of cross contamination during meat handling, meat cutting and further processing of different meat products in restaurants,2 adding another possible explanation for our patients’ contamination. given the possible exposure, how could the bacterial pathogen have caused the meningeal symptoms and hearing loss? auger and gottschalk in 2017 explained that the pathogen is believed to penetrate mucosal barriers eventually passing through the bloodstream which then leads to eventual dissemination to different organs and the blood brain barrier.5 they further discussed that the h factor (one of its several virulence factors) has the ability to avoid “opsonophagocytosis” and in turn increases its binding to host cells.5 the capability and virulence factor of the bacterium explains its clinical manifestations. as with other cases of bacterial central nervous system infection, our patients presented with fever, changes in sensorium, and meningeal symptoms. what is interesting in both cases is the presentation of severe dizziness philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery featured grand rounds and hearing loss. in a span of 5 days, both our patients had persistent and progressive hearing loss in both ears. this corresponds to common clinical features which includes fever, meningitis, headache, dizziness, and hearing loss.6 according to wertheim et al., symptoms typically occur within 2-5 days from initial exposure.6 moreover, huh et al. said that around 2/3 of s. suis meningitis patients may present with hearing loss with a guarded prognosis for recovery.1 tan et al. indicated that the hearing loss is often bilateral, profound, sensorineural and likely permanent.7 as seen in our cases, vestibular dysfunction also accompanies the hearing loss. because the s. suis pathogen is able to cross the bloodstream and blood brain barrier through its virulence factors,5 infection through the blood brain barrier then enables the bacterium to also affect the cochlea. huh et al. in 2011 explained that the bacterium crosses the cochlear aqueduct then migrates to the perilymph.1 tan et al. further explain that the presence of the pathogen in the perilymphatic spaces causes a cascading inflammatory response, in turn creating an osteoid matrix and fibrosis, which then eventually leads to labyrinthitis ossificans.7 similar to other bacterial meningitis cases, timely diagnosis and early initiation of antibiotic therapy is recommended. penicillin g was started immediately upon diagnosis through lumbar puncture and blood culture of both patients. the recommended dose for penicillin g is 24 million units over 24 hours for at least 10 days6 which both patients were able to complete during their hospital admission. we have mentioned that the bacterium causes an inflammatory response triggering the cascading effect leading to labyrinthitis ossificans. over the years, there have been differing opinions regarding the role of corticosteroids in hearing loss management. brouwer et al. concluded that the overall effect of corticosteroids in reducing hearing loss in adult bacterial meningitis patients is not as well established as in the pediatric population.8 however, a more recent study by rayanakorn et al. in 2018 supported the use of corticosteroids as an adjunct to antibiotic therapy, reducing complications and hearing loss.9 dexamethasone, compared to other corticosteroids, has a higher biological half-life, greater anti-inflammatory property, and lower molecular weight and high liposolubility.10,11 hence at the time of referral of our patients, adjunct use of dexamethasone was started immediately along with serial monitoring of hearing level through audiometry. over the course of two weeks, we saw improvement in the hearing thresholds of both patients. imaging also showed significant regression of hyperintensities and leptomeningeal enhancement after treatment. subjectively, both patients reported general improvement of hearing and tinnitus as well as dizziness. vestibular rehabilitation was then recommended by the team to address the vertigo and gait instability caused by the infection. for the professional singer, a series of audiometric and vestibular function tests can monitor progress, and options for hearing devices such as hearing aids may be considered to amplify sounds and frequencies that are affected.12 newer hearing aids feature directional microphones, wind noise elimination and binaural coupling.12 early assessment may help in determining the role of cochlear implants, as infections spread to the inner ear structures rapidly and may occur within hours of the diagnosis of meningitis.13 currently, no prophylactic treatment is available for s. suis pathogens. avoidance of transmission is vital to the prevention of spread to public consumers. we recommend raising public awareness through campaigns and educating high risk populations (such as hog farm workers) in the use of personal protective equipment. safety protocols for restaurants should also be established especially for handling different meat products to avoid cross-contamination. references 1. huh hj, park k-j, jang j-h, lee m, lee jh, ahn yh, et al. streptococcus suis meningitis with bilateral sensorineural hearing loss. korean j lab med. 2011 jul;31(3):205–11. doi:  10.3343/ kjlm.2011.31.3.205; pubmed pmid: 21779197; pubmed central pmcid: pmc3129354. 2. boonyong n, kaewmongkol s, khunbutsri d, satchasataporn k, meekhanon n. contamination of streptococcus suis in pork and edible pig organs in central thailand. vet world. 2019 jan;12(1):165–169. doi:  10.14202/vetworld.2019.165-169; pubmed pmid:  30936671; pubmed central pmcid: pmc6431799. 3. huong vtl, ha n, huy nt, horby p, nghia hdt, thiem vd, et al. epidemiology, clinical manifestations, and outcomes of streptococcus suis infection in humans. emerg infect dis. 2014 jul;20(7):1105–14. doi:  10.3201/eid2007.131594; pubmed pmid:  24959701; pubmed central pmcid: pmc4073838. 4. nhung nt, yen ntp, cuong n, kiet bt, hien vb, campbell j, et al. carriage of the zoonotic organism streptococcus suis in chicken flocks in vietnam. zoonoses public health. 2020 dec; 67(8):843–8. doi: 10.1111/zph.12711; pubmed pmid: 32342661. 5. auger jp, gottschalk m. the streptococcus suis factor h-binding protein: a key to unlocking the blood-brain barrier and access the central nervous system? virulence. 2017 oct 3;8(7):10811084. doi: 10.1080/21505594.2017.1342027; pubmed pmid: 28622084; pubmed central pmcid: pmc5711356. 6. wertheim hfl, nghia hdt, taylor w, schultsz c.  streptococcus suis:  an emerging human pathogen,  clin infect dis. 2009 mar 1;48(5):617–25. doi:  10.1086/596763; pubmed pmid: 19191650. 7. tan jh, yeh bi, seet csr. deafness due to haemorrhagic labyrinthitis and a review of relapses in streptococcus suis meningitis. singapore med j. 2010 feb;51(2):e30-3. pubmed pmid: 20358139 8. brouwer mc, mcintyre p, prasad k, van de beek d. corticosteroids for acute bacterial meningitis. cochrane database syst rev. 2015 sep 12;2015(9):cd004405. doi: 10.1002/14651858. cd004405.pub5; pubmed pmid: 26362566; pubmed central pmcid: pmc6491272. 9. rayanakorn a, katip w, goh bh, oberdorfer p, lee lh. a risk scoring system for predicting streptococcus suis hearing loss: a 13-year retrospective cohort study. plos one. 2020 feb 4;15(2):e0228488; doi: 10.1371/journal.pone.0228488. pubmed pmid: 32017787; pubmed central pmcid: pmc6999904. 10. leung ma, flaherty a, zhang ja, hara j, barber w, burgess l. sudden sensorineural hearing loss: primary care update. hawaii j med public health. 2016 jun; 75(6):172-4. pubmed pmid: 27413627; pubmed central pmcid: pmc4928516. 11. chandrasekhar ss, rubinstein ry, kwartler ja, gatz m, connelly pe, huang e, et al. dexamethasone pharmacokinetics in the inner ear: comparison of route of administration and use of facilitating agents. otolaryngol head neck surg. 2000 apr;122(4):521-8. doi:  10.1067/ mhn.2000.102578; pubmed pmid: 10740171. 12. hoppe u, hesse g. hearing aids: indications, technology, adaptation, and quality control. gms curr top otorhinolaryngol head neck surg.  2017 dec 18;16: doc08.   doi:  10.3205/cto000147; pubmed pmid: 29279726; pubmed central pmcid: pmc5738937. 13. orzan e, muzzi e, caregnato i, cossu p, marchi r, ghiselli s. uncommon post-meningitis hearing threshold improvement: a case report. j int adv otol. 2018 dec;14(3): 484-487. doi:  10.5152/ iao.2018.4993; pubmed pmid: 30411708; pubmed central pmcid: pmc6354543. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the patterns of regional neck node metastasis in laryngeal squamous cell carcinoma in filipinos according to subsite and clinical stage and to determine possible factors associated with level v involvement. methods: design: retrospective case series setting: tertiary national university hospital participants: a chart review was conducted for patients diagnosed with laryngeal squamous cell carcinoma who underwent laryngectomy with neck dissection from january 2011 to april 2015. medical information obtained included demographics, clinical parameters and histopathologic reports of nodal involvement. the rate and location of positive neck nodes was recorded according to clinical stage and primary subsite. fisher exact test was used to determine significant risk factors for level v cervical lymph node involvement. results: from the 56 patients included, most were male with an average age of 61 years. most patients had cancer originating from the glottic subsite with the majority being staged iii and iva according to the tnm classification. histopathologically, positive neck nodes were centered at levels ii to iv. no significant association was seen between level v involvement and the studied clinicopathologic factors (age, sex, tumor differentiation, subsite involvement, involvement of other neck node levels). conclusion: cervical neck node levels ii, iii and iv are the most commonly involved in neck dissection with many being positive for nodal metastasis for these levels. level v nodes may be removed when clinically positive, but elective neck dissection may exclude this level. the current practice of neck dissection appears to be appropriate in terms of selecting the most likely locations of metastatic spread. further study is recommended with a greater population and standardized levels of neck dissection. keywords: laryngeal cancer, lymphatic metastasis, neck dissection, squamous cell carcinoma histopathologically positive regional neck node metastasis among patients with laryngeal squamous cell carcinoma efren gerald l. soliman, md alfredo quintin y. pontejos, jr., md department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: dr. alfredo quintin y. pontejos department of otorhinolaryngology philippine general hospital ward 10 university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 554 8400 local 2152 email: orlpgh@yahoo.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery, analytical research contest, november 9, 2017, menarini office, bonifacio high street, taguig city. philipp j otolaryngol head neck surg 2018; 33 (1): 30-33 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles laryngeal squamous cell carcinoma is one of the less common cancers but has significant morbidity and mortality.1 treatment commonly involves concomitant partial or total laryngectomy with neck dissection.2 involvement of levels ii, iii and iv has been demonstrated in prior studies in other populations even for patients with n0 necks, supporting selective neck dissection for these levels.2,3 the study aims to provide a guide for management of laryngeal squamous cell carcinoma by describing the patterns of neck node metastasis in filipinos and comparing it to data in other countries and determining possible factors associated with involvement of level v nodes. this may guide the determination of nodal subsites recommended for neck dissection during surgery according to the patient’s clinical stage. methods with institutional review board approval, this retrospective study accessed the patient database of medical records of the philippine general hospital, university of the philippines manila. records included charts from patient admissions at ward 10, department of otorhinolaryngology, surgeries performed in the right central block operating room complex and histopathologic readings compiled at the surgical pathology section, department of laboratories. records of patients aged 18 years old and above diagnosed with histopathologically-confirmed laryngeal squamous cell carcinoma, stage i-iv and admitted at the department of otorhinolaryngology charity ward of the philippine general hospital from january 2011 – april 2015, who underwent laryngeal surgery with neck dissection were considered for inclusion in the study. following the department protocol for management of laryngeal cancer, patients were diagnosed with laryngeal squamous cell carcinoma with a minimum of a complete head and neck examination and direct laryngoscopy with biopsy proving the pathology. a contrast computed tomography (ct) scan of the larynx and neck was obtained in patients with t2, t3 and t4 tumors, all patients with mucosal or submucosal tumors, and those with suspected cervical nodal metastasis. chest radiographs and liver function tests were also performed to rule out distant metastasis. neck dissection was done according to each surgeon’s judgment, guided but not dictated by the department protocol. for glottic and subglottic cancer, neck dissection is usually done for stage iii or worse; and dissection of levels ii to iv is done with inclusion of surrounding structures (such as the sternocleidomastoid, internal jugular vein, and spinal accessory nerve) as needed. for supraglottic cancer, no set guidelines were given for stage i and ii necks but both sides were advised to be addressed surgically due to risk of occult metastasis. suggested neck dissection for stage iii and worse was the same as for glottic cancer. patients with unavailable or incomplete records were excluded from the study. data was collected for each patient regarding demographics and initial clinical impression in terms of stage and primary subsite. postoperative records were reviewed to obtain surgical information on the laryngeal tumor and nodal involvement. pertinent data obtained is summarized in the following table. after obtaining the pertinent data, tabulation using ms excel version 1803 (build 9126.2152 click-to-run), (microsoft corporation, redmond wa, usa) was done according to primary subsite and clinical stage for each patient to determine the levels of neck nodes dissected and levels with positive involvement. descriptive statistics were used to summarize this and demographic data. to determine the association between level v nodal spread and the clinicopathologic factors (age, sex, tumor differentiation, primary subsite and involvement of other nodal levels), the fisher exact test was done using spss version 24, ibm 64-bit edition (ibm corp, armonk, ny, usa), with a p-value of less than .05 being considered significant. results collection and tabulation of the patient database showed 185 patients in the census of patient admissions with suspicion or assessment of laryngeal malignancy for any purpose. review of patient records narrowed the list of patients with available charts, diagnosed with laryngeal squamous cell carcinoma based on biopsy and treated with surgery that specifically included neck dissection to 56 patients (53 males, 3 females). ages ranged from 40 to 77 years and the mean age was 61 years. most patients presented with laryngeal cancer in the fifth decade of life (25 patients) followed by the sixth decade (18 patients) and seventh decade (10 patients). in terms of primary subsite based on clinical history, physical examination and diagnostic tests, 46 had glottic involvement followed by 8 supraglottic and 2 subglottic. using the tnm classification, most patients were staged iii (11 patients) and iva (40 patients). patient data histopathologic results age sex clinical stage (tnm) clinical primary subsite tumor differentiation involved laryngeal subsites neck node levels dissected neck node levels with positive involvement number of nodes involved table 1. patient data and histopathologic results obtained philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles table 2. rate of histopathologically positive neck node metastasis among patients with glottic primary subsite. stage # of pts (n=46) level i n/subtotal (%) level ii n/subtotal (%) level iii n/subtotal (%) level iv n/subtotal (%) level v n/subtotal (%) level vi n/subtotal (%) glottic primary subsite ii iii iva ivb 1 9 33 3 1/2 (50) 0/5 (0) 1/1 (100) 0/1 (0) 2/8 (25) 10/33 (30) 2/3 (66) 0/1 (0) 2/8 (25) 10/33 (30) 3/3 (100) 0/1 (0) 2/8 (25) 9/33 (27) 1/3 (33) 1/4 (25) 1/14 (7) 0/1 (0) 1/1 (100) 2/6 (33) in the eight patients with supraglottic primary subsite involvement, 3 had level ii involvement, 2 in level iii and 1 in level iv. for the two patients with subglottic primary, one patient had involved nodes at levels i, ii, iii and iv. distribution of histopathologically positive nodes for the 46 glottic patients is detailed in table 2. focusing on levels ii to iv, 25 percent of neck nodes in stage iii patients and approximately 30 percent in stage iv patients had positive involvement. notably, this is despite all stage iii glottic patients having been pre-operatively assessed as n0. no statistically significant association was noted between level v involvement and any of the pre-operative patient characteristics, namely age (p = .32), sex (p = 1.0), primary subsite involved (p = 1.0), preoperative clinical stage (p = .12), as well as post-operative histopathologic findings of tumor differentiation (p = 1.0), level ii involvement (p = .48), level iii involvement (p = .21) and level iv involvement (p = .39). discussion cancer of the larynx is one of the less common cancers ranking at 21st total, 14th for men and 21st among women in 2010; incidence rises at age 50 for men and 70 for women.1 the vast majority of laryngeal malignancies, more than 95 percent are squamous cell carcinomas.1,4 extension into tributary lymph nodes is a well-known possibility in all neck cancers including malignant laryngeal tumors.2 however, there is no general agreement on optimal elective neck dissection for glottic cancer, especially in clinically n0 patients.2,3 limiting functional damage needs to be balanced with increasing the patient’s chance of survival.2 in other populations, neck dissection of only levels ii, iii and iv has been shown to be comparable to more extensive neck dissections in terms of neck control, survival and accuracy of staging.3 however, no local studies have been found at present describing regional metastasis in laryngeal cancer or ideal treatment for such patients. to address this deficit, our study aimed to document the current practice in our institution regarding neck dissection, as well as the outcomes in terms of the likelihood of nodal metastasis contrasted with the frequency of dissection done per nodal level. this would help determine whether our institution is correctly balancing the need to maximize regional control and limit functional damage. while the study is small in terms of population size, certain patterns and trends can be noted. age and sex correlate well with existing local and international data that shows a greater risk of malignancy in age 50 and above and in men.1,7 also consistent with prior data is the finding that the glottic subsite is the most commonly involved followed by the supraglottic area with the subglottic area rarely being the site of origin.7 in terms of tnm staging, it is notable that most patients involved were staged as iva likely due to the specific criteria necessary to be included in the study. for patients with lower tnm stage, treatment may mostly involve radiotherapy and more conservative surgery for the larynx without necessarily including neck dissection unless with clinically apparent metastasis, hence exclusion from this study. for patients staged higher than iva, definitive surgery may be seen as a less desirable and much riskier treatment option due to extensive primary involvement, nodal spread or distant metastasis; such patients would likely be treated with palliative radiotherapy instead. accordingly, in our institution mostly patients staged iii and iva are perceived as benefitting from aggressive surgical treatment and neck node dissection due to the perceived risk of regional spread. this mode of thinking for treatment of laryngeal malignancies is in line with current guidelines that are based on tnm classification.5 while neck dissection is usually done for laryngeal squamous cell carcinoma, there is no general agreement regarding the best choice of nodal levels to involve,6 and this is apparent in our institution as well. the results of our study showed that levels ii, iii and iv are always included by surgeons in our institution in neck dissection for all primary subsites when doing total laryngectomy, regardless of t and n staging. other levels are included only infrequently, selected in addition to levels ii philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles to iv according to surgeon’s preference, possibly because of clinically obvious or suspicious involvement. the lack of significant association between level v involvement and the clinicopathologic factors reviewed in this study would indicate that basing the surgical plan on these factors may be misleading. the low rate of level v involvement even in higher stages would support excluding dissection of this level except for clinically apparent involvement. due to the limited number of subjects, it is difficult to draw definite conclusions regarding the rate of nodal spread according to subsite, stage and neck node level. in general, significant risk of nodal spread is present in levels ii to iv in all subsites even in clinically n0 patients but mostly in stage iva and above. the high percentage of histopathologically involved nodes in certain other node levels where neck dissection was seldom done may be attributed to the selection of these nodes for surgery only in cases already with a high chance of positive results such as clinically enlarged nodes or involvement of other sites such as the thyroid gland. although the findings provide some insight into the effectiveness of our current practice, the small sample size and retrospective nature of this study prevent further analysis. more extensive study of the distribution of regional metastasis with laryngeal squamous cell carcinoma would ideally necessitate standardization of neck dissection to include all relevant neck node levels. such a surgical practice would be difficult to defend ethically since only particular levels are known to be usually involved in most patients. the risk of involvement of levels i and v could, however, be measured indirectly in future studies by studying recurrence rates for these levels especially in patients who do not undergo post-operative irradiation. the predominance of highstaged lesions in this study with transglottic extension and bilateral involvement precludes determination of the ideal laterality of elective neck dissection – specifically, whether bilateral dissection is warranted for smaller masses isolated to one side. further investigation can be aimed at creating a more highly controlled, ideally prospective study with standardized neck node dissection with some levels aside from ii, iii and iv included as much as can be reasonably allowed by risk of nodal spread and concern for patient safety. a longer timeframe and a larger patient population, possibly involving several treatment centers may be included to allow for richer examination of the patterns of nodal metastasis. patient status on follow-up could be assessed as well with study of rate of recurrence and location of recurrent nodal metastasis since local control is the critical hallmark of adequate neck dissection when doing therapeutic surgery. comparison of post-operative histopathology with pre-operative diagnostics such as the ct scan may also be done to determine their accuracy in predicting nodal involvement as a justification for using ct findings to determine selection of neck node levels for dissection. this study suggests that in the patients studied, cervical neck node levels ii, iii and iv are the most commonly involved in neck dissection with many being positive for nodal metastasis for these levels. our results suggest that the current practice of always including levels ii, iii and iv may be appropriate in anticipation of occult nodal metastasis even in patients with n0 necks. due to the low number of patients who underwent neck dissection for levels i and v, it is difficult to say whether elective neck dissection is justified for these levels for any stage given the present data. however, many study factors limit the ability of the study to generalize to a larger population. the data collected from this study will ultimately serve not so much to affect surgical practice directly or immediately but as a basis for more extensive studies in the future. further studies may include an examination of recurrence rates and patient status after follow up. references 1. laudico av, medina v, lumague mrm, mapua ca, redaniel mtm, valenzuela fg, et al. 2010 philippine cancer facts and estimates. philippine cancer society inc; manila, 2010. 2. fiorella r, di nicola v, fiorella ml, russo c. “conditional” neck dissection in management of laryngeal carcinoma. acta otorhinolaryngol ital. dec 2006; 26(6): 356–359. pmid: 17633155 pmcid: pmc2639994. 3. gallo o, deganello a, scala j, de campora e. evolution of elective neck dissection in n0 laryngeal cancer. acta otorhinolaryngol ital. 2006 dec; 26(6): 335–344. pmid: 17633152 pmcid: pmc2639990. 4. marioni g, marchese-ragona r, cartei g, marchese f, staffieri a. current opinion in diagnosis and treatment of laryngeal carcinoma. cancer treat rev. 2006 nov; 32(7): 504-515. doi: 10.1016/j.ctrv.2006.07.002; pmid: 16920269. 5. takes rp, rinaldo a, silver ce, piccirilllo jf, haigentz jr m, suarez c, et al. future of the tnm classification and staging system in head and neck cancer. head neck. 2010 dec; 32(12): 16931711. doi: 10.1002/hed.21361; pmid: 20191627. 6. ferlito a, rinaldo a, silver ce, robbins kt, medina je, rodrigo jp, et al. neck dissection for laryngeal cancer. j am coll surg. 2008 oct; 207(4): 587-593. doi: 10.1016/j.jamcollsurg.2008.06.337; pmid: 18926464. 7. american cancer society. [internet]. laryngeal and hypopharyngeal cancers. atlanta, ga: american cancer society, inc. 2016 [cited 2016 jul 23] available from: http://www.cancer.org/ acs/groups/cid/documents/webcontent/003108-pdf.pdf. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports philippine journal of otolaryngology-head and neck surgery 39 abstract objectives: to report a case of congenital oval window aplasia (cowa) in a filipino adult presenting with unilateral maximal conductive hearing loss and discuss the diagnostic considerations, pathophysiology and management. methods: design: case report setting: tertiary public referral center patient: one results: audiometric evaluation showed a maximal unilateral left conductive hearing loss. high resolution temporal bone ct showed absence of the oval window on the left along with facial and stapes abnormalities. exploratory tympanotomy showed an aberrant facial nerve, monopodal and abnormally located stapes and absent oval window. postoperative hearing gain achieved after a neo-oval window and schuknecht piston wire prosthesis remained stable over two years. conclusion: a congenital minor ear anomaly classified as cremers class 4a in which a congenital oval window aplasia was associated with an aberrant facial nerve anomaly and a monopodal stapes is reported. recent literature supported the view that congenital oval window aplasia can in selected cases be amenable to various surgical approaches and a stable postoperative hearing gain is achievable in the long term. keywords: oval window absence, cremers classification, congenital middle ear congenital anomalies of the oval window found in only 0.5%-1.2% of children with conductive hearing loss, are considered a rare cause of congenital hearing loss-more so in adults where tympanosclerosis, otosclerosis and other acquired conditions predominate.1 to the best of our knowledge, congenital oval window aplasia has not been reported in a filipino adult. controversy exists with respect to surgical intervention especially in unilateral cases. we report one such case presenting with unilateral maximal conductive hearing loss and discuss the diagnostic considerations, pathophysiology and management. congenital oval window aplasia: an unusual cause of conductive hearing loss in an adult charlotte m. chiong, md, phd1,2,3 rachel t. mercado-evasco, md3 alessandra e. chiong, bs2 mary ellen c. perez, md4 franco louie l. abes, md, msc1,3 abner l. chan, md1,2,3 1philippine national ear institute national institutes of health university of the philippines manila 2department of otorhinolaryngology college of medicine philippine general hospital university of the philippines manila 3department of otolaryngology manila doctors hospital 4department of anesthesiology college of medicinephilippine general hospital university of the philippines manila correspondence: dr. charlotte m. chiong philippine national ear institute, national institutes of health and ear unit, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 554 8400 email: cmchiong@up.edu.ph; charlotte_chiong@yahoo.com the authors declare that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at philippine society of otolaryngology – head and neck surgery interesting case contest, may 22, 2014, menarini, w office bldg, bonifacio high street, bgc, taguig city. presented in part at the asean orl congress, november 12, 2015, empress convention centre, chiang mai, thailand philipp j otolaryngol head neck surg 2016; 31 (1): 39-44 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports 40 philippine journal of otolaryngology-head and neck surgery case report a 37-year-old man reported a history of left-sided hearing loss noticed at age 15. he initially benefited from several hearing aids (cros aids included) but hearing loss eventually progressed over the recent six months prior to consultation in a tertiary referral clinic. two previous specialist consults yielded different opinions regarding possible surgical management. the first specialist considered otosclerosis and advised exploratory tympanotomy while the second assessed the facial nerve anomaly as serious and deemed surgical intervention impossible given the high risk of facial nerve injury. the patient denied a family history of hearing loss, previous ear diseases and vestibular conditions. there was no history of facial nerve paresis and normal facial function (house brackmann grade i/vi) was evident. otoscopic exam of the tympanic membrane was normal and pneumatic otoscopy showed good mobility. tuning fork test showed weber lateralization and negative rinne in the left with contralateral normal rinne. pure tone audiometry revealed a severe conductive hearing loss and maximal air bone gap of 65 db in the left and mild high frequency sensorineural hearing loss in the right. (figure 1) a type a tympanogram was recorded in both ears. axial temporal bone high resolution computed tomography (hrct) showed a malpositioned stapes and an aberrant facial nerve that coursed along the promontory below the putative oval window area (figure 2), near the round window niche. there was no bony destruction of the malleus or incus and no demonstrable soft tissue densities in the mastoid air cells. coronal hrct thin slice temporal bone window cuts revealed an absent oval window (figure 3) but no round window aplasia was notable. the malpositioned stapes was seen directed more posteroinferiorly relative to the facial nerve canal which was absent in the usual tympanic segment; instead soft tissue was found below the usual area of the oval window. (figure 4) magnetic resonance imaging (mri) showed no evidence of a tumor in the middle ear, internal auditory canals or inner ear, and brain. various options such as conventional hearing aids, active or passive bone conduction devices (bone bridge and baha) were discussed with the patient, including exploratory tympanotomy to confirm the initial impression of cowa cremers type 4a congenital minor ear anomaly. the patient consented to the latter along with possible surgical reconstruction of the hearing mechanism. a neo-oval window or vestibulotomy (0.6) was performed using a hand perforator (mco218-6, microfrance, st. aubin, france) and a 0.6 mm schuknecht wire piston prosthesis (richards medical co., memphis, tn, u.s.a.) was placed. intraoperative facial nerve monitoring (nim 2.0 / xomed minneapolis, mn, u.s.a.) helped map out the exact borders of the facial nerve in the middle ear. (figures 5 and 6) there was no postoperative facial nerve paresis. postoperative hearing outcomes after one month, one year, and two years (figure 7) documented the closure of an ab gap at about 25 db which remained consistent over the follow up period. figure 1. preoperative audiograms six months apart (january and june 2012) showing severe conductive hearing loss and maximum air-bone gap in the left ear with only a mild high frequency sensorineural hearing loss in the right ear. philippine journal of otolaryngology-head and neck surgery 41 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports figure 5. an abnormal monopodal stapes (b) was malpositioned and directed towards the inferior portion towards the sinus tympani (a) and the facial nerve (fn) was found below the area of the putative oval window (arrow). figure 2. axial temporal bone ct of the patient showing the soft tissue (facial nerve over the promontory (solid arrow) at the round window niche area in the left middle ear compared to its usual location in the right. figure 3. axial ct of the temporal bone showing absence of the oval window, a malpositioned stapes and the absent tympanic segment of the facial nerve (solid arrow) on the left compared to the normal right side. figure 4. coronal temporal bone ct shows the facial nerve soft tissue under the putative absent oval window. the oval window is present on the right side (solid arrow) under the facial nerve in the tympanic segment. a b discussion congenital minor ear anomalies are classified as cremers’ type 1 (fixation of stapes footplate alone), type 2 (stapes footplate fixation with other ossicular anomalies), type 3 (mobile stapes footplate with other ossicular anomalies) and type 4 ( 4aaplasia of the oval window or round window (4bdysplasia) with aberrant facial nerve.2 morphodysplasia of autosomal recessive transmission was reported by sterkers3 while to jahrsdoerfer4 the anterior displacement of the facial nerve between the stapes blastema and the otic capsule is responsible for preventing the development of the oval window and lamina stapedialis. otoscopy is done to rule out common causes of conductive hearing loss such as otitis media and its sequelae as well as tympanosclerosis or other mass lesions in the middle ear. puretone audiometry philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports 42 philippine journal of otolaryngology-head and neck surgery and tympanometry is used to assess the ipsilateral ear, the type of hearing loss, severity of the hearing impairment and the status of the contralateral ear. the presence of bilateral involvement will necessitate more aggressive management for hearing amplification in children to optimize language learning and speech production at the earliest time. surgical management hinges on high resolution temporal bone imaging with coronal and axial bone window cuts or multiplanar reformatting to evaluate the oval window or absence thereof as well as the facial nerve course and the ossicular structures as these may predict possible complications.5,6 an mri study may delineate concomitant inner ear anomalies and rule out tumors or other conditions within the inner ear that can give rise to inner ear conductive hearing loss. subtle anomalies of the ossicles may still be missed on computed tomography such that an exploratory tympanotomy will be more definitive.1,5 future use of cone beam ct scanning will be of significant value in giving higher resolution images though this is still of limited availability in our country as in other developing countries. table 1 summarizes the reports of several authors on various methods for hearing improvement ranging from the most conservative approach such as conventional hearing aids to more invasive approaches such as malleostapedotomy or incudostapedotomy following oval window drill out or platinotomy or vestibulotomy and shows the studies where details on the laterality as well as the surgical technique utilized.5-11 a variety of prosthesis such as a teflon piston, and a cartilage columella have been used.6 thomeer’s report published in 2012 provided a summary of 70 cases in several series from 1950-2010 mostly comprising class 1-3, with the largest series of 144 cases reported from nijmegen by cremers and colleagues while only ten percent (14 patients from 1986-2001) of cases were of the rarest class 4a type anomaly.10 the preferred surgical approach was a transcanal approach, with the creation of a neo-oval window or vestibulotomy and malleostapedotomy comprising the most common procedures utilized, though incudostapedotomy have also yielded good postoperative outcomes in the immediate and long term postoperative period.10 surgical outcomes range from complicated postoperative profound sensorineural hearing loss to significant long term closure of air bone gaps up to ten years.11,12 the possibility of iatrogenic sensorineural hearing loss from inner ear damage or facial nerve injury though transient have also been described.9 given this, figure 7. postoperative audiogram of the patient at six months has remained stable over two years showing ab gap closure within 25 db figure 6. intraoperative picture (a) of the wire-piston prosthesis placed between the neo-oval window and the incus with an artist’s rendition (b) and a postoperative coronal ct (c) to show the prosthesis placement (arrow) for hearing reconstruction. b a c philippine journal of otolaryngology-head and neck surgery 43 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports table 1. summary of reports on surgery for congenital oval window aplasia. author, year published ardah, 1996 martin et al.,2006 esteves et al.,2013 ahn et al., 2013 kutluhan et al., 2010 thomeer et al., 2012 hasegawa et al., 2012 number of ears with oval window agenesis/ aplasia 1 *only the right ear was explored 4 6 *case 5 – stated “bony blades into the oval window” 3 2 10 4 unilateral/ bilateral cases bilateral *cannot be determined bilateral: 2 unilateral: 2 bilateral: 2 unilateral: 1 bilateral: 1 unilateral: 2 bilateral: 0 *cannot be derived unilateral:1 bilateral :2 percentage of ears with facial nerve anomaly dehiscent bony canal of the facial nerve 100% 50% 100% 50% 90% 100% remarks/surgical outcome incudostapedotomy, bur 0.7 mm hole plus teflon piston (0.6 mm x 4.5 mm) and periosteal graft around the piston; hearing gain of 40 db, stable over three years follow-up case 1 incudostapedotomy. 0.8-mm platinotomy plus 0.8mm teflon piston case 2 incudostapedotomy, 0.4-mm hole drilled under facial nerve and fisch piston 6 months later contralateral 0.4-mm hole drilled over facial nerve and 0.4-mm teflon-wire piston clipped on incus long process case 1 bilateral baha with subsequent hearing gain case 2 conventional bilateral hearing aids with auditory gain case 3 no auditory rehabilitation, with outpatient surveillance case 4 conventional prosthesis was chosen case 1 malleostapedotomy via endaural approach on second surgery, facial nerve rolled, 0.6-mm window drilled using 0.4-mm skeeter drill, piston wire prosthesis bent 20°, modified to 7-mm length and fixed on normal malleus case 2 stapedotomy after “facial roll” and 0.6-mm window using 0.4-mm skeeter drill, piston wire 7-mm-long used, transient house-brackmann grade iii recovered by 1 month case 1 vestibulotomy using a pick then teflon prosthesis case 2 tragal cartilage, incus long process with bone cement as complex at footplate, postoperative hearing gain 42 db and air conducting hearing level 20 db on right side transcanal approach for exploratory tympanotomy and malleostapedotomy, hearing improved but deteriorated in long term inner ear fenestration in 3 followed by piston; exploratory tympanotomy only in 1; hearing improved in all cases after surgery and to within 25 db in two and within 45 db in one philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports 44 philippine journal of otolaryngology-head and neck surgery references 1. quesnel s, benchaa t, bernard s, martinef, viala p, abbeele tvd, teissier n. congenital middle ear anomalies: anatomical and functional results of surgery. audiol neurotol. 2015; 20(4):237242. 2. teunissen eb, cremers wr. classification of congenital middle ear anomalies. report on 144 ears. ann otol rhinol laryngol. 1993 aug;102(8 pt 1):606-12. 3. sterkers jm, sterkers o. surgical management of congenital absence of the oval window with malposition of the facial nerve. adv otorhinolaryngol. 1988;40 :33-7184. 4. jahrsdoerfer ra. congenital malformation of the ear: analysis of 94 operations. ann otol rhinol laryngol. 1980 jul-aug;89(4 pt 1):348-52. 5. esteves sd, silva ap, coutinho mb, abrunhosa jm, almeida e sousa c. congenital defects of the middle ear--uncommon cause of pediatric hearing loss. braz j otorhinolaryngol. 2014 mayjun;80(3):251-6. 6. kutluhan a, salviz m, çetin h, bilgen as. two unusual case of congenital conductive hearing loss related to anomaly of stapes. cumhuriyet med j. 2010; 32(3):345-51. 7. ardah nm. congenital absence of oval window. ann saudi med. 1999 nov-dec;19(6):536-8 8. martin c, oletski a, bertholon p, prades jm. abnormal facial nerve course associated with stapes fixation or oval window absence: report of two cases. eur arch otorhinolaryngol.2006 jan; 263(1):79-85. 9. ahn sh, kim dh, choi jy, kim bg. two cases of malleostapedotomy in congenital oval window atresia. korean j audiol. 2013 dec; 17(3):152-155. 10. thomeer h, kunst h, verbist b, cremers c. congenital oval or round window anomaly with or without abnormal facial nerve course: surgical results for 15 ears. otol neurotol. 2012 jul;33(5):779-84. 11. hasegawa j, kawase t, hidaka h, oshima t, kobayashi t. surgical treatment for congenital absence of the oval window with facial nerve anomalies. auris nasus larynx. 2012 apr;39(2):249255. 12. snik af, mylanus ea,cremers cwr. speech recognition with the bone-anchored hearing aid determined objectively and subjectively. ear nose throat j. 1994 feb;73(2):115-117. 13. agterberg mjh, hol mks, cremers cwr, mylanus eam, van opstal j, snik afm. conductive hearing loss and bone conduction devices: restored binaural hearing? adv otorhinolaryngol. basel, karger, 2011:71:84-91. 14. takahashi h, kawanishi m, maetani t. abnormal branching of the facial nerve with ossicular anomalies: report of two cases. am j otol. 1998 nov;19(6):850-53. 15. cremers cwr, teunissen e. the impact of syndromal diagnosis on surgery for congenital minor ear anomalies. int j pediatr otorhinolaryngol. 1991 jul;22(1):59-74. both conventional hearing aids and passive or active bone conduction devices remain viable options, especially in bilateral cases.7,13 long term hearing improvement has been notable in these novel active bone conduction devices in recent reports.12 for unilateral cases, no consensus has been reached but recent literature points to a more aggressive approach that involves surgically correcting the unilateral loss for better hearing in noise and sound localization. some have reported repeated surgeries before attaining a successful outcome, highlighting the risk of failure when doing procedures for such rare conditions.1 though surgery for otosclerosis provided ample experience for doing the reconstruction in other centers the rarity of otosclerosis in the philippines makes this surgery even more challenging. facial nerve injury (transient or permanent) deserves consideration in preoperative decision. intraoperative monitoring of the facial nerve was not discussed in most reports but was considered important in cases where an aberrant course or branching of the facial nerve is suggested on the preoperative ct scan.14 the use of neuromuscular blocking agents are best limited to induction of anesthesia so that electrical stimulation can map out the actual course and functionality of the facial nerve. this may help avoid injury while the nerve is being manipulated in order to insert a prosthesis after making a neo-oval window, as in this case. there are reports of postoperative facial nerve paresis that could have been avoided had intraoperative facial nerve monitoring been done.3,9 moreover, worse postoperative hearing needs to be honestly discussed. should the incus be short or abnormal then malleostapedotomy can be performed instead of an incudostapedotomy. the use of a piston wire prosthesis with an incudostapedotomy proved successful in this patient but he continues to be monitored for the possible need for both active and passive middle ear or bone conduction devices. these options remain open though cost considerations in the setting of a developing country remain formidable. the status of hearing in the contralateral ear provides a major impact on the decision with respect to surgery, given that binaural benefit with such passive or active bone conduction devices is achievable only if contralateral hearing remains normal. on the other hand, ossicular chain reconstruction following a neo-oval window and prosthesis placement that provides postoperative hearing within 30 db of the good contralateral ear in this case and ab gap closure to within 25 db rendered subjective benefit well appreciated by this patient. however, it has been emphasized that a 15 db inner ear conductive deafness that remains in these patients would be another limiting factor in the success of ab gap closure in these patients. the presence of other syndromes may also affect the outcomes of hearing reconstruction but this issue remains controversial given the contrasting reports of their impact on hearing results.12,15 the continued development of bone conduction devices and middle ear implants can improve outcomes such that the surgical choices will likely expand. improved diagnostic imaging may also aid in evaluating failures in surgery such as a round window atresia with the potential to be missed or evidence of prosthesis or implant displacement so that the feasibility of revision will be better informed. ultimately the patient’s active role in the decision making must be based on a discussion of all options as illustrated in this adult patient with only unilateral involvement. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 featured grand rounds 58 philippine journal of otolaryngology-head and neck surgery when evaluating patients presenting with progressive unilateral hearing loss without a history of trauma or infection, it is important consider the clinical correlation of physical examination findings, imaging and audiograms. it is crucial that all findings are correctly reviewed and analyzed to provide an accurate assessment and appropriate management for the patient. case report a 46-year-old woman presented with a gradually progressing left-sided hearing loss with associated continuous tinnitus for a period of 14 months. there was no history of trauma or ear infection. on prior consultation with an ent specialist, the patient was diagnosed to have otitis media with effusion and initially managed medically. persistence of symptoms without improvement prompted a follow-up consult where pure tone audiometry (pta) and speech testing showed normal hearing in the right ear, and a moderate to severe mixed hearing loss in the left ear. (figure 1) significant bleeding was encountered on myringotomy, and the possibility of a glomus tympanicum was entertained. a plain temporal bone ct scan revealed a soft tissue density occupying the left middle ear space, with bony erosion in the area of the jugular foramen which suggested the possibility of a tympanojugular paraganglioma. (figure 2) the patient was subsequently referred to our institution for surgical management. on physical examination, the left tympanic membrane was bulging with note of a pinkish retrotympanic mass. lateralization to the right was noted on weber testing using 0.5, 1 and 2khz tuning forks. subjectively, the patient could not hear anything on the left side. due to the inconsistency noted between the tuning fork test finding and the initial audiometric test result, the patient was advised to undergo a second audiometric test under the supervision of a reliable audiologist. this second audiogram revealed normal hearing in the right and profound hearing loss in the left ear (figure 3), a finding that was consistent with the patient’s subjective hearing perception and tuning fork test results. meningioma in the middle ear: an unusual case of hearing loss correspondence: dr. nathaniel w. yang department of otorhinolaryngology head and neck surgery the medical city ortigas avenue, pasig city 1600 philippines phone: (632) 635 6789 local 6250 fax: (632) 687 3349 email: nwyang@gmx.net the authors declared that this represents original material, that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery inter hospital grand rounds. june 28, 2016. the medical city, pasig city. danezza mae d. lim, md nathaniel w. yang, md department of otorhinolaryngology head and neck surgery the medical city philipp j otolaryngol head neck surg 2016; 31 (2): 58-62 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 59 featured grand rounds figure 1. audiogram, right: normal hearing; left: downsloping moderate to severe mixed hearing loss. note that masking was not done consistently on the left, and that the speech discrimination score of 80 on the left was significantly lower than the score of 96 on the right. figure 2. ct of the temporal bone, axial views. figure a. soft tissue lesion occupying a portion of the middle ear space at the level of the basal turn of the cochlea (solid white arrow). b. shows soft tissue infiltration in the region of the jugular foramen with patchy bone destruction (outlined white arrow). a b philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 featured grand rounds 60 philippine journal of otolaryngology-head and neck surgery with the finding of a sensorineural rather than a conductive type of hearing loss, additional imaging to investigate the presence of retrocochlear pathology became necessary. a gd-enhanced mri examination revealed the presence of a 2.6 x 4.5 cm cerebello-pontine angle mass causing pressure on the adjacent pons and left cerebellar hemisphere. the lesion appeared to arise from the posterior face of the temporal bone, with extension into the jugular foramen and middle ear (figure 4). a dural tail sign was likewise noted, and this led to a change in diagnosis to a posterior fossa meningioma with extension into the temporal bone and middle ear. the patient was then referred to a neurosurgeon, who expressed some doubt regarding the diagnosis and requested a biopsy. due to the accessibility of the middle ear component, the patient underwent a transcanal middle ear exploration with biopsy. the histopathology report confirmed the impression of meningioma (meningotheliomatous subtype). the patient subsequently underwent neurosurgical management for the intracranial portion of the tumor. discussion neoplasms of the cerebellopontine angle (cpa) are most common in the posterior cranial fossa which account for 5-10% of all intracranial tumors.1 the two most common lesions which comprise 79% of incidents recorded are vestibular schwannomas and meningiomas. other pathologies include epidermoid cysts, facial and lower cranial nerve schwannomas, and arachnoid cysts.2 up to 20% of intracranial meningiomas may have extracranial extension.3-5 these areas may include the scalp, sinonasal tract, orbit, soft tissues, ear and temporal bone. due to its low invasive properties, incidence of extension particularly to the middle ear is less than 2%.4-6 figure 3. repeat audiogram. right: normal hearing threshold sloping to mild hearing loss; left: profound hearing loss, srt conforms with the pta, sds 100% on the right, no response on the left. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 61 featured grand rounds figure 4. mri of the posterior fossa, gd-enhanced t1-weighted image, axial view, at the level of the horizontal petrous carotid artery (broken-line white arrow) showing an enhancing lesion in the left cerebellopontine angle (black asterisk) that appears to have a broad-based attachment to the posterior face of the temporal bone. there is patchy infiltration into the temporal bone with extension into the middle ear space (solid white arrow). a dural tail (white outlined arrow) is evident. the common presenting symptoms of temporal meningioma include otalgia, hearing loss (conductive, mixed or sensorineural),5 tinnitus and facial palsy. our patient presented with progressive unilateral hearing loss with tinnitus without history of trauma or infection. given that otitis media with effusion is a more commonly encountered condition, it is not surprising that she was initially managed as such. when excessive bleeding was noted during myringotomy, it is not again surprising that a glomus tumor of the tympanicum type was considered, as it is the most common middle ear tumor that would present as such. during the initial work up, the audiogram showed normal hearing in the right, and moderate to severe mixed hearing loss in the left. on review, we noted certain irregularities in the audiogram such as the inconsistent use of masking and the placement of notations for both the masked and unmasked results. the latter finding indicated a seeming hesitancy on the part of the audiologist to commit to a definite hearing level. anecdotal clinical experience of the senior author with audiometric testing in the philippines has shown that inaccurate audiometric examinations are not uncommon. as such, it is important to review audiometric test results with a critical eye, and to always corroborate it with tuning fork testing. in this case, tuning fork testing indicated a hearing loss with a very significant sensorineural component at 0.5, 1 and 2 khz, a finding that was not consistent with the audiometric test results. repeat audiometry showed normal hearing in the right and profound hearing loss in the left. although this finding was now consistent with tuning fork testing, it unfortunately raised suspicion regarding the true nature of the middle ear pathology. for patients with purely middle ear glomus tumors, the expected audiometric finding is a conductive hearing loss as obstruction from the mass deters conduction of sound through the middle ear. with the seemingly limited extent of the soft tissue lesion within the middle ear and jugular foramen, the sensorineural hearing loss remained unexplained. hence, further investigation via mri with gadolinium was warranted to rule out a retrocochlear pathology. the gadolinium-enhanced mri examination of our patient showed a cpa tumor with a dural tail sign causing mass effect on the adjacent pons and left cerebellar hemisphere. the dural tail sign occurs secondary to the enhancement of the thickened dura. it is the characteristic sign philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 featured grand rounds 62 philippine journal of otolaryngology-head and neck surgery most commonly seen adjacent to a meningioma.8-9 however, the dural tail sign has been increasingly recognized in other intracranial tumors as well.9 as a confirmatory measure, a middle ear exploratory tympanostomy and biopsy was performed. this approach provided direct access to sample the tumor without resorting to an open approach. the final histopathology report confirmed that the cpa tumor was a meningioma extending into the middle ear space. it may be said that the diagnosis of this case was delayed from initial presentation due to the rarity of the condition. however, it may be argued that a careful analysis of the audiometric examination in relation to the findings on tuning fork testing, a simple office procedure that is often neglected, would have revealed inconsistencies that could lead to a more detailed diagnostic pathway that may have eventually led to the correct diagnosis. as such, it cannot be overemphasized references 1. berkowitz o, iyer ak, kano h, talbott eo, lunsford ld. epidemiology and environmental risk factors associated with vestibular schwannoma. world neurosurg. 2015 dec. 84 (6):1674-80. doi: 10.1016/j.wneu.2015.07.007 pubmed pmid: 26171891. 2. bonneville f, sarrazin jl, marsot-dupuch k, iffenecker c, cordoliani ys, doyon d, et al. unusual lesion of the cerebellopontine angle: a segmental approach. radiographics. 2001 mar-apr; 21(2): 419-38. doi: 10.1148/radiographics.21.2.g01mr13419 pubmed pmid: 11259705. 3. buehrle r, goodman ws, wortzman g. meningioma of the temporal bone. can j otolaryngol. 1972; 1: 16–20. 4. civantos f, ferguson lr, hemmati m, gruber b. temporal meningiomas presenting as chronic otitis media. am j otol. 1993 jul; 14(4): 403–406. pubmed pmid: 8238280. 5. thompson ld, bouffard jp, sandberg gd, mena h. primary ear and temporal bone meningiomas: a clinicopathologic study of 36 cases with a review of the literature. mod pathol. 2003 mar; 16(3): 236–245. doi: 10.1097/01.mp.0000056631.15739.1b pubmed pmid: 12640104. 6. ruchenstein mj, cueva ra, morrison dh, press g. a prospective study of abr and mri in screening vestibular schwannomas. am j otol. 1996 mar; 17(2): 317-20. pubmed pmid: 8723969 7. isaacson je, vora nm, milton s. differential diagnosis and treatment of hearing loss. am fam physician, 2003 sep;68(6):1125-1132. pubmed pmid: 14524400. 8. wallace ew. the dural tail sign. radiology. 2004 oct; 233 (1): 56-7. doi: 10.1148/radiol.2331021332. pubmed pmid: 15454617. 9. sotoudeh h, yazdi hr. a review on the dural tail sign. world j radiol. 2010 may; 188-192. doi: 10.4329/wjr.v2.i5.188 pubmed pmid: 21161034 pubmed central pmcid: pmc2999017 . that audiometric testing is not a fail-safe method of determining hearing levels, as it is dependent on the level of skill and training of the audiologist or audiometrician performing the test. tuning fork testing although not allowing the determination of actual hearing levels does allow one to determine whether hearing loss is conductive, sensorineural or of a mixed type. if the type of hearing loss determined on tuning fork testing does not correlate with that found on standard pure tone audiometry, then the accuracy of the audiometric test must be placed under close scrutiny. an audiogram should be repeated if there is incongruence with simple clinical testing. a cranial mri should always be done when a patient presents with a unilateral sensorineural hearing loss to rule out any retrocochlear pathology. with the aid of appropriate ancillary procedures, along with thoughtful clinical correlation, a directed approach to diagnosing an unusual cause of hearing loss may be achieved. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 17 abstract objective: to evaluate the quality of life before, and after functional endoscopic sinus surgery (fess) among patients with nasal obstruction due to nasal polyposis using the nasal obstruction symptom evaluation (nose) questionnaire translated in filipino (nose-ph) in a tertiary government hospital in metro manila. methods: design: cross-sectional qol study setting: tertiary government hospital participants: forty (40) patients with nasal polyposis who underwent fess from april 2014 to june 2015 were included in the study. patients who underwent fess due to other nasal tumors other than nasal polyp were excluded. the subjects answered the previouslyvalidated nose-ph questionnaire preand post-operatively and the scores were gathered and analyzed. results: based on the pre and post-operative scores, there was a statistically significant improvement in all 5 parameters (1. nasal congestion, 2. nasal obstruction, 3. trouble breathing, 4. trouble sleeping, and 5. inability to get enough air through the nose during exercise). conclusion: there was a statistically significant improvement in the quality of life of patients who underwent fess based on the pre and post-operative scores using the nose-ph questionnaire translated in filipino. keywords: nasal obstruction symptom evaluation scale nasal obstruction is a subjective complaint of discomfort manifested by a feeling of insufficient airflow through the nose.1 this may be due to anatomic obstruction of the ostium, septal deviation, concha bullosa, paradoxic middle turbinate, nasal polyps and others.2 several instruments to assess quality of life and quantify improvement or relief of nasal symptoms after nasal surgery have been formulated, but are quite lengthy.3 the nasal obstruction symptom evaluation scale developed by stewart in 2004 is composed of only 5 questions that are very brief and easy to accomplish and understand.4 the questionnaire addresses the severity of complaints that the patient has been experiencing for the past month: nasal congestion and stuffiness, nasal blockage and obstruction, trouble breathing through the nose, trouble sleeping and unable to get enough air through the nose during exercise or exertion. quality of life after fess among patients with nasal polyps using the nose questionnaire translated in filipino (nose-ph) mary ann v. macasaet, md1 emmanuel tadeus s. cruz, md1, 2 1department of otolaryngology head & neck surgery quezon city general hospital 2department of otolaryngology head & neck surgery manila central university filemon d. tanchoco medical foundation hospital correspondence: dr. mary ann v. macasaet department of otorhinolaryngology-head & neck surgery quezon city general hospital and medical center seminary road, munoz, quezon city 1106 philippines phone: (632) 426 1314 local 232 fax: (632) 920 7081; 920 6270 email: rainmacasaet@gmail.com the authors declare that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery analytical research contest (3rd place), bella ibarra, quezon city, november 10, 2015. philipp j otolaryngol head neck surg 2016; 31 (1): 17-21 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles 18 philippine journal of otolaryngology-head and neck surgery the original nose questionnaire in english may be difficult to administer to non-english speakers and has been previously translated and validated in spanish,5 chinese,6 greek,7 french,8 and italian.9 this study aimed to translate and validate the nose questionnaire in filipino (nose-ph) and to use the nose-ph to evaluate the quality of life before, and after fess among patients with nasal obstruction due to nasal polyposis in a tertiary government hospital in metro manila. methods instrument development the nose questionnaire in english (figure 1) was separately translated by a professor of filipino language from the university of the philippines and a physician, and the results were synthesized. the synthesized version was back translated by an english teacher. all versions were submitted to the university of the philippines – sentro ng wikang filipino where experts in the filipino language10 made the final version (nose-ph): 1. paninikip ng ilong, 2. pagbabara ng ilong, 3. hirap ang paghinga gamit ang ilong, 4. hirap sa pagtulog, 5. hindi makalanghap ng sapat na hangin gamit ang ilong tuwing nag-eehersisyo o nagbubuhat. this questionnaire required rating of items on a 5 point scale as follows: 1 hindi problema, (not a problem) 2 – napakabahagyang problema, (very mild problem) 3 – katamtamang problema, (moderate problem) 4 – medyo masamang problema, (fairly bad problem) and 5 – (malalang problema). (figure 2) the highest score was 20 with severe nasal obstruction and the lowest was 0 with no nasal obstruction. not a problem very mild problem moderate problem fairly bad problem severe problem 1. nasal congestion or stuffiness 2. nasal blockage or obstruction 3. trouble breathing through my nose 4. trouble sleeping 5. unable to get enough air through my nose during exercise or exertion 0 0 0 0 0 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 nasal obstruction symptom evaluation scale (nose) patient id: __________________ age: _______ date: ____/____/___ __ over the past one month, how much of a problem were the following conditions for you? please circle the most correct response figure 1. nasal obstruction symptom evaluation scale (nose). adapted, with permission from stewart mg, witsell dl, smith tl, weaver em, yueh b, hannley mt. development and validation of the nasal obstruction symptom evaluation (nose) scale. otolaryngol head neck surg. 2004 feb; 130(2): 157-163 nose questionnaire filipino translation (nose-ph) pangalan __________________ edad: ______ petsa: ____/____/___ __ sa nakaraang isang buwan, gaano kalaking problema/sagabal ang sumusunod na kondisyon sa iyo? pakibilugan ang pinakatamang/ pinakaangkop na sagot. hindi problema napakabahagya ang problema katamtamang problema medyo masamang problema malalang problema 1. paninikip ng ilong 2. pagbabara ng ilong 3. hirap sa paghinga gamit ang ilong 4. hirap sa pagtulog 5. hindi makalanghap ng sapat na hangin gamit ang ilong tuwing nageehersisyo o nagbubuhat 0 0 0 0 0 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 figure 2. nose questionnaire filipino translation (nose-ph) philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 19 n = (zα + β)2 (sd 1 + sd 2 )2 e 2 table 1. inter-item correlation matrix nasal congestion or stuffiness nasal blockage or obstruction trouble breathing through my nose trouble sleeping unable to get enough air through my nose during exercise or exertion nasal congestion or stuffiness nasal blockage or obstruction trouble breathing through my nose trouble sleeping unable to get enough air through my nose during exercise or exertion 1.000 0.539 -0.87 0.265 0.306 0.539 1.000 0.149 0.422 0.470 -0.087 0.149 1.000 0.113 0.126 0.265 0.422 0.113 1.000 0.278 0.306 0.470 0.126 0.278 1.000 table 2. item total statistics scale mean if item deleted scale variance if item deleted corrected item total correlation squared multiple correlation chronbach’s alpha if item deleted nasal congestion or stuffiness nasal blockage or obstruction trouble breathing through my nose trouble sleeping unable to get enough air through my nose during exercise or exertion 15.00 14.98 14.98 15.03 14.93 1.846 1.410 2.333 1.820 1.866 0.410 0.652 0.105 0.416 0.461 0.326 0.459 0.071 0.191 0.236 0.696 0.554 0.774 0.694 0.675 the minimum number of samples for the assessment of the improvement of quality of life after fess was computed using a 95% level of confidence and 80% power of the study. with estimated standard deviations of 11.46 and 3.86 for the preand postoperative nose scores respectively based on a previous study,11 less than 10 subjects were needed. where: n = number of subjects needed sd1 = standard deviation pre nose score = 11.46 sd2 = standard deviation post nose score = 3.86 e = measure of effect or the difference in the pre and post nose score = 61.63 – 8.75 = 52.88 zα = 95% confidence level = 1.96 zβ= 80% power of the study = 1.28 the nose-ph was pre-tested and validated among 10 subjects with nasal polyposis based on the computed sample size. the results revealed that the nose-ph questionnaire was valid with cronbach’s alpha of 0.752 showing that it is a reliable questionnaire. inter-item and item-total correlations demonstrated associations. (table 1 and 2) each question contributed to the total reliability of the questionnaire since it did not increase the cronbach’s alpha when each item was deleted. subject selection and questionnaire administration with institutional review board approval, this cross-sectional study considered patients with nasal polyposis who underwent fess at a tertiary government hospital from april 2014 to june 2015 for inclusion. patients with nasal tumors other than nasal polyp were excluded. after obtaining written informed consent, a complete history and ent examination with emphasis on nasal problems was obtained for each patient. nasal endoscopy was performed by 2 senior ent residents using a zero degree, 4 mm rigid nasal endoscope (chammed, china) and the following rhinologic findings were recorded: grade of the nasal polyp using the mackay classification12 and severity of nasal disease on pns ct using lund mackay scores.13 patients underwent fess (anterior to posterior approach) with or without caldwell luc and/or septoplasty by senior ent residents, and were discharged after polyvinyl alcohol nasal pack (netcell, network medical products ltd., uk) removal. they were asked to accomplish the philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles 20 philippine journal of otolaryngology-head and neck surgery table 3. comparison of the pre and post nasal obstruction symptom evaluation scores of subjects pre mean ± sd (median) post mean ± sd (median) p-value* 1. nasal congestion or stuffiness 2. nasal blockage or obstruction 3. trouble breathing through my nose 4. trouble sleeping 5. unable to get enough air through my nose during exercise or exertion 3.70 ± 0.52 (4) 3.73 ± 0.59 (4) 3.78 ± 0.42 (4) 3.62 ± 0.54 (4) 3.75 ± 0.49 (4) 0.25 ± 0.58 (0) 0.18 ± 0.38 (0) 0.15 ± 0.36 (0) 0.15 ± 0.36 (0) 0.25 ± 0.58 (0) <0.0001 (s) <0.0001 (s) <0.0001 (s) <0.0001 (s) <0.0001 (s) * p-values >0.05not significant; p-values ≤0.05-significant n mean rank sum of ranks q2tot-q1tot negative ranks positive ranks ties total 40a 0b 0c 40 20.50 0.00 820.00 0.00 q2tot-q1tot z asymp. sig. (2-tailed) -5.567a 0.000 table 4. wilcoxon signed rank test a. q2tot < q1tot b. q2tot>q1tot c. q2tot=q1tot a. based on positive ranks nose-ph questionnaire pre-operatively and upon follow up 1 month after surgery. they were advised to ask questions if they needed any clarification. outcome measure the main outcome measure was improvement of the quality of life based on the nose-ph questionnaire scores preand 1 month postsurgery. data processing and analysis data were encoded and tallied in spss version 10.0 for windows (ibm, armonk, ny, usa). descriptive statistics were generated for all variables. for nominal data frequencies and percentages were computed. for numerical data, mean ± sd were generated. analysis of the different variables was done using the following test statistics to compare the pre-operative and post-operative nose-ph scores of the patients: paired t-test to compare two groups with numerical data that are dependent and wilcoxon signed ranks test, a non-parametric equivalent of the paired t-test. results a total of 42 patients underwent fess in our institution during the study period. the nose-ph questionnaire was administered preand post-operatively among the patients with nasal polyps who met the inclusion criteria. excluded were two patients whose histopath results revealed inverting papilloma and squamous cell carcinoma, respectively. subsequently, 40 patients were finally included, 20 males (50%) and 20 females (50%), age 10 to 77 years with a mean age of 38.85 years. the grade of the nasal polyps were as follows: grade 1 0 (0%), 2 5 (12.5%), and 3 – 35 (87.5%). lund mackay scores were obtained individually for the right and left and combination of right and left nasal cavities based on the pns ct scan. the total lund mackay score ranged from 3-24 with a mean of 17.96± 6.63. surgical procedures performed were: fess, 17 (45.94%), fess with caldwell luc, 20 (54.06%) and fess with septoplasty, 3 patients (7.5%). before fess, there were 29 (72.5%) subjects with severe nasal congestion or stuffiness, 10 (25.0%) with fairly bad, and 1 (2.5%) with moderate nasal congestion. after fess, 82.5% were relieved of nasal congestion or stuffiness while 4 (10%) and 3 (7.5%) had a very mild or moderate problem respectively. based on the pre-operative nasal obstruction scores, 31 (77.5%) had severe nasal congestion or stuffiness, 8 (20.0%) had fairly bad, and 1 (2.5%) had very mild nasal congestion. post-operatively, 33 (82.5%) were relieved from nasal blockage or obstruction while 7 (17.5%) had a mild problem. with regards to trouble breathing through the nose before fess, 31 (77.5%) had severe trouble breathing while 9 (22.5%) had fairly bad trouble breathing through the nose. after fess, 34 (85%) had no trouble breathing through nose while 6 (15%) had very mild problem. with regards to trouble sleeping, preoperatively, there were 26 (65%) subjects with severe trouble sleeping, while 13 (32.5%) had fairly bad trouble sleeping. postoperatively, 34 (85%) had no trouble sleeping, and 6 (15%) had a very mild problem. with regards to inability to get enough air through the nose during exercise or exertion, prior to fess, 33 (82.5%) subjects were unable to get enough air through the nose during exercise or exertion, while 6 (15%) and 1 (2.5%) had a fairly bad and moderate problem, respectively. after fess, 32 (80%) improved while 6 (15%) and 2 (5%) had moderate and a fairly bad problem, respectively. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 21 references 1. jessen m, malm m. definition, prevalence and development of nasal obstruction. allergy 1997: 52 (suppl40): 3-6. 2. stankiewicz j, lal d. primary sinus surgery. in: flint p, haughey b, lund v, niparko j, robbins k, tomas jr, et al. cummings otolarygology head and neck surgey sixth edition. philadelphia: elsevier. 2015; 752-782. 3. baumann i. subjective outcomes assessment in chronic rhinosinusitis. the open otorhinolaryngology journal. 2010; 4:28-33. 4. stewart mg, witsell dl, smith tl, weaver em, yueh b, hannley mt. development and validation of the nasal obstruction symptom evaluation (nose) scale. otolaryngol head neck surg. 2004 feb; 130(2): 157-163. 5. larrosa f, roura j, dura mj, guirao m, alberti a, alobid i. adaptation and validation of the spanish version of the nasal obstruction symptom evaluation (nose) scale. rhinology. 2015 jun; 53(2): 176-180. 6. dong d, zhao y, stewart mg, sun l, cheng h, wang j, et al. development of the chinese nasal obstruction symptom evaluation (nose) questionnaire. zhonghua er bi yan hou tou jing wai ke za zhi. 2014 jan; 49(1):20-26. 7. lachanas va, tsiouvaka s, tsea m, hajiioannou jk, skoulakis ce. validation of the nasal obstruction symptom evaluation (nose) scale for greek patients. otolaryngol head neck surg. 2014 nov;151(5):819-23. 8. marro m, mondina m, stoll d, de gabory l. french validation of the nose and rhinoqol questionnaires in the management of nasal obstruction. otolaryngol head neck surg. 2011 jun;144(6):988-93. 9. mozzanica f, urbanni e, atac m, scotta g, luciano k, bulgheroni c, et al. reliability and validity of the italian nose obstruction symptom evaluation (i-nose) scale. eur arch otorhinolaryngol. 2013 nov; 270(12):3087-3094. 10. camagay l, isang institusyonal na kasaysayan: ang kaso ng sentro ng wikang filipino. manual ng sentro ng wikang filipino. philippine humanities review. 2014;(1):43-52. 11. beg maa, ahmed m. evaluation of septoplasty outcome using nose (nasal obstruction symptom evaluation) scale. international journal of scientific research. 2014 feb; 3:2. 12. mackay is, lund vj. imaging and staging. in: mygind n, lindholdt y. ed. nasal polyposis: an inflammatory disease and its treatment. copenhagen, munksgaard, 1997:137-144. 13. lund vj, kennedy dw. staging for rhinosinusitis. otolaryngol head neck surg 1997 sep; 117(3 pt 2): s35-s40. comparison between the mean preoperative 18.55 ± 1.76 and postoperative 0.95 ± 1.26 scores showed that there was a significant difference noted, with all p values <0.0001. the scores significantly decreased after nasal surgery in all 5 parameters as follows: nasal congestion or stuffiness, nasal blockage or obstruction, trouble breathing through nose, trouble sleeping and trouble getting enough air through nose during exercise or exertion. (table 3) using the wilcoxon signed rank test (p value < 0.000, mean: 20.5), there was a significant decrease between the preand post-operative nose-ph scores implying relief from the 5 symptoms after fess and subsequent improvement in the quality of life. (table 4) discussion when administered to 40 subjects with nasal polyps who underwent fess, there was statistically significant improvement in all 5 variables of the nose-ph questionnaire and no difficulty was reported during the administration and course of the study. the nose-ph scores significantly decreased from baseline 18.55 ± 1.76 to 0.95 ± 1.26 after fess in all 5 parameters: nasal congestion, nasal blockage, trouble breathing through nose, trouble sleeping and trouble getting enough air through nose during exercise. this implies that fess may result in postoperative improvement of the quality of life of patients with nasal obstruction. that the majority of patients (87%) had grade 3 nasal polyps with mean lund mackay scores of 17.96 reflecting relatively severe nasal disease associated with nasal obstruction was also noteworthy. the nose questionnaire was selected because it specifically deals with nasal obstruction. it only includes a minimum of 5 variables. it is brief, simple, and direct to the point and when translated in a local language is relatively easy to understand as shown by the outcome of this study. the nose-ph demonstrated internal consistency reliability, testretest reliability and validity which are consistent with the original english language validation by stewart4 as well as several previous adaptations of nose questionnaire in spanish,5 chinese,6 greek,7 french,8 and italian.9 in this study, subjects were not randomized and included patients who underwent fess within a time period. the study focused primarily on the viability and applicability of using the nose-ph questionnaire in evaluating the quality of life of actual patients who underwent nasal surgery. normal or asymptomatic subjects with no complaints of nasal obstruction were excluded because the study aimed primarily to evaluate improvement in the quality of life after nasal surgery and did not intend to differentiate those with or without symptoms of nasal obstruction. inclusion of normal subjects may be considered when a given test aims to identify those with and without disease which is beyond the scope of the present study. in future studies, it is also important to consider comorbid conditions such as allergic rhinitis, asthma, copd and others which may affect the outcome of the scores post-operatively. the nose-ph questionnaire may be validated through serial monitoring of improvement of quality of life among patients suffering from nasal obstruction in the outpatient clinic, and in different centers. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2019; 34 (1): 48-51 c philippine society of otolaryngology – head and neck surgery, inc. non-traumatic cerebrospinal fluid leak from a sphenoid sinus midline roof defect previously managed as allergic rhinitis jan paul d. formalejo, md jay pee m. amable, md department of otorhinolaryngology head and neck surgery university of the east – ramon magsaysay memorial medical center, inc. correspondence: dr. jay pee m. amable department of otorhinolaryngology head & neck surgery rm. 463, hospital service bldg., uermmmc, inc., 64 aurora blvd., quezon city 1113 philippines telephone: +632-7150861 loc. 257 telefax: +632-7161789 e-mail: jpamablemd@gmail.com the authors declare that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery interesting case contest (1st place). may 12, 2018. citystate asturias hotel, puerto princesa, palawan. abstract objective: to present a case of a non-traumatic cerebrospinal fluid (csf) rhinorrhea from a midline sphenoid sinus roof that presented as a persistent postnasal drip and was previously managed as allergic rhinitis for 43 years. methods: design: case report setting: tertiary private university hospital participants: one results: a 58-year-old obese and hypertensive man presented with persistent post nasal drip and intermittent clear watery rhinorrhea. he had been managed as a case of allergic rhinitis for 43 years and was maintained on nasal steroid sprays without relief. nasal endoscopy revealed pulsating clear watery discharge from the sphenoid ostium. on trans-sphenoidal surgery, a midline sphenoid sinus roof defect was sealed using a hadad-bassagasteguy flap. conclusion: csf rhinorrhea is uncommon and may mimic more common diseases such as allergic rhinitis. because misdiagnosis can then lead to life threatening complications, physicians should be vigilant when seeing patients with clear watery rhinorrhea to be able to arrive at a proper diagnosis and provide prompt treatment. keywords: cerebrospinal fluid rhinorrhea; cerebrospinal fluid leak; sphenoid sinus midline roof defect cerebrospinal fluid (csf) leaks are uncommon with most cases due to traumatic causes (iatrogenic or head injury) accounting for 80% of all csf rhinorrhea.1 spontaneous csf rhinorrhea is even more uncommon accounting for only 4% of all csf leaks.1 there is limited clinical data available regarding csf rhinorrhea.1 patients can be mismanaged when they only present with clear watery rhinorrhea and no other associated symptoms. this may result in life threatening complications such as meningitis or brain abscess if not addressed appropriately. 1 we report a case of a non-traumatic cerebrospinal fluid leak in a hypertensive obese man with a 43-year history of post nasal drip and clear watery rhinorrhea. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery case reports case report a 58-year-old obese, hypertensive man who had no previous history of surgery or trauma presented with persistent post nasal drip and intermittent clear watery rhinorrhea. the postnasal drip started 43 years prior to admission, accompanied by intermittent clear watery rhinorrhea especially when he would lean forward. multiple physicians managed this as a case of allergic rhinitis and he was maintained on various of nasal steroid sprays without relief. these symptoms persisted until 2 months prior to admission when the patient experienced headache, fever and decrease in sensorium. admitted at a local hospital with an impression of meningitis, a possible csf leak was considered. his rhinorrhea revealed an elevated glucose level. other laboratory tests were normal. the patient was discharged after 2 weeks of antibiotics and advised to consult a neurosurgeon. a month prior to admission, recurrence of fever, headache and decrease in sensorium prompted readmission for meningitis and antibiotic therapy. a computed tomography (ct) scan showed a non-communicating hydrocephalus and polysinusitis with soft tissue densities in the ethmoid and sphenoid sinuses. (figure 1) magnetic resonance imaging (mri) showed expansion of the pituitary fossa, associated with a crescent-shaped hypoenhancing soft tissue material involving the infrasellar region and the left parasellar region. (figure 2) the patient was eventually discharged and was advised to undergo repair of the csf leak. he consulted a neurosurgeon 1 week before admission. a repeat ct scan showed abnormal widening of the sella turcica, thinning of the clivus with destruction of the left parasellar margins and inferior wall of the left sphenoid sinus, abnormal fluid collection in the left sphenoid sinus with near-csf attenuation, and a bone defect on the sphenoid roof. (figure 3) the patient was referred to our service and nasal endoscopy showed pulsating clear watery discharge from the left sphenod ostium. (figure 4) the patient was admitted for endoscopic transsphenoidal repair of the csf leak. intraoperatively, edema of the sphenoid mucosa was noted. (figure 5a) upon stripping of the mucosa, there was a welldefined circular hole in the sphenoid sinus wall. the hole extended superiorly consistent with the ct scan image. (figure 5b) cerebrospinal fluid was noted to be pulsating out of the dura. inspection of the lateral sphenoid sinus was unremarkable. the defect was repaired using a hadad-bassagasteguy flap. (figure 6) repeat nasal endoscopy 16 days after surgery revealed the flap in place and no csf leak. (figure 7) discussion cerebrospinal fluid leak is caused by a direct communication between the subarachnoid space and the mucosa of the paranasal a b figure 1. plain cranial ct scan. a. non-communicating hydrocephalus (arrow). b. polysinusitis involving the sphenoid (arrow). figure 2. cranial mri with contrast, midsagittal view. note expansion of the pituitary fossa with crescent shaped hypoenhancing soft tissue material (arrow). figure 3. cranial ct scan with contrast, midsaggital view. there is absence of bone on the sphenoid roof (arrow). sinuses.1 the first report of csf leak was from the time of galen in 200 b.c. when they thought that this was a physiologic phenomenon.2 it was only in 1899 when thomson noted that csf leak is an abnormal phenomenon in a series of 21 cases coining the term “cerebrospinal rhinorrhea.”3 the largest case series of csf leak reported 161 cases, of which only 5% were idiopathic.2,4 philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery case reports what was also interesting was that our patient was previously managed as a case of allergic rhinitis for 43 years. he was only treated repeatedly with nasal sprays. csf rhinorrhea can have fatal consequences when not treated appropriately. it can lead to meningitis and intracranial infections as was the case with our patient. it was only when the patient presented with meningitic symptoms that the possibility of a csf leak was investigated. the patient already had two episodes of meningitis when the csf leak was diagnosed. diagnosis of csf leak is confirmed by the presence of csf and localization of the skull base defect.1 confirmation of the presence of csf leak is ideally done using β-2 transferrin or β trace protein.1 glucose testing may also be done however there are cases of false positives and false negatives.1 localization of the skull base defect may be done through csf tracers via ct, mr cisternography and nasal endoscopy after intrathecal tracer fluorescein.1 however in case reports of spontaneous csf leak, diagnosis is mostly made through nasal endoscopy, ct scan and mri.2,6 in some case reports, the csf leak was an incidental finding during transsphenoidal surgery for sellar masses.7 the csf leak was figure 4. preoperative nasal endoscopy. arrow shows a wave of clear fluid coming from the sphenoid ostium. the usual profile of a patient with spontaneous csf rhinorrhea is an obese, hypertensive female who has no history of head trauma or surgery.2,5 our patient was an obese, hypertensive male with no history of head trauma or surgery. also, csf leak usually presents as a clear watery rhinorrhea.2 however, the clinical presentation of our patient was mostly postnasal drip. the patient would only have watery rhinorrhea whenever he would lean forward. figure 6. hadad-bassagasteguy flap (broken lines), right middle turbinate (rmt), right inferior turbinate (rit), left middle turbinate (lmt), left inferior turbinate (lit). figure 7. hadad-bassagasteguy flap 16 days after surgery (broken lines) figure 5. intraoperative findings. a. edematous sphenoid sinus mucosa (arrow). b. hole in the sphenoid sinus wall after mucosal stripping (arrow). a b philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery case reports references 1. citardi m, samer f. cerebrospinal fluid rhinorrhea in flint p, haughney b, lund v, niparko j, robbins t, regan t et al, editors. cummings otolaryngology head and neck surgery. 6th ed. philadelphia city: elsevier; 2015. 803-815. 2. darouassi y, mliha touati m, chihani m, akhaddar a, ammar h, bouaity b. spontaneous cerebrospinal fluid leak of the sphenoid sinus mimicking allergic rhinitis, and managed successfully by a ventriculoperitoneal shunt: a case report. j med case rep. 2016 nov 3; 10(1): 308. doi: 10.1186/s13256-016-1107-0; pmid: 27809892 pmcid: pmc5094058. 3. thomson s. the cerebrospinal fluid. its spontaneous escape from the nose. with observations on its position and function in the human subject. the journal of nervous and mental disease. 1900 feb; 27(2):125. 4. schick b, weber r, mosler p, keerl r, draf w. long-term follow up of fronto-basal dura-plasty. hno. 1997;45(3):117-22. 5. kortbus mj, roland jt, lebowitz ra. sphenoid sinus cerebrospinal fluid leak: diagnosis and management. operative techniques in otolaryngology-head and neck surgery. 2003 sep;14(3):207-211. doi: https://doi.org/10.1016/s1043-1810(03)90027-3. 6. schuknecht b, simmen d, briner hr, holzmann d. nontraumatic skull base defects with spontaneous csf rhinorrhea and arachnoid herniation: imaging findings and correlation with endoscopic sinus surgery in 27 patients. am j neuroradiol. 2008 mar; 29(3): 542-549. doi: 10.3174/ajnr.a0840; pmid: 18079185. 7. ntsambi-eba g, fomekong e, raftopoulos c. spontaneous submucosal sphenoidal fistula discovered intraoperatively: a case report. neurochirurgie. 2014 oct; 60(5): 262-264. doi: 10.1016/j.neuchi.2014.02.009; pmid: 24856048. 8. schlosser r, bolger w. significance of empty sella in cerebrospinal fluid leaks. otolaryngology– head and neck surgery. 2003;128(1):32-38. 9. pérez m, bialer o, bruce b, newman n, biousse v. primary spontaneous cerebrospinal fluid leaks and idiopathic intracranial hypertension. journal of neuro-ophthalmology. 2013;33(4):327-334. 10. hadad g, bassagasteguy l, carrau rl, mataza jc, kassam a, snyderman ch, et al. a novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. laryngoscope. 2006 oct; 116(10):1882-1886. doi: 10.1097/01. mlg.0000234933.37779.e4; pmid: 17003708. 11. brunworth j, lin t, keschner db, garg r, lee jt. use of the hadad-bassagasteguy flap for repair of recurrent cerebrospinal fluid leak after prior transsphenoidal surgery. allergy rhinol (providence). 2013 fall; 4(3): e155-161. doi: 10.2500/ar.2013.4.0072; pmid: 24498521 pmcid: pmc3911805. 12. singh c, shah n. hadad-bassagasteguy flap in reconstruction of skull base defects after endonasal skull base surgery. international journal of otorhinolaryngology and head and neck surgery. 2017;3(4):1020. confirmed in our patient using glucose testing. repeat ct scan of the patient also noted a bone defect in the roof of the sphenoid sinus. nasal endoscopy also revealed a pulsating clear watery discharge from the sphenoid ostium. in our patient, the defect was found in the midline sphenoid sinus roof. this is a rare location of csf leak.6 the defect was a well-defined circular hole in the wall of the sphenoid sinus. traumatic csf leaks do not usually create a defect that well-defined. the exact etiology of non-traumatic csf leaks is still unclear. there are studies that point to increased intracranial pressure (icp). benign intracranial hypertension (bih) or pseudotumor cerebri is a syndrome of increased icp in the absence of specific causes such as intracranial masses, hydrocephalus and dural sinus thrombosis.1 clinical manifestations include headache, pulsatile tinnitus, papilledema and visual disturbances.1 pulsatile increased hydrostatic pressure is capable of bone erosion during the course of many years.6 another syndrome implicated in non-traumatic csf leak is empty sella syndrome.8 the postulated mechanism of csf leak from empty sella is basically the same as benign intracranial hypertension which is increased icp that can eventually cause progressive bone erosion.8 however, we can rule out empty sella syndrome as our patient had a normal-appearing pituitary on mri. hydrocephalus is a condition in which there is an accumulation of csf in the brain.1 this typically causes increased icp and could also cause csf leak.6 however, there were no signs of hydrocephalus in our second ct scan. intracranial neoplasm can cause csf leak in two ways. it can cause a direct invasion to the sinuses thus creating a csf leak. another is through increased intracranial pressure.9 in our case, there was no imaging evidence of an intracranial neoplasm. non-traumatic csf rhinorrhea can also be idiopathic when all other causes have been ruled out.1 having ruled out other causes, our patient may have had an idiopathic case of csf rhinorrhea. our patient had no headache, pulsatile tinnitus, papilledema or visual disturbances. however, patients who have csf rhinorrhea would be asymptomatic even if they have benign intracranial hypertension due to the csf leak acting as a pressure valve that releases pressure.6 pressure measurement using lumbar puncture would also yield normal results because of this phenomenon.6 postoperatively, the patient should present with benign intracranial hypertension since the defect that acts as a valve pressure has been closed. however, our patient did not present with postoperative papilledema, headache and visual disturbances. furthermore, the postoperative increase in icp can cause failure of flap closure. postoperative follow up after 1 month showed an intact flap and the patient was asymptomatic. our patient underwent endoscopic transsphenoidal repair of the csf leak using a hadadbassagasteguy flap. endoscopic management is the primary technique for surgical management of skull base defects.1,6,11 hadad et al.10 first described the use of a neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, a branch of the posterior septal artery. they coined the term hadad-bassagasteguy flap for this type of reconstructive technique.10 this technique has decreased the rate of csf leak post operatively from >20% to only 5%.10,11 a recent prospective study involving 53 patients who underwent hadad bassagasteguy flap reconstruction showed only 3.8% rate of csf leak post operatively.12 a hadadbassagasteguy flap therefore is an efficient technique in repairing csf leak defects with low recurrence of csf leak. postoperatively our patient has no recurrence of csf leak. the patient underwent repeat nasal endoscopy after 16 days post surgery. there was no noted csf leak and the hadad flap was in place. in conclusion, csf rhinorrhea is uncommon and physicians may tend not to consider a diagnosis of csf leak. because the presentation of csf leak can mimic that of more common diseases such as allergic rhinitis, patients can be easily misdiagnosed. a misdiagnosis of csf leak can lead to life threatening complications and physicians should be vigilant when seeing patients with clear watery rhinorrhea to be able to arrive at a proper diagnosis and provide prompt treatment. philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2018; 33 (2): 21-23 c philippine society of otolaryngology – head and neck surgery, inc. prevalence of supraorbital ethmoid air cells among filipinos avian loren c. carlos, md, mba1 january e. gelera, md1,2 1department of otorhinolaryngology head and neck surgery ‘amang’ rodriguez memorial medical center 2department of otorhinolaryngology head and neck surgery university of santo tomas correspondence: dr. january e. gelera department of otorhinolaryngology head and neck surgery ‘amang’ rodriguez memorial medical center sumulong hi-way, sto. niño, marikina city 1800 philippines phone: (632) 941-5854 email: vignettejan@gmail.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the 10th international symposium on recent advances in rhinosinusitis and nasal polyps, and 61st annual convention of the philippine society of otolaryngology head and neck surgery. “cesar villafuerte sr. research contest”. november 30, 2017. manila hotel, manila. presented at the 10th international academic conference in otology, rhinology, and laryngology (orliac). march 2, 2018. fairmont hotel, makati, metro manila. abstract objective: this study aims to determine the prevalence of supraorbital ethmoidal cells (soec) among filipinos in a single tertiary government institution. methods: design: retrospective review of ct scan images setting: single tertiary institution patients: 123 patients aged 13-years-old and above results: a total of 474 ct scans (60 pns and 414 craniofacial) performed during the study period were considered with 55 excluded for age < 13 and 296 excluded for craniofacial fractures. none had congenital craniofacial deformities. eighty-five (85) of 123 ct scans (69.11%) or 147 of 246 sides (59.76%) demonstrated supraorbital ethmoidal cells. there were 62 (72.94%) males and 23 (27.06%) females, ages ranging from 13 to 83 (mean age between male and female was 39.53 and 43.57). the scans showed 62 (50.41%) patients with bilateral and 23 (18.70%) with unilateral soec. twenty-two (25.9%) patients were identified with chronic rhinosinusitis and two of whom were considered to have maxillary sinus mass. two out of 5 patients with soec presented with aplastic/hypoplastic frontal sinus. conclusion: our study suggests that filipinos may have a higher prevalence rate of soec than their chinese, japanese and korean counterparts and bilateral soec are more predominant than unilateral soec. keywords: supraorbital ethmoid cell, anterior ethmoid artery, paranasal ct scan, craniofacial ct scan, frontal sinus surgery completing a functional endoscopic sinus surgery for frontal sinus diseases entails opening and clearing of the frontal recess. computed tomographic (ct) scans are used as a roadmap to guide surgeons in preventing such complications as bleeding, orbital injuries and csf leaks. in particular, anterior ethmoid artery (aea) bleeds are serious, and difficulty in identifying the aea predisposes to intraoperative complications. with the advent of technology, an endoscopic approach provides an effective means to approximate the location of the aea. several studies have shown that with identification of supraorbital ethmoidal cells (soec)-the “pneumatization of the orbital plate of the frontal bone” located posterolateral to the frontal sinus1 -aea location can be predicted.1-5 creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles the prevalence of soec in caucasians is high, involving more than 60% of the population according to 3 studies.5-7 ethnic variations in incidence have been reported ranging from 2.4% in koreans, 5.4% in chinese to 36% in blacks and 69% in caucasians.8 ethnic variations may be a determining factor for the course of the aea and comparative studies have stated that caucasians have a tendency for supraorbital ethmoidal cells while asians have a tendency for suprabullar cells.6,9 we can neither confirm nor deny these findings, because to the best of our knowledge, a search of medline (pubmed), herdin, embase, and google scholar, yielded no published studies on the prevalence of supraorbital ethmoidal cells in filipinos. hence, this study aims to determine the prevalence of supraorbital ethmoidal cells (soec) among filipinos in a single tertiary government institution. methods study design with approval of the ‘amang’ rodriguez memorial medical center institutional review board (erb protocol number: r2017-08-00), this was a retrospective review of paranasal sinus (pns) ct scans and craniofacial ct scans done at a single tertiary government hospital from october 2016 to august 2017. subjects all pns and craniofacial ct scans performed in ‘amang’ rodriguez memorial medical center for various indications during the study period were retrieved chronologically and reviewed by both authors at the radiology department workstation. demographic data included were: age, gender, presence and laterality of soec, presence of aplastic/ hypoplastic frontal sinuses, sinonasal diseases and tumors. excluded were scans of patients below 13 years of age, patients with craniofacial fractures and patients with congenital craniofacial malformations. computed tomography protocol and soec identification all scans had been obtained using a hitachi eclos (hitachi medical corp., tokyo, japan) using a fine-cut (1.25-2.50mm) triplanar study in high-speed mode [collimation: 1.25x8mm, scan time 21s, scan length: 250mm, rotation time: 1.0s, tube settings: 120kv, 150 mas, eff. dose: 29.8mgy]. identification of the soec was consensually arrived at by both authors using van alyea’s definition of soec,3 tracing the border of this air cell from the anterior ethmoids superiorly towards the ethmoid roof and laterally towards the middle orbital wall. when in doubt, a board-certified radiologist was consulted to confirm soec. data analysis data was recorded and tabulated using microsoft® excel for mac v. 16.16.3 (181015) (microsoft corp., redmond, wa, usa) and simple descriptive statistics were applied. results a total of 474 ct scans (60 pns and 414 craniofacial) performed during the study period were considered with 55 excluded for age < 13 and 296 excluded for craniofacial fractures. none had congenital craniofacial deformities. eighty-five (85) of 123 ct scans (69.11%) or 147 of 246 sides (59.76%) demonstrated soec. there were 62 (72.94%) males and 23 (27.06%) females, ages ranging from 13 to 83 (mean age between male and female was 39.53 and 43.57). the scans showed 62 (50.41%) patients with bilateral and 23 (18.70%) with unilateral soec. figure 1 shows an example of a pns ct scan with a unilateral soec on the left. figure 1. representative pns ct scan, bone window. (top right) coronal view at the level of the orbital roof, with corresponding axial (top left) and sagittal (bottom right) views showing the presence of sinonasal disease in both maxillary sinuses and soec on the left frontal recess. note the presence of the supraorbital ethmoid air cell extending posteriorly and superiorly over the left orbital roof within the ipsilateral frontal recess as seen on the sagittal and coronal views. twenty-two (25.9%) patients were identified with chronic rhinosinusitis and two of whom were considered to have maxillary sinus mass. also, 2 out of 5 patients with soec presented with aplastic/ hypoplastic frontal sinus. table 1 summarizes the profiles of patients with soec and aplastic/hypoplastic frontal sinuses. philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles table 1. profile of soec patients with aplastic/hypoplastic frontal sinus patient age gender soec laterality aplastic/hypoplastic sinus laterality 1 2 3 4 5 72 60 63 24 23 f m f m f l l b r r b b discussion the overall prevalence of supraorbital ethmoidal cells in our study was 69.1%. this was 10x more than that previously reported among koreans (2.4%),6 chinese (5.4%)5 and japanese (6%)7 but less than that reported among whites (64.6%).6,10 comparing the prevalence of soec with other races, filipinos in our study have a more than 50% chance of having soec. establishing the consistency of this air cell among filipinos in general can make it a reliable landmark for identifying the aea. we compared our findings with previous studies on the prevalence of soec. a study by bhatt et al. of 531 paranasal sinus ct scans showed a 56.3% prevalence of soec bilaterally and 4.7% unilaterally.4 among filipinos in our series, the presence of bilateral soec was higher than unilateral soec (62% vs 23%, respectively). compared to the general population, 50.4% would have bilateral soec and 18.7% would have unilateral soec. however, there are patients presenting with soec despite having a hypoplastic/aplastic frontal sinus. comer et al. mentioned that septations of the frontal sinus have a higher correlation to the incidence of soec. the stated prevalence values in their study were said to be related to the craniofacial variations between the different ethnicities. it has been said that in caucasians, the development of soec relates to the prominence of the glabella and superior orbital rim. it was also concluded that the skull base length and anteroposterior diameter of the skull was not significant in the development of soec. 6 frontal sinus septations were not measured in this study, however, we found that soec can be present despite having an aplastic or hypoplastic frontal sinus, as seen in table 1. of the 85 patients with soec, 22 were radiographically diagnosed with sinonasal diseases. in terms of having pathology in the sinuses, a study of 70 pns ct scans of patients who were to undergo fess concluded there was “no significant difference in frontal sinus mucosal disease in presence or absence of frontal cells.”6 therefore, having sinonasal diseases would not change the presence or absence of soec in patients. however, having soec may predispose the patient to frontal sinusitis when the frontal sinus drainage pathway is obstructed. kubota et al. reported that in patients with chronic rhinosinusitis, frontal bullar cells were more frequently seen.7 jang et al. mentioned that there may be significant expansion of the soec due to pathology (laterally) but the aea remain within its posterior acknowledgements we would like to thank the armmc department of radiology for allowing us the use of their workstation.to sumitanand mishra, mbbs, pgds, md radiology, april camille g. morillo, rn, md and rainier a. agustines, md for providing their technical knowledge and assistance in confirming the presence of soec in some of the scans. to lourdes a. tan, md, dpbr for her technical knowledge and insights. references 1. simmen d, rghavan u, briner hr, schuknecht b, groscurth p, jones ns. the surgeon’s view of the anterior ethmoid artery. clin otolaryngol. 2006 jun: 31(3):187-91. doi: 10.1111/j.13652273.2006. 01191.x; pmid: 16759237. 2. souza sa, souza mm, gregoria lc, ajzen s. anterior ethmoidal artery evaluation on coronal ct scans. braz j otorhinolaryngol. 2009 jan-feb; 75(1):101-6. pmid: 19488568. 3. jang dw, lachanas va, white lc, kountakis se. supraorbital ethmoid cell: a consistent landmark for endoscopic identification of the anterior ethmoidal artery. otolaryngol head neck surg. 2014 dec; 151(6): 1073-1077. doi: 10.1177/0194599814551124; pmid: 25257902. 4. bhatt nj, yardimci s. supraorbital ethmoidal cell: anatomical prevalence and surgical significance. otolaryngol head neck surg. 2004 aug; 131(2). 5. zhang l, han d, ge w, tao j, wang x, li y, zhou b. computed tomographic and endocoscopic analysis of supraorbital ethmoidal cells. otolaryngol head neck surg. 2007 oct; 137(4): 562-568. doi: 10.1016/j.otohns.2007.06.737; pmid: 17903571. 6. cho jh, citardi mj, lee wt, sautter nb, lee hm, yoon jh, et al. comparison of frontal pneumatization patterns between koreans and caucasians. otolaryngol head neck surg. 2006 nov; 135(5): 780-786. doi: 10.1016/j.otohns.2006.05.750; pmid: 17071312. 7. kubota k, takeno s, hirakawa k. frontal recess anatomy in japanese subjects and its effect on the development of frontal sinusitis: computed tomography analysis. j otolaryngol head neck surg. 2015 may 29; 44:21. doi: 10.1186/s40463-015-0074-6; pmid: 26021826 pmcid: pmc4459068. 8. comer bt, kincaid nw, smith nj, wallance jh, kountakis se. frontal sinus septations predict the presence of supraorbital ethmoid cells. laryngoscope. 2013 sep; 123(9): 2090-2093. doi: 10.1002/lary.23705; pmid: 23821470. 9. ko yb, kim mg, gi jung y. the anatomical relationship between the anterior ethmoid artery, frontal sinus, and intervening air cells; can the artery be useful landmark?. korean journal of otorhinolaryngology-head and neck surgery. 2014; 57(10): 687-691. doi: : https://doi. org/10.3342/kjorl-hns.2014.57.10.687. 10. comer bt, kountakis se. the supraorbital ethmoid cell. in: kountakis s, senior b, draf w (editors). the frontal sinus. springer, berlin, heidelberg. 2016. pp. 315-323. border.3 the 22 patients with sinonasal diseases in our study did not show any significant expansion of the soec radiographically making the location of the aea still predictable. our study has several limitations. first, our study has design issues. thus, despite the data obtained in our study, no correlations or associations were explored among variables. further studies should be undertaken to establish such relationships. second, our study has ascertainment and selection bias. our sample of pns ct scans consisted entirely of patients with indications for these scans and may not represent the larger population to which our results are meant to apply. future studies can pay more attention to sample size, sampling methods and criteria for inclusion and exclusion. third, our study also has observer bias. assessment of soec was consensually performed by unblinded authors who were both ent clinicians although a boardcertified radiologist was consulted for equivocal images. independent evaluations by blinded board-certified radiologists may be performed in future studies. despite these limitations, our study may be a stepping stone toward providing data for a meta-analysis among asean countries provided that other asean countries like thailand, malaysia, indonesia conduct their own prevalence studies. in conclusion, our study suggests that filipinos may have a higher prevalence rate of soec compared to their chinese, japanese and korean counterparts. bilateral soec are more predominant than unilateral soec. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2023; 38 (1): 54-57 c philippine society of otolaryngology – head and neck surgery, inc. combined cartilage graft reconstruction of the nasal tip complex after resection of nasal tip schwannoma: a case report faith jennine p. bacalla, md joman, q. laxamana, md department of otorhinolaryngology head and neck surgery jose b. lingad memorial general hospital correspondence: dr. joman q. laxamana department of otorhinolaryngology head and neck surgery jose b. lingad memorial general hospital mcarthur highway, dolores san fernando, pampanga 2000 philippines phone: +63 45 409 6688 local 144 email: jqlaxamana@gmail.com the authors of this case report declare that this manuscript is an original material, which has not been published or is being considered for publication, partially or in full, in any form. each author believes the manuscript represents honest work, and all have met the requirements for authorship. disclosures: the authors signed a disclosure that no financial or other personal relationships, intellectual passion, or personal beliefs and institutional affiliations may lead to conflict of interests. abstract objective: to present a rare case of nasal tip schwannoma and describe its resection and reconstruction using combined cartilage grafts. methods: design: case report setting: tertiary government training hospital patient: one results: a 13-year-old boy presented with a progressively enlarging nasal tip and severe left nasal obstruction causing breathing difficulties and psychosocial distress. there was a bulging septal mass obstructing 90% of the left nasal cavity. septal incision biopsy revealed schwannoma and definitive surgery via open rhinoplasty approach was done. the non-encapsulated schwannoma extended from the subcutaneous nasal tip to the left septal mucosa. there was no evidence of skin or cartilage invasion, but prolonged pressure from the expansile schwannoma caused severe lower lateral cartilage and anterior septal atrophy leading to a collapsed and expanded nasal tip after resection. to correct this, a total reconstruction of the anterior tip complex was done using combined ear cartilage seagull wing graft, shield graft and septal extension graft. conclusion: nasal tip and septal schwannoma is rare and can cause significant nasal obstruction and deformity. complete excision is vital to avoid recurrence. total reconstruction of the lower lateral cartilages using autologous septal and ear cartilage grafts may be a safe and effective technique that yields acceptable aesthetic results. keywords: nasal septum; nasal tip; schwannoma; ear cartilage; rhinoplasty; nasal cartilages; esthetics; neurilemmoma; adolescent schwannomas are slow growing, benign tumors originating from schwann cells of the peripheral nerve sheath. about 20-40% of cases occur in the head and neck but it is rarely found in the sino-nasal area1 and even more rare in the pediatric age group.2 delayed diagnosis and treatment can result in expansive growth that may cause severe functional and aesthetic complications. we present one such case. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international case reports philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery case reports case report a 13-year-old boy presented with a 1-year history of enlarging nasal tip and progressive left nasal obstruction and nostril asymmetry. the nasal tip was bulbous, firm, non-tender and with no skin discoloration. (figure 1) he had no complaints of nasal discharge, pain, anosmia, epistaxis or paresthesia. anterior rhinoscopy revealed a smooth, fleshy mass on the left side of the nasal septum occupying 90% of the nasal vestibule. (figure 2) contrast-enhanced paranasal sinus computed tomography (ct) scan showed a 2.0 x 1.5 x 3.0 centimeter enhancing soft tissue mass occupying the nasal tip and supratip, extending into the mid-portion of the left nasal cavity. (figure 3) there was thinning of the anterior septal cartilage with no bone erosion. endoscopic incision biopsy of the septal mass revealed schwannoma. definitive surgery involved an open rhinoplasty approach under general anesthesia. a transcolumellar incision combined with a bilateral marginal incision was done to fully expose the mass and nasal septum. the mass was non-encapsulated with its bulk occupying the subcutaneous nasal tip and its flat end extending to the left nasal septal mucosa up to the bony-cartilaginous junction. there was no involvement of the cartilaginous septum and nasal tip skin. excision of the mass with a margin of normal soft tissue and mucosa was done. the tip component of the mass measured 3.5 x 2.0 x 1.0 cm and the septal component measured 2.5 x 2.0 x 1.0 cm. (figure 4) after excision, both the lateral and medial crura of the atrophied lower lateral cartilage were unable to support the expanded nasal tip skin and alae. a neo-cartilage complex was designed using both septal and ear cartilage. the central septal cartilage was harvested while leaving an intact 1cm caudal and dorsal l-strut. the right concha cavum and cymba were also harvested via an anterior incision. (figure 5) the septal cartilage was used as an extended septal extension graft a small shield graft. the conchal cartilage was divided lengthwise and shaped into the medial and lateral crura. (figure 6) total blood loss was negligible and there was no post-operative pain, bleeding or infection. after 3 months, the nasal tip skin had wrapped around the neo-cartilage complex with good projection and no drooping. there was improvement of the nostril asymmetry and resolution of the left nasal obstruction. (figure 7) our patient is being monitored for recurrence and advised to undergo definitive rhinoplasty after 4-5 years. discussion schwannomas, also known as neurilemmomas are benign usually solitary tumors that originate from schwann cells of peripheral figure 1. preoperative photos showing the enlarged nasal tip: a. bulbous nasal tip deviated to the right; b. asymmetrical nostril shape; and c. slight tip rotation and supratip fullness. figure 2. anterior rhinoscopy findings; a. patent right nasal cavity; b. smooth, pink, fleshy mass occupying 90% of left nasal vestibule and attached medially to the membranous septum and caudal septum. figure 4. . intraoperative findings: a. open rhinoplasty exposure of non-encapsulated mass firmly attached to nasal vestibular skin and nasal tip soft tissue; b. tip component measuring 3.5 x 2.0 x 1.0 cm; and c. septal component measuring 2.5 x 2.0 x 1.0 cm. figure 3. preoperative contrast enhanced paranasal sinus computed tomography (ct) scans; a. coronal view showing an enhancing midline mass predominantly bulging in the left nasal vestibule (encircled); b. axial view showing involvement of the nasal tip superiorly (encircled); and c. axial view showing septal cartilage atrophy where the mass traverses the septum (encircled). a a b b c a a c b bb cc nerve sheaths, which may arise from motor, sensory, sympathetic, or cranial nerves, and thus grow anywhere. in this case the nasal tip schwannoma may have originated from the nasopalatine or nasociliary nerves.3 these tumors usually appear between the 2nd and 4th decade of life and pediatric occurrence as in this case is also extremely rare.2 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery case reports (plexiform subtype), making total excision more difficult, as in this case5. frozen section biopsy may be helpful in ensuring tumor-free margins.6 a ct scan is useful to determine extent of the mass and involvement of adjacent bony structures but is usually non-diagnostic.7 schwannomas are seen microscopically with cellular antoni a areas with verocay bodies and hypocellular myxoid antoni b areas.8 magnetic resonance imaging (mri) can distinguish between schwannomas with predominant antoni a component (intermediate signal on t1 and t2) or predominant antoni b component (hyperintense t2), but it does not show the relevant sinonasal bony anatomy crucial for operative planning.7 immunostaining using s-100 protein can also be done to confirm the diagnosis.9 in this case, the bulky schwannoma caused expansion of the nasal tip skin and weakening of the lower lateral cartilages and disruption of fibrous tip support structures. left unsupported, the unsightly wide tip collapses and constricts the nasal vestibule. to ensure nostril patency and correct the severe tip drooping, the lower lateral cartilage framework should be restored. the ideal material for nasal cartilage reconstruction is autologous septal and ear cartilage. the straight and resilient septal cartilage is ideal for central support and tip projection while the flexible and naturally arched ear cartilages can be formed into similarly curved lower lateral cartilages. there is low morbidity of the donor sites with high resistance to infection and a low rate of resorption.10 extracorporeal nasal cartilage reconstruction has been used for cleft nose deformities and severe nasal deformities.11 in 2006, pedroza et al., developed the seagull wing graft composed of cut conchal cartilages sutured together designed to replace the lower lateral cartilages.12 using the limited cartilage we harvested, we constructed figure 5. cartilage harvesting: a. anterior incision with preservation of the helix; b. harvested right conchal cartilage; and c. harvested central portion of the septal cartilage. figure 6. reconstruction of nasal tip framework: a. schematic diagram of combined seagull wing graft (blue solid lines) and septal extension graft (yellow dashed lines); b. insinuated seagull wing grafts fold to form bilateral crura of the nasal tip; c. portion of septal cartilage used as a shield graft for better tip definition; and d. adequate nasal tip projection and acceptable definition after closure. a c b a c b d about 25-40% of cases are seen on the head and neck and only 4% are sino-nasal.4 these most commonly arise from the ethmoid sinuses followed by  the maxillary sinuses,  nasal cavity  and  sphenoid  sinuses.4 schwannomas of the nasal tip are rare, with to our knowledge, only 11 patients documented in the english literature, based on a search of medline (pubmed), the directory of open access journals (doaj), and google scholar, using the search terms “nasal tip”, “schwannoma” and “neurilemmoma”. similarly, we found no documented case in the philippines with an expanded search including herdin plus, the asean citation index (aci) and western pacific region index medicus (wprim). schwannomas may appear as well delineated, globular, firm to rubbery masses. they can be encapsulated or non-encapsulated figure 7. three month post operative photos: a. acceptable aesthetic outcome and shrinkage of the nasal tip; b. tip is fairly projected even after nasal tip shrinkage and expected natural resorption of cartilage grafts. a b philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery case reports references 1. karatas a, cebi it, salviz m, kocak a, selcuk t. schwannoma of the nasal septum. egypt j ear nose throat allied sci. 2016 nov;17(3):185-188. doi: 10.1016/j.ejenta.2016.06.001. 2. başar i̇, hanalioğlu ş, narin f, bilginer b. pediatric vestibular schwannomas: evaluation of clinical features, treatment strategies and long-term results of 10 cases. tr-ent. 2018;28(3):116-125. doi: 10.5606/tr-ent.2018.57966. 3. dhawle ms, rathod sg, bhatkule ma, bindu rs. sinonasal schwannoma a case report. j cin diagn res. 2017 may;11(5):ed22-ed23. doi:10.7860/jcdr/2017/21532.9851; pubmed pmid: 28658783; pubmed central pmcid: pmc5483685. 4. kumar s, sayoo c. sinonasal schwannoma: a rare sinonasal neoplasm.  indian j otolaryngol head neck surg. 2017 sep;69(3):425-427. doi:10.1007/s12070-017-1125-2; pubmed pmid: 28929080; pubmed central pmcid: pmc5581763. 5. destro f, sharma s, maestri l, vella c, collini p, riccipetitoni g. visceral plexiform schwannoma: a case series. mol clin oncol. 2021 jan;14(1):14. doi:10.3892/mco.2020.2176; pubmed pmid: 33282289; pubmed central pmcid: pmc770955. 6. nanarng v, jacob s, mahapatra d, mathew je. intraoperative diagnosis of central nervous system lesions: comparison of squash smear, touch imprint, and frozen section. j cytol. 2015 jul-sep;32(3):153-158. doi:10.4103/0970-9371.168835; pubmed pmid: 26729974; pubmed central pmid: 26729974. 7. kim ys, kim hj, kim ch, kim j. ct and mr imaging findings of sinonasal schwannoma: a review of 12 cases. ajnr am j neuroradiol. 2013 mar;34(3):628-33. doi: 10.3174/ajnr.a3257; pubmed pmid: 22954739; pubmed central pmcid: pmc7964917. 8. wippold fj 2nd, lubner m, perrin rj, lämmle m, perry a. neuropathology for the neuroradiologist: antoni a and antoni b tissue patterns. ajnr am j neuroradiol. 2007 oct;28(9):1633-8. doi: 10.3174/ajnr.a0682; pubmed pmid: 17893219; pubmed central pmcid: pmc8134199. 9. buob d, wacrenier a, chevalier d, aubert s, quinchon jf, gosselin b, leroy x. schwannoma of the sinonasal tract: a clinicopathologic and immunohistochemical study of 5 cases. arch pathol lab med. 2003 sep;127(9):1196-9. doi: 10.5858/2003-127-1196-sotsta; pubmed pmid: 12946223. 10. kim jy yang hj, jeong jw. a new technique for conchal cartilage harvest. arch plast surg. 2017 mar;44(2):166-169. doi:10.5999/aps.2017.44.2.166; pubmed pmid: 28352607; pubmed central pmcid: pmc5366525. 11. tasca i, compadretti gc, losano ti, lijdens y, boccio c. extracorporeal septoplasty with internal nasal valve stabilisation. acta otorhinolaryngol ital. 2018 aug;38(4):331-337. doi:10.14639/0392100x-1525; pubmed pmid: 30197424; pubmed central pmcid: pmc6146577. 12. pedroza, f, anjos, gc, patrocinio, lg, barreto, jm, cortes, j, quessep, sh. seagull wing graft. arch facial plast surg. 2006 nov-dec;8(6):396-403. doi: 10.1001/archfaci.8.6.396; pubmed pmid: 17116787. 13. fehlings mg, nater a, zamorano jj, tetreault la, varga pp, gokaslan zl, et al. risk factors for recurrence of surgically treated conventional spinal schwannomas: analysis of 169 patients from a multicenter international database.  spine (phila pa 1976). 2016 mar;41(5):390-398. doi:10.1097/brs.0000000000001232; pubmed pmid: 26555828; pubmed central pmcid: pmc4769652. 14. mey kh, buchwald c, daugaard s, prause ju. sinonasal schwannoma--a clinicopathological analysis of five rare cases. rhinology. 2006 mar;44(1):46-52. pubmed pmid: 16550950. 15. van der heijden p, korsten-meijer ag, van der laan bf, wit hp, goorhuis-brouwer sm. nasal growth and maturation age in adolescents: a systematic review. arch otolaryngol head neck surg. 2008 dec;134(12):1288–1293. doi:10.1001/archoto.2008.501; pubmed pmid: 19075124. a nasal tripod by combining the seagull wing graft, septal extension graft and a shield graft. this complex could support the weight of the nasal tip and withstand the forthcoming wound contracture thereby preventing tip collapse, alar pinching and poor tip definition. to the best of our knowledge, our case is the first instance of nasal tip framework reconstruction using combined conchal seagull wing graft and a septal extension graft based on a search of medline (pubmed), the directory of open access journals (doaj), and google scholar, using the mesh terms “rhinoplasty”, “ear cartilage” and “surgical flaps”. our initial results suggest that the composite neo-cartilage structure may act as an effective tripod for long term tip support. the expanded skin and soft tissue envelope are also expected to “shrink-wrap” around the neo-cartilage over time leading to a more aesthetically pleasing tip shape. after total excision, the recurrence rate is 5%13 and there are accounts of rare malignant transformation so that long-term follow-up is advised.14 our case is further complicated by the young age of the patient. his facial skeleton and nasal septal cartilages will mature to adult size around the age of 1815 and definitive rhinoplasty should be delayed until that time. in summary, schwannoma of the nasal tip and septum is rare and can cause significant nasal obstruction and deformity. the plexiform non-encapsulated subtype necessitates more aggressive resection to ensure tumor free margins and low risk of recurrence. our novel technique of total lower lateral cartilage reconstruction using combined seagull wing ear cartilage graft, shield graft and a septal extension graft may be a safe and effective procedure with an acceptable aesthetic outcome. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: this study aims to describe a new extraoral technique for reducing bilateral temporomandibular joint (tmj) dislocations. methods: design: retrospective preliminary case series setting: tertiary government training hospital participants: ten (10) adults with bilateral tmj dislocation results: ten patients, 7 males and 3 females with median age of 35.50 (iqr:21.25 [23.50, 44.75]) years old were included in our series. seven had more than one previous episode of tmj dislocation, and the dislocation spontaneously occurred while yawning or eating in six patients. our new technique resulted in complete bilateral reduction in three patients who had first-episode tmj dislocations but only in four out of seven with previous dislocation. the three others (two partial, unilateral failure of reduction and one complete failure of reduction) needed conventional extraoral reduction (hippocratic technique). conclusion: this new extraoral technique may show promising preliminary results in the management of temporomandibular joint dislocation, but a larger trial in comparison with other techniques is needed. keywords: temporomandibular joint; tmj; temporomandibular joint disorders; joint dislocations; therapy temporomandibular joint (tmj) dislocations have an incidence of 3% among all the possible dislocations occurring in the human body.1,2 dislocations can occur medially, laterally, posteriorly and anteriorly, and may be classified as partial (subluxation) or complete (luxation), bilateral or unilateral, acute, chronic protracted or chronic recurrent.3 in the emergency department (ed) alone, the spontaneous type of anterior tmj dislocation was reported to have annual incidence a new extraoral closed reduction technique for temporomandibular joint dislocation: a preliminary case series marice b. sangalang md1 fatima m. gansatao, md1 alfred peter justine e. dizon md2 rubiliza dc. onofre-telan, md1 1department of otolaryngology-head and neck surgery ‘amang’ rodriguez memorial medical center 2department of surgery angeles medical center, pampanga, philippines correspondence: dr. rubiliza dc. onofre-telan department of otolaryngology-head and neck surgery ‘amang’ rodriguez memorial medical center sto. niño, marikina city 1800 philippines phone: (+63) 917 575 1982 email: rubiliza.onofre8211@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest (1st place), november 8, 2021. philipp j otolaryngol head neck surg 2022; 37 (2): 34-37 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery original articles of 5.3 per 1,000,000 patients.1 associated discomfort due to limitation of joint mobility with impaired functions of speaking and chewing and resulting muscle spasm warrant the need for repositioning the joints.1,4 however, due to instances of prolonged dislocation, extreme pain, stiffening of the jaw muscle and anxiety of patients, there are cases that needed sedation to facilitate reduction.4,5 acute dislocations (isolated events presenting in 2 weeks which have no long-term sequalae when managed appropriately) can readily be reduced by intraoral approaches.2 two of the most common intraoral approaches, the hippocraticthe conventional method and wrist pivot methods,6 are comparable in terms of success rate, reduction-related pain, and reduction time.2 however, disadvantages associated with these techniques include bite injuries which can lead to the possibility of the operator contracting hepatitis and hiv-aids thru open wounds.4,6 on the other hand, the extraoral method as described by chen et al.7 remained to be difficult for both patients and physicians, attributed to the placement of direct pressure on the cheek bone and the coronoid process.4,7 moreover, extraoral techniques attain better resolution when applied to unilateral tmj dislocations than to bilateral dislocations4,8 and there were no significant differences between the time duration of performing the technique and failure rate compared to hippocratic method.4 therefore, the difficulty of performing the current extraoral technique, and risk of bite injury to the operators associated with the intraoral techniques prompted us to develop an alternative extraoral technique that can possibly address these two issues related with current available techniques in the management of tmj dislocations. this study aims to describe our preliminary experience using a new extraoral technique for reducing bilateral temporomandibular joint dislocations. methods with ‘amang’ rodriguez memorial medical center research board approval (armmc-erb r-2021-02-00), this retrospective case series reviewed records of patients aged 18-65 years old with acute anterior tmj dislocation (less than 2 weeks) and no other associated temporomandibular joint disorders seen in our emergency department from july 1, 2020 to may 31, 2021. excluded were those with incomplete data in the medical records and those who cases had mandibular dislocations with associated mandibular and facial fractures. this new extraoral technique was conceived by co-investigator apjed (then a level 1 orl-hns resident in training at the east avenue medical center) in 2014. he first performed it successfully on an emergency room patient with spontaneous tmj dislocation who was agitated when an intraoral technique was initially attempted. seeing its potential, he started to apply the technique in reducing tmj dislocations among awake patients throughout his residency training but did not write about it or publish any scientific article or technical note about it. neither did we find this exact technique described as we searched through herdin plus, medline (pubmed, pmc), embase, google scholar, directory of open access journals (doaj), and science direct using the keywords “temporomandibular joint dislocation”, “closed reduction”, “tmj”, “temporomandibular joint disorders”, “management”, “treatment” and “therapy”. in 2019, co-investigator fmg (who had performed the technique with apjed as a co-resident in the previous institution) joined our institution (armmc) and started teaching our residents the maneuver, applying it on patients who had tmj dislocation. together with the primary investigator (mbs), some modifications were made on the original technique, and with permission from the originator (apjed), the modified combined technique was called the dgs extraoral tmj reduction technique (combining the letters of the last names of the three developers). this technique was employed by second year residents in training, assisted and supervised by a consultant, on all the patients with spontaneous bilateral anterior tmj dislocation reported in this series. decisions to proceed with performing hippocratic method in cases of failed reduction using the developed technique were made after assessment and intervention by the supervising consultant. our extraoral tmj reduction technique patients were seated on a stool with their head resting on the physician’s abdomen who was standing behind. (figure 1) the physician’s thumbs were positioned along the mandibular oblique line while the rest of the fingers were curled at the inferior mandibular border. (figure 2) the patient was asked to slowly elevate and depress the mandible several times. during an active depression, the physician applied a sudden downward parallel force along the mandibular oblique line followed by an immediate reciprocal pull by the fingers on the inferior border of the mandible in a reverse “hockey stick” shaped direction. (figure 3) successful reduction was defined as complete reduction, evidenced by complete repositioning of both condylar heads into the glenoid fossa. post-reduction measures included application of a barton bandage, soft diet, and oral muscle relaxants and analgesics. data analysis records of patients meeting inclusion and exclusion criteria were collected, and the demographic profiles, previous history of tmj dislocation, and outcomes of the reduction were extracted from the records and tabulated. an outcome was considered failed if philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery original articles repositioning of both condylar heads into the glenoid fossa using the developed extraoral reduction technique was not achieved resulting to conversion to the hippocratic tmj reduction method. descriptive statistics (median, iqr, frequencies and ratios) were utilized to describe the data. xlstat version 2021.3.1 (addinsoft, ny, usa) was used for data analysis. results ten patients with bilateral anterior dislocations were included in our series, 7 males and 3 females, with median age of 35.50 (iqr:21.25 [23.50, 44.75]) years old. seven out of 10 patients had experienced more than one previous episode of tmj dislocations. one reported spontaneous reduction and resolution of dislocation with his previous episode while the others had their previous episodes reduced by doctors during er visits. six out of 10 disclosed that they were yawning prior to the event while 2 were eating before the dislocation happened. the interval between the occurrence of the dislocation to arrival of these patients at our emergency room for consult ranged from few minutes to 3 days. upon application of the new technique, resolution of the dislocation was attained among the three patients who came in with the first episode of bilateral dislocation. for the seven cases who had more than one previous dislocation, we were able to completely reduce the bilateral dislocation in 4 out of 7. for the three other patients out of these seven, we were not able to reduce either joint in one while we attained unilateral reduction in the other two. these three were eventually managed using the hippocratic method. no fractures resulted among these 10 patients when performing the new technique. discussion our new extraoral closed reduction technique yielded a total of seven out of 10 successful reductions (three in first-episode, and four in repeat-episode dislocations), and three out of 10 failed reductions (one complete and two partial failures, all in repeat-episode dislocations). in comparison, all seven patients who underwent the extraoral tmj dislocation reduction technique of chen et al. in 20077 (applying pressure over the cheek bones and coronoid process) attained full reduction. they further reported that other tmj spontaneously reduced in cases where they were only able to initially reposition one of the joints in the fossa.7 this differed from our experience as we did not encounter any such spontaneous reduction of the contralateral joint when only one joint was initially reduced. our series showed that our new technique may be useful in reducing bilateral dislocations, but we had three failurestwo wherein we were only able to reduce one joint and one wherein we were not able to reduce both dislocations necessitating intraoral hippocratic tmj reduction. this finding showed a possible limitation of our extraoral approach in managing bilateral tmj dislocations. a systematic review by perchel et al. in 20182 reported that extraoral reduction techniques have low success rates when used for patients with bilateral dislocation. similar observations were reported by aredhali et al.8 in their 2009 figure 1. positioning the patient with the physician standing behind. figure 2. model illustration of grasping the mandible along the mandibular oblique line. a. lateral view; and b. superior view. figure 3. model illustrations of a. application of a sudden downward parallel force along the mandibular oblique line; b. pulling on the inferior border of the mandible in a reverse “hockey stick” direction; and c. completed reduction. a b c a b philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery original articles series where they employed the intraoral approach when they failed to reduce the other joint in two of their cases and they had to revert to the extraoral method developed by chen et al.7 more importantly, all our three failures involved repeat-episode dislocations. of the seven patients with a history of more than one episode of dislocation, we were only able to reduce four using our technique. this may suggest that the extraoral maneuver may be less effective when performed among patients with past histories of tmj dislocations. the 20098 and 20164 studies of ardehali et al. reported the ratio of recurrent dislocations to first encounter dislocations among their patients on whom the extraoral maneuver developed by chen et al.7 was performed but did not report the frequency of resolution in this subgroup of patients. in our present series, we may possibly attribute the difficulty or failure to attain bilateral reduction in three cases with previous dislocations to: 1) time from dislocation to intervention which was evident in one patient who came in with 3 days history of tmj dislocation; 2) spasms of the pterygoid and masseteric muscles or laxity of the joint itself due to prior dislocations1 where use of muscle relaxant or sedation could have help in the ease of reduction; and 3) patient and operator fatigue caused by repeated trials of the new procedure. although no condylar fractures (common sequela of tmj reduction)8,9 resulted from our technique, it is premature to assume that our technique is safe to perform compared to intraoral and other extraoral techniques. our initial results may not demonstrate the maximum potential of this new technique, and our method still cannot be generalized to apply to all cases of bilateral tmj dislocation. limitations of this preliminary series include a small sample size and steep learning curve in mastering the technique. performing the technique more often among patients who meet eligibility criteria and with guidance from its proponents to correct possible errors in performance and master the technique for those who will apply the maneuver may address this limitation. further prospective studies involving more participants must be conducted to further assess its effectiveness and safety for these subsets of patients in comparison with the other intraoral and extraoral closed reduction techniques. in conclusion, our new extraoral technique may show promising preliminary results in the management of bilateral temporomandibular joint dislocations, but a larger trial in comparison with other techniques is needed.. acknowledgements we would like to acknowledge ms. jenica sangalang who modeled for the photos illustrating the technique. references 1. papoutsis g, papoutsis s, klukowska-rotzler j, schaller b, exadaktylos ak. temporomandibular joint dislocation: a retrospective study from a swiss urban emergency department. open access emerg med. 2018 oct 30;10:171-176. doi:10.2147/oaem.s174116; pubmed pmid: 30464655; pubmed central pmcid: pmc6214416. 2. prechel u, ottl p, ahlers om, neff a. the treatment of temporomandibular joint dislocation—a systematic review. dtsch arztebl int. 2018 feb 2;115(5):59–64. doi: 10.3238/arztebl.2018.0059; pubmed pmid: 29439762; pubmed central pmcid: pmc5817180. 3. akinbami bo. evaluation of the mechanism and principles of management of temporomandibular joint dislocation. systematic review of literature and a proposed new classification of temporomandibular joint dislocation. head face med. 2011 jun 15;7:10. doi: 10.1186/1746-160x-7-10; pubmed pmid: 21676208; pubmed central pmcid: pmc3127760. 4. ardehali mm, tari n, amirizad be. comparison of different approaches to the reduction of anterior temporomandibular joint dislocation: a randomized clinical trial. int j oral maxillofac surg. 2016 aug;45(8):1009-14. doi: 10.1016/j.ijom.2016.04.015; pubmed pmid: 27160610. 5. totten vy, zambito rf. propofol bolus facilitated reduction of luxed temporomandibular joints. j emerg med.1998 may-jun;16(3):467-70. doi: 10.1016/s0736-4679(98)00018-3; pubmed pmid: 9610979. 6. gorchynski j, karabidian e, sanchez m. the syringe technique: a hands-free approach for the reduction of acute nontraumatic temporomandibular dislocations in the emergency department. j emerg med. 2014 dec;47(6):676-81. doi: 10.1016/j.emermed.2014.06.050; pubmed pmid: 2528137. 7. chen yc, chen ct, lin ch, chen yr. a safe and effective way of reduction of temporomandibular joint dislocation. ann plast surg. 2007 jan;58(1):105-8. doi:  10.1097/01. sap.0000232981.40497.32; pubmed pmid: 17197953. 8. ardehali mm, kouhi a, meighani a, rad fm, emami h. temporomandibular joint dislocation reduction technique. a new external method vs. the traditional. ann plast surg. 2009;63(2):176178. doi: 10.1097/sap.0b013e31818937aa; pubmed pmid: 19542876. 9. shun tat, wai wt, chiu lc. a case series of closed reduction for acute temporomandibular joint dislocation by a new approach. eur j emerg med. 2006 apr;13(2):72-5. doi: 10.1097/01. mej.0000192046.19977.5a; pubmed pmid: 1652532. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles philippine journal of otolaryngology-head and neck surgery 27 abstract objective: to describe the type and determine the number of motorcycle related craniomaxillofacial injuries that were seen by the orl service in the emergency room of a tertiary hospital from january 2013 to december 2013. methods: design: cross sectional retrospective chart review setting: tertiary national university hospital participants: one hundred nine (109) charts of patients seen at the emergency room from january 2013 to december 2013 were reviewed results: of the 109 charts of patients involved in vehicular accidents, there were 76 documented cases of motorcycle related accidents. of these, 91% involved males and 9% involved females. seventy one percent (71%) did not wear helmets, of whom 36% were young adult males between the ages of 18-30 years. those that wore helmets had a total of 27 different facial fracture sites: 19% zygomatic tripod fractures, 15% temporal bone fractures and 11% with no fractures noted. among those who did not wear helmets 75 fractures were noted. twenty four percent (24%) were tripod fractures, 15% temporal bone fractures and 12% maxillary fractures. only one did not incur any fractures. conclusion: most cranio-maxillofacial fractures seen at the emergency room were from motorcycle related injuries (70%). despite implementation of republic act 10054 (the motorcycle helmet act of 2009) majority of motorcycle-related accidents are still incurred by riders without helmets. keywords: cranio-maxillofacial fractures, motorcycle accidents, helmet, tripod fracture, temporal bone fracture motorcycles have become an increasingly popular form of transportation due to their low cost in fuel consumption and flexibility in avoiding traffic conditions in the metropolitan area. however, this type of transport is the top cause of fatal and nonfatal injuries in vehicular accidents.1 several studies have shown that the use of helmets decreased the incidence of fatal and nonfatal injuries.2-5 the enactment of the universal helmet law also decreased hospital admissions for motorcycle related injuries.2-5 in the philippines, the motorcycle helmet act was signed into motorcycle related cranio-maxillofacial injuries at a tertiary hospital in the philippines rhodieleen anne r. de la cruz, md1 rene s. tuazon, md2 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2department of otorhinolaryngology college of medicine philippine general hospital university of the philippines manila correspondence: dr. rene s. tuazon department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone (632) 554 8467 email: rstuazonmd@gmail.com reprints will not be available from the author. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest. september 18, 2014. natrapharm, the patriot building, parañaque city. philipp j otolaryngol head neck surg 2016; 31 (2): 27-30 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 28 philippine journal of otolaryngology-head and neck surgery original articles law in march 2010.6 despite the enactment of this law there have still been numerous cases of motorcycle related accidents without helmet use.7 as, such there is a need to collect epidemiological data on the frequency of helmet use among motorcyclists. determining the number of motorcycle accidents, demographics, frequency of helmet use and type of injuries may assist in formulating a program to increase awareness of the law and its provisions, and lessen injuries from road accidents. the aim of this study was to determine the following: 1) frequency of helmet use in drivers or riders involved in motorcycle accidents; 2) the number of motorcycle-related cranio-maxillofacial injuries; 3) type of cranio-maxillofacial fracture incurred by patients who were helmets users versus non-users; and 4) mechanisms of injury. methods with institutional ethical review board approval, a retrospective cross sectional chart review of cases involving vehicular accidents between january 1 and december 31, 2013 was conducted. charts were retrieved from the hospital medical records section using the patient’s case number and name obtained from the emergency room census. included were records of those 1) referred to the otorhinolaryngology emergency room (orl er) service from january 2013 to december 2013; 2) who were drivers and passengers involved in motorcycle accidents; and 3) who underwent radiographic tests. excluded were records of patients 1) who absconded or went home against advice before they underwent radiographic tests; 2) who were involved in other types of vehicular accidents; and 3) involved in motorcycle accidents but not referred to the orl service. a data abstraction sheet was used to encode data from the charts. data regarding qualitative variables were summarized using frequencies and percentages. quantitative data were summarized using mean, standard deviation and these were analyzed using microsoft excel 2010 version 14.0.7015.1000 sp2 (microsoft corp., redmond, wa, usa). results of the 121 charts of patients incurring cranio-maxillofacial injuries initially retrieved from the medical records section, 109 charts of patients meeting inclusion and exclusion criteria were involved in vehicular accidents. seventy-six (70%) of these were motorcycle related. there were 69 males and 7 females, with ages ranging 14-60 years old. demographic data of the patients are summarized in table 1. only 29% of the patients in the charts reviewed wore a helmet during the time of the accident. most of the patients who did not wear table 1. distribution of age according to sex of patients involved in motorcycle accidents (n=76) frequency mean age +/standard deviation range males females total 69 7 76 30 +/11 years old 29 +/-11 years old 30 +/11 years old 14-60 years old 17-47 years old 14-60 years old frequencytype percent motorcycle vs pavement motorcycle vs post motorcycle vs tricycle motorcycle vs bus motorcycle vs truck motorcycle vs motorcycle motorcycle vs gutter motorcycle vs car motorcycle vs jeep unknown mechanism motorcycle vs building motorcycle vs canal motorcycle vs wire motorcycle vs pedestrian motorcycle vs wall motorcycle vs truck motorcycle vs van motorcycle vs taxi motorcycle vs plant box motorcycle vs dog motorcycle vs tree motorcycle vs rock total 39 5 4 3 3 3 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 76 51.32 6.58 5.26 3.95 3.95 3.95 2.63 2.63 2.63 1.32 1.32 1.32 1.32 1.32 1.32 1.32 1.32 1.32 1.32 1.32 1.32 1.32 100.00 table 2. distribution of mechanism of injury (n=76) helmets were between the ages of 18-30 years old and those that did wear helmets were mostly between the ages of 31-50 years old. males and females showed the same trend of helmet use. cranio-maxillofacial fractures were noted for all the charts reviewed. most patients had multiple fracture sites resulting in 102 fractures documented for the 76 patients. seventy-five (75) fracture sites were noted for 54 patients not wearing helmets. approximately 1.22 fractures philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles philippine journal of otolaryngology-head and neck surgery 29 accidents regardless of helmet use however more cranio-maxillofacial fractures were seen for patients not wearing helmets. motorcycle users most commonly hit the pavement, which caused their injuries. in other developed countries such as italy there was decrease in hospital admissions for traumatic brain injuries after stricter implementation of the motorcycle helmet law.5 a meta-analysis in the united states showed that a universal helmet act does decrease the number of hospital admissions.8 the data from our study showed that less than 25% used helmets during the time of the accident which is well below the values of other developing countries with a universal helmet law. in a similar study in brazil, 76% of patients wore helmets during the time of the accident.4 our values were much closer to a study in jamaica where only 34% wore helmets.3 even though these three countries had a universal helmet law, its effectiveness was not the same. for this study, motorcycle accidents with or without helmets were more common in 30-year-old males (30 +/11 years old) and 29-year-old females (29 +/-11 years old). this data is comparable to similar studies in developing countries such as brazil and jamaica, except for a younger peak age incidence of 10 to19 years among female motorcyclists in the former.3,4 motorcycle riders were at a disadvantage when collision occured due to the lack of safety devices like seat belts and air bags. a helmet was the most important safety gear. a prospective cross-sectional study in a trauma center in jamaica showed a 70% reduction in injury severity and 40% reduction in mortality of helmet users as compared to non-helmet users.3 a cochrane review of 53 observational studies concluded that motorcycle helmets reduce the risk of mortality with an odds ratio (or) of 0.58, 95% confidence interval (ci) 0.50 to 0.68 among the 4 crosssectional studies provided. the same review also found that helmets decrease the risk of head injury with an or of 0.23 to 0.35.9 although insufficient to generate a hypothesis on the impact of helmets on head injuries, our data suggests that when a ratio of the number of fractures per patient is obtained, more fractures were seen per person for the non-helmet group compared to the helmet group. the data also suggests that there were more instances where no fractures were seen for the group who used helmets compared to those who did not use helmets. although our results were not concurred with by the brazil study, where more fractures were seen for the groups who wore helmets, this may be because those that did not wear helmets in that study sustained encephalic trauma and treatment for the facial fractures were not prioritized. 4 helmets may not always protect riders from facial fractures but have been proven to prevent significant traumatic brain injuries.3 in the study in jamaica, those who did not wear helmets had more intracranial lesions (44.7%) and had more severe traumatic brain injuries (46.8%).7 figure 1. most common fractures of patients with helmets during motorcycle accidents (n=27) figure 2. most common fractures of patients without helmets during motorcycle accidents. (n=75) per patient with helmets were observed while 1.37 fractures per patient were sustained by those who did not wear helmets. only 1 out of the 54 patients without helmets had no fractures. the most common fractures incurred by patients with and without helmets are described in figures 1 and 2. there were several mechanisms of injury noted for the charts reviewed. motorcycle riders hit the pavement causing craniomaxillofacial fractures more than 50% of the time. (table 2) discussion our study showed that 70% of vehicle related accidents are due to motorcycle use and the frequency of helmet use was low. tripod and temporal bone fractures were commonly seen for patients in motorcycle philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 30 philippine journal of otolaryngology-head and neck surgery original articles references 1. aaphilippines.org [homepage on the internet]. philippines: metro manila development authority. road safety unit traffic operations center. metro manila accident reporting and analysis system: traffic accident report january to december accident report january to december 2009; [updated 2011 cited 2014 aug 3]. available from: http://www.aaphilippines. org/roadsafety/.../mmaras%20annual%20report%202009.pdf. 2. tsai mc, hemenway d. effect of the mandatory helmet law in taiwan. inj prev. 1999 dec [cited 2014 aug 3]; 5(4): [290-1]. available from: http://injuryprevention.bmj.com/content/5/4/290. full . doi: 10.1136/ip.5.4.290; pubmed pmid: 10628919; pubmed central pmcid: pmc1730540. 3. crandon iw, harding he, cawich so, frankson ma, gordon-strachan g, mclennon n, et al. the impact of helmets on motorcycle head trauma at a tertiary hospital in jamaica. bmc res notes. 2009 aug. [cited 2014 aug 3]; 2(1):[about 5p]. available from: http://www.biomedcentral. com/1756-0500/2/172. doi: 10.1186/1756-0500-2-172; pubmed pmid: 19715612; pubmed central pmcid: pmc2746805. 4. maliska mc, borba m, asprino l, moraes md, moreira rw. oral and maxillofacial surgery-helmet and maxillofacial trauma: a 10-year retrospective study. brazilian journal of oral sciences. [serial on internet] 2012 jun. [cited 2014 aug 3];11(2):[125-9]. available from: http://revodonto. bvsalud.org/scielo.php?script=sci_arttext&pid=s1677-32252012000200010&lng=en. 5. servadei f, begliomini c, gardini e, giustini m, taggi f, kraus j. effect of italy’s motorcycle helmet law on traumatic brain injuries. inj prev. 2003 sep. [cited 2014 aug 3]; 9(3):[257-60]. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1731012/pdf/v009p00257. pdf. doi:10.1136/ip.9.3.257; pubmed pmid: 12966016; pubmed central pmcid: pmc1731012. 6. senate.gov [homepage on the internet]. philippines: republic of philippines congress of the philippines [updated 2009 cited 2013 september 2]. available from: https://www.senate.gov. ph/republic_acts/ra%2010054.pdf. 7. official gazette [homepage on the internet]. philippines: republic of the philippines department of health. [updated 2013 cited 2014 august 15]. available from: http://www.gov. ph/2013/04/29/9-out-of-10-doa-motorcycle-riders-found-not-wearing-helmet/. 8. macleod jb, digiacomo jc, tinkoff g. an evidence-based review: helmet efficacy to reduce head injury and mortality in motorcycle crashes: east practice management guidelines. j trauma. 2010 nov. [cited 2014 aug 3]; 69(5): [1101-11]. available from: http://journals.lww.com/ jtrauma/citation/2010/11000/an_evidence_based_review__helmet_efficacy_to.12.aspx. doi: 10.1097/ta.0b013e3181f8a9cc; pubmed pmid: 21068615. 9. liu bc, ivers r, norton r, boufous s, blows s, lo sk. helmets for preventing injury in motorcycle riders. cochrane database syst rev. 2008 jan 23 [cited 2014 aug 3]. 1(cd004333): [about 44p]. available from: http:// http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd004333.pub3/ pdf. doi: 10.1002/14651858.cd004333.pub3; pubmed pmid: 18254047. the previously cited study in brazil noted that mandibular fractures and fractures of the midface were common.4 they associated it with the fact that even with helmets there is still a prominence of the mandible and dissipation of forces to the midface.4 in contrast, the most common fractures seen for both helmet and non-helmet users in our study were tripod fractures followed by temporal bone fractures. mandibular fractures were not as common. temporal bone fractures were also noted in our study but not mentioned in the brazil study,4 perhaps because they did not consider these part of maxillofacial injuries. temporal bone fractures were common in both helmet and nonhelmet groups in our study may suggest that helmets do not offer significant protection from this type of fracture. the study had several limitations. the charts reviewed were limited to those referred to the orl service at a tertiary hospital in the philippines from january 2013-december 2013. records of persons with motorcycle-related injuries that were not referred to our service were not included. charts not retrieved by the records section were also excluded from data analysis. radiographic images were not reviewed for confirmation of injuries listed in the charts. the study did not also account for those patients with fatal injuries or those who had traumatic brain injuries that could have been a significant addition to the data gathered. it is recommended that a prospective study will yield a more valid estimate of the cases referred to our service since we will no longer be dependent on the medical records being complete. it may also be important to note the frequency of use of department of trade and industry (dti) approved helmets specifically and to determine the efficacy of these helmets in preventing head injuries. it will also be interesting to determine the efficacy of the different types of helmets in preventing certain facial fractures. traffic road accidents are a major public health problem because of the consequences of injuries to riders and destruction of property. thus, several countries have already passed laws to prevent this, one of which is the universal helmet law. however, compliance to this law has still been low. as evidenced by our study, motorcycle related accidents continue to be a common reason for hospital admission. most craniomaxillofacial injuries are incurred by those who did not use helmets during the time of the accident. data from this study can be used for further public health researches to improve health policies on road traffic accident prevention. there is still room for improvement in the implementation of the motorcycle helmet act of 2009. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles 8 philippine journal of otolaryngology-head and neck surgery abstract objective: to determine the prevalence of otorhinolaryngologic (ent) manifestations in people living with human immunodeficiency virus (hiv) infection seen in our institutions and to determine the association of these manifestations with age, sex, cd4 count and antiretroviral treatment. methods: design: cross-sectional study setting: two tertiary government hospitals subjects: adult patients (>19 years old) confirmed to be hivinfected were seen at jose r. reyes memorial medical center and san lazaro hospital from february to july 2014. a data sheet regarding ent manifestations was filled upon examination. age, sex, cd4 count and antiretroviral treatment data were recorded. independent samples t-test was used to determine age association with manifestations. fischer’s exact test was used to determine association of sex and manifestations. chi-square test of independence was used to determine association of cd4 count and antiretroviral treatment with manifestations. association was considered statistically significant if p< 0.05. results: three hundred one (301) patients participated with 287 males (95.3%) and 14 females (4.7%). the mean age was 31.7 ± 8. one hundred ninety seven (197 or 65.4%) had ent manifestations. the most common areas of manifestations came from the oral cavityoropharyngeal area (n=104, 37%), nasal cavity-nasopharyngeal area (n=73, 26%) and ear (n=43, 15%). the most frequent manifestations were cervical lymphadenopathy, aphthous stomatitis and acute rhinitis. there was no significant difference in the age (p=0.31) and sex (p=0.15) of patients with and without manifestations. however, there was a direct association of manifestations with low cd4 count (p<0.001) and inverse association with antiretroviral treatment (p=0.036). conclusion: our findings emphasize the importance of screening for ent manifestations, regular cd4 monitoring and enrollment to antiretroviral therapy in persons with hiv. baseline otorhinolaryngologic examination upon hiv diagnosis and prior to initiating treatment should be followed by regular surveillance. conversely, physicians should also be aware that patients with ent manifestation may have hiv infection. keywords: hiv, otorhinolaryngologic diseases, cd4 lymphocyte count, anti-retroviral agents, stomatitis, rhinitis otorhinolaryngologic manifestations of human immunodeficiency virus infection in manila, the philippines anna carlissa p. arriola, md1 antonio h. chua, md1 rosario jessica f. tactacan-abrenica, md2 1department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center 2hiv department san lazaro hospital manila correspondence: dr. antonio h. chua department of otorhinolaryngology head and neck surgery 4th floor, jose r. reyes memorial medical center rizal avenue, sta. cruz, manila 1003 philippines phone: (632) 743 6921; (632) 711 9491 local 320 email: entjrrmmc@yhoo.com reprints will not be available from the authors. the authors declare that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery analytical research contest (first place), hall a unilab bayanihan center, pioneer st. brgy kapitolyo, pasig city, october 23, 2014. philipp j otolaryngol head neck surg 2015; 30 (2): 8-12 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 9 human immunodeficiency virus (hiv) infection has been increasing in the philippines. from 2010 to 2013, newly-diagnosed hiv cases increased from 1,591 to 4,814, with 2,951 newly-reported cases from february to july 2014.1 studies have found that over 80% of hiv-infected individuals present with otorhinolaryngologic symptoms during the course of infection.2 the onset of opportunistic infections in hiv-positive patients is generally associated with a low cd4 count.3 highly active antiretroviral therapy has greatly improved the control of the immune-deficiency while reducing the number of otorhinolaryngological manifestations.4 otorhinolaryngologists should take an active role in the holistic management of hiv infected persons. despite studies in other countries regarding ent manifestations seen in hiv patients, limited studies have been conducted to determine hiv-associated otorhinolaryngologic manifestations in the philippines. this paper aims to determine the prevalence of otorhinolaryngologic manifestations in hiv-infected patients in manila, and to determine the associations of otorhinolaryngologic manifestations with age, sex, cd4 count and antiretroviral treatment. methods this was a cross-sectional study conducted at the hiv department of the san lazaro hospital and the department of otorhinolaryngology head and neck surgery of the jose r. reyes memorial medical center, both located in manila, the philippines. the target population was hiv-infected patients diagnosed by the hiv department, above 19 years old, and seen at the department of otorhinolaryngology head and neck surgery from february to july 2014. the study protocol and informed consent were reviewed and approved by the research and ethics review committee of our institutions. an infectious disease specialist oriented the ear, nose, throat (ent) examiner on hiv counseling and confirmed diagnosis of hiv-infected patients. all patients that were seen by the infectious disease specialist were referred to the ent examiner for evaluation. after obtaining informed consent, 301 patients were seen by the ent examiner. a clinical history was obtained and physical examination conducted for each patient. examination instruments included an otoscope, tuning fork, nasal speculum, laryngeal mirror and rigid endoscope which were disinfected according to standard protocol.5 a data sheet regarding ent manifestations was completed after each examination and an assessment made. the independent variables (age, sex, cd4 count and antiretroviral treatment) were recorded. the dependent variable was presence or absence of ent manifestations. mean and standard deviation were computed to summarize age and sex of the subjects. the statistical analysis was carried out through pasw statistics for microsoft windows version 18.0 (spss inc., chicago, usa). independent samples t-test was used to determine the association of age in patients with or without manifestations. fischer’s exact test was used to determine association of sex with manifestations. cd4 count was categorized according to cd4 levels based on immunosuppression.6 chi-square test of independence with cramer’s v test was used to determine association of cd4 count among those with and without manifestations. chi-square test of independence with phi was used to determine association of antiretroviral treatment among those with and without manifestations. p values of less than 0.05 were considered significant. results three hundred one patients (301) participated with 287 males (95.3%) and 14 females (4.7%). ages ranged from 20 to 59. the mean age was 31.7± 8. of the 301 patients, 197 (65.4%) had ent manifestations. the mean age of patients with ent manifestations was 31.4 (sd 7.86) compared to the mean age of patients without ent manifestations of 32.4 (sd 8.30) which was not statistically significant (t-test 1.02, p = 0.31, two-tailed). otorhinolaryngologic manifestations were present among 185/287 males (64.5%) and 12/14 females (85.7%). there was no statistical significance in presence of ent manifestations among males and females. (fischer’s exact test p=0.15). of the 284 ent manifestations found (table 1), the most to least common groups of manifestations were oral cavity-oropharyngeal, nasal cavity-nasopharyngeal, ear, head and neck and laryngeal. (figure 1) overall, the most frequent manifestations were cervical lymphadenopathy (9.8%), aphthous stomatitis (9.5%) and acute rhinitis (7.3%). among otologic manifestations, chronic otitis media was the most common. laryngopharyngeal reflux was the most common laryngeal manifestation. in terms of severity of hiv status, ent manifestations were seen in 16 patients categorized as “not with significant immunosuppression” (cd4 >/=500 cell/ul), 26 patients with “mild immunosuppression” (cd4 350-499 cell/ul ), 39 patients with “advanced immunosuppresion” (200-349 cell/ul) and 115 patients with “severe immunosuppression” (<200 cell/ul). cd4 count and ent manifestations were found to have a direct association that was statistically significant, (χ2 =35.42; p<0.001; cramers’s v = 0.34). among patients without antiretroviral therapy, 27/33 presented with ent manifestations compared to the 170/268 patients with antiretroviral therapy. antiretroviral treatment and manifestations were inversely associated and statistically significant (χ2 = 4.39; p= 0.036; φ= -0.12.). philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles 10 philippine journal of otolaryngology-head and neck surgery table 1. ent manifestations and their frequencies encountered in our study. otologic nasal cavitynasopharyngeal oral cavityoropharyngeal laryngeal head and neck chronic otitis media chronic suppurative otitis media acute otitis externa sensorineural hearing loss otomycosis acute suppurative otitis media benign paroxysmal positional vertigo acute otitis media chronic otitis externa, psoriasis eustachian tube dysfunction conductive hearing loss otitis media with effusion kaposi’s sarcoma acute rhinitis nonallergic rhinitis allergic rhinitis acute rhinosinusitis chronic rhinosinusitis epistaxis secondary to manipulation crusting vitiligo hyperemic nasal mucosa nasal vestibulitis adenoid hypertrophy nasal polyp aphthous stomatitis oral candidiasis acute pharyngitis white hairy leukoplakia acute tonsillopharyngitis exfoliative cheilitis hyperemic soft palate odontogenic infection pigmented tongue chronic tonsillar hypertrophy median rhomboid glossitis petechiae palate atrophic glossitis leukoplakia, hardpalate erythematous vermillion telangectasia hard palate angular cheilitis erosive glossitis fissured tongue oral herpes tmj dysfunction chronic lymphadenopathy acute lymphadenitis bilateral parotid enlargement preseptal cellulitis acute bacterial parotitis consider branchial cleft cyst parotid abscess lymphoma multiple cystic masses (forehead,submandibular area, parietal area) laryngopharyngeal reflux acute laryngitis ulcer leukoplakia epiglottis chronic laryngitis vocal fold paralysis vocal fold polyp 7 6 6 5 3 3 3 2 2 2 2 1 1 43 21 15 12 9 7 2 2 1 1 1 1 1 73 27 20 10 9 7 5 4 3 3 3 2 2 1 1 1 1 1 1 1 1 1 104 11 5 3 2 1 1 1 24 28 4 2 1 1 1 1 1 1 40 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 11 discussion this study showed that 65% of subjects with hiv, 64.5% of males and 85.7% of females had ent manifestations. although ent manifestations may have been present prior to or during hiv infection, their high prevalence in our sample emphasizes the pivotal role of the otorhinolaryngologist in managing hiv patients. the most common areas involved were the oral cavityoropharyngeal followed by the nasal cavity-nasopharyngeal and the ear. cervical lymphadenopathy, aphthous stomatitis and acute rhinitis were the most prevalent manifestations. these parallel findings of other studies that showed oropharyngeal and cervical lymphadenopathy as predominant manifestations.2 a study of oral manifestations found the most common oral lesions were candidiasis, hairy leukoplakia, recurrent aphthous-like ulcerations, kaposi’s sarcoma, herpes simplex infection, herpes zoster infection, warts and periodontal diseases.7 our study showed that aphthous stomatitis was the most common oral manifestation followed by oral candidiasis. other oral manifestations seen in this study were hairy leukoplakia, exfoliative cheilitis, odontogenic infection and median rhomboid glossitis. acute rhinitis was the most common nasal manifestation in our study. some patients noted recurrent acute rhinitis. disruption in the immune system and loss of allergic control may lead to the development of frequent acute rhinitis, allergic rhinitis and nonallergic rhinitis. hiv infection depresses the immune system and may explain the presence of rhinitis in this population. on the other hand, some patients had a history of allergic rhinitis prior to hiv diagnosis and not all patients with rhinitis should be suspected to have hiv. chronic otitis media was the most common otologic manifestation in this study. one presented with sensorineural hearing loss after an episode of meningitis while another was diagnosed after tuberculosis treatment. an hiv-associated malignancy, kaposi’s sarcoma of the auricle presented with a black lesion in one patient. otitis externa and suppurative otitis media were also observed. these reflect the findings of a study by moazzez et al. that demonstrated otitis externa, otitis media, kaposi’s sarcoma and sensorineural hearing loss as common ear manifestations.8 otologic symptoms may not be the direct effect of hiv alone but result from a combination of the effects of hiv infection with opportunistic microorganisms and/or possible ototoxic effects of certain therapeutic agents.4 a previous study found an association between age and male sex with otological manifestations.9 no such association was found in our study. however, the large disparity between the number of male and female subjects in our sample could have affected our findings. that the majority of our participants were male may reflect the incidence of hiv in the philippines occuring predominantly in males with the predominant type of transmission being through males having sex with other males.1 a significant association between cd4 count and ent manifestations was seen in our study. the cd4 count is an immunological parameter that is used to monitor the burden of hiv. the cd4 count categorization used in this study was based on the world health organization immunological staging of hiv infection.6 although ent manifestations were evident even in patients without significant immunosuppression, table 2. association of age, sex, cd4 count and anti-retroviral treatment with ent manifestations. without manifestations with manifestations p value age sex cd4 count antiretroviral (arv) therapy mean sd female male <200 cell/ul 200-349 cell/ul 350-499 cell/ul >/=500 cell/ul without arv treatment with arv treatment 32.4 ± 8.30 2 102 24 40 24 17 6 98 31.4 ±7.86 12 185 115 39 26 16 27 170 0.31 0.15 <0.001 0.036 figure 1 ent manifestations (n=284) 8% n=24 26% n=73 14% n=40 37% n=104 15% n=43 oral cavity-oropharyngeal nasal cavitynasopharyngeal ear head and neck larynx philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles 12 philippine journal of otolaryngology-head and neck surgery acknowledgements the authors would like to thank dr. samantha s. castañeda for her guidance and the h4 staff of san lazaro hospital for their valuable assistance. references 1. national hiv-aids and sti strategic information and surveillance unit. philippine hiv/aids registry july 2014. national epidemiology center, department of health manila philippines. [cited 2014 aug 21] available from:http://www.pnac.org.ph/uploads/documents/publications/ nec_hiv_july-aidsreg2014.pdf. 2. prasad hk, bhojwani km, shenoy v. hiv manifestations in otolaryngology. am j otolaryngol [serial on the internet]. 2006 [cited 2013 sept 11];27:179-185. available from:http://www.ncbi. nlm.nih.gov/pubmed/16647982. 3. davoodi p, hamian m, nourbaksh r, motamayel fa. oral manifestations related to cd4 lymphocyte count in hiv-positive patients. j dent res dent clin dent prospects. 2010; 4(4):115119. 4.campanini a, marani m, mastroianni a, cancellieri c, vicini c. human immunodeficiency virus infection: personal experience in changes in head and neck manifestations due to recent antiretroviral therapies. acta otorhinolaryngol ital. 2005 february; 25(1): 30–35. 5. rutala wa, weber dj, healthcare infection control practices advisory committee. guidelines for disinfection and sterilization in healthcare facilities,2008. [ cited 2013 sept 9] available from: http://www.cdc.gov/hicpac/pdf/guidelines/disinfection_nov_2008.pdf. 6. interim who clinical staging of hiv/aids and hiv/aids case definitions for surveillance. [cited 2013 sept 9] available from:www.who.int/hiv/pub/guidelines/clinicalstaging.pdf. 7. baccaglini l, atkinson jc, patton ll, glick m, ficarra g, peterson de. management of oral lesions in hiv-positive patients.oral surg oral med oral pathol oral radiol endod. 2007 mar;103 suppl:s50.e1-23. 8. moazzez ah, alvi a. head and neck manifestations of aids in adults. am fam physician.1998 april 15:57(8):1813-22. 9. jafari s, razmpa e, saeedinejad z, sadrhosseini m, paydary k. otolaryngological manifestations in hiv infected patients, tehran, iran. j aids clinic res .2012;3:160. 10. neto cdp, weber r, araújo-filho bc, miziara id. rhinosinusitis in hiv-infected children undergoing antiretroviral therapy. rev. bras. otorrinolaringol [serial on the internet]. 2009 feb[cited 2014 sep 13]; 75(1): 70-75. available from: http://www.scielo.br/scielo. php?script=sci_arttext&pid=s0034-72992009000100011&lng=en. http://dx.doi.org/10.1590/ s0034-72992009000100011. 11. weber r, neto cdp, miziara id, araújo-filho bc. haart impact on prevalence of chronic otitis media in brazilian hiv-infected children. rev. bras. otorhinolaringol. [serial on the internet]. 2006 [cited 2014 sep 13];72(4):509-14. available from: http://www.scielo.br/pdf/rboto/v72n4/ en_a12v72n4.pdf more patients who were severely immunosuppressed presented with ent manifestations than those who were not significantly immunosuppressed. (table 2) a direct association of ent manifestations with low cd4 count (p<0.001) was observed. similar studies have described oral manifestations such as candidiasis to be significantly associated with low cd4 count.3 opportunistic infection in the ears, nose and throat could reflect a decreased cd4 count. on the other hand, the ent manifestations may project the immunosuppression status of the patient. a cohort study could be recommended to establish causality of manifestations and cd4 count. a significant inverse association between antiretroviral treatment and manifestation was recognized (p=0.036), consonant with previous studies. an antiretroviral regimen has been associated with higher mean cd4 count and lower prevalence of chronic rhinosinusitis10 and chronic otitis media.11 another study observed a significant decrease in the incidence of oral infections after triple antiretroviral therapy.4 antiretroviral therapy is efficient in reducing the viral load of hiv and increasing cd4 count.4 although antiretroviral treatment may decrease ent manifestations, antiretroviral treatment may also be a precursor to other ent manifestations. further studies may determine ent adverse effects of antiretroviral therapy. our study only saw 301 out of the 18,923 documented cases in the philippines.1 moreover, hiv infected persons possess different levels of immune severity. our study represented the status of severity at the time of examination based on the cd4 count. we were only able to determine the prevalence of ent manifestations and the association of ent manifestations with age, sex, cd4 count and antiretroviral therapy in these particular patients at a definite place and time context. other limitations of our study include a lack of baseline (pre-hiv infection) history of ent manifestations and ent examination, noninclusion of duration and transmission of hiv infection or duration of ent manifestations, non-consideration of cd4 count patterns and length of enrollment to antiretroviral therapy and specific therapeutic combinations. the association of cd4 count and antiretroviral treatment with ent manifestations emphasizes the importance of regular monitoring and enrollment to antiretroviral therapy. the degree of ent manifestations present in hiv patients warrant vigilance through baseline otorhinolaryngologic examination upon hiv diagnosis and prior to initiating treatment. this should then be followed by regular surveillance. with the rising incidence of hiv in the philippines, physicians should also be aware that patients with ent manifestation may have hiv. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: this study aimed to determine the prevalence of nasopharyngeal tuberculosis among patients who were initially assessed to have a nasopharyngeal mass and subsequently underwent biopsy in a philippine tertiary general hospital from year 2013 to 2015. methods: design: case series setting: tertiary national university hospital participants: all patients with nasopharyngeal mass identified from january 2013 to december 2015 from a hospital wide census who underwent biopsy were investigated using chart and histopathology review. the prevalence of tuberculosis, malignancies and other findings were determined. results: among 285 nasopharyngeal biopsies done between 2013 and 2015, 33 (11.6%) were histologically compatible with nasopharyngeal tuberculosis, 177 (62.1%) were different types of nasopharyngeal carcinoma, 59 (20.7%) were chronic inflammation, 4 (1.4%) were lymphoma, 5 (1.8%) were normal, and 7 (2.5 %) had diagnoses other than those above.. conclusion: this study suggests a relatively high prevalence rate (11.6%) of nasopharyngeal tuberculosis in patients who have a nasopharyngeal mass. this indicates that nasopharyngeal tuberculosis should always be a differential when confronted with a mass in the nasopharynx especially in tuberculosis endemic areas. keywords: nasopharyngeal tuberculosis; prevalence; censuses; tertiary care centers; philippines; carcinoma; nasopharynx; biopsy; tuberculosis; lymphoma while the majority of tuberculosis infection is found in the lungs, tuberculosis can manifest in the head and neck region including cervical lymph nodes, parotid, the larynx, middle ear and tonsils.1-4 nasopharyngeal tuberculosis (nptb) is rarer and to the best of our knowledge, has been characterized in only a few case reports and series worldwide. there has only been one published case report in the philippines.5 nasopharyngeal tuberculosis in a philippine tertiary general hospital mark anthony t. gomez, md, mpm-hsd1 romeo l. villarta, jr., md, mph1,2 ruzanne m. caro, md3 criston van c. manasan, md4 jose m. carnate, jr., md5 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2department of epidemiology and biostatistics college of public health university of the philippines manila 3department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila 4department of laboratories philippine general hospital university of the philippines manila 5department of pathology college of medicine university of the philippines manila correspondence: dr. jose m. carnate, jr. department of pathology philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8400 local 3200 email: jmcjpath@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery annual convention free paper forum, december 2, 2017, the manila hotel. philipp j otolaryngol head neck surg 2019; 34 (2): 7-10 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery original articles years old. the mean age of patients with nasopharyngeal carcinoma was 47.84 years old while the mean age of patients with nasopharyngeal tuberculosis was younger at 29.15 years old. the mean age of patients with chronic inflammation and lymphoma were 38.82 and 40.5 years old, respectively. the youngest patients with npca, chronic inflammation, nptb and lymphoma were 15, 15, 14 and 17 years old, respectively. the oldest patients with npca, chronic inflammation, nptb and lymphoma were 78, 70, 60 and 66 years old, respectively. the patients had variable distributions among different age groups. the distribution of disease according to age group is shown in table 1. in terms of sex, the ratio of nasopharyngeal carcinoma and chronic inflammation were almost the same at 3:1. on the other hand, the sex ratio for nasopharyngeal tuberculosis and lymphoma were the same and equal at 1:1. the distribution of patients is shown in table 2. of the 33 patients with nptb, only seven complete patient charts were retrieved. most of the records of other patients had been transferred to their local tuberculosis treatment center or were missing. among the seven patients whose complete charts were reviewed, two had a previous history of pulmonary tuberculosis and had been treated with anti-tuberculosis chemotherapy and one had a history of unrecalled chronic lung illness which could also be pulmonary tuberculosis. all the seven patients had presence of cervical lymphadenopathy which prompted the initial medical consult. there was no mention of history of human immunodeficiency virus infection, multidrug resistant tuberculosis infection or diabetes mellitus in the charts of the seven nptb patients. table 1. distribution of disease according to age group age group (years) nasopharyngeal carcinoma (%) n=177 nasopharyngeal tuberculosis (%) n=33 chronic inflammation (%) n=59 lymphoma (%) n=4 14-20 21-55 56-70+ 5 (2.8%) 127 (71.8%) 45 (25.4%) 10 (30.3%) 20 (60.6%) 3 (9%) 9 (15.3%) 38 (64.4%) 12 (20.3%) 1 (25%) 2 (50%) 1 (25%) based on available literature, nptb usually presents with nasopharyngeal mass associated with cervical lymphadenopathy as well as nasal, ocular and otologic symptoms.6-10 these findings overlap with the clinical presentation of nasopharyngeal malignancies, posing important diagnostic and therapeutic issues.6,11-15 the study aimed to determine the prevalence of nasopharyngeal tuberculosis among patients who underwent nasopharyngeal biopsy in the philippine national university hospital from january 2013 to december 2015. methods with institutional ethical and technical review board approval (upmreb orl 2016-387-01), this descriptive case series sought to review records of patients of any age who were previously assessed to have a nasopharyngeal mass on endoscopy and who eventually underwent nasopharyngeal mass biopsy at the philippine general hospital from january 1, 2013 to december 31, 2015. patients who underwent nasopharyngeal mass biopsies were initially identified from the department of otorhinolaryngology census and logbooks of the in-patient and out-patient operating rooms. records were retrieved by the first author and basic demographic (age and sex) and histopathologic data were collated and recorded using microsoft office professional plus 2010 for windows (microsoft corporation, redmond, wa usa). excluded were patients whose biopsies were deferred due to other health reasons, who underwent intranasal (instead of nasopharyngeal) mass biopsies and those with incomplete entries. patients who had previous recurrences of the condition and appeared twice in the registry were considered as one patient. the final histopathological diagnoses were retrieved from the database of histopathology results at the department of laboratories. full hospital chart reviews were attempted on all patients with nptb. descriptive statistics were used to define demographics and summarize and describe the data. the prevalences of each of the diagnosis were computed based on the data. the different prevalences were then described. results among the 285 nasopharyngeal biopsies we identified between 2013 and 2015, 33 (11.6%) were histologically compatible with nasopharyngeal tuberculosis (nptb), 177 (62.1%) were different types of nasopharyngeal carcinoma (npca), 59 (20.7%) were interpreted as chronic inflammation, four (1.4%) were lymphoma, five (1.8%) were normal, and seven (2.5 %) were diagnosis other than those mentioned. the mean age of all patients with nasopharyngeal mass was 43.47 table 2. distribution of disease according to sex diagnosis male (%) female (%) sex npca (n=177) nptb (n=33) chronic inflammation (n=59) lymphoma n=4 132 (74.6%) 17 (51.5%) 45 (76.3%) 2 (50%) 45 (25.4%) 16 (48.5) 14 (23.7%) 2 (50%) philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery original articles‰ discussion nasopharyngeal tuberculosis (nptb) has been described prior to the advent of the anti-tuberculosis antibiotics in 1936 by graff who identified a high presence (82%) of nasopharyngeal tuberculosis by histology in 118 pulmonary tuberculosis cases.16 after the emergence of anti-tuberculosis medications, there was a dramatic decrease in cases of nasopharyngeal tuberculosis. a 1976 survey of 843 cases of pulmonary tuberculosis by rohwedder found 16 patients with tuberculosis of the upper respiratory tract and only one of these had nasopharyngeal tuberculosis.17 the recent worldwide upsurge in the incidence of nasopharyngeal tuberculosis in the literature could be due to increased awareness of disease, improvement of knowledge regarding the entity, improved diagnostic techniques and of course, increase in incidence of the disease itself.6 most of the literature on the topic is only in the form of case reports and series that were gathered over many years and are not enough to give a clear picture of the prevalence of the illness. as of this writing, we could find no other studies detailing its prevalence. based on our study, the prevalence of nptb can reach as high as 1.1 for every 10 nasopharyngeal biopsies. this prevalence of nasopharyngeal tuberculosis is second only to nasopharyngeal carcinoma and even higher than lymphoma. there are several important implications of the results of our study. first, clinicians usually have two main differential diagnoses when faced with a nasopharyngeal mass –nasopharyngeal carcinoma or lymphoma. the results of our study would add nasopharyngeal tuberculosis to the differentials especially in areas where tuberculosis is endemic. these three diagnoses each entail totally different managements and accurate diagnosis is necessary to provide proper treatment. the additional differential should guide other medical specialists. pathologists must thoroughly analyse histopathologic slides especially those with chronic inflammatory patterns because hidden in the sea of inflammatory cells might be islands of tuberculosis or granulomatous lesions that may be overlooked. pathologists should also be careful in making diagnosis because concomitant tb infection of the nasopharynges of patients with nasopharyngeal carcinoma may be present.18 radiologists should consider the possibility of nasopharyngeal tuberculosis in interpreting ct scans of patients with a nasopharyngeal mass. the possibility of nasopharyngeal tuberculosis should also be mentioned in patient education, and patient anxiety may be decreased by the knowledge that not all nasopharyngeal masses are cancer. there are also important implications related to the safety of clinicians. although it is the usual practice for otorhinolaryngologists to wear standard personal protective equipment in performing nasopharyngeal biopsies, the high prevalence of tuberculosis in patients with nasopharyngeal mass will require additional precautions such as wearing n95 masks instead of regular masks and ultraviolet disinfection after surgery. as patients with nasopharyngeal tuberculosis may have other co-morbidities such as hiv infection, these additional precautionary measures mentioned are well-justified. diagnosis of nptb in previous reports were done initially by nasal endoscopy, biopsy and culture of tuberculous bacilli from secretions and nasopharyngeal tissue. histopathology of the biopsied nasopharyngeal may also be helpful since results of tb culture may cause delays in diagnosis up to 6 weeks.6 additional radiologic examinations may also be helpful such as ct scan and mri.6 a study in china reported that a presence of necrosis and striped pattern in nasopharyngeal lesions and lack of invasion of regional structures as seen in ct and mri of 36 nptb patients may suggest the diagnosis of nptb instead of malignancy.19 in terms of management, previous reports differed in the duration of anti-tuberculosis treatment. some had the minimal six-month course of triple combination therapy that included isoniazid, rifampicin and ethambutol. others were treated with nine months of quadruple therapy (adding an initial short course of pyrazinamide). there is even a study in china which used an oral anti tuberculosis regimen of 3hrzs(e)/9hr(e) for one year combined with nasal spray combination medication of isoniazid, rifampicin and streptomycin injection solution for 3 months.20 however, to the best of our knowledge, there have been no published recommendations on the proper diagnosis, treatment and monitoring of response to treatment specifically for nasopharyngeal tuberculosis. while this may reflect the global rarity of the disease, further studies must be performed in tuberculosis endemic countries like the philippines to evaluate the means of diagnosis and treatment response of nasopharyngeal tuberculosis so that management can be optimised to prevent development of multiple drug resistance. there were at least two patients in our study with a past history of previously treated pulmonary tuberculosis. although it is not known whether the nasopharyngeal tuberculosis appeared before or after pulmonary tuberculosis treatment, this finding could mean that the nasopharyngeal tuberculosis in these patients may not have been affected by the initial treatment given or may have developed despite treatment. although there have been no studies that state the clear association between disseminated tuberculosis and development of multi-drug resistant tuberculosis, having multiple sites in a patient might trigger the development of resistance especially if the other sites are not known or undiagnosed. for example, a known pulmonary tuberculosis patient with a hidden or undiagnosed nasopharyngeal component will only be given six months of initial pulmonary tuberculosis treatment. because an extrapulmonary site is involved, nasopharyngeal tuberculosis might need a longer anti philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery original articles tuberculosis treatment regimen or additional medications on top of the usual medications for pulmonary tuberculosis. the treatment for such a hypothetical patient may only be enough for the pulmonary involvement but insufficient for the nasopharyngeal disease which may lead to development of drug resistance. moreover, should nasal endoscopy be recommended to search for nasopharyngeal masses in patients with pulmonary tuberculosis prior to treatment? further studies are needed in this regard. there are several limitations of our study. the purely observational and descriptive study design makes it only a preliminary study to generate epidemiological knowledge and local information among filipinos. the study only involved a database review and it is possible that not all data were available. the study only sought to establish a local picture of nasopharyngeal tuberculosis using the limited data gathered within a tertiary general hospital. even if it is the national university hospital, many other regions of the country were not represented by the study population and our findings may not be generalizable to them. in conclusion, this study suggests a relatively high prevalence rate of nasopharyngeal tuberculosis (11.6%) in patients who have a nasopharyngeal mass. although nasopharyngeal carcinoma (62.1%) remains to be the most common diagnosis, nasopharyngeal tuberculosis should always be a differential aside from lymphoma (1.8%) when confronted with a mass in the nasopharynx in areas with high tuberculosis endemicity. acknowledgements we would like to thank dr. cristina c. arcinue gomez for assistance with data collection and initial editing of the manuscript. we would also like to express our gratitude to dr. jose florencio f. lapeña jr. for helping us rewrite the manuscript. lastly, we are also immensely grateful to the nurses of the tb-dots office and personnel of the records section at the philippine general hospital for their time and effort in helping us retrieve the patient records within their respective offices. references 1. menon k, bem c, gouldesbrough d, strachan dr. a clinical review of 128 cases of head and neck tuberculosis presenting over a 10-year period in bradford, uk. j laryngol otol. 2007 apr;121(4):362-8. doi: 10.1017/s0022215106002507. pmid: 16923320. 2. choudhury n, bruch g, kothari p, rao g, simo r. 4 years’ experience of head and neck tuberculosis in a south london hospital. j r soc med. 2005 june; 98(6): 267–269. doi: 10.1258/ jrsm.98.6.267 pmid: 15928377 pmcid: pmc1142231. 3. das s, das d, bhuyan ut, saikia n. head and neck tuberculosis: scenario in a tertiary care hospital of north eastern india. j clin diagn res 2016 jan;10(1): mc04-7. doi:10.7860/ jcdr/2016/17171.7076 pmid: 26894099 pmcid: pmc4740627. 4. vayisoglu y, unal m, ozcan c, görür k, horasan es, sevük l. [lesions of tuberculosis in the head and neck region: a retrospective analysis of 48 cases]. kulak burun bogaz ihtis derg 2010 marapr;20(2):57-63. [turkish] pmid: 20214547. 5. nieves cs, onofre rd, aberin-roldan fca, gutierrez rlc. nasopharyngeal tuberculosis in a patient presenting with upper airway obstruction. philipp j otolaryngol head neck surg.  2010 jan-jun;25(1):20-22. doi: 10.32412/pjohns.v25i1.653. 6. srivanitchapoom c,  sittitrai p. nasopharyngeal tuberculosis: epidemiology, mechanism of infection, clinical manifestations, and management. int j otolaryngol. 2016; 2016:4817429 doi: 10.1155/2016/4817429 pmid: 27034677 pmcid: pmc4789561. 7. kim ks. primary nasopharyngeal tuberculosis mimicking carcinoma: a potentially false-positive pet/ct finding. clin nucl med. 2010 may;35(5):346-8. doi: 10.1097/rlu.0b013e3181d624ff pmid:20395711. 8. basal y, ermişler b, eryilmaz a, ertuğrul b. two rare cases of head and neck tuberculosis. bmj case rep. 2015 oct 23;2015. doi: 10.1136/bcr-2015-211897 pmid: 26498669 pmcid: pmc4620213. 9. richardus ra, jansen jc, steens sc, arend sm. two immigrants with tuberculosis of the ear, nose, and throat region with skull base and cranial nerve involvement. case rep med. 2011; 2011:675807. doi: 10.1155/2011/675807 pmid: 21541186. pmcid: pmc3085480. 10. zhang y, chen y, huang z, cai l, wu j. nasopharyngeal tuberculosis mimicking nasopharyngeal carcinoma on (18)f-fdg pet/ct in a young patient. j.clin nucl med. 2015 jun;40(6):518-20. doi: 10.1097/rlu.0000000000000656. pmid: 25546210. 11. takagi a, nagayasu f, sugama y, shiraishi s. primary nasopharyngeal tuberculosis. kekkaku. 2013 may;88(5):485-9. pmid: 23882729. 12. sithinamsuwan p, sakulsaengprapha a, chinvarun y. nasopharyngeal tuberculosis: a case report presenting with diplopia. j med assoc thai. 2005 oct;88(10):1442-6. pmid: 16519394. 13. taş a, yağiz r, koçyiğit m, karasalihoğlu ar. primary nasopharyngeal tuberculosis. kulak burun bogaz ihtis derg. 2009 mar-apr;19(2):109-11. pmid: 19796011. 14. kuran g, sagit m, saka c, saka d, oktay m, hucumenoglu s, et al. nasopharyngeal tuberculosis: an unusual cause of nasal obstruction and snoring. b-ent. 2008;4(4):249-51. pmid: 19227032. 15. prstačić r, jurlina m, žižić-mitrečić m, janjanin s. primary nasopharyngeal tuberculosis mimicking exacerbation of chronic rhinosinusitis. j laryngol otol. 2011 jul;125(7):747-9. doi: 10.1017/s0022215110002835 pmid: 21481293. 16. graff s. [die bedeutung des epipharynx for die menachlidie pathologie]. klin wochenschr. 1936; 15:953-7. 11. [german] doi: 10.1007/bf01777670. 17. rohwedder jj. upper respiratory tract tuberculosis. sixteen cases in a general hospital. ann intern med 1974; 80:708-13. doi:10.7326/0003-4819-80-6-708. pmid: 4832158. 18. zalesska-krecicka m, krecicki t, morawska-kochman m, mosiniak-trajnowicz k, kuliczkowski. [nasopharyngeal carcinoma coexistent with lymph node tuberculosis, diagnostic difficulties-case report]. k.otolaryngol pol. 2005;59(4):607-9. [polish] pmid: 16273871. 19. cai pq, li yz, zeng rf, xu jh, xie cm, wu yp, et al. nasopharyngeal tuberculosis: ct and mri findings in thirty-six patients. eur j radiol. 2013 sep;82(9):e448-54. doi: 10.1016/j. ejrad.2013.04.015 pmid: 23689055. 20. jian y, liu b, guo l, kong s, su x, lu c. pathogeny and treatment of 50 nasopharyngeal tuberculosis cases. lin chung er bi yan hou tou jing wai ke za zhi. 2012 dec;26(24):1138-40. pmid: 23477122. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles 16 philippine journal of otolaryngology-head and neck surgery abstract objective: to determine the association between the laterality of chronic suppurative otitis media (csom) and the laterality of sinonasal disease, based on temporal bone ct scan results and lund-mackay scoring system, among patients admitted for ear surgery in a tertiary government hospital in metro manila. methods: design: retrospective review of records setting: tertiary government hospital participants: ninety-eight (98) patients diagnosed with chronic suppurative otitis media admitted for otologic surgery in the department of otorhinolaryngology – head and neck surgery from january 2011 to june 2014 were considered for inclusion. hospital charts and temporal bone ct scan results were retrieved and analyzed for ear and sinonasal radiographic abnormalities and laterality. excluded were those without ct scan plates, who underwent temporal bone surgery for reasons other than chronic suppurative otitis media, and those with incomplete records. the lund-mackay scoring system was used to grade sinonasal findings which were compared to csom complications. data was analyzed using t-test, anova for homogenous numerical data, kruskal-wallis for heterogenous numerical data, and chi-square test for nominal type of data. results: of the 64 patients included in the study, 12 or 18.75% had radiographic sinonasal abnormalities. there was no significant association between the laterality of ear disease and the laterality of sinonasal pathology as there was no significant difference in the proportion of subjects with sinonasal disease according to laterality of csom (p=.32). when site of nose pathology was compared to lund-mackay graded scores, it was found that bilateral nose pathology generally had a higher lund-mackay score of 8.60 ± 5.60. however, there was no significant difference in the lund-mackay score according to the nose pathology site (p=.20). an association was seen between total lms and patients with ear pathologies, but no significant difference was noted (p=.44). although patients with ear complications had higher lm scores, this was not statistically significant. conclusion: laterality of ear disease was not associated with the laterality of sinonasal disease, although csom complications were associated with high lund-mackay scores. future, betterdesigned studies may shed more light on these associations. keywords: chronic suppurative otitis media, sinonasal disease, lund-mackay, temporal bone ct scan association of the laterality of chronic suppurative otitis media and sinonasal disease based on temporal bone ct scans and lund mackay scoring system walfrido c. adan, jr., md emmanuel tadeus s. cruz, md department of otorhinolaryngology head and neck surgery quezon city general hospital correspondence: dr. emmanuel tadeus s. cruz department of otorhinolaryngology head and neck surgery quezon city general hospital seminary road, barangay bahay toro, project 8, qc 1106 philippines phone: (632) 426 1314 email: emancrz@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represent honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political views or beliefs, and institutional affiliations that might lead to conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest. september 18, 2014. natrapharm, the patriot building, paranaque city. philipp j otolaryngol head neck surg 2016; 31 (2): 16-19 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles philippine journal of otolaryngology-head and neck surgery 17 patients suffering from chronic suppurative otitis media (csom) may have underlying sinonasal problems. in children, otitis media is usually preceded by upper respiratory tract infections. this may be related to the wider, shorter, and more horizontally-oriented eustachian tube in children.1 yoelekar and dasgupta related the origin of chronic suppurative otitis media to sinonasal pathology, particularly eustachian tube dysfunction.2 out of the 200 patients in the study, 50% had tubotympanic type chronic suppurative otitis media, 80% had deviated nasal septum, 13.5% sinusitis, 10.5% nasal polyps.2 however, diagnosis was based on physical examination and endoscopy and use of imaging was not mentioned. neither was an association between the laterality of ear disease and laterality of paranasal sinus disease determined. a pubmed review of medline using the keywords “sinonasal disease,” “chronic suppurative otitis media,” and “laterality” yielded a paucity of data on the relationship between chronic suppurative otitis media and laterality of sinonasal disease. because the paranasal sinuses can be visualized on routine temporal bone ct scans in our institution, we aimed to determine the association between laterality of chronic suppurative otitis media and laterality of sinonasal disease among csom patients admitted for surgery based on temporal bone ct scan results. methods this retrospective review of records was approved by the quezon city general hospital research review board. ninety-eight (98) patients diagnosed with chronic suppurative otitis media, admitted for ear surgery under the department of otorhinolaryngology – head and neck surgery of the quezon city general hospital from january 2011 to june 2014 were initially considered for inclusion. hospital records and plain temporal bone ct scans were retrieved. excluded were those without ct scan plates, who underwent temporal bone surgery for reasons other than chronic suppurative otitis media, and those with incomplete records. using epi info version 7 (centers for disease control, atlanta, ga, usa) software, the minimum sample size was estimated to be at least 61 using the following parameters: alpha (α) = 5%, with the prevalence of sinonasal disease in the philippines at 20%4 with a maximum tolerable error (e) = 10. data were encoded and tallied in spss version 10 for windows (statistical package for the social sciences inc., chicago, il, usa). patient records were analyzed and anonymized data on the history (duration of ear discharge, presence of chronic suppurative otitis media complications and nasal symptoms) and physical examination (otoscopy, tuning fork test, rhinoscopy and nasal endoscopy) with emphasis on the ear and sinonasal details were tabulated. all the temporal bone ct scan results were evaluated by a single board-certified radiologist for the presence of cholesteatoma, soft tissue densities and bony defects. to describe the laterality of the diseased ear, the following numbers were designated: 1-left, 2-right, 3-bilateral. the same radiologist was oriented to, and graded the severity of sinonasal disease using the lund-mackay scoring system.3 the laterality of sinonasal disease was designated: 0-none, 1-left, 2-right, 3-bilateral. based on the grading system, the right or left sinuses were divided into 6 portions: maxillary, anterior and posterior ethmoid, sphenoid, frontal sinuses, and ostiomeatal complex. the severity of sinus mucosal inflammation or fluid accumulation was scored as follows: 0 for complete lucency, 1 for partial lucency and 2 for complete opacity. in addition, the ostiomeatal complex was scored as either 0 for not obstructed or 2 for obstructed. the 10 scores for the various sinuses and bilateral ostiomeatal complexes were summed up to give a bilateral total lund-mackay score that could range from 0 (complete lucency of all sinuses) to 24 (complete opacity of all sinuses).3 a bilateral score of 5 and above, and a unilateral score of 4 and above was considered severe sinonasal disease. the association between the laterality of chronic suppurative otitis media and laterality of sinonasal disease was determined and the unilateral and bilateral lund-mackay scores were compared against ears with, and without complications. descriptive statistics were generated for all variables. for nominal data frequencies and percentages were computed. for numerical data, mean ± sd were generated. medians were computed for non-homogenous data, specifically in the comparison of lund-mackay scoring of subjects with or without ear complications. the one-way analysis of variance (anova) was used for comparing the lund-mackay scoring according to nose or ear pathology site. however, if there was a difference in the homogeneity of the data the non-parametric equivalent of the anova, the kruskal wallis test-was used instead. chi-square test was used for determining the association between laterality of csom and sinonasal disease. t-test was used in comparing the lms score with the presence of complications of csom. level of significance was set at p < .05. results a total of 64 patients were finally included in the study, 37 (57.8%) female and 27 (42.2%) male. the mean age was 37 years old (range 4 77 years old). majority (54) were service patients belonging to lower socio-economic brackets while the remaining 10 were private patients. all 64 patients underwent ear surgery, 25 (39%) had intact canal wall mastoidectomy while 39 (61%) had canal wall down mastoidectomy. thirty-four (34) right and 31 left ears were operated on with a total of 36 tympanoplasties performed. of the 64 mastoidectomies, 30 (46.88%) had complications of chronic suppurative otitis media such as cholesteatoma (23), brain abscess (6), subperiosteal abscess (3), suppurative labyrinthitis (2), bezold abscess (2), gradenigo syndrome (2), facial nerve paralysis (1), aural polyp (1). hearing loss was seen in philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles 18 philippine journal of otolaryngology-head and neck surgery varying severity among all patients who had a pure tone audiometry done. on review of the temporal bone ct scans, 17 patients had radiographic findings of cholesteatoma solely in the left ear, 18 patients in the right ear, and 30 patients had bilateral ear disease. with regard to the laterality of ear disease, the distribution was almost equal between right and left ears with 15/64 and 18/64 patients, respectively. however, there were more cases (31/64) with bilateral ear disease than unilateral right or left ear abnormality. with regard to the sinonasal findings, out of the 64 subjects, only 12 (18.75%) had positive findings on ct scan, while the other 52 patients had normal findings. of the 12 patients, 7 (58.3%) had bilateral involvement, only 1 (8.33%) had left-sided sinonasal pathology and 4 (33.3%) had right-sided sinonasal involvement. using the chi-square test, there was no significant difference in the proportion of subjects with sinonasal disease according to laterality of otitis media (p=.32). (table 1) when the site of nose pathology was compared to the lund-mackay graded score, heterogeneity in the data set was found, thus a kruskalwallis test was used. this analysis showed that bilateral nose pathology generally had a higher lund-mackay score of 8.60 ± 5.60, compared to no pathology at 0.10 ± 0.50, left nose pathology at 3.00 ± 0, and right nose pathology at 2.00 ± 0.00. however, there was no significant difference in the lund-mackay score according to the nose pathology site (p=.20). table 2 shows the association of the laterality of csom with the laterality of sinonasal disease among the 12 patients who had sinonasal finding on temporal bone ct scan. only one patient had left ear pathology with bilateral nose pathology. of the 4 patients with right ear pathology, 1 had left nose pathology and 3 had bilateral nose pathology, none had right nose pathology. seven had bilateral otitis media in whom 1 had right nose pathology and 6 had bilateral nose pathology. analysis by chi-square test showed that there was no significant association between laterality of csom with the laterality of sinonasal disease (p=.59) the 12 patients with sinonasal pathologies on ct scan were graded using the lund-mackay scoring system. the average lund-mackay score was 7, with the highest score of 17 and the lowest of 2. table 1. distribution of subjects with sinonasal disease according to laterality of chronic suppurative otitis media patients p = .32 (not significant) sinonasal disease (-) (n/52),% (+) (n/12),% total csom left ear right ear bilateral total 1 ( 8.3) 4 (33.3) 7 (58.3) 12 15 (28.8) 15 (28.8) 22 (42.3) 52 16 19 29 64 table 3. lund-mackay scoring * p>.05not significant; p ≤.05-significant † between none and not none (with) ‡ between bilateral and none only mean ± sd (median) frequency (n=64) *p-valuenose pathology site none left right bilateral 52 1 1 10 0.01 ± 0.50 3.00 ± 0.00 (3) 2.00 ± 0.00 (2) 8.60 ± 5.60 (7) <.01 (s)† – – <.01 (s)‡ table 4. lund-mackay scoring of patients with sinonasal disease according to ear pathology site * p>.05not significant; † between none and not none ‡ between bilateral and none only § between bilateral and not bilateral mean ± sd (median) frequency (n/12) *p-value ear pathology site left right bilateral total 1 4 7 12 14.00 ± 0.00 (14) 9.25 ± 7.32 (8.5) 5.71 ± 4.23 (4) 1.00 (ns)† 1.00 (ns)‡ .23 (ns)§ table 2. association of the laterality of csom with laterality of sinonasal disease sinonasal disease right bilateral totalleftcsom left ear right ear bilateral total 0 1 (1.6%) 0 1 0 0 1 (1.6%) 1 1 (1.6%) 3 (4.7%) 6 (9.4%) 10 1 4 7 12 p = .59 (not significant) comparison of the lund-mackay to ear pathology site using anova yielded no statistical significance (p=.44), although the left ear had a higher score compared to right and bilateral ear pathologies. (table 4) of the 12 patients with positive sinonasal findings, 7 (58.3%) had ear complications such as cholesteatoma, subperiosteal abscess and brain abscess. it was observed that these patients with ear complications generally obtained higher lund-mackay scores. the ear complication patients had an average lund-mackay score of 9.28, compared to the score of patients without ear complications with a 5.20 lund-mackay score average. t-test analysis showed that the difference was not statistically significant (p=.22). (table 5) table 5. lund-mackay scoring of patients with sinonasal disease according to ear complications mean ± sdfrequency (n=12) *p-valueear complications with without 7 5 9.28 ± 5.74 5.20 ± 4.97 .22 (ns) .22 (ns) * p>.05not significant; p ≤.05-significant philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 original articles philippine journal of otolaryngology-head and neck surgery 19 references 1. acuin j. chronic suppurative otitis media burden of illness and management options. child and adolescent health and development prevention of blindness and deafness. world health organization. geneva, switzerland. 2004; p.9-15. 2. yeolekar am, dasgupta ks. otitis media: does the onus lie on sinonasal pathology? indian j otol [serial online] 2011 oct;17(1):8-11. [cited 2014 jul 10]. available from: http://www.indianjotol. org/text.asp?2011/17/1/8/85784 doi: 10.4103/0971-7749.85784. 3. chen j-j, chen d-l, chen c-j. the lund-mackay score for adult head and neck computed tomography. j radiol sci. 2011; 36(4): 203-208. [cited 2014 aug 1]; available from: http://www. rsroc.org.tw/db/jrs/article/v36/n4/360402.pdf. 4. abong jm, kwong sl, alava hd, castor ma, de leon, jc. prevalence of allergic rhinitis in filipino adults based on the national nutrition and health survey 2008. asia pac allergy 2012 apr;2(2):129-135. [cited 2013 march 19]. available from: http://dx.doi.org/10.5415/ apallergy.2012.2.2.129. 5 leung rs, katial r. the diagnosis and management of acute and chronic sinusitis. prim care. 2008 mar; 35(1): 11-24. doi: 10.1016/j.pop.2007.09.002 pmid: 18206715. discussion there was no association between laterality of chronic ear disease and sinonasal disease in this study. this was supported by a low 18.75% incidence of sinonasal abnormalities in the sample population of surgical ear patients, where only 12 patients out of 64 with csom had positive findings of sinonasal disease on ct scan. in spite of the reasonable hypothesis that a unilateral ear problem should be associated with ipsilateral sinonasal problems, we found no such correlation between the laterality of sinonasal disease and csom. while this may be due to our failure to differentiate between atticoantral and tubotympanic otitis media, as well as failure to catch previous sinonasal disease that may have precipitated ear disease but was subsequently treated, or sinonasal disease that was not severe enough to manifest radiographically, it may still be argued that in patients with csom a thorough examination of all the sinuses, and not just the ipsilateral sinuses, should be performed. having said that, by focusing on radiographic findings, we failed to analyze the histories and physical examination findings of otitis and sinonasal disease in our sample; additional data that may have strengthened the association of laterality. despite these shortcomings, the correlation seen between complications of csom and severity of sinonasal disease support the association between ear and sinonasal problems. a study by yeolekar and dasgupta relied on history and anterior rhinoscopy to diagnose sinonasal disease2 without the benefit of a ct scan which may show evidence of radiographic abnormalities in the paranasal sinuses. because the paranasal sinuses and ostiomeatal complexes can be visualized in routine temporal bone ct scans in our institution, this study intended to go further by investigating radiographic evidence of sinonasal disease among csom patients admitted for surgery. unfortunately, we erred on the opposite side of yeolekar and dasgupta’s study2 by focusing on imaging to the detriment of history and anterior rhinoscopy. a study by chen et al. in taiwan, using head and neck ct scans in 600 patients determined a control dataset for taiwanese individuals to show what bilateral and unilateral right and left lms score was considered severe.3 bilateral total lms was separated from unilaterally total lms because there were significant differences found among bilateral, control, unilateral right and unilateral left sinuses groups. after exclusions, there were 490 study subjects and 119 controls. in the taiwan study group, the bilaterally total lms obtained for the dataset was 0.96 ± 1.91 (mean ± sd) with a right total lms of 0.46 ± 1.28 and a left total lms of 0.50 ± 1.41. thus, a patient with bilateral total lms of more than 5 (considered severe), or with a unilateral lms of more than 4, was considered beyond 97.7% of the common population.3 these thresholds were used in this study to indicate the severity of our findings. when we compared the site of nose pathology to the lms in this study, no significant difference was found (p=0.20). this is in contrast with the taiwan study, wherein they had to separate the right from left and bilateral pathology since significant differences were found in their data set. since no significant difference was found in our data set, the lms was treated as a total score and not individually compared against each other. in this study, 6 or 9.38% of the sample population had a bilateral total lms score greater than 5. the association between high lundmackay scores, which reflect the severity of sinonasal disease, and csom complications among patients in this study, warrants further inquiry. it may also be interesting to note that in our dataset, the left ear (14.00 ± 0.00 sd=14) had a higher score compared to the right or bilateral ear pathology. a major limitation of this study was the non-segregation of atticoantral from tubo-tympanic csom. the former would theoretically have little or no relation to sinonasal disease, which the latter would be expected to have. our definition of csom complications (which strictly speaking, include tympanic membrane perforation and hearing impairment) is another limitation of our paper. we only used the term to apply to more serious complications listed in our results (various abscesses, suppurative labyrinthitis, gradenigo syndrome, facial nerve paralysis), and yet, we also included cholesteatoma and aural polyp. despite our retrieving history and physical examination results, we did not consider a history of hearing impairment and hearing test results (which were also incomplete), or tympanic membrane perforations in our list of complications. in addition, co-morbidities identified among our patients were not analyzed against ear and sinonasal complications and actual physical examination findings. other limitations include the unvaliditated use of temporal bone ct scans in interpreting and grading the severity of sinonasal disease using the lund-mackay scoring system. although laterality of ear disease was not associated with the laterality of sinonasal disease in this study, csom complications were associated with high lund-mackay scores. future, more rigorouslydesigned studies with a larger and more diverse population may yet determine an association between csom and laterality of sinonasal disease. a better-designed study with a larger population may also establish the predictive value of a high lms for csom complications. philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2018; 33 (1): 21-24 c philippine society of otolaryngology – head and neck surgery, inc. evaluation of the newborn hearing screening program in the medical city based on joint commission on infant hearing (jcih) 2007 position statement quality indicators mary harmony b. que, md, mba1 maria rina t. reyes-quintos, md, phd1,2,3,4 1department of otolaryngology head and neck surgery the medical city 2hearing and dizziness center the medical city 3department of otorhinolaryngology college of medicine philippine general hospital university of the philippines manila 4philippine national ear institute national institutes of health university of the philippines manila correspondence: dr. maria rina t. reyes-quintos department of otorhinolaryngology ward 10, philippine general hospital taft ave., ermita, manila 1000 philippines phone: (632) 526-4360 fax: (632) 525-5444 email: rinatrq@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not yet been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to conflict of interest. presented at the philippine society of otolaryngology – head and neck surgery descriptive research contest (1st place). august 10, 2017. natrapharm, the patriot bldg., parañaque city. abstract objective: the objective of this study is to evaluate the newborn hearing screening program in the medical city based on the joint committee on infant hearing (jcih) 2007 position statement quality indicators. methods: design: cross sectional survey setting: tertiary private hospital participants: all newborns who underwent newborn hearing screening in the medical city for the year 2015. results: of 2,010 patients delivered in the hospital in year 2015, 1,986 (98.8%) were screened. among the 59 babies with initial “refer” results, 15 (25.42%) “referred” a second time while 24 (40.68%) “passed” the rescreening. twenty (33.89%) did not undergo rescreening (10 were classified as dropouts while another 10 did not undergo rescreening for various reasons. of those who “referred” during rescreening, only 9 (60%) had further evaluation done with abr/assr. among these, 4 (26.66%) had hearing loss and proceeded with the appropriate monitoring and management while 5 (33.33%) had normal hearing. conclusion: the current newborn hearing screening program in the medical city was able to reach jcih 2007 quality indicators for screening but not for confirmation of hearing loss. all patients with hearing loss were managed with early rehabilitation. keywords: newborn hearing screening, otoacoustic emission test, auditory brainstem response test, auditory steady state response test along with other countries around the globe, the philippines has established newborn hearing screening programs to detect hearing loss in children at a very young age. screening is only the beginning of the audiological testing battery which often involves rescreening and additional audiological tests to confirm or repudiate the initial findings before diagnosis and rehabilitation.1 the joint committee on infant hearing (jcih) is an association made up of members who are creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles experts in their fields of audiology, otolaryngology, pediatrics and nursing. they are responsible for making recommendations concerning the early identification of children with or at risk for hearing loss. in 2007, they published the jcih 2007 position statement which includes the benchmarks and quality indicators as a guide and goal for hospitals with hearing screening programs.2 the medical city is a tertiary private hospital with a newborn hearing screening program. the medical city is also a joint commission international (jci) accredited institution. this means that it is committed to quality improvement and dedicated to providing the best possible care for their patients. thus, the impetus for this study which is to improve the newborn hearing screening program of the hospital. a study in the united states of america from year 2005-2011 showed a rescreen follow up rate of 65% in 2011,3 similar to findings in an unpublished medical city study of 66.8% in 2009.4 according to jcih, the quality indicators for screening include a screening rate of > 95%, and a “refer” rate of ≤ 4%.2 for the quality indicators for confirmation of hearing loss, 90% must complete a comprehensive audiological evaluation.2 to the best of our knowledge, there has also been no published data about jci and jcih nor jci and newborn hearing screening programs. it is important to know how the medical city newborn hearing screening program compares with the jcih quality indicators for screening and confirmation of hearing loss. this information can tell us if the program is reaching the goals set by the quality indicators, and if not, the possible reasons and solutions. the objective of this study is to evaluate the newborn hearing screening program in the medical city based on the joint committee on infant hearing (jcih) 2007 position statement quality indicators. methods with institutional review board approval, this cross sectional study retrieved the records of all newborns delivered in 2015 in medical city, a tertiary private hospital in the philippines. the total number of babies who underwent newborn hearing screening and the number of babies who obtained “pass” and “refer” results using an otoport lite teoae model (otodynamics ltd., uk) were gathered and recorded from the logbooks accomplished by the nurses after testing. as a routine hospital practice before discharge, babies with persistent “refer” results on hearing screening are automatically scheduled for rescreening at the hearing and dizziness center of the medical city after 1 month. they are given reminders of their rescreening schedule by the hearing and dizziness center (hdc) staff and the pediatric resident rotator via phone calls. the hdc staff routinely inquire about the reasons why the mother (or caregiver) refused or cancelled their appointment. the parents answers are recorded in logbooks. these were the logbooks searched by the investigators. the investigators searched for the rescreening records of those who had “refer” results and these were also collated. the parents of the babies with “refer” results had all been advised to undergo rescreening at the hearing and dizziness center as well as diagnostic testing using abr and assr if the result was still a “refer.” the madsen accuscreen® two-step (oae/abr) hand-held screening system (gn otometrics, a/s, denmark) had been used for rescreening, and the navigator pro multiple auditory steady-state evoked response system ii (bio-logic® master® ii) (natus, ca, usa) for additional diagnostic testing. parents or caregivers of all babies who deviated from the protocol anywhere in the course of the program were identified. those who failed to follow-up for rescreening were contacted by non-recorded phone calls and asked through open-ended questions why they did not undergo the recommended tests. parents or caregivers of babies who were identified to have hearing loss based on diagnostic testing were questioned if they had already proceeded with rehabilitation and, if applicable, why not. the number of attempts to contact respondents was also recorded. those who could not be contacted by the hearing and dizziness staff after 3 attempts, and for whom no evidence of a repeat test in the medical city could be found, were classified as dropouts. based on the responses, factors such as ‘lack of education / knowledge about the need for a repeat test,’ ‘lack of time,’ ‘unavailable testing center (scheduling/ machine problems),’ ‘financial constraints,’ ‘poor customer service,’ ‘advise not to proceed with retesting,’ ‘opted to transfer to another hospital or testing center,’ ‘have forgotten or do not care for a repeat test,’ ‘changed doctors,’ were identified and recorded. percentages were used to determine the fraction of newborn babies screened, the fraction of babies who had a “pass” or a “refer result,” fraction of babies returning for rescreening and those who did not, fraction of babies who had a “pass” or a “refer” result after the repeat screen, fraction of babies who underwent confirmatory tests and those who did not. the software used was microsoft excel for windows version 16.0.6769.2017 (microsoft corp., redmond, wa, usa). results out of 2,010 babies delivered in our hospital for 2015, 1,986 (98.8%) were screened. the remaining 21 patients (1%) were either discharged against medical advice, transferred or expired before the hearing tests could be done while 3 (0.1%) refused testing. of the 1,986 babies screened, 1,927 (97.02%) had initial screening test results of “pass” and 59 (2.97%) had initial screening test results of “refer.” this is seen in the first column in figure 1. philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles among the 59 babies with initial “refer” results, 15 (25.42%) “referred” a second time while 24 (40.68%) “passed” the rescreening. (figure 1) twenty (33.89%) did not undergo rescreening, 10 of these were classified as dropouts while another 10 did not undergo rescreening for other reasons seen in table 1 below. table 1. reasons why parents did not bring their child for rescreening reason for not having a repeat hearing screening number of patients parent has no time to bring patient for repeat oae patient had other more pressing medical problems parent advised by pediatrician to observe patient parent advised to have repeat hearing test but has not yet been able to do so oae machine was broken and parent couldn’t schedule a repeat oae parent clinically assessed patient to have no problems in hearing hence did not schedule a repeat oae total 2 1 3 1 2 1 10 among those with hearing loss, 2 (50%) had unilateral mild hearing loss for which they were advised close monitoring, 1 (25%) had bilateral hearing loss (right moderate hearing loss and left moderate to severe hearing loss) for which hearing aids were prescribed, while 1 (25%) had bilateral profound hearing loss for which preparation for cochlear implantation is being started. hence, only 0.2% of 1,986 patients screened had hearing loss and all have proceeded with the appropriate management. our results show that the medical city was able to reach the jcih 2007 quality indicators for screening but not the quality indicators for confirmation of hearing loss. (table 2) discussion the medical city was able to reach the jcih 2007 quality indicators for screening but not for confirmation of hearing loss. this problem has also been seen in other places besides the philippines and successful interventions have been done for better compliance with the many diagnostic audiological procedures needed prior to starting rehabilitation. a university of illinois study showed that they were able to decrease loss to follow-up and documentation rate from 71.36% to 46.36%.5 their strategy involved educating the primary health care providers and parents and preparing english and spanish materials about the importance of the program. program implementors also met regularly to monitor their progress.5 two studies in massachusetts showed a loss to follow-up rate of 25% and 50.9% respectively.6,7 these losses to follow-up were attributed to several factors such as being non-white, receiving public insurance and a mother who smoked during pregnancy. those who had unilateral and mild to moderate hearing loss were also more likely to be lost to followup. 6,7 a possible solution to this problem was proposed by hunter in 2016.8 her research showed that collaborating with the women, infants, and children program in ohio (wherein staff members would contact family members to remind them of their pending schedules based on figure 1. number of patients with a “pass” or “refer” and number of drop outs on 1st and 2nd oae and number of patients with normal or abnormal results after abr/assr tests. of the 15 babies with rescreening results of “refer,” 9 (60%) had further evaluation with abr/assr. of these, 4 (26.66%) were diagnosed to have hearing loss and 5 (33.33%) had normal hearing. five other babies (33.33%) were considered dropouts, and 1 (6.66%) had not undergone abr/assr because the mother had no time to bring the infant for the test. (figure 1) table 2. jcih quality indicators for screening and confirmation of hearing loss compared with the medical city results jcih 2007 quality indicators the medical city quality indicators for screening % babies screened % babies who “refer” quality indicators for confirmation of hearing loss % diagnostic testing completed ≥ 95 % < 4 % ≥ 90 % 98.8 % 0.75 % 60 % philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles their newborn hearing screening protocol), as well as counselling and educating them, had a strong impact on decreasing the loss to follow up rate from 33% to 9.6%.8 these same strategies may also be applied in our setting: making sure that stakeholders are regularly reminded and updated about the existence and importance of the newborn hearing screening program, hiring dedicated staff responsible for advising the parents after screening (who should also be monitored so that they impart the proper information in the proper manner), and writing easy to understand brochures in the vernacular, may be instrumental in educating reminding and encouraging the parents to continue with the newborn hearing screening program and that it is worthwhile to do so. one of the limitations of this study is the study population; only patients who were born in the medical city on the year 2015 were included in this study and these may not represent the larger population of filipino children with hearing loss since majority of the mothers who give birth in the said institution are among the higher classes who have better access to proper healthcare. the methodology can also be improved to include a uniform script of questioning with a set of choices for the parents to select as reasons why they did not come back for further testing. future studies can take these into consideration. this study showed that the medical city has attained the jcih benchmarks for screening but still needs to improve with regards to follow up for confirmation of hearing loss which was 60% compared to a minimum of 90% benchmark from jcih. steps should be taken to address this low follow up for confirmation of hearing loss so that the hearing screening program in the medical city will fulfill its goal of early screening and intervention for children with hearing loss. references 1. universal newborn hearing screening and intervention act of 2009. republic act no. 9709. republic of the philippines. (aug 12 2009). 2. joint committee on infant hearing. year 2007 position statement: principles and guidelines for early hearing detection and intervention programs. pediatrics. 2007 oct; 120(4): 898-921. doi: 10.1542/peds.2007-2333; pubmed pmid: 17908777. 3. alam s, gaffney m, eichwald j. improved newborn hearing screening follow-up results in more infants identified. j public health manag pract. 2014 mar; 20(2): 220-223. doi: 10.1097/ phh.0b013e31829d7b57. pubmed pmid: 23803975 pubmed central pmcid: pmc4470168. 4. abratique rj, batayola mc, reyes-quintos mrt. current state of the universal new born hearing screening program at the medical city. unpublished 2009: 1-17. 5. reducing loss to follow-up after failure to pass newborn hearing screening. illinois program narrative. chicago: the university of illinois. 2010-2011. 1-18. [cited 2017 june 12] available from:https://www.infanthearing.org/stategrants/grants_supplemental_2009/4-il%20 supplemental%202010-2011.pdf. 6. liu cl, farrell j, macneil jr, stone s, barfield w. evaluating loss to follow-up in newborn hearing screening in massachusetts. pediatrics. 2008 feb; 121(2) e335-43, doi:10.1542/peds.2006-3540. epub 2008 jan 10. pubmed pmid:18187812. 7. crouch e, probst j, bennett k and carroll t. evaluating loss to follow-up in newborn hearing screening in a southern state. jehdi. 2017; 2(1):40-47. [cited 2017 june 12] retrieved from http://digitalcommons.usu.edu/cgi/viewcontent.cgi?article=10438&content=jehdi. 8. hunter ll, meinzen-deir, wiley s, et al. influence of the wic program on loss to followup for newborn hearing screening. pediatrics. 2016 jul; 138(1) e20154301. pubmed pmid: 27307144 pubmed central pmcid: pmc4925076. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the quality of life among sars-cov-2 (covid-19) positive patients with anosmia using the short version questionnaire of olfactory disorders negative statements translated in filipino (sqod-ns ph). methods: design: cross-sectional study setting: tertiary government training hospital participants: sars-cov-2 (covid-19) rt-pcr positive patients aged 18 years old and above with covid-19 symptoms and anosmia in a tertiary government hospital who consulted from march 2020 to august 2021 answered the short version of sqod-ns ph. results: out of 108 participants with positive sars-cov-2 (covid-19) rt-pcr test, 72 (66%) presented with anosmia, and sqod-ns ph scores ranged from 1 to 21 with a mean of 14.78. thirty two (44%) encountered problems in eating while 21 (29%) had feelings of isolation due to loss of smell. there was an inverse correlation of -0.478 between recovery time of olfaction and qol score, hence the longer the recovery time, the lower the qol score, while the shorter the recovery time, the higher the qol score (p < .0001). conclusion: majority of covid-19 patients with anosmia had mild or negligible impairment, while a small percentage had impaired quality of life. the low percentage may be due to high number of patients who may have recovered their sense of smell along the course of the disease. keywords: covid-19; olfaction; anosmia; quality of life; qod-ns; smell; smell loss olfaction plays an important role in protecting and conserving life. it is involved in food intake, social communication, reproductive behavior, and may influence working abilities.1 it also helps in the early detection of fire, gas leaks, spoiled food or dangerous fumes. while these may be less important to a person’s well-being, olfactory dysfunction may affect the individual’s quality of quality of life among sars-cov-2 (covid-19) positive patients with anosmia using the short version questionnaire of olfactory disorders negative statements translated in filipino (sqod-ns ph) anjenneth mallari-bernarte, md emmanuel tadeus s. cruz, md department of otorhinolaryngology head and neck surgery quezon city general hospital correspondence: dr. emmanuel tadeus s. cruz department of otorhinolaryngology head and neck surgery quezon city general hospital seminary rd., bgy. bahay toro, quezon city 1106 philippines phone: (+632) 8863 0800 local 401 email: orl_hns_qcgh@yahoo.com.ph the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery virtual analytical contest november 10, 2021. philipp j otolaryngol head neck surg 2022; 37 (2): 20-25 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles life (qol) and functionality.2 patients with lost sense of smell showed significant impairment in eating, safety, personal hygiene and sex life.3 corollary to this, quality of life, safety issues, interpersonal relations and eating habits are severely altered in patients with olfactory disorders and patients with olfactory loss reported higher level of disability and lower qol than those who recovered.1 anosmia and dysgeusia have been identified among the many symptoms of covid-19 infection. patients who complain of anosmia and flu-like symptoms are more likely to test positive for covid-19 infection.4 studies regarding the prevalence of smell loss and taste alteration in covid-19 patients have been reported.5-7 our previous study showed 95% of patients with anosmia had a positive sars-cov-2 (covid-19) rt-pcr test.8 another study found that out of 394 covid-19 patients, 161 (41%) exhibited sudden olfactory and/or gustatory dysfunction, 66.2% suffered from anosmia and 88.8% reported gustatory disorders.5 this olfactory dysfunction is believed to ensue from damages inflicted on the olfactory epithelium which prevent odors from binding to olfactory receptors.9 with the advent of sarscov-2 (covid-19) infection that may compromise the sense of smell, an evaluation tool translated in filipino is essential to assess the quality of life of patients affected along the clinical spectrum. this study aims to determine how having an anosmic condition among sars-cov-2 (covid-19) positive patients impacts the way they live or their quality of life using the short version questionnaire of olfactory disorders negative statements translated in filipino (sqodns ph). methods this cross sectional study was approved by the quezon city general hospital bioethics committee. patients aged 18 years old and above with symptoms of cough, colds, fever, difficulty of breathing, and anosmia with positive sars-cov-2 (covid-19) rt-pcr test who consulted in covid-19 tent screening areas or were admitted at the quezon city general hospital from july 2021 to august 2021 and who were able to accomplish the questionnaire were considered for inclusion. patients with covid-19 symptoms and anosmia with positive sars-cov-2 (covid-19) rt-pcr test in the past who followed up in the study period were also considered. informed consent was obtained from participants prior to inclusion. excluded were patients who had a past history of anosmia prior to the pandemic, those with chronic sinonasal conditions (sinusitis, septal deviation, nasal mass, nasal polyps, history of nasal trauma etc.), neuropsychiatric or mental illnesses and those with critical conditions. the sample size was computed using a 95% level of confidence. with an estimated proportion of patients with anosmia among covid-19 patients of 25%, based from the al-ani, et al.10 at least 72 patients were needed at 10% error. where: n = is the number of participants/subjects needed p = estimated proportion of patients with anosmia among covid-19 patients = 60%=0.60 q = 1 – p = 1 – 0.60 = 0.40 zα = 95% confidence level = 1.96 e = error of 10% with permission for its translation and utilization in filipino, the short version questionnaire of olfactory disorders-negative statements (sqod-ns) composed of a 7-item patient reported outcome questionnaire was translated and certified in filipino language by the university of the philippines sentro ng wikang filipino. (figure 1) the sqod-ns ph incorporates the following items: 3 – from social subdomain involving impacts on patients’ daily activities and feelings of isolation and anger; 2 – from eating subdomain regarding impacts on attending restaurants and food consumption; 1 – from anxiety subdomain inquiring on relaxation; and 1 – from annoyance subdomain involving adapting to changes in olfactory dysfunction. each item is rated on a scale of 0 to 3, with higher scores reflecting better olfactoryspecific qol while a low score harbors poor qol due to anosmia. the total score ranges from 0 (severe impact on qol) to 21 (no impact on qol). the short version of the questionnaire of olfactory disordersnegative statements translated in filipino (sqod-ns ph) was initially administered to a group of 20 patients with or without anosmia to determine reliability. after cronbach’s alpha was computed, the questionnaire was then administered to sars cov-2 (covid-19) positive patients with anosmia. data on demographics (age, sex), date of covid-19 diagnosis, signs and symptoms, whether admitted or quarantined at home, duration and recovery from anosmia and sars-cov-2 (covid-19) rt-pcr results (from department of health (doh) approved testing facilities, the philippine genome center, or st. luke’s medical center) were obtained. the questionnaire was administered to participants, assisted by a resident physician if needed. the data and questionnaires were then collated using ms excel for mac version 16.13 (microsoft corporation, redmond, wa, usa) and the scores were tabulated and analyzed. cronbach’s alpha was computed to measure the reliability of philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles the questionnaire. descriptive statistics were used to summarize the demographic characteristics of the patients. frequencies and percentages were used for categorical data and means and standard deviations for normally distributed numerical variables. spearman rank correlation was used to determine the correlation of the individual items with the over-all response. t-test was used to compare the age of patients according to qol (impaired or not impaired). chi-square test was used to compare the proportions. the ibm spss statistics for windows, version 26.0, released 2019 (ibm corp., armonk, ny, usa) was used for data processing and analysis. results out of 108 subjects with positive sars-cov-2 (covid-19) rtpcr test, 72 (66.6%) presented with anosmia while 36 (33.3%) had normal sense of smell. their ages ranged from 18 to 69 years with a mean of 35.75 years. thirty-seven (51.4%) were male and 35 (48.6%) were female. thirty-five (48.6%) were admitted while 37 (51.4%) were advised to undergo quarantine at home. other clinical manifestations include fever (52.5%), colds (47.5%) and cough (40%). of these 72 sars-cov-2 (covid-19) rt-pcr positive patients with anosmia, 52 (72.2%) recovered olfaction within 1 to 90 days with a mean duration of 7.56 days while 20 (27.8%) had anosmia at the time of enrolment in this study. the time between diagnosis and date of interview ranged from 0 to 490 days with a mean interval period of 73.36 days. the translated version revealed a cronbach’s alpha of 0.875 which reflects good reliability and internal consistency of the questionnaire. the questionnaire was administered to 72 sars-cov-2 (covid-19) rt-pcr positive patients with anosmia with the following responses: whether changes in their sense of smell made them feel isolated (q1); 9 (12.5%), 12 (16.7%), 17 (22.2%) and 36 (48.6%), agreed, partly agreed, partly disagreed and disagreed, respectively. with regards to problems with taking part in activities of daily life (q2); 8 (11.1%), 15 (20.8%), 10 (13.9%) and 39 (54.2%), agreed, partly agreed, partly disagreed and disagreed, respectively. when asked if changes in their sense of smell made them feel angry (q3); 5 (6.9%) agreed and 9 (12.5%) partly agreed, while 8 (11.1%) and 50 (69.4%) partly disagreed and disagreed, respectively. because of the changes in their sense of smell, 8 (11.1%) agreed that they went to restaurants less often than they used to (q4), 5 (6.9%) partly agreed, 19 (26.4%) and 40 (55.6%) partly disagreed and disagreed, respectively. eighteen (25%) agreed and 14 (19.4%) partly agreed that they ate less than they used to or more than they used to (q5), while 11 (15.3%) and 29 (40.3%) partly disagreed and disagreed, respectively. when asked if they tried harder to relax because of changes in sense of smell (q6); 13 (18.1%) each both partly agreed short version of questionnaire of olfactory disorders-negative statements maikling bersiyon ng kuwestiyonaryo ng olfactory disorders-negative statements agree sumasangayon (0) partly disagree bahagyang hindi sumasangayon (2) partly agree sumasangayon (1) disagree hindi sumasangayon (3) figure 1. short version questionnaire of olfactory disorders negative statements translated in filipino (sqod-ns ph) (original english statements are included for illustration). the changes in my sense of smell make me feel isolated. pakiramdam ko nag-iisa ako nang magbago ang aking pang-amoy. because of the changes in my sense of smell, i have problems with taking part in activities of daily life. nagkakaproblema ako sa pangaraw-araw na gawain dahil pagbabago sa aking pang-amoy. the changes in my sense of smell make me feel angry. nagagalit ako dahil nagbago ang aking pang-amoy. because of the changes in my sense of smell. i go to restaurants less often than i used to. kumpara noon, bihira na akong pumunta sa mga restawran dahil sa pagbabago sa aking pang-amoy. because of the changes in my sense of smell, i eat less than i use to or more than i used to. mas kaunti o mas marami kaysa dati ang kinakain ko simula nang magbago ang aking pang-amoy. because of the changes in my sense of smell, i try harder to relax. mas sinisikap kong makapagpahinga o makapag-relax nang magbago ang aking pangamoy. i am worried that i will never get used to the changes in my sense of smell. nag-aalala ako na baka hindi ako masanay sa mga pagbabago sa aking pang-amoy. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles and disagreed while 8 (11.1%) and 38 (52.8%) agreed and disagreed, respectively. eight (11.1%) agreed that they were worried that they would never get used to the changes in their sense of smell (q7), while 35 (48.6%) disagreed, and 14 (19.4%) and 15 (20.8%) partly agreed and partly disagreed, respectively. scores ranged from 1 to 21 with a mean of 14.78. five (6.9%) had a score of 0 – 5, 11 (15.3%) 6 – 10, 17 (23.6%) 11 – 15, and 39 (54.2%) had a score of 16 – 21. a score of less than or equal to 10 reflects impairment in the quality of life comprising of 16 (22.2%), while a score of more than 11, composed of 56 (77.8%) respondents were classified with slight or negligible impairment. there was no significant difference in the age of respondents (p = .53). likewise, there was no significant difference in the proportion of males and females with impaired qol (p = .22). on the other hand, there was a significant difference in the proportion of respondents with impaired qol between those who were either admitted or homequarantined. more respondents who were quarantined had impaired qol than those who were admitted; 32.4% and 11.4%, respectively (p = .03). significant correlation was noted between recovery time of olfaction and the over-all qol score as shown by the correlation coefficient of -0.478 (p < .0001). a negative correlation indicates an inverse correlation which means that the longer the recovery time of olfaction, the lower the over-all qol score, while the shorter the recovery time of olfaction, the higher the over-all qol score. discussion our study showed that majority or 78% of sars-cov-2 (covid-19) positive patients with anosmia had minimal or negligible impairment in quality of life, while 22% had impaired quality of life based on the scores of the respondents. in contrast, lechien reported that covid-19 patients with olfactory dysfunction had significantly lower scores in sqod-ns which reflect impairment and deterioration of qol after the onset of smell loss in 76% of patients.6 in a study by elkholi et al., 73% reported negative effects pertaining to awareness to personal hygiene, interest in food, and drinks associated with significant reduction in health-related qol.11 patients with olfactory loss disclosed difficulties in everyday activities and decrease in the quality of life.12 in our study, problems encountered included eating less than they were used to and feelings of isolation due to loss of smell while only a few reported feelings of anger and going less often to restaurants. olfactory deprivation becomes a problem if it persists for more than 2 months which may affect qol. on the other hand 23% of patients with anosmia reported that it was beneficial since they were no longer bothered by unpleasant odors.11 there was no significant difference in the proportion of males and females with impaired qol in our present study. on the contrary, there are reports that females are commonly affected6,11 and have higher susceptibility to develop olfactory and gustatory dysfunctions.6 our current study also revealed that a higher proportion of patients who were advised quarantine at home had impaired quality of life 12 (32.4%) compared to those who were admitted 4 (11.4%). while it appears paradoxical that the quality of life of admitted patients was affected more compared to those advised to be quarantined at home, further investigation into possible reasons is beyond the scope of our study. regarding pathophysiology of anosmia, it has been hypothesized that the sars-cov2 virus does not directly affect the nerves, but other non-neuronal cells with ace2 receptors including olfactory epithelium sustentacular cells, microvillar cells, bowman’s gland cells and others.13 the prevalence of anosmia in patients with covid-19 infection ranges from 5 to 26, 32, 35, 48, and 79 percent.7-8, 14-16 alega and cruz reported that 51% (60/117) of covid-19 positive individuals reported loss of smell8 while regalado et al. reported an overall prevalence of 71% in a systematic review.18 the prevalence rate of 66% in our present study is consonant with other reports that anosmia is associated with covid-19 infection. with regards to recovery from loss of smell, our present study showed a mean duration of 7.46 days; 52 (72.2%) had resolution of anosmia while 20 (27%) had olfactory dysfunction at the time of enrollment. this is comparable with lechien who reported recovery of olfaction in 72.6% of patients within 8 days after resolution of the disease.6 this may be apparent since the viral load decreased within 17 days following the beginning of olfactory dysfunction and complete recovery occurs after two weeks.16, 19 the sense of smell improved in 28 and 21 days, with 98% and 79% recovering, according to klopfenstein and hopkins, respectively.20, 21 in another study, the mean duration was 8 days in 60% of patients while 39% claimed to have persistence of loss of smell.4 it may be presumed that the 20 (27%) patients who experienced anosmia during the interview developed infection a few days prior to inclusion in the study, and may have a higher viral load that may compromise olfaction. there was a negative or inverse correlation between recovery time of olfaction and the over-all qol score which indicates that the longer the recovery time of olfaction, the lower the over-all qol score or impaired qol, while the shorter the recovery time of olfaction, the higher the over-all qol score or less impaired qol. it is worthwhile to consider hopkins’ observation that olfactory loss in covid-19 patients is usually severe and abrupt in onset but is only transient or temporary and only about 10% may not recover within a month.21 there are other questionnaires dealing with qol of patients affected by anosmia12, 22, 23 but they have many items that need a lot philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles of time to answer and become tedious for respondents. those written in a foreign language may not be easily understood in the local setting. locally published olfactory tests and questionnaires dealing with nasal problems include the sto. tomas smell identification test (st-sit) which uses 45 inhaled odorants,24 the nasal obstruction symptom evaluation scale (nose-ph) which addresses severity of nasal obstruction,25 and the filipino sino-nasal outcome test (snot 22) that evaluates quality of life in chronic rhinosinusitis.26 the sqod-ns ph may be a valuable addition to evaluation tools dealing with quality of life of patients suffering from anosmia, being validated and translated in filipino. our questionnaire was derived from a brief version of the qod-ns by mattos to streamline clinical care and research, reducing 17 questions to only 7.27 the shorter version was developed to increase the response rate and reduce the patient’s mental processing when answering the questionnaire. it was translated in spanish28 and italian6 and was used to investigate impact of olfactory dysfunction on quality of life among covid-19 patients.29 the short version was used due to good reliability, ease of answering which requires a short amount of time, and relevance of the 4 subdomains covered. limitations of our current study include the lack of objective testing to evaluate olfaction and not performing nasal endoscopy to avoid prolonged exposure and risk of infection. additional questionnaires dealing with psychological aspects like depression which might influence the perceived qol in affected individuals in relation to the various domains were not measured. in some participants, the long interval between onset or span of time prior to responding to the questionnaire may have affected memory or recall of the specific time or day when anosmia developed and subsequently resolved. this is a continuous variable that may vary and is beyond our control in a crosssectional study wherein the impact of a certain disease is observed over a given period. some may contend that the responses may not be reliable since they may have negative rt-pcr at the time of inclusion in the study because they had infection way back in the past. while this may be so, they were included with a previous positive rt-pcr test for the simple reason that this study aimed to determine if anosmia improves, lingers, or persists afterwards. to our knowledge, there is no gold standard to compare with and evaluation tools or questionnaires for anosmia are varied and arbitrary because respondents’ perceptions differ in many aspects and a standardized and universally accepted tool may take time to develop. the sqod-ns was selected because of the attributes cited earlier and because it was already validated to evaluate anosmia in covid-19 individuals in earlier studies.27 the results of this study are in agreement with the recommendation of other reports that anosmia should be included in the routine screening of covid-19 patients’ health declaration protocol. patients who develop anosmia after covid-19 infection can be advised that olfactory dysfunction may improve later. olfactory retraining programs may help facilitate recovery for those with anosmia. determination of qol scores using sqod-ns ph or other questionnaires may be performed before and after recovery for comparison in future studies. since the sqod-ns ph was not solely developed for patients with covid-19 infection, the questionnaire may be used in clinic or other research settings to determine quality of life of patients with anosmia in general. in summary, our study revealed a high prevalence of anosmia in confirmed covid-19 patients in consonance with other reports6-8, 17-18 with a good percentage of patients recovering from anosmia spontaneously. the majority of covid-19 patients with anosmia had minimal or negligible impairment, while a small percentage had impaired quality of life. the low percentage of patients with impaired qol may be due to high number of patients who may have recovered their sense of smell along the course of the disease. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles references 1. hummel t, nordin s. olfactory disorders and their consequences for quality of life.  acta otolaryngol. 2005 feb;125(2):116-121. doi: 10.1080/00016480410022787; pubmed pmid: 15880938. 2. miwa t, furukawa m, tsukatani t, costanzo rm, dinardo lj, reiter er. impact of olfactory impairment on quality of life and disability. arch otolaryngol head neck surg. 2001 may;127(5):497–503. doi: 10.1001/archotol.127.5.497; pubmed pmid: 11346423. 3. hufnagl b, lehrner j, deecke l. development of a questionnaire for the assessment of selfreported olfactory functioning. chemical senses. 2003 jan;28:e27. doi: 10.1007/s12078-0129127-7. 4. yan c, faraji f, prajapati d, boone c, deconde as. association of chemosensory dysfunction and covid‐19 in patients presenting with influenza‐like symptoms. int forum allergy rhinol. 2020 jul;10(7):806-813. doi: 10.1002/alr.22579; pubmed pmid: 32279441; pubmed central pmcid: pmc7264557. 5. qiu c, cui c, hautefort c, haehner a, zhao j, yao q, et al. olfactory and gustatory dysfunction as an early identifier of covid-19 in adults and children: an international multicenter study. otolaryngol head neck surg. 2020 oct;163(4):714-721. doi: 10.1177/0194599820934376; pubmed pmid: 32539586; pubmed central pmcid: pmc7298561. 6. lechien jr, chiesa-estomba cm, de siati dr, horoi m, le bon sd, rodriguez a, et al. olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (covid-19): a multicenter european study. eur arch otorhinolaryngol. 2020 aug;277(8):2251-2261. doi: 10.1007/s00405-020-05965-1; pubmed pmid: 32253535; pubmed central pmcid: pmc7134551. 7. beltran-corbellini a, chico-garcia jl, martinez-poles j, rodriguez-jorge f, natera-villalba e, gomez-corral j, et al. acute-onset smell and taste disorders in the context of covid-19: a pilot multicenter polymerase chain reaction based case-control study. eur j neurol. 2020 sep;27(9):1738-1741. doi: 10.1111/ene.14273; pubmed pmid: 32320508; pubmed central pmcid: pmc7264557. 8. alega jj, cruz et. association of anosmia and positive sars-cov-2 (covid-19) rt-pcr test results among patients in the quezon city general hospital. philipp j otolaryngol head neck surg. 2021 may 29;36(1):33. doi: 10.32412/pjohns.v36i1.1631. 9. murphy c, doty rl, duncan hj. clinical disorders of olfaction. handbook of olfaction and gustation. 2nd ed crc pess; 2003. doi: 10.1201/9780203911457.ch22. 10. al-ani rm, acharya d. prevalence of anosmia and ageusia in patients with covid-19 at a primary health center, doha, qatar. indian j otolaryngol head neck surg. 2020 aug 19;1-7. doi: 10.1007/s12070-020-02064-9; pubmed pmid: 32837952; pubmed central pmcid: pmc7435125. 11. elkholi sma, abdelwahab mk, abdelhafeez m. impact of the smell loss on the quality of life and adopted coping strategies in covid-19 patients. eur arch otorhinolaryngol. 2021 sep;278(9):3307-3314. doi: 10.1007/s00405-020-06575-7; pubmed pmid: 33464401; pubmed central pmcid: pmc7814376. 12. pusswald g, auff e, lehrner j. development of a brief self-report inventory to measure olfactory dysfunction and quality of life in patients with problems with the sense of smell. chemosensory perception. 2012 dec;5(3-4):292-299. doi:10.1007/s12078-012-9127-7. 13. brann dh, tsukahara t, weinreb c, lipovsek m, van den berge k, gong b et al. non-neuronal expression of sars-cov-2 entry genes in the olfactory system suggests mechanisms underlying covid-19-associated anosmia. sci adv. 2020 jul 31;6(31):eabc5801. doi: 10.1126/ sciadv.abc5801; pubmed pmid: 32937591. 14. xie j, tong z, guan x, du b, qiu h, slutsky as. critical care crisis and some recommendations during the covid-19 epidemic in china. intensive care med. 2020 may;46(5):837-840. doi: 10.1007/s00134-020-05979-7; pubmed pmid: 32123994 pubmed central pmcid: pmc7080165 15. kaye r, chang cwd, kazahaya k, brereton j, denneny jc. covid-19 anosmia reporting tool: initial findings. otolaryngol head neck surg. 2020 jul;163(1):132-134. doi: 10.1177/0194599820922992; pubmed pmid: 32340555. 16. paolo g. does covid-19 cause permanent damage to olfactory and gustatory function? med hypotheses. 2020 oct;143:110086. doi: 10.1016/j.mehy.2020.110086; pubmed pmid: 32721795; pubmed central pmcid: pmc7346823. 17. sutton d, fuchs k, d’alton m, goffman d. universal screening for sars-cov-2 in women admitted for delivery. n engl j med. 2020 may 28;382(22):2163-2164. doi: 10.1056/ nejmc2009316; pubmed pmid: 32283004; pubmed central pmcid: pmc7175422. 18. regalado ja, tayam mm, santos r, gelera j. prevalence of olfactory dysfunction among covid-19 patients with self-reported smell loss versus objective olfactory tests: a systematic review and meta-analysis. philipp j otolaryngol head neck surg 2021 may;36(1):6. doi: 10.32412/ pjohns.v36i1.1649. 19. biguenet a, bouiller k, marty-quinternet s, brunel as, chirouze c, lepiller q. sars-cov-2 respiratory viral loads and association with clinical and biological features. j med virol. 2021 mar;93(3):1761-1765. doi: 10.1002/jmv.26489; pubmed pmid: 32889755. 20. klopfenstein t, kadiane-oussou nj, toko l, royer py, lepiller q, gendrin v. et al. features of anosmia in covid-19. med mal infect. 2020 aug;50(5):436-439. doi: 10.1016/j. medmal.2020.04.006; pubmed pmid: 32305563; pubmed central pmcid: pmc7162775. 21. hopkins c, surda p, whitehead e, kumar bn. early recovery following new onset anosmia during the covid-19 pandemic an observational cohort study. j otolaryngol head neck surg. 2020 may 4;49(1):26. doi: 10.1186/s40463-020-00423-8; pubmed pmid: 32366299; pubmed central pmcid: pmc7196882. 22. frasnelli j, hummel t. olfactory dysfunction and daily life. eur arch otorhinolaryngol. 2005 mar;262(3):231-5. doi: 10.1007/s00405-004-0796-y; pubmed pmid: 15133691. 23. nordin s, brämerson a, murphy c, bende m. a scandinavian adaptation of the multi-clinic smell and taste questionnaire: evaluation of questions about olfaction. acta otolaryngol. 2003 may;123(4):536-42. doi: 10.1080/00016480310001411; pubmed pmid: 12809108. 24. david j, campomanes b, dalupang j, loberiza f. smell identification test. philipp j otolaryngol head neck surg 1994;62-68. available from: https://pjohns.pso-hns.org/index.php/pjohns/ issue/view/81/29. 25. macasaet mav, cruz ets. quality of life after fess among patients with nasal polyps using the nose questionnaire translated in filipino (nose-ph). philipp j otolaryngol head neck surg. 2016 jun;31(1):17-21. doi: https://doi.org/10.32412/pjohns.v31i1.305. 26. maningding cac, roldan ra. reliability and validity of the filipino sino-nasal outcome test (snot) 22. philipp j otolaryngol head neck surg. 2018 jul;33(1):17-20. doi:  https://doi. org/10.32412/pjohns.v33i1.51. 27. mattos jl, edwards c, schlosser rj, hyer m, mace jc, smith tl et al. a brief version of the questionnaire of olfactory disorders in patients with chronic rhinosinusitis. int forum allergy rhinol. 2019 oct;9(10):1144-1150. doi: 10.1002/alr.22392; pubmed pmid: 31430061; pubmed central pmcid: pmc6773507. 28. chiesa-estomba cm, lechien jr, calvo-henríquez c, mayo m, maldonado b, maza j, et al. translation and validation of the short version of the questionnaire of olfactory disordersnegative statements to spanish. am j otolaryngol. 2021 jan-feb;42(1):102775. doi: 10.1016/j. amjoto.2020.102775; pubmed pmid: 33125905. 29. vandersteen c, payne m, dumas le, metelkina-fernandez v, plonka a, chirio d. et al. persistent olfactory complaints after covid-19: a new interpretation of the psychophysical olfactory scores. rhinology online. 2021 apr;4:66-72. doi: http://doi.org/10.4193/rhinol/21.010. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 6968 philippine journal of otolaryngology-head and neck surgery doknet’s world captoons assistant professor william u. billones, md de la salle health sciences institute creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery captoons assistant professor william u. billones, md de la salle health sciences institute creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international doknet’s world philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 editorial 4 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 5 there is justifiable pride in completing the arduous journey: the 4to 5-year post-baccalaureate doctor of medicine degree capped with a grueling year of internship, passing the professional licensure examinations, obtaining a 3to 7-year post-graduate residency training, hurdling diplomate specialty board examinations, perhaps even completing a 1to 2-year clinical and/or research fellowship subspecialty qualification and becoming a full-fledged fellow of a specialty society, college, or academy after a 2-year probation or initiation period. a full 15 to 20 years after high school, you are finally on your own. armed with encyclopedic knowledge and cutting-edge skills, you confidently (even cockily) set out to conquer case after clinical case as you “exercise awesome power over life and death.”2 you may even succeed in your campaign for some time, and pride can easily bloat out of proportion into hubris -“excessive pride toward or in defiance of the gods, leading to nemesis.”3 thus was the weaver arachne transformed into a spider after challenging (and being defeated by) the goddess athena.4 unfortunately, arachne was oblivious to her web. you would not be where you are were it not for the countless people who directly or indirectly supported you throughout your journey. your parents and family, clan and community, teachers and classmates were certainly there. but more than them, the nameless--even faceless-others whose lives and services (yes, including the cadaver you dissected in anatomy) made yours possible were also there. ultimately, many others had to die, figuratively and literally, so that others-you included-may live. the very persons you now perceive as patients represent the collective people (living and dead) who made your becoming a physician possible. you owe them. if you still have not learned by now, patients are not cases to be solved but persons to serve. engaging whole but broken people, people in pain or dis-ease, entails more than expert knowledge and sharply honed skills. as sir william osler said, “to know the patient that has the disease is more important than to know the disease that the patient has.”5 head and hands are worthless without heart. competence needs to be motivated by compassion and enabled by communication. it has little place for pride and none for hubris. on the contrary, its primary stance is one of humility— true concern for others as opposed to self-concern: 6 correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 554 8467 telefax: (632) 524 4455 email: lapenajf@upm.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines hubris, humility and healing philipp j otolaryngol head neck surg 2017; 32 (1): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international “pride goeth before destruction, and an haughty spirit before a fall. better it is to be of an humble spirit with the lowly, than to divide the spoil with the proud.” proverbs 16:18-191 philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 4 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 5 editorial “do not imagine that if you meet a really humble man he will be what most people call ‘humble’ nowadays: he will not be a sort of greasy, smarmy person, who is always telling you that, of course, he is nobody. probably all you will think about him is that he seemed a cheerful, intelligent chap who took a real interest in what you said to him. if you do dislike him it will be because you feel a little envious of anyone who seems to enjoy life so easily. he will not be thinking about humility: he will not be thinking about himself at all.” this concern for others, rather than for the self, may mark the so-called “sweet spot between hubris and humility” where one feels “small and insignificant but empowered at the same time.”7 being confronted by and surmounting the tension between life and death with each patient encounter (some more than others) redefines and reinforces this spot over and over again -but not without taking its toll. after so many years, a part of me still dies with each patient’s death. i suppose that one cannot deal with wellness and illness, and living and dying, without sustaining collateral damage in the process— far beyond the inevitable wear and tear that accompany our own aging process. and this is a truly humbling realization. we can choose to wallow in self-pity and even despair. or we can bracket our pains and concerns, and practice the compassion of the wounded healer, where “in our own woundedness, we can become a source of life for others.”8 compassion is enabled and concern communicated when we ourselves embrace pain, dis-ease and brokenness—ours, as well as that of our patients. it is not easy, but we fully begin to serve as worthy instruments of healing when with each death, we die; and with each life, we live again. references 1. the holy bible, king james version. cambridge edition: 1769; king james bible online, 2017. [cited 2017 june 11.] available from: https://www.kingjamesbibleonline.org/proverbs-chapter-16/. 2. lapeña jf. from here and now to infinity and eternity: a message to new medical doctors. mens sana monogr. 2014 jan-dec; 12(1):153-160. doi: 10.4103/0973-1229.130328 pmcid: pmc4037894 pmid: 24891804. 3. oxford living dictionaries. oxford university press 2017. [cited 2017 june 12.] available from:: https://en.oxforddictionaries.com/definition/hubris. 4. karas m, megas c. arachne. in greekmythology.com © 1997-2017. [cited 2017 june 9.] available from https://www.greekmythology.com/myths/mortals/arachne/arachne.html. 5. osler w. the principles and practice of medicine: designed for the use of practitioners and students of medicine. new york, london: d. appleton and company, 1912. 6. lewis cs. mere christianity. new york: harpercollins publishers, 2009. p. 121 ff. 7. bergland c. the sweet spot between hubris and humility. cited 2017 june 11. available from:: https://www.psychologytoday.com/blog/the-athletes-way/201303/the-sweet-spot-betweenhubris-and-humility. 8. nouwen jm. the wounded healer: ministry in contemporary society. new york: image books, doubleday, 1979. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 philippine journal of otolaryngology-head and neck surgery 51 case reports philipp j otolaryngol head neck surg 2017; 32 (2): 51-54 c philippine society of otolaryngology – head and neck surgery, inc. supernumerary nostril in a 15-year-old girlann christie p. lluisma, md cagayan de oro consortium of otorhinolaryngology head and neck surgery correspondence: dr. ann christie p. lluisma cagayan de oro consortium of otorhinolaryngology head and neck surgery northern mindanao medical center capitol compound, cagayan de oro city 9000 philippines phone: (6388) 726362 local 636 email: anners.alovera@gmail.com the author declares that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery interesting case contest. june 30, 2016. unilab bayanihan center, pasig city. abstract objectives: to describe a rare case of a supernumerary nostril and its management and to discuss the different theories pertaining to this type of deformity. methods: design: case report setting: tertiary government hospital patient: one results: a 15-year-old girl was born with one extra nasal opening. nasal endoscopy after 15 years revealed a mucosa-lined cavity that ended blindly. computed tomography scan showed a small opening lateral to the right nasal ala which did not communicate with the right nasal cavity. a crescent incision was made along the inner circumference of the supernumerary nostril and the blind ending nasal tract was excised. a portion of the ala was removed and a z-plasty repair was performed. conclusion: treatment has to be tailored as to the presentation of a supernumerary nostril and any other associated deformity. though various surgical interventions exist, the goal of repair is to create a functioning and normal-appearing nose. keywords: supernumerary nostril, accessory nostril a supernumerary nostril is a congenital malformation characterized by an accessory nasal cavity that usually manifests as a small nasal orifice with surrounding redundant soft tissue.1 the accessory nostril is similar to a normal nostril which has vibrissae and an intranasal opening, can be unilateral or bilateral and may have a communication with the ipsilateral nostril.2 the first reported case was published in 1906 by lindsay who described a patient with bilateral supernumerary nostrils.2 in the english literature, there have been about 40 reported cases of supernumerary nostrils.2-12 to the best of our knowledge based on a search of herdin using the keywords “supernumerary” “accessory” and “ nostril,” there has been no locally-reported case of a supernumerary nostril. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 a c b d case reports 52 philippine journal of otolaryngology-head and neck surgery we describe a rare case of a supernumerary nostril and its management and discuss the different theories pertaining to this type of deformity. case report a 15-year-old girl presented to the ear nose throat (ent) outpatient department due to an accessory nostril on the right side of her nose since birth. (figure 1) there was no history of bleeding or discharge (although she reported recurrent yellowish discharge from the other nostrils). she had no previous medical consultations due to financial constraints. she was vaginally born to a then 22-year-old gravida 1 mother. the prenatal history was unremarkable with no history of exposure to alcohol, drugs or ionizing radiation. there was no history of consanguineous marriage or family history of birth defects and the antenatal and neonatal history were also uneventful. on physical examination, the left nasal opening was wider compared to the right with two nasal openings. the smaller supernumerary nostril had an internal diameter of about 5 mm located lateral to and at the same level as the right nostril. (figure 2) anterior rhinoscopy revealed that the accessory nostril was lined with hair follicles. the septum between the right and left nasal cavities was midline. the inferior turbinates were not congested. however, there was yellowish discharge in both right and left nostrils. nasal endoscopy revealed no communication between the normal and accessory nasal cavity which ended blindly and was lined by mucous membrane. a polypoid mass was noted within the left middle meatus. computed tomography scans of the paranasal sinuses revealed soft tissue thickening of the right nasal ala with a small opening laterally. there were no bony or cartilaginous abnormalities. there were opacifications seen in the left frontal sinus, left anterior ethmoid, both maxillary sinuses and mucosal thickening of the right sphenoid sinus. (figure 3) the patient was admitted with an impression of right unilateral supernumerary nostril and chronic rhinosinusitis with left nasal polyp and underwent surgery under general anesthesia. a crescent incision figure 1. preoperative frontal and basal view (published in full with permission) figure 2. small blind mucous membrane-lined pocket with vibrissae located lateral to and at the same level as the right nostril figure 3. paranasal sinus ct scans. a. coronal and b. axial cut show a small opening lateral to the right nasal ala that does not communicate with the right nasal cavity. c. and d. axial cuts reveal opacifications in the left frontal sinus, left anterior ethmoid, both maxillary sinuses and mucosal thickening of the right sphenoid sinus with deviated nasal septum to the right. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 philippine journal of otolaryngology-head and neck surgery 53 case reports was made along the inner circumference of the supernumerary nostril and the blind ending nasal tract was excised. the result was a medial nostril and untouched ala with dead space in between. a portion of the ala was removed and a z plasty was designed. through-and-through sutures were placed to obliterate dead space. (figure 4) endoscopic sinus figure 4. intraoperative photos a. crescent incision b. blind ending nasal tract excised c. z-plasty and d. closure figure 5. postoperative frontal and basal view (published in full with permission) surgery was performed to remove the left nasal polyp and establish a functional osteomeatal complex. the post-operative period was uneventful and she was discharged after 2 days with a slightly swollen right nostril. results at 2 months showed improvement in the contour of the right nostril. (figure 5) discussion supernumerary nostrils are rare congenital anomalies with unclear etiology. a review of literature reveals that there are about 40 published cases since 1906.2-12 of these 40 cases, 23 were isolated supernumerary nostrils and 15 had associated anomalies; more than half of the reported cases were from the asian continent of which 10 were from india.2-12 there is no known exact mechanism and stage of embryological development at which the error occurs and because of its rarity, different speculative theories exist related to its embryogenesis.11 according to erich, lindsay described a case of bilateral supernumerary nostrils and proposed the theory of dichotomy by atavism or parallel evolution in 1906.2 in biology, “an atavism is an evolutionary throwback, such as traits reappearing which had disappeared generations before… that can occur in several ways. one way is when genes for previously existing phenotypical features are preserved in dna, and these become expressed through a mutation that either knock out the overriding genes for the new traits or make the old traits override the new one.”13 in 1962, erich reported a case of a patient with two noses and explained the development of that deformity and the accompanying four nostrils by the appearance of four nasal pits instead of two, horizontally, each forming a nasal sac.2 he hypothesized that “the medial sacs are interposed between the nasal laminae, preventing their fusion into one septum and resulting in a double nose and suggested that when the accessory nasal pit is located too laterally, the fusion of the laminae is not disturbed and one nose with a supernumerary nostril is formed.”2 nakamura and onizuka advanced a new theory when they reported a case of supernumerary nostril in 1987.3 they suggested that “the supernumerary nostrils resulted from a localized abnormality of the lateral nasal process, with a fissure appearing accidentally and dividing the lateral nasal process in two, resulting in two nostrils on one side of the nose.”3 also in 1987, reddy and rao reported a case of triple nostrils and assumed that the “deformity developed as a result of an accessory olfactory pit appearing either above or below the normal location of the placode.”4 as for treatment, there is no generally accepted method of surgical repair. the goal of repair is to create a functioning and normal-appearing nose with minimal deformity.5 my review of literature revealed a systematic classification of supernumerary nostril by saiga and matsua and its corresponding surgical technique.6 the classification is based on the shape of the nasus externus. (figure 8) based on this classification, our patient belongs to type 1 where the inner nostril is sufficiently large and symmetry with the unaffected side can be obtained. in this case, the suggested surgical technique is resection of the outer nostril. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 case reports 54 philippine journal of otolaryngology-head and neck surgery acknowledgements i would like to thank dr. vincent mark jardin who handled the case with me and who never get tired of pushing me to write this case report; dr. stephanie e. jacutin for the help in doing the nasal endoscopy and documentation; and all the consultants and residents of the cagayan de oro consortium of orl-hns for their inputs and comments. references 1. elluru rg. “cogenital malformations of the nose and nasopharynx”. in: flint pw, haughey bh, robbins kt, thomas jr, niparko jk, et al. (editors). cummings otolaryngology head and neck surgery, 6th ed, vol. 3, canada: elsevier saunders 2015. p.2950. 2. erich jb. nasal duplication: case report of a patient with two noses. plast reconstr surg transplant bull. 1962 feb; 29:159-66. pmid: 13890550. 3. nakamura k, onizuka t. a case of supernumerary nostrils. plast reconstr surg. 1987 sep; 80(3):436-41. pmid: 3306743. 4. reddy ka, rao ak. triple nostrils: a case report and review. br j plast surg. 1987 nov; 40(6): 651652. pmid: 3318987. 5. shaye da, tibesar rj. repair of supernumerary nostril. j craniofac surg. 2014 may; 25(3): 978-9. doi: 10.1097/scs.0000000000000549; pmid: 24699105. 6. saiga a, mitsukawa n. case of supernumerary nostril. j plast reconstr aesthet surg. 2013 jan; 66(1): 126-128. doi: 10.1016/j.bjps.2012.05.014; pmid: 22687717. 7. rout sk, lath mk. supernumerary nostril. j craniofac surg. 2013 jan; 24(1): e13-5. doi: 10.1097/ scs.0b013e3182668b14; pmid: 23348320. 8. uppal sk, garg r, gupta a, pannu ds. supernumerary nostril: a rare congenital anomaly. ann maxillofac surg. 2011 jul; 1(2): 169-171. doi: 10.4103/2231-0746.92788; pmid: 23483576 pmcid: pmc3591022. 9. upernumerary nostril: an extremely rare case. int j pediatr otorhinolaryngol. 2012 mar; 7(2): 89-91. https://doi.org/10.1016/j.pedex.2012.02.001. 10. kashyap sk, khan ma. supernumerary nostril: a case report and review. int j morphol. 2009; 27(1): 39-41. http://dx.doi.org/10.4067/s0717-95022009000100007. 11. sah bp, bhandary s, pokharel a, shilpakar sl, chettri st, paudel d. a supernumerary nostril associated with dermoid cyst: a rare case report and review of literature. american journal of medical case reports. 2014; 2(3): 52-54. doi: 10.12691/ajmcr-2-3-3. 12. krishna nr, kumar br, srinivas k, akurati l. a rare congenital anomaly of accessory nose: case report. indian j otolaryngol head neck surg. 2006 oct; 58(4): 389-391. doi: 10.1007/bf03049606; pmid: 23120359 pmcid: pmc3450355. 13. hall bk. atavisms and atavistic mutations. nat genet. 1995 jun; 10(2): 126-127. doi: 10.1038/ ng0695-126; pmid: 7663504. although various types and techniques exist for the management of a supernumerary nostril, most of the authors advocated the circumferential excision of the accessory cavity and resection of the entire fistulous tract.2,5-8,11-12 as to the timing of surgery, it is advisable to operate in early childhood to prevent deformity of normal nostrils.4 for adult patients, surgical treatment should be planned in stages to achieve a good outcome. because of the rarity of this congenital anomaly, the etiology and mechanism of developmental error remain hypothetical. an observation of a high incidence in the asian continent calls for further investigation to identify common factors in this geographical region that contribute to the deformity.7 as mentioned by rout and lath, there is no cookbook for the correction of this defect.7 treatment has to be tailored as to the presentation of a supernumerary nostril and any other associated deformity. though various surgical interventions exist, the goal of repair is to create a functioning and normal-appearing nose essential for normal psycho-social development. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles abstract objective: to determine the correlation between pre-operative in-house temporal bone ct scan readings and intraoperative findings during mastoidectomy for cholesteatoma in a tertiary government hospital from january 2018 to december 2019. methods: design: review of records setting: tertiary government hospital participants: a total of 25 charts were included in the study. surgical memoranda containing intraoperative findings were scrutinized. data on key structures or locations were filled into a data gathering tool. categorical descriptions were used for surgical findings: “present” or “absent” for location, and “intact” or “eroded” for status of ossicles and critical structures. radiological readings to describe location and extent of disease were recorded as either “involved” or “uninvolved,” while “intact” or “eroded” were used to describe the status of ossicles and critical structures identified. statistical correlations were computed using cohen kappa coefficient. sensitivity, specificity, and predictive values were also computed. results: no correlation between radiologic readings and surgical findings were found in terms of location and extent of cholesteatoma (κ < 0). however, moderate agreement was noted in terms of status of the malleus (κ = .42, 95% ci, .059 to .781, p<.05), substantial agreement noted for the incus status (κ = 0.682, 95% ci, .267 to .875, p<.05), and fair agreement noted for the stapes status (κ = .303, 95% ci, -.036 to .642, p>.05). slight agreement was also noted in description of facial canal and labyrinth (κ =.01, 95% ci, -.374 to .394, p>.05), while no correlation was noted for the status of the tegmen (κ = 0, 95% ci, -.392 to .392, p<.05). conclusion: our study shows the unreliability and shortcomings of ct scan readings in our institution in detecting and predicting surgical findings. an institutional policy needs to be considered to ensure that temporal bone ct scans be obtained using techniques that can appropriately describe the status of the middle ear and adjacent structures with better reliability. keywords: cholesteatoma; temporal bone, tomography, x-ray computed, mastoidectomy pre-operative temporal bone ct scan readings and intraoperative findings during mastoidectomy dominador b. toral, md chris robinson d. laganao, md department of ent-head and neck surgery southern philippines medical center correspondence: dr. chris robinson d. laganao department of ent-head and neck surgery southern philippines medical center, jica building bajada, davao city 8000 philippines phone: +63 916 539 5589 / +63 925 795 7538 email: chrisrdlaganao@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by both authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery analytical research contest 2020. (2nd place) november 18, 2020. philipp j otolaryngol head neck surg 2021; 36 (2): 8-12 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles cholesteatoma is a benign keratinizing mass lined by stratified squamous epithelium in the middle ear cavity.1 it is associated with bony erosion into neighboring structures and can give rise to intracranial and extracranial complications.2 in 2017, the european academy of otology and neurotology/japanese otological society (eaono/jos) joint consensus statements defined the stages of cholesteatoma to achieve a uniform classification on the extent of disease and guide surgical decisions and predict outcomes.1,2 the classification however, is based solely on intraoperative findings and does not rely on preoperative imaging studies.1 this raises questions on the reliability and practicality of preoperative ct scans in accurately predicting intraoperative findings during mastoidectomy. critical to the management of cholesteatoma is the definitiveness of diagnostic workups.3,4 in particular, ct scans often dictate whether surgery is indicated in problematic and chronically discharging ears.5,6 preoperative ct scans influence the decision for and timing of surgical exploration.7 however, although temporal bone ct scans can accurately demonstrate the presence of abnormal tissue in the middle ear, they cannot ascertain whether or not this soft tissue density represents a cholesteatoma.8 this study aims to determine the correlation between pre-operative in-house temporal bone ct scan readings and intraoperative findings during mastoidectomy for cholesteatoma in a tertiary government hospital. methods this review of records was conducted with approval of the department of health cluster research ethics committee and southern philippines medical center institutional review board. the annual census of the department of ent-hns was reviewed for mastoidectomies performed from january 2018 to december 2019. there were only 22 mastoidectomies for middle ear cholesteatoma in 2018, doubling to 46 in 2019. of the two-year total of 68 patients, only 27 obtained their preoperative temporal bone ct scans in our institution. given this number, the adequate sample size needed was 25 to achieve 95% confidence level and 5% margin of error. all charts of patients who underwent mastoidectomy and had in-house preoperative temporal bone ct scans were considered for inclusion in this study. charts with incomplete data, missing surgical memoranda, technique, and operative findings, history of craniofacial trauma, and temporal bone neoplasms were excluded. if the official temporal bone ct scan reading was not available in the chart or in the hospital pacs system, the chart was not included in the study. there was no third-party consult with the radiology department in terms of verifying official temporal bone ct interpretations to avoid bias. the radiographic descriptions of structures concerned were based solely on what was described on the official results available in the chart. in-house temporal bone ct scans were all performed using a hitachi 128 slice high resolution ct scanner (scenaria se 128, hitachi ltd., japan) with 5mm cuts. comparison of findings was based on the template utilized by the department of radiology in reading temporal bone ct scans which include the following parameters: extent and location of cholesteatoma (mastoid or tympanic), status of ossicles, facial canal, labyrinth, and tegmen. once charts were retrieved from the medical records section, the surgical memoranda containing intraoperative findings were scrutinized. data on the key structures or location were filled into a data gathering tool. categorical descriptions were used for surgical findings. descriptions for location were either “present” or “absent.” the terms “intact” or “eroded” were used to describe the status of ossicles and critical structures. radiological findings to describe the location and extent of the disease were either “involved” or “uninvolved,” while the terms “intact” or “eroded” were used to describe the status of ossicles and critical structures identified. cohen’s kappa coefficients were used to determine agreement of surgical findings and radiological readings. a result of less than 0 (<0) meant no agreement. kappa values between 0.00 and 0.20 meant slight agreement; 0.21 and 0.40 meant fair agreement; 0.41 and 0.60 meant moderate agreement; 0.61 and 0.80 meant substantial agreement, and 0.81 and 1.00 meant almost perfect agreement. sensitivity, specificity, and predictive values were also computed. results of the 27 charts that met inclusion criteria, two charts were further excluded for malignancy recorded in the official histopathology report. thus, only 25 charts were finally included in this study. table 1 shows the correlations between surgical findings and radiologic readings in terms of location and extent of cholesteatoma (e.g., attic, attico-antral, tympanic, and tympanomastoid). cohen’s kappa coefficient statistical test results suggested that ct scan readings did not correlate with surgical findings. negative values were noted in terms of accurately predicting the extent of the disease for the attic (κ = -.5, 95% ci, -1.194 to .194, p > .05), attico-antral (κ = -.5, 95% ci, -1.235 to .235, p > .05), tympanic areas (κ = -.33, 95% ci, -.893 to .173, p > .05), and a low correlation was noted in the tympanomastoid area (κ = .695, 95% ci, -.382 to .740, p > .05). table 2 shows the correlations between surgical findings and radiologic readings regarding the status of ossicles (intact or eroded). there was moderate agreement in the determination of the status of the malleus (κ = .42, 95% ci, .059 to .781, p < .05). in seven cases, philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles the malleus was radiologically intact and confirmed intraoperatively intact. eleven cases that were read as abnormal on ct scan were also confirmed to be eroded during surgery. however, there were seven cases where the radiologic readings were contradicted by intraoperative findings. in these seven cases, three had radiologic readings of erosion but were surgically intact while four had normal radiologic readings but were found to be eroded intraoperatively. for the incus, substantial agreement (κ = 0.682, 95% ci, .267 to .875, p < .05) was noted between radiologic readings and surgical findings. a total of 21 cases were consistently intact (10) or eroded (11). three cases were noted to be radiologically abnormal but surgically intact, while one case noted to be radiologically intact was found to be eroded during surgery. for the stapes, there was fair agreement (κ = .303, 95% ci, -.036 to .642, p > .05) between radiologic readings and surgical findings. nine cases considered intact radiologically were confirmed intact surgically, while seven cases read as abnormal radiologically were confirmed eroded surgically. there was also disagreement in the case of nine patients (two cases found radiologically intact but found to be eroded intraoperatively, and seven cases read as abnormal on ct scans but surgically intact). table 3 shows the correlations between surgical findings and radiologic readings in terms of the status of critical structures such as the facial canal, labyrinth, and tegmen. generally, surgical findings agreed only slightly with the radiological readings (between 0.00 and 0.20). the facial canal was noted to be radiologically intact in 21 cases, but only 16 of those were confirmed intraoperatively. among the four cases in which the facial canal was diagnosed as radiologically abnormal, three were intact surgically. only one case was found to be abnormal both radiologically and intraoperatively. similar values were seen for the status of the labyrinth and tegmen. the computed correlation coefficient for the status of facial canal and labyrinth was κ = .01 (95% ci, -.374 to .394, p > .05) suggesting slight agreement; and κ = 0 (95% ci, -.392 to .392, p < .05) for the tegmen, suggesting no agreement. table 4 shows the sensitivity, specificity, positive and negative predictive values of radiological readings for surgical findings. the sensitivity of in-house temporal bone ct scan readings was only 50% in the determination of minimal/limited disease (attic and tympanic), and 0% in the case of attico-antral involvement but were 86.62% sensitive in detecting tympanomastoid involvement. however, in-house temporal bone ct scan readings had 0% specificity in terms of location. in terms of erosion of ossicles, the sensitivity of in-hospital temporal bone ct scan readings was consistently above 70%. specificity slightly varied from 70% for the malleus, 72.73% for the incus, and 56.25% for stapes erosion. the positive predictive value for malleus and incus was 78.57% table 1. correlation of surgical and radiologic findings in terms of location and extent of cholesteatoma (attic, attico-antral, tympanic, tympanomastoid) among patients admitted for mastoid surgery (n=25). table 2. correlation of surgical and radiologic findings in terms of status of ossicles (intact or eroded) among patients admitted for mastoid surgery (n=25). table 3. correlation of surgical and radiologic findings in terms of status of critical structures (facial canal, labyrinth, tegmen) among patients admitted for mastoid surgery (n=25). ci (95%,α=0.05) interpretationsurgical finding p value upper limit lower limit kappa coefficient radiological findings involved uninvolved attic present absent attico-antral present absent tympanic present absent tympanomastoid present absent .134 .248 .361 .473 0.194 0.235 0.173 0.740 1.194 1.235 0.893 0.382 -.5 -.5 -.36 0.179 1 0 2 1 2 0 2 1 no agreement no agreement no agreement no to low agreement 1 1 0 1 2 1 11 2 ci (95%,α=0.05) interpretationsurgical finding p value upper limit lower limit kappa coefficient radiological findings intact abnormal malleus intact eroded incus intact eroded stapes intact eroded .032 .002 .100 0.781 0.875 0.642 0.059 0.267 0.036 0.42 0.571 0.303 3 11 3 11 7 7 moderate agreement substantial agreement fair agreement 7 4 10 1 9 2 ci (95%,α=0.05) interpretationsurgical finding p value upper limit lower limit kappa coefficient radiological findings intact abnormal facial canal intact eroded labyrinth intact eroded tegmen intact eroded .959 .959 .000 0.394 0.394 0.392 0.374 0.374 -0.392 .01 .01 0 3 1 3 1 4 1 slight agreement slight agreement no agreement 16 5 16 5 16 4 but only 50% for predicting stapes erosion. the negative predictive values were consistently above 60%. in-house temporal bone ct scan readings were not very sensitive in terms of identifying abnormalities in philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles other critical structures such as facial canal erosion, labyrinthine fistula, or tegmen erosion, with sensitivity below 20%, although specificity was at least 80%. these readings also had low positive predictive value around 20% only but high negative predictive value above 70%. discussion computed tomography scans are highly regarded guides to plan the surgical approach, prognosticate cases, and most importantly, advise patients on the possible outcomes of surgery and manage expectations.9,10 we aimed to determine the correlation between preoperative in-house temporal bone ct scan readings and intraoperative findings during mastoidectomy for cholesteatoma but did not find any correlation between radiologic readings and surgical findings in terms of location and extent of cholesteatoma. the identification of the location and extent of cholesteatoma is important to plan the surgical approach. however, one major disadvantage of ct is that it can overestimate the disease as it cannot distinguish definitively between cholesteatoma and granulation tissue.11 cholesteatoma has a tendency to reside in hidden areas such as the sinus tympani and anterior epitympanum.13 preoperative knowledge of disease extent and information on degree of mastoid pneumatization seen in ct scans therefore facilitates planning of the surgical approach, whether to keep the canal wall up or take it down. there is a wide range of agreeability of ct scans in terms of identifying the location and extent of cholesteatoma, with correlation coefficients ranging from moderate to substantial (κ = 0.41 to 0.80). 9,12,14 even so, most authors agree that ct can only detect presence or absence of soft tissue density in the middle ear, and cannot distinguish the type of tissue (cholesteatoma vs granulation).9 our study found no agreement between radiologic interpretations and surgical findings (κ <0). sensitivity was only 50% in detecting cholesteatoma in the attic and tympanic cavity, while specificity was 0%. furthermore, the sensitivity of ct findings in detecting cholesteatoma surgically in the tympanomastoid was 84.62% but remained nonspecific (0%). the positive predictive value (defined as the ability of the test, in this case ct scan readings, to correctly predict the presence of disease) was also equivocal in this study (50%). the condition of the ossicles is well depicted in a high-resolution ct scans.10,12 the literature reports that preoperative temporal bone ct scans have a moderate to substantial correlation with intraoperative findings in terms of detecting ossicular pathology (0.41 to 0.80).9,12,14 in our study, moderate statistical agreement was found between preoperative temporal bone ct scan readings and intraoperative findings during mastoidectomy in terms of determining the status of the malleus, substantial agreement for the status of the incus, and fair agreement for the status of the stapes. similarly, preoperative ct scans had a sensitivity and specificity of 90.32% and 81.82% in detecting erosion in the ossicles.14 in our study, sensitivity to detect erosion in the malleus, incus, and stapes was above 70% at least. specificity, on the other hand, fell to 56.25% in ruling out erosion of stapes, while remaining above 70% for the two other ossicles. most common alterations found include medial displacement of the chain, fusion and hardening of the chain, and erosion of the long process of the incus. similar to other studies, the status of the stapes was the most difficult to assess radiologically.15 facial canal dehiscence is a fairly common finding in 55% of temporal bones and usually occurs in a focal area in the tympanic portion of the fallopian canal.13 high-resolution ct scan findings are usually straightforward.2,13 however, in overly diseased middle ears the soft tissue density may abut on the fallopian canal and cause problems in assessing its integrity.14 a problem with partial volume averaging artifact is evident as the fallopian canal can be so thin even in a nonpathological ear as to appear dehiscent on ct scan. this may explain poor radiological correlations with surgical findings.13 in one study, the sensitivity of ct scans was only 66.67%.15 in our study, the sensitivity and specificity in detecting facial canal erosion was 16.67% and 84.21%, respectively. this means that less than one-fifth of facial canal erosions noted intraoperatively were seen in the preoperative ct scan, and that normal radiologic findings translated to normal surgical findings in at least 80% of the time. similar to the results of other studies, there was only slight agreement between preoperative ct scan readings and surgical findings in terms of determining facial canal status in our study.11,13,14 the most commonly affected structure in cases of middle ear cholesteatoma is the lateral semicircular canal.10,14 a prospective study consisting of 100 cases of cholesteatoma revealed that their ct scan images only showed thinning of the bone over the lateral semicircular canal with no obvious fistulization. and yet, careful dissection of the table 4. sensitivity, specificity, positive and negative predictive values of radiological findings on surgical findings among patients admitted for mastoid surgery (n=25). ct findings sensitivity (%) specificity (%) positive predictive value (%) negative predictive value (%) attic involvement attico-antral tympanic tympanomastoid malleus erosion incus erosion stapes erosion facial canal erosion labyrinth fistula tegmen erosion 50.00 0.00 50.00 84.62 73.33 78.57 77.78 16.67 16.67 20.00 0.00 50.00 0.00 0.00 70.00 72.73 56.25 84.21 84.21 80.00 50.00 0.00 66.67 100.00 78.57 78.57 50.00 25.00 25.00 20.00 0.00 33.33 0.00 0.00 63.64 72.73 81.82 76.19 76.19 80.00 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles references 1. yung m, tono t, olszewska e, yamamoto y, sudhoff h, sakagami m, et al. eaono/jos joint consensus statements on the definitions, classification and staging of middle ear cholesteatoma. j int adv otol. 2017 apr;13(1):1-8. doi: 10.5152/iao.2017.3363 pubmed pmid: 28059056. 2. gaurano jl, joharjy ia. middle ear cholesteatoma: characteristic ct findings in 64 patients. ann saudi med. 2004 nov-dec;24(6):442-7. doi: 10.5144/0256-4947.2004.442 pubmed pmid: 15646162 pubmed central pmcid: pmc6147845. 3. belal a, reda m, mehana a, belal y. functional middle ear and mastoid surgery (fmms). int adv otol, 2013;9(1):21-29. doi: https://www.advancedotology.org/content/files/sayilar/68/buyuk/ iaojan2013p21-29.pdf. 4. nager fr. ci. the cholesteatoma of the middle ear its etiology, pathogenesis, diagnosis and therapy. ann otol rhinol laryngol. 1925 dec 1;34:1249-58. doi: 10.1177/000348942503400421. 5. gerami h, naghavi e, wahabi-moghadam m, forganparast k, akbar mh. comparison of preoperative computerized tomography scan imaging of temporal bone with the intraoperative findings in patients undergoing mastoidectomy. saudi med j. 2009 jan;30(1):104-8. pubmed pmid: 19139782. 6. jackler rk, dillon wp, schindler ra. computed tomography in suppurative ear disease: a correlation of surgical and radiographic findings. laryngoscope. 1984 jun;94(6):746-52. doi: 10.1288/00005537-198406000-00004; pubmed pmid: 6727511. 7. ruben rj. the disease in society. evaluation of chronic otitis media in general and cholesteatoma in particular. 2nd international conference of cholesteatoma and mastoid surgery. amsterdam: kugler publications; 1982. p. 111-16. 8. cook ja, krishnan s, fagan pa. hearing results following modified radical versus canal-up mastoidectomy. ann otol rhinol laryngol, 1996 may;105(5):379-83. doi: 10.1177/000348949610500510 pubmed pmid: 8651632. 9. chavada ps, khavdu pj, fefar ad, mehta mr. middle ear cholesteatoma: a study of correlation between hrct temporal bone and intraoperative surgical findings. int j otorhinolaryngol head neck surg. 2018; 4(5):1252-1257. doi: 10.18203/issn.2454-5929.ijohns20183702. 10. sevil e, bercin s, muderris t, gul f, cetin h, kiris m. ct scan versus surgery: how necessary is the mastoidectomy in patients with chronic otitis media? glob j oto. 2018 apr;14(1): 1-4. doi: 10.19080/gjo.2018.14.555880. 11. chee nw, tan ty. the value of pre-operative high resolution ct scans in cholesteatoma surgery. singapore med j. 2001 apr;42(4):155-9. pubmed pmid: 11465314. 12. mafee mf, levin bc, applebaum el, campos m, james cf. cholesteatoma of the middle ear and mastoid. a comparison of ct scan and operative findings. otolaryngol clin north am. 1988 may;21(2):265-93. pubmed pmid: 3357696. 13. kumaresan s, nirmala m. usefulness of pre-operative high-resolution computed tomography in middle ear cholesteatoma. int j sci stud. 2017 aug;5(5):248-251. doi: 10.17354/ijss/2017/434. 14. boruah dk, sharma bk, sanyal s, malakar n, dhingani dd, prakash a, et al. role of highresolution computed tomography in the evaluation of suppurative diseases of middle ear and mastoids and their complications with surgical correlation. j evolution med dent sci. 2016 feb;5(17):850-858, doi: 10.14260/jemds/2016/197. 15. prata aas, antunes ml, cesario de abreu ce. frazatto r, lima bt. comparative study between radiological and surgical findings of chronic otitis media. int arch otorhinolaryngol. 2011 march;15(1):72-78. doi: 10.1590/s1809-48722011000100011. 16. poursadegh m, hashemi g, jalali mm. evaluation of anatomical variations of vestibular aqueduct dimensions in temporal bone ct scan. mjiri. 2000 nov; 14(3):199-202. cholesteatoma matrix over the dome of the lateral semicircular canal revealed a tiny bony canal fistula.9 this explains how minute fistula may be missed radiographically in some patients. in one study, the sensitivity and specificity in detecting labyrinthine fistula was 80% and 100%.16 in our study, the sensitivity and specificity were 16.67% and 84.21%, respectively. with that, the positive predictive value of preoperative ct scans was pegged at 25.00% which means that only a quarter of the true labyrinthine fistulas can be detected by ct scans. the negative predictive value of temporal bone ct scans in our institution was 76.19% which means that there is a good chance that intact semicircular canals noted radiologically are also intact intraoperatively. only 16 out of 21 cases that were reported intact radiologically were indeed intact during the surgery. overall, preoperative radiological reading and surgical findings had only slight agreement at 0.01. in contrast, other studies reveal a correlation coefficient as high as 0.712 (substantial agreement).13,14,15 assessing access by examining the tegmen tympani and dural height can alter the surgical method and plan. the surgeon may opt for a canal wall up or canal wall down mastoidectomy depending on that information. tegmen erosion is well seen on coronal imaging, but again misinterpretations may result from volume averaging effects. in one study, the correlation of preoperative ct scan and surgical finding on the status of the tegmen was 0.712 (substantial agreement).13 in our study, the computed correlation coefficient was only 0 (no to slight agreement). likewise, positive and negative predictive values of preoperative ct were 20% and 80%, respectively. this means that ct scan readings in our study were unable to detect the presence of the disease even if it was actually present. our study has several limitations, and several confounding variables were present. interrater reliability may have affected our study findings since the temporal bone ct scan images were interpreted by different radiology consultants. in the same way, surgeries were performed by different surgeons, accounting for variations in their descriptions of intraoperative findings. our use of cohen’s kappa coefficient was deemed the most appropriate tool to ensure that interrater reliability was taken into consideration. correlation coefficient values vary among institutions depending largely on the availability of the high-resolution ct machine, personnel experience, and lag time, among others.13 moreover, the size of each ct imaging cuts done in the institution is significantly larger than the ones done in other studies (5 mm vs. 1mm).13-16 in turn, the effect of partial volume averaging will cause difficulties in terms of determining status of minute bony structures in the middle ear. thus, it is highly recommended to employ thinner cuts (1mm) in every temporal bone ct scan performed. furthermore, it is also recommended to develop a unified system of describing radiological readings unique to the temporal bone ct scan to prevent missing out describing structures significant to the surgeon in terms of planning the surgery and advising the patient. in conclusion, our study shows the unreliability and shortcomings of ct scan readings in our institution in detecting and predicting surgical findings. an institutional policy needs to be considered to ensure that temporal bone ct scans be obtained using techniques that can appropriately describe the status of the middle ear and adjacent structures with better reliability. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery abstract objective: to compare outcomes of covid-19 positive and covid-19 negative patients who underwent tracheostomy for prolonged intubation in terms of weaning duration, length of icu and hospital stay, overall and 30-day mortality, and explore risk factors for particular outcomes (mortality, 30-day mortality and weaning duration post tracheostomy). methods: design: retrospective cohort study setting: tertiary national university hospital participants: of 122 adult patients that underwent tracheotomy between march 30, 2020 and march 30, 2021; 76 adult patients underwent tracheostomy for prolonged intubation were analyzed. results: open tracheotomy was performed on 122 adult patients. seventy six (62.3%) due to prolonged intubation and 46 (37.7%) for airway prophylaxis. among the former, the mean age was 58.46±16.81 and 54 (71.05%) patients were female, 22 (28.95%) tested covid-19 positive and 54 (71.05%) tested negative. mean apache ii score was 16.62±6.78. average days of intubation prior to tracheostomy was 29.14±17.66 days. no statistically significant difference in outcomes (weaning days, length of stay, days discharge from icu and hospital, 30-day mortality, days to death) were noted between covid19 positive and negative patients who underwent tracheostomy for prolonged intubation. mortality rates post tracheostomy in this institution appear to be higher than existing literature. on multiple linear regression analysis, days of intubation prior to tracheostomy was associated with increased weaning time post-tracheostomy (or: 0.35 ci:0.18-0.51 95% p = <.001). this implies that for every additional day of intubation prior to tracheostomy, weaning days increase by 0.35 of a day. conclusion: outcomes of covid-19 compared to non-covid-19 patients undergoing tracheostomy for prolonged intubation do not seem to be significantly different which is consistent with existing literature. keywords: covid-19; tracheostomy; prolonged mechanical ventilation; ventilatory weaning. outcomes of covid-19 positive and covid-19 negative adult patients who underwent tracheostomy for prolonged intubation in a covid-19 referral center during the pandemic eljohn c. yee, md1 anna pamela c. dela cruz, md1 teresa luisa g. cruz, md, mhped1 cary amiel g. villanueva, md2 enrick joshua m. cruz, md3 1department of otolaryngology head and neck surgery philippine general hospital 2department of medicine, philippine general hospital 3section of pulmonology, department of medicine, philippine general hospital correspondence: dr. anna pamela c. dela cruz department of otolaryngology head and neck surgery philippine general hospital university of the philippine manila ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: +632 8554 8467 email: acdelacruz14@up.edu.ph the authors declared that this represents original material, that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosure: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the 2023 international federation of otorhino laryngological societies conference, january 17-21, 2023, dubai, united arab emirates presented at the 2nd congress of the asia-pacific laryngological society research contest, december 3, 2022, palawan ballroom, edsa shangri la hotel, mandaluyong city presented at the philippine society of otolaryngology head and neck surgery 3rd virtual analytical research contest. november 16, 2022. philipp j otolaryngol head neck surg 2023; 38 (1): 39-44 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international original articles philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery open tracheostomy is often performed for patients under prolonged mechanical ventilation.1 during the covid-19 pandemic, tracheostomy was considered aerosol-generating, posing a high-risk of contamination for medical staff, and adjustments in its indications and conduct were recommended across institutions in various regions around the world.2 before the pandemic, patients under prolonged intubation were usual candidates for tracheostomy, involving ~10% of mechanically ventilated patients with significant variability in optimal timing and patient selection.3 because of the severity of symptoms in covid-19 pneumonia, patients often required prolonged periods of mechanical ventilation, with reports of as many as 32% of patients with covid-19-related mv undergoing elective tracheostomy due to prolonged intubation.4 as of this writing, there exists conflicting recommendations on patient selection, timing and performance of tracheostomy and eventual management in the setting of covid-19.2 tracheostomy provides many advantages (improved comfort, reduced sedative and paralytic medications, reduced dead space and airway resistance, lessened work of breathing optimizing pulmonary toilette).5 however, because of the poor prognosis of covid-19 pneumonia and the risk to health care professionals, tracheostomies were generally deferred until patients tested covid negative.6 mortality was also high among patients needing mechanical ventilation, with rates of 25% among icu covid-19 patients undergoing tracheostomy (close to overall mortality rates of 26%) suggesting that tracheostomy did not impact the natural course of the disease.5 these studies evaluated outcomes of tracheostomies among patients with covid-19; but currently, studies comparing the outcomes of tracheostomies between covid and noncovid-19 tracheostomies are still lacking especially in the local setting, with none in our hospital. we aim to compare the outcomes of covid-19 positive and covid-19 negative patients who underwent tracheostomy for prolonged intubation in terms of weaning duration, length of icu and hospital stay, overall and 30-day mortality, and to explore risk factors for particular outcomes (mortality, 30-day mortality and weaning duration post tracheostomy). methods with university of the philippines manila research and ethics board (upmreb) approval (upmreb code 2020-585-01), this retrospective review of records considered for inclusion all adult patients who underwent tracheotomy between march 30, 2020 and march 30, 2021 at the philippine general hospital (pgh). records of adults >18 years old who had undergone open tracheostomy at pgh during this period were screened. all patients had been tested for sars-cov-2 rna detection via documented polymerase chain reaction (pcr) swab test and were classified as covid-19 positive or covid-19 negative. patients were further classified according to the reason for tracheostomy (prolonged intubation or airway prophylaxis), but only those under the prolonged intubation (intubated 14 or more days) category were compared and analyzed. excluded were incomplete physical or electronic in-patient records, or those missing the official records of operative technique. a study registry was formulated using patient case numbers obtained from the census of the operating room complex (since all tracheostomy procedures during the pandemic were only performed in the operating room). medical records were retrieved and reviewed for demographic data as well as laboratory data, ventilator data, and medical comorbidities identified as potential prognostic risk factors for the outcomes of interest at the onset of the study. medical comorbidities included in the study were hypertension, type 2 diabetes mellitus, obesity, dyslipidemia, cerebrovascular disease, chronic obstructive pulmonary disease, heart disease, asthma, chronic kidney disease, tuberculosis and malignancies. the data collected included age, sex, comorbidities, apache (acute physiologic assessment and chronic health evaluation) ii score, days intubated, covid status at the time of procedure, weaning days posttracheostomy, days post-tracheostomy discharged from critical care, days post-tracheostomy discharged from hospital or died, cause of death (if applicable) and total length of stay. for the tracheotomized patients due to prolonged mechanical ventilation, differences in outcome variables between covid positive and covid negative patients were analyzed. data analysis data was encoded using microsoftò excel 2016 for mac version 16.16.18 (microsoft corp., redmond wa, usa). data for categorical variables were summarized in frequency counts and percentages while summary measures were presented in terms of mean and standard deviation. pairwise comparisons were performed using fisher exact test or the chi-square test for categorical variables and independent two-sample t-tests for continuous variables. multiple logistic regression was used to explore possible factors associated to mortality and 30day mortality and multiple linear regression for weaning days and its associated factors (95% confidence interval). all statistical results were considered statistically significant at a two-sided level of 0.05. the statistical software, stata version 16.1 (statacorp llc college station, texas) was used for all statistical analyses. original articles philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery results of the 122 adult patients who underwent open tracheotomy at the pgh between march 30, 2020 and march 30, 2021, 76 (62.3%) were due to prolonged intubation and 46 (37.7%) were for airway prophylaxis. of those who underwent tracheostomy for prolonged intubation, 22 (28.95%) tested positive for covid-19 and 54 (71.05%) tested negative. their mean age was 58.46±16.81 (range 1991 years old) and most were female (54; 71.05%). the most common medical comorbidity was hypertension (46; 60.53%) followed by cerebrovascular disease (28; 37.33%). only 34 patients (44.74%) were admitted in an intensive care unit prior to performing the tracheostomy. mean apache ii score was 16.62±6.78. all in all, average days of intubation prior to tracheostomy was 29.14±17.66 days. the baseline characteristics between covid-19 positive and covid-19 negative patients were not significantly different. (table 1) table 1. characteristics of patients who underwent tracheostomy for prolonged intubation at the pgh from march 30, 2020-march 30, 2021 (n=76) all n=76; (%) covid-19 positive n=22; (%) covid-19 negative n=54; (%) p-value age sex (female) area (outside ncr) hypertension type 2 diabetes mellitus dyslipidemia cerebrovascular disease chronic obstructive pulmonary disease heart disease asthma chronic kidney disease tuberculosis (any subsite) cancer apache ii score days of intubation prior to tracheostomy 58.46±16.81 54 (71.05) 37 (48.68) 46 (60.53) 19 (25.00) 4 (5.26) 28 (37.33) 2 (2.63) 6 (7.89) 1 (1.32) 8 (10.53) 9 (11.84) 9 (11.84) 16.62±6.78 29.14±17.66 59.27±17.37 14 (63.64) 11 (50.00) 16 (72.73) 6 (27.27) 1 (4.55) 11 (50.00) 2 (9.09) 4 (18.18) 1 (4.55) 1 (4.55) 5 (22.73) 1 (4.76) 16.09±6.02 29.23±10.91 58.13±16.73 31 (57.4) 26 (48.15) 30 (55.56) 13 (24.07) 3 (5.56) 17 (31.48) 0 2 (3.70) 0 7 (12.96) 4 (7.41) 8 (14.81) 16.83±7.12 29.11±19.86 .7901a .616a .884a .165a .770a .672b .093a .081b .055b .289b .262b .073b .216b .6683b .9795b achi-square test; bfisher exact test table 2. outcomes of surviving patients who underwent tracheostomy for prolonged mechanical ventilation all (n=45) covid-19 positive (n=15) covid-19 negative (n=30) p-valueoutcome weaning days days after tracheostomy before discharged from icu total days on mechanical ventilation days after tracheostomy discharged from hospital length of hospital stay 12.48±13.29 18.59±20.78 40.05±21.81 30.07±23.75 59.51±30.04 9.75±10.10 19.3±23.85 37.92±14.67 26.93±28.80 55.93±35.00 13.64±14.45 18.21±8.73 40.96±24.42 31.69±21.07 61.3±27.72 .4029a .8961a .6910a .5352a .5781a at-test table 3. outcomes of expired patients who underwent tracheostomy for prolonged intubation all (n=31) covidpositive (n=7) covidnegative (n=24) p-valueoutcome days after tracheostomy prior to expiry 30-day mortality length of hospital stay 41.34±37.96 17 (54.84%) 72.45±41.95 27.14±26.46 2 (28.57%) 58.86±29.70 45.86±40.40 15 (62.50%) 76.42±44.64 .2632a .198b .3383a attest; bfisher exact test of the 76 who underwent tracheostomy for prolonged intubation, 45 (59.21%) survived and 31 (40.79%) expired. among the 22 who were covid-19 positive, 15 (68.18%) survived and 7 (31.81%) expired while among the 54 who were covid-19 negative, 30 (55.56%) survived and 24 (44.44%) expired. (tables 2, 3) among those who survived, there were no significant differences in outcomes between covid-19 positive and negative patients who underwent tracheostomy in terms of weaning days, total days on mechanical ventilation, discharge from icu, discharge from hospital after tracheostomy, and total length of hospital stay. although covid-19 negative patients who underwent tracheostomy had longer weaning days from mechanical ventilator, longer total days on mechanical ventilation, longer days to discharge from hospital after tracheostomy, original articles philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery original articles and longer total length of hospital stay, these were all not significant. (table 2) among those who expired, there were no significant differences between covid-19 positive and negative patients who underwent tracheostomy in terms of number of days after tracheostomy prior to expiry, 30-day mortality, and total length of hospital stay. however, covid-19 negative patients survived longer after tracheostomy and had a longer length of hospital stay prior to expiry. (table 3) in this cohort of 76 patients, there was a 30-day mortality of 17 (22.36%) overall, involving 2 out of 15 (9.09%) covid-19 positive patients and 15 out of 54 (27.78%) covid-19 negative patients. figure 1 summarizes the outcomes of the study based on mortality and covid status. in analyzing the possible factors associated with mortality and 30day mortality, none of the listed factors (age, area of residence, days of intubation, apache ii score, covid-19 status) were significantly associated with the outcomes (mortality, weaning days and 30-day mortality). (table 4) however, in terms of weaning days, for every additional day of intubation prior to tracheostomy, weaning days increased by 0.35 of a day (ci:0.18-0.51 95% p = <.001). (table 5) none of the participants were discharged against medical advice or transferred to a different institution. none of the patients who survived in the course of the study were decannulated. discussion our current study found no statistically significant differences in outcomes (weaning days, length of stay, days to discharge from icu and hospital, 30-day mortality, days to death) between covid-19 positive and covid-19 negative patients undergoing tracheostomy for prolonged intubation. in our study, 59.21% (45/76) were successfully liberated from mechanical ventilation and discharged. among the covid-19 positive, 68.18% (15/22) while among the covid-19 negative, 55.56% (30/54) were weaned and discharged. mean days to wean off mechanical ventilation and days post-tracheostomy to discharge from the hospital were shorter for those who were covid-19 positive (9.75±10.10 days) than for those who were covid-19 negative (13.64±14.45 days), but the difference was not statistically significant (p = .4029; p = .5352, respectively). these findings appear consistent with the existing literature. the covid trach collaborative group from the uk nhs study reported 11..00 median days (iqr 7.00 – 18.00) liberation from mechanical ventilation after tracheostomy covid-19 patients with a weaning success rate of 52% (219/465) during the first two months of the pandemic,7 while a national cohort study in spain reported successful liberation from table 4. multiple logistic regression on factors associated with mortality and 30-day mortality mortality 30-day mortality age area (ncr) days of intubation apache ii score covid status (positive) age sex (female) area (ncr) days of intubation apache ii score covid status (positive) 0.88 (0.75-1.04) 0.55 (0.03-11.40) 0.97 (0.88-1.06) 1.25 (0.84-1.86) 0.91 (0.03-25.18) 1.00 (0.95-1.05) 1.60 (0.31-8.22) 0.92 (0.18-4.70) 1.00 (0.99-1.00) 0.97 (0.87-1.08) 0.21 (0.03-1.61) .135 .702 .491 .277 .955 .921 .576 .922 .443 .567 .132 variable variable or (95% ci) or (95% ci) p-value p-value table 5. multiple linear regression on factors associated with weaning weaning (days after tracheostomy liberated from mechanical ventilation) age sex (female) area (ncr) days of intubation apache ii score covid status (positive) 0.14 (-0.11-0.39) -2.82 (-10.06-4.40) -0.53 (-7.30-6.25) 0.35 (0.18-0.51) -0.30 (-0.94-0.34) -2.19 (-9.64-5.27) .276 .433 .875 <.001*** .352 .556 variable coefficient (95% ci) p-value r2 = 0.32 or 32% figure 1. outcomes of tracheostomy march 30, 2020 march 30, 2021 n=122 adults with tracheostomy n=46 airway prophylaxis n=15 (68.18%) survived n=7 (31.81%) expired n=30 (55.56%) survived n=24 (44.44%) expired n=76 prolonged intubation n=22 covid positive n=54 covid negative philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery original articles mechanical ventilation in 52.1% (842/1616) of patients undergoing tracheostomy.8 in a systematic review on covid-19 patients, metaanalysis showed 61.2% of patients were weaned from mechanical ventilation, the overall weighted mean time from tracheostomy to mechanical ventilatory weaning was 24.14±10.19 days.9 a study done prior to the pandemic on tracheostomy for respiratory failure noted that 57% of survivors were liberated from mechanical ventilation in 16 median days (iqr 1-93) post tracheostomy.10 in our study, the mean hospital stay among covid-19 positive patients (55.93±35.00) was shorter than among covid-19 negative patients (61.3±27.72). however, the difference between the two groups was not significant (p= .5781). our post-tracheostomy mortality rates appear higher than those in other studies. our overall mortality was 40.79% (31/76). the mortality rate among those who underwent tracheostomy was 31.81% (7/22) for covid-19 positive patients and 44.44% (24/54) for covid-19 negative patients. from existing literature, post-tracheostomy covid-19 mortality rates ranged from 19.23 to 23.7%.9, 11 in studies prior to the pandemic, hospital mortality rates for prolonged intubation patients who underwent tracheostomy were 19-20%.3,10 it is interesting to note that a study comparing crude icu and hospital mortality of ventilated covid-19 and non-covid-19 (including those who may or may not have undergone tracheostomy) were at 43.8 vs. 40% and 43.8 vs. 41.1% respectively; which were evaluated to have no significant difference p >.05.12 overall, mortality data appears to vary across the literature. the higher mortality rates in our institution particularly in the covid-19 negative group could be attributed to selection bias as we are the national end-referral center for both covid-19 (severe and critical) and non-covid-19 cases. it is important to note that there were no statistically significant differences in outcome variables between covid-19 and noncovid-19 groups. this is consistent with the findings of tang, where tracheostomy-specific and all-cause mortality rates between the covid-19 and non-covid-19 groups were not statistically significant— indicating that tracheostomy is safe to perform on covid-19 patients.13 on the association of factors to outcomes of post-tracheostomy patients, we did find that the number of days of intubation prior to tracheostomy was associated with increased weaning time posttracheostomy, implying that for every additional day of intubation prior to tracheostomy, weaning days increase by 0.35 of a day. although the comparison of outcomes between early and late/delayed tracheostomies is not within the scope of this study, it is interesting to look into how the additional days of intubation increase weaning time. in a systematic review in 2012 on early vs. late tracheostomy outcomes, no mortality difference was found.14 in another systematic review on covid-19 tracheostomy patients, no difference was found in mortality (rr 1.57, p = .43) between early and late tracheostomy, and timing of tracheostomy was not able to predict time to decannulation.9 although delaying tracheostomy for patients with covid-19 might reduce risks for staff, extended duration of intubation, sedation, mechanical ventilation, and icu stay associated with such delays can lead to further complications.2 questions are raised on the utility of negative tests prior to tracheostomy procedure and whether the detection of viral rna by pcr predicts risk of infectivity to health care professionals still uncertain. in the study of the covid trach collaborative group, delaying tracheostomy to achieve negative tests could possibly prolong endotracheal ventilation and thus lessen the potential benefits of the procedure whilst increasing the risk of complications relating to prolonged intubation.7 in our study, average days of intubation prior to tracheostomy were 29.14±17.66; 29.23±10.91 days for covid-19 positive and 29.11±19.86 days for covid-19 negative. the timing of tracheostomy for patients in our study was notably longer than existing literature. in a multicenter cohort in japan in 2021, tracheostomy for 66 covid-19 patients was performed at a median of 15 days (iqr: 10.5–21.5) after commencement of mechanical ventilation.15 in a national cohort in spain, the median timing of tracheostomy was 12 days (4–42 days) since orotracheal intubation. 11 in practices of other centers, the tracheotomy was performed within 24 hours from the indication.16 this delay in surgery in our institution is not purely by choice of the medical team but due to the inherent limitations on accommodation with limited operating rooms during this time, existing hospital operational protocols on covid-19-related surgeries, and poor surgical optimization. given this finding, important decisions have to be made balancing the possible effect of further prolonging intubation vs. optimal surgical timing coupled with existing hospital policies on infectious diseases. our study has several limitations. because this was a retrospective observational study, our results are more prone to misinterpretation and residual confounding. a recent study suggested tracheostomyrelated complications and decannulation as an outcome to monitor.9 decannulation rates were not monitored in the study sample due to unavailability of out-patient records for their specific follow up. this can be explored further to analyze the survival rate of the cohort of patients. in addition, day-by-day knowledge on covid-19 progresses. since the study was performed prior to public availability of covid-19 vaccinations, the effect of vaccinations on covid-19 related mortalities was not studied. hence it can also be recommended to extend the existing study with a larger sample size, including vaccination status philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery original articles acknowledgements we thank drs. louella carpio and john robert medina for aiding in the statistical analysis, mr. jervis tan for helping organize our data and ms. jane yapo for helping in the data collection. references 1. kraft, shannon; schindler j. tracheotomy. in: lesperance pfbhvljnkrjrtm, editor. cummings otolaryngology head and neck surgery. 7th ed. philadelphia,: saunders; 2021. p. 82. 2. mcgrath b, brenner m, warrillow s, pandian v, arora a, cameron t, et al. tracheostomy in the covid-19 era: global and multidisciplinary guidance. lancet respir med. 2020 jul:8(7):717– 725. doi: 10.1016/s2213-2600(20)30230-7; pubmed pmid:  32422180; pubmed central pmcid: pmc7228735. 3. freeman bd, borecki ib, coopersmith cm, buchman tg. relationship between tracheostomy timing and duration of mechanical ventilation in critically ill patients. crit care med. 2005 nov;33(11):2513–20. doi: 10.1097/01.ccm.0000186369.91799.44; pubmed pmid: 16276175. 4. turri-zanoni m, battaglia p, czaczkes c, pelosi p, castelnuovo p, cabrini l. elective tracheostomy during mechanical ventilation in patients affected by covid-19: preliminary case series from lombardy, italy. otolaryngol head neck surg. 2020 jul;163(1):135-137. doi: 10.1177/0194599820928963; pubmed pmid: 32396455. 5. chao tn, braslow bm, martin nd, chalian aa, atkins jh, haas ar, et al. tracheotomy in ventilated patients with covid-19. ann surg. 2020 jul;272(1):e30-e32. doi: 10.1097/ sla.0000000000003956; pubmed pmid: 32379079; pubmed pmcid: pmc7224612. 6. mattioli f, fermi m, ghirelli m, molteni g, sgarbi n, bertellini e, et al. tracheostomy in the covid 19 pandemic. eur arch otorhinolaryngol. 2020 jul;277(7):2133-2135. doi: 10.1007/s00405-02005982-0; pubmed pmid: 32322959; pubmed central pmcid: pmc7174541. 7. hamilton nji, jacob t, schilder agm, arora a, george mm, green f, et al. covidtrach; the outcomes of mechanically ventilated covid-19 patients undergoing tracheostomy in the uk: interim report. br j surg. 2020 sep 17;107(12):e583–4. doi: https://doi.org/10.1002/bjs.12020. 8. sancho j, ferrer s, lahosa c, posadas t, bures e, bañuls p, et al. tracheostomy in patients with covid-19: predictors and clinical features. eur arch otorhinolaryngol. 2021 oct;278(10):39113919. doi: 10.1007/s00405-020-06555-x; pubmed pmid: 33386436; pubmed central pmcid: pmc7775730. 9. ferro a, kotecha s, auzinger g, yeung e, fan k. systematic review and meta-analysis of tracheostomy outcomes in covid-19 patients. br j oral maxillofac surg. 2021 nov;59(9):1013– 1023. doi: 10.1016/j.bjoms.2021.05.011; pubmed pmid:  34294476; pubmed central pmcid: pmc8130586. 10. engoren m, arslanian-engoren c, fenn-buderer n. hospital and long-term outcome after tracheostomy for respiratory failure. chest. 2004 jan;125(1):220-7. doi: 10.1378/ chest.125.1.220; pubmed pmid: 14718444. 11. zuazua-gonzalez a, collazo-lorduy t, coello-casariego g, collazo-lorduy a, leon-soriano e, torralba-moron a, et al. surgical tracheostomies in covid-19 patients: indications, technique, and results in a second-level spanish hospital. oto open. 2020 sep 15;4(3):2473974x2095763. doi: 10.1177/2473974x20957636; pubmed pmid: 32974425; pubmed central pmcid: pmc7495941. 12. todi s, ghosh s. a comparative study on the outcomes of mechanically ventilated covid-19 vs non-covid-19 patients with acute hypoxemic respiratory failure. indian j crit care med. 2021;25(12):1377–81. doi: 10.5005/jp-journals-10071-24009; pubmed pmid: 35027797; pubmed central pmcid: pmc8693121. 13. tang l, kim c, paik c, west j, hasday s, su p, et al. tracheostomy outcomes in covid-19 patients in a low resource setting. ann otol rhinol laryngol. 2022 nov;131(11):1217-1223. doi: 10.1177/00034894211062542; pubmed pmid: 34852660. 14. andriolo bng, andriolo rb, saconato h, atallah án, valente o. early versus late tracheostomy for critically ill patients. in: gomes silva bn, editor. cochrane database of systematic reviews. cochrane database syst rev. 2015 jan 12;1(1):cd007271. doi:  10.1002/14651858.cd007271. pub3; pubmed pmid: 25581416; pubmed central pmcid: pmc6517297. 15. tanaka a, uchiyama a, kitamura t, sakaguchi r, komukai s, enokidani y, et al. association between tracheostomy and survival in patients with coronavirus disease 2019 who require prolonged mechanical ventilation for more than 14 days: a multicenter cohort study. auris nasus larynx 2022 jun 13; s0385-8146(22)00164-x. doi: 10.1016/j.anl.2022.06.002; pubmed pmid: 35764477; pubmed central pmcid: pmc9189113. 16. botti c, lusetti f, peroni s, neri t, castellucci a, salsi p, et al. the role of tracheotomy and timing of weaning and decannulation in patients affected by severe covid-19. ear nose throat j. 2021 apr;100(2_suppl):116s-119s. doi: 10.1177/0145561320965196; pubmed pmid:  33035129; pubmed central pmcid: pmc7548540. as a comparator for analysis since most of the countries now have high vaccination rates. in conclusion, outcomes of patients under prolonged mechanical ventilation between covid-19 and non-covid-19 tracheostomies do not seem to be significantly different. in our study, a day longer of intubation is found to be associated with a 0.35 day longer weaning time; with no associations to mortality or 30-day mortality. evaluating the need and timing for tracheostomy in both groups of patients is still best decided on the overall status of the patient in accordance with existing hospital protocols and relevant guidelines. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery president’s page the year 2022 created new challenges to our profession and to our lives. we used the unexpected struggles we have endured over the past two years as an encouragement to anticipate for the volatile and uncertain future. this pertains to the personal level, to the pso-hns and to the community we serve. to be triumphant, we need to amplify our voices about what matters in otolaryngologic health care, and to continually demonstrate how orl-hns research and training translate to the community and to the environment. early this year, we spoke of this year’s battle cry: “move up and forward.” i challenged all of us to upgrade some aspect of our lives, our profession, our colleagues, and our community. we have to “entrust ourselves to anything greater than ourselves.” the pandemic is certainly still here and we never cease to navigate these unforeseeable times. we still go on and constantly renew our professional aspirations and personal desires. we pray for more lustrous days and catch on from this experience so that we are better rehearsed and better equipped and all set for the next challenge. we keep the faith that we can make a difference and know that we can make longer strides. we have seen and dealt with challenges during this pandemic. we are overworked and worn out, we continue to struggle, and are figuring out how to stay focused and move forward. it is fitting for us to revitalize the energy that drives the pso-hns to be the amazing fellows for our country. moving forward means using that “take the lead and earn the wings” attitude that we all have and applying it to our own profession. with these, i believe we have been made stronger. our strength is made clear in being complacent with the bothersome and preparing for the unpredictable. this is taxing and demanding. we all need to continue to support one another for the years to come. the orl-hns specialty is unique and has trained us to be prepared for the unexpected. we will hold on and see it through, and we will reach out and keep in touch. we forge commitments to ourselves and to each other. a positive attitude is fundamental to be triumphant. we need to stay clear and confident; it will encourage others to be optimistic. this has not been the year that we had envisioned months ago, but it has been a year that has challenged us in ways we could not have foreseen. we acknowledge the challenge and remain energetic. we do not know why things happen the moment they occur, but we believe that there is a reason and that we must have faith, hope, and trust in the journey of life. we cannot live freely and thrive by living in the past. we must move up and forward. with that goal in mind, if we push everyone forward and move up toward our highest hopes and aspirations, the momentum of the pso-hns community will build toward positive change. it starts for each of us today. find your compass and prove to yourself that constancy pays off. choose your journey, choose your battles and follow your dreams. let’s keep challenging one another to move up and forward. stay organized, have a purpose and be the best version of yourself. frederick mars b. untalan, md, mbah, fpso-hns president philippine society of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 case reports philippine journal of otolaryngology-head and neck surgery 47 abstract objective: to present a case of thyroid tuberculosis and to discuss its clinical presentation, differential diagnoses and management. methods: design: case report setting: tertiary government hospital patient: one results: a 55-year-old farmer presented with an 8-month progressively enlarging anterior neck mass, and fine needle aspiration biopsy yielded grossly turbid straw-colored aspirate admixed with blood with microscopy showing scattered inflammatory cells and macrophages set against a colloid background. after total thyroidectomy, hispathology revealed parenchymal infiltration by multiple aggregates of plump spindled to epitheloid cells forming granulomas with interspersed multinucleated giant cells, central caseation necrosis and surrounding fibrosis with chronic inflammatory infiltrates. the nodal masses also showed prominent germinal centers with interspersed epitheloid cells and foamy macrophages. final diagnosis was chronic granulomatous inflammation consistent with tuberculosis. conclusion: tuberculosis (tb) of the thyroid is a rare occurrence that can present as inflammation, infection or tumor formation of the thyroid gland. diagnosis depends on identification of the tubercle from tissues and aspirates by acid fast staining and tb culture. treatment consists of multiple drug therapy for tuberculosis but thyroidectomy may be an option if the thyroid gland is severely diseased. keywords: tuberculosis, endocrine; thyroid disease tuberculosis (tb) is one of the leading causes of morbidity and mortality affecting one-third of the world’s population.1 it has been reported to occur in many parts of the human body but thyroid gland involvement is extremely rare and its true incidence is unknown.1 thyroid tuberculosis is rare even in countries in which tuberculosis constitutes an endemic disorder, barely 200 cases have been reported in the world literature.2 tuberculosis of the thyroid can present as inflammation, infection or tumor formation of the thyroid gland. bacteriological studies are needed to make a specific diagnosis.2 tuberculosis of the thyroidelmer f. fabito, jr., md mary jane tipayno-lubos, md felixberto d. ayahao, md department of ear nose throat – head and neck surgery baguio general hospital and medical center correspondence: dr. felixberto d. ayahao department of otorhinolaryngology head and neck surgery baguio general hospital and medical center governor pack road, baguio city, benguet 2600 philippines telefax: (074) 444 4176 email: entbaguio@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery, interesting case contest. june 2, 2015. menarini office, 4/f w building, bgc taguig city. philipp j otolaryngol head neck surg 2017; 32 (1): 47-50 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 figure 2. gross specimen of the thyroid gland, showing multiple complex nodules in both thyroid lobes 48 philippine journal of otolaryngology-head and neck surgery case reports case report a 55-year-old male farmer from pangasinan, philippines was admitted on february 12, 2014 with a chief complaint of anterior neck mass. he was apparently in good general condition until 8 months prior to admission when he noticed a non-tender, soft, approximately golf ball sized mass in the anterior neck over the left lobe of the thyroid with no associated dysphagia, dyspnea, palpitations or tremors. despite two unrecalled medications and regular follow-up with a private physician, the mass persistently enlarged. he consulted in our institution 2 months prior to admission. thyroid hormone test results were normal but neck ultrasonography revealed bilaterally enlarged thyroid lobes with cystic mass lesions measuring 30 x 23 x 11 mm and 40 x 38 x 32 mm in the right and left lobe, respectively. the cysts exhibited internal comet tail signs reflective of benign colloid lesions. fine needle aspiration biopsy on the left anterolateral neck mass yielded grossly turbid straw-colored aspirate admixed with blood. microscopy showed scattered inflammatory cells and macrophages set against a colloid background. cell block revealed few inflammatory cells scattered in fibrinous background consistent with benign cystic fluid. the patient was admitted for total thyroidectomy with a clinical impression of multinodular non-toxic goiter. intraoperative findings revealed a multinodular thyroid gland with approximate combined size of 5 x 5 x 2 cm with firm yellow nodules in both lobes and isthmus with the largest nodule on the left lobe measuring approximately 3 x 2 x 3 cm. the rest of the cut specimen showed a meaty surface. the postoperative course was unremarkable. hispathology revealed the left thyroid lobe parenchyma to be infiltrated by multiple aggregates of plump spindled to epitheloid cells forming granulomas with interspersed multinucleated giant cells, central caseation necrosis and surrounding fibrosis with chronic inflammatory infiltrates. the nodal masses attached to the isthmus and right thyroid lobe also showed prominent germinal centers with interspersed epitheloid cells and foamy macrophages. microsection of the right thyroid lobe revealed varisized, well circumscribed nodules of small to cystically dilated follicles containing scant to abundant colloid and lined by flattened to cuboidal lining cells. the isthmus appeared histologically unremarkable. the final histopathologic diagnosis was chronic granulomatous inflammation consistent with tuberculosis, left thyroid lobe and lymph nodes attached to the right thyroid lobe and isthmus; nodular hyperplasia, right thyroid lobe; no histopathologic change, isthmus. he was started on a course of anti-tb drugs. discussion tuberculosis of the thyroid gland whether primary or secondary, is an extremely rare disease with only isolated reports, and a small number of case series have been reported in the literature even in countries endemic for tb.3-4 this may be attributed to the resistance of the thyroid gland to infections due to a number of factors, namely, a prosperous lymphatic and vascular supply, well developed capsule, high iodine content of the gland and bactericidal effect of the colloid and iodine.5-9 iodine can interact on the outermost layer of microbial cells producing significant effect on their viability. in most cases, although dysphagia, dyspnea and more rarely dysphonia are the main symptoms of the disease, the patient may be asymptomatic as our patient was.10 in thyroid tuberculosis, the duration of presenting symptoms varies from 2 weeks to more than a year and there is no relationship with age or figure 1. fine needle aspiration cytologic smear, polychromatic stain, medium power objective (100 x), arrow pointing at a macrophage. medium power objective (100 x) philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 philippine journal of otolaryngology-head and neck surgery 49 case reports lymphatic routes or directly from the larynx or cervical lymphadenitis.2 tuberculosis primarily affecting the thyroid gland is much more rare and predictably more difficult to diagnose. the diagnosis is mainly by fine-needle aspiration cytology, a diagnostic step that helps to avoid unnecessary surgery.2 tuberculous lymphadenitis may manifest as a neck mass. fine needle aspiration (fna) specimens may yield cytologic evidence consistent with tuberculosis including granulomatous inflammation and/or caseation necrosis. multiple recent studies have demonstrated greater than 90% accuracy in diagnosis of tuberculous lymphadenitis with fna.19,21 an improvement in technique to yield more positive acid-fast bacilli (afb) and culture results from aspirate is called forin which uses a large bore needle for aspiration of abscess, digesting it with sodium hydroxide and centrifuging it to concentrate microbes at the base of the tube.19 in most cases definitive diagnosis is made post-operatively by means of histopathological examination of the surgical specimen as in our patient.7,22 since granulomatous lesions are not pathognomonic of tuberculosis (as they may be seen in sarcoidosis and subacute thyroiditis), caseating necrosis, if present, confirms the diagnosis of tuberculosis.10,22,23 as in our case, the left thyroid lobe parenchyma was infiltrated by multiple aggregates of plump spindled to epitheloid cells forming granulomas, with interspersed multinucleated giant cells, central caseation necrosis and surrounding fibrosis with chronic inflammatory infiltrates. the nodal masses attached to the isthmus and right thyroid lobe also showed prominent germinal centers with interspersed epitheloid cells and foamy macrophages. the demonstration of afb in the gland by ziehl nelsen stain can also validate the diagnosis.2 however, the mycobacteria are rarely recognised by the stain.2 furthermore, the surgical specimen is rarely submitted for culture unless an infectious process is suspected.2 other investigative modalities include chest x-ray, sputum analysis, polymerase chain reaction and cultures with labelled compounds.1 treatment includes anti-tb drugs combined with surgical removal of the affected parts of the thyroid gland or surgical drainage with a good outcome.2 for early minor cases, drugs alone are sufficient. in our patient, the affected lobe was also resected and post-operative multiple tb drug therapy was instituted in accordance with our national tb control program.2 thyroid tuberculosis is difficult to diagnose or to differentiate from other thyroid masses due to non-specific signs and symptoms as mentioned in this case. if a patient presents with a strong history of exposure to tuberculosis with cervical lymph adenopathy and fever with a concomitant anterior neck mass that is cystic, tender, erythematous and with abscess formation, then thyroid tb should be considered.2 unfortunately, these were not present in our case. the routine diagnostic tests performed on our patient did not help us in making the diagnosis either. if there is a high index of suspicion based on physical examination and strong history of exposure, it is figure 3. histopathologic specimen, hematoxylin-eosin, medium power objective (100 x), arrow pointing at multinucleated giant cell figure 4. histopathologic slide, hematoxylin and eosin, low power objective (40x), showing caseation necrosis. hematoxylin-eosin medium power objective (100 x) hematoxylin-eosin low power objective (40 x) sex.11 the most frequent clinical presentation is a solitary thyroid nodule that may present with a cystic component.12 sometimes the patients present with thyrotoxicosis, hypothyroidism, thyroid abscess, thyroid enlargement mimicking cancer, or show signs of subacute granulomatous thyroiditis (de quervain’s) or of chronic non-suppurative thyroiditis.13-16 in the majority of cases, patients are euthyroid just like in our case.9,10 imaging techniques are not helpful in establishing the diagnosis. ultrasonography mostly shows a heterogeneous, hypoechogenic mass that may include cystic degeneration9,17 which is similar to our case. contrast-enhanced computed tomography (ct) may reveal a necrotic centre with a peripheral rim enhancement related to the caseous lesion along with regional lymphadenopathy.17 a ct scan was not done in our case as it is not routinely requested for thyroid masses unless mediastinal extension is entertained. tuberculous thyroiditis can mimic many pathologies.2 localized pain is a predominant symptom and facilitates differential diagnosis in such cases.2 other pathologies to consider are infectious thyroiditis and subacute granulomatous thyroiditis (de quervain’s and thyroid sarcoidosis).18 in the event that pain is absent, tuberculous thyroiditis can be mistaken for carcinoma19 with which it may coexist.5,11,20 tuberculosis of the thyroid gland may be primary or occur in association with tuberculous infection of other organs.7 in such cases, the thyroid is affected by the spread of bacilli via hematogenous or philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 case reports 50 philippine journal of otolaryngology-head and neck surgery references mpikashe p, sathekge mm, mokgoro np. tuberculosis of the thyroid gland: a case report. 1. south afr fam pract. 2004; 46:19-20. zendah i, daghfous h, ben mrad s, tritar f. primary tuberculosis of the thyroid gland. 2. hormones (athens). 2008 oct-dec; 7(4): 330-3. pmid: 19121995. collar fa, huggins cb, 1926 tuberculosis of the thyroid gland. ann surg 84: 804-8203. kukreja hk, sharma ml. primary tuberculosis of the thyroid gland. 4. ind j surg. 1982; 44:190. al-mulhim aa, zakaria hm, abdel hadi ms, al-mulhim fa, al-tamimi dm, wosornu l. thyroid 5. tuberculosis mimicking carcinoma: report of two cases. surg today. 2002;32(12): 1064-1067. doi: 10.1007/s005950200214; pmid: 12541023. dawka s, jayakumar j, ghosh a. primary tuberculosis of the thyroid gland. 6. kathmandu univ med j. 2007 jul-sep; 5(3):405-7. pmid: 18604064. bulbuloglu e, ciralik h, okur e, ozdemir g, ezberci f, cetinkaya a. tuberculosis of the thyroid 7. gland: review of the literature. world j surg. 2006 feb; 30(2):149-55. doi: 10.1007/s00268-0050139-1; pmid: 16425087. mpikashe p, sathekge mm, mokgoro np. tuberculosis of the thyroid gland: a case report. 8. south afr fam pract. 2004; 46:19-20. terzidis k, tourli p, kiapekou e, alevizaki m. thyroid tuberculosis. 9. hormones (athens). 2007 janmar; 6(1): 75-9. pmid: 17324921. abdulsalam f, abdulaziz s, mallik aa. primary tuberculosis of the thyroid gland. 10. kuwait med j. 2005; 37: 116-118. alan r, o’flynn w, clarke se. tuberculosis of the thyroid bed presenting as recurrent medullary 11. thyroid carcinoma. tubercle. 1990 dec;71(4): 301-302. pmid: 2267683. khan em, haque i, pandey r, mishra sk, sharma ak. tuberculosis of the thyroid gland: 12. a clinicopathological profile of four cases and review of the literature. aust n z j surg. 1993 oct;63(10): 807-810. pmid: 8274125. das dk, pant cs, chachra kl, gupta ak. fine needle aspiration cytology diagnosis of tuberculous 13. thyroiditis. a report of 8 cases. acta cytol. 1992 jul-aug;36(4): 517-522. pmid: 1636345. johnson ag, phillips me, thomas rj. acute tuberculous abscess of the thyroid gland. 14. br j surg. 1973 aug; 60(8): 668-9. pmid: 4724211. ghosh a, saha s, bhattacharya b, chattopadhay s. primary tuberculosis of thyroid gland: a rare 15. case report. am j otolaryngol. 2007 jul-aug; 28(4): 267-270. doi: 10.1016/j.amjoto.2006.09.005; pmid: 17606045. barnes p, weatherstone r. tuberculosis of the thyroid. two case reports. 16. br j dis chest. 1979 apr; 73(2):187-191. pmid: 119548. kang bc, lee sw, shim ss, choi hy, baek sy, cheon yj. us and ct findings of tuberculosis of the 17. thyroid gland: three case reports. clin imaging. 2000 sep-oct;24(5): 283-286. pmid: 11331157. talwar vk, gupta h, kumar a. isolated tuberculous thyroiditis. 18. jiacm. 2003;4(3): 238-239. maharjan m, hirachan s, kafle pk, bista m, shrestha s, toran kc, et al. incidence of tuberculosis in 19. enlarged neck nodes, our experience. kathmandu univ med j (kumj). 2009 jan-mar; 7(25):54-8. pmid: 19483454. magboo ml, clark oh. primary tuberculous thyroid abscess mimicking carcinoma diagnosed 20. by fine needle aspiration biopsy. west j med. 1990 dec;153(6): 657-659. pmid: 2127330; pmcid: pmc1002655. khan r, harris sh, verma ak, syed a. cervical lymphadenopathy: scrofula revisited. 21. j laryngol otol. 2009 jul;123(7):764-7. doi: 10.1017/s0022215108003745; pmid: 18845038. el malki ho, mohsine r, benkhraba k, amahzoune m, benkabbou a, el absi m, et al. 22. thyroid tuberculosis. diagnosis and treatment. chemotherapy 2006;52(1): 46-49. doi: 10.1159/000090244; pmid: 16340200. kabiri h, atoini f, zidane a. thyroid tuberculosis. 23. ann endocrinol (paris). 2007 jun;68(2-3): 196198. doi: 10.1016/j.ando.2007.04.007; pmid: 17532284. recommended that erythrocyte sedimentation rate (esr) and chest x-ray should be done.1 the most helpful diagnostic test is an ultrasound guided fna and microbiological tests.2 because we had not made the diagnosis of tb preoperatively and with multiple nodules in both lobes, our patient underwent total thyroidectomy. he was subsequently prescribed anti-tb drugs following the histopathologic report. appropriate treatment still consists of antitb drugs since it is now recognized that complete resolution usually follows an appropriate antituberculous drug treatment only. the total duration of chemotherapy was 8 months with favourable outcome.2 surgical intervention is recommended in cases with large abscess or a grossly diseased thyroid gland.2 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the prevalence of hearing loss and otologic diseases among filipinos living in the southern tagalog region iv-a: calabarzon (cavite, laguna, batangas, rizal and quezon), philippines. methods: design: retrospective review of community survey data setting: communities in region iv-a provinces, philippines participants: 3267 residents of the five provinces aged 0 months and above results: about 71.29% and 74.60% had at least mild hearing loss, in right and left ears, respectively. for disabling hearing impairment, overall prevalence was 26.33%, distributed into 11.87% among 4 to 18-year-olds; 8.97% for 19 to 64-year-olds; and 3.17% for 65-year-olds and above. absence of prevalent and hearing loss-associated diseases: serous otitis media [or 0.362, 95% ci 0.167 to 0.782, p = .010], csom [or 0.407, 95% ci 0.236 to 0.703, p = .001] com [or 0.229, 95% ci 0.106 to 0.494, p < .001] can decrease the risk for hearing loss development in the region. prevention of noise-induced hearing loss or delay in the manifestation of presbycusis can reduce the risk of having hearing loss by as much as 75% [or 0.253, 95% ci (0.180 to 0.355), p < .001]. all pure tone audiometry measurements were obtained with surrounding median ambient noise of 55db (iqr 46 to 60db). conclusion: the prevalence of hearing loss among surveyed residents of the southern tagalog region iv-a provinces was high compared to the previous nationwide study but low compared to other lowand middle-income countries. the top otologic conditions of this population (ear occlusion with ear wax, chronic suppurative otitis media, chronic otitis media, presbycusis, noiseinduced hearing loss) were associated with hearing loss and their absence decreased the risks for hearing impairment. hearing and clinical otologic profile of filipinos living in southern tagalog region iv-a (calabarzon), philippines: the southern tagalog ent hearing specialists (stents) survey 2012-2017 patrick joseph m. pardo, md1 angeline niñal-vilog, md1 jose m. acuin, md, msc1,2 christopher malorre e. calaquian, md2,3 rubiliza dc. onofre-telan, md4 1department of otorhinolaryngology head and neck surgery de la salle university medical center 2department of otorhinolaryngology head and neck surgery asian hospital and medical center 3department of otolaryngology head and neck surgery philippine general hospital university of the philippines manila 4qualimed hospital-santa rosa correspondence: dr. patrick joseph m. pardo department of otorhinolaryngology head and neck surgery de la salle university medical center gov. d. mangubat ave., dasmariñas, cavite 4114 philippines phone: +63 46 481 8000 email: orl-hns@dlshsi.edu.ph the authors declared that this represents original material, that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosure: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philipp j otolaryngol head neck surg 2022; 37 (2): 8-15 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery original articles keywords: prevalence; hearing loss; csom, pediatrics; adults; presbycusis; survey; otoscopy; otology the world health organization has estimated about 466 million people worldwide have moderate or greater hearing loss1,2 with 80% residing in lowand middle-income countries (lmics)2 like the philippines. however, less programs are devoted to hearing loss detection, prevention, and remediation programs among these countries.1,3 according to newall et al. in 2020,1 the philippines has a prevalence of moderate or worse hearing loss (4 frequency average > 41dbhl was 7.5% in children, 14.7% in adults 18-65 years old, and 49.1% among adults >65 years old) nationwide. to the best of our knowledge, there is no published data on the prevalence of hearing loss and otologic diseases in the southern tagalog region iv-a or calabarzon, composed of the five provinces of cavite, laguna, batangas, rizal and quezon. identifying the hearing profiles of constituents of municipalities and provinces in this region can help local health providers, health care workers and health policy makers design ear and hearing care programs that will fit their community’s needs. our study aimed to determine the prevalence of hearing loss and otologic diseases among filipinos living in the southern tagalog region iv-a: calabarzon (cavite, laguna, batangas, rizal, quezon), philippines based on data from the survey conducted by otolaryngologists who were practicing in this region from 2012 to 2017. methods our study began after the approval of its research protocol submitted to the independent ethics committee of the de la salle health sciences institute, iec protocol code: 2021-54-01-a. we performed the procedural steps and conduct of this study following the declaration of helsinki of 1975, the 2017 national ethical guidelines for health and health-related research and the implementing rules and regulations of the data privacy act of 2012. study design and setting we conducted a retrospective review of charts and records based on the data gathered from a community survey by collaborating otolaryngologists practicing in the southern tagalog region iv-a comprising the provinces of cavite, laguna, batangas, rizal, and quezon, philippines from 2012-2017. population and sample size our study reviewed and analyzed all 3452 charts and medical information obtained by the southern tagalog ent specialists (stents) 2012-2017 hearing survey collaborators from residents of the region aged 0 months and above, who consented to participate (or whose parents or guardians gave consent). all charts with incomplete, missing or erroneously encoded data were excluded. proxy consents were obtained from the current president of the stents chapter of the philippine society of otolaryngology – head and neck surgery (psohns) and from the lead collaborator (rvcj) who conducted the survey in 2012-2017 to use the database for the analysis of this study. data collection and analysis we analyzed the demographic data (age and sex) and clinical data (ear symptoms, duration of hearing disability if present, family history of hearing loss, otoscopy findings, pure tone audiometry for participants 4 years old and above, behavioral hearing responses for children below 4 years old, and the need for ear and hearing condition management) collected from the survey, performed by otorhinolaryngologists, following the procedures recommended when utilizing the who/peb ear and hearing disorders examination form version 7.1a.4 we categorized pure tone hearing levels based on the who 2008 recommendation: pure tone averages (ptas) of < 25 dbhl for normal hearing or no impairment, 26 to 40 dbhl for mild impairment, 41 to 60 dbhl for moderate impairment, 61 to 80 dbhl for severe impairment, and > 80 dbhl for profound impairment.5 we also classified their hearing acuity based on the who definition of disabling hearing impairment as pta thresholds at 500, 1000, 2000 and 4000hz in the better ear > 41 db hl among adults5 and > 31dbhl for the pediatric age group.6 these pure tone audiometry measurements were conducted in a single quiet room available in the health centers and primary hospitals located in each identified site. all ambient sound levels recorded in these sites obtained from the survey were also analyzed. statistical analysis we used descriptive statistics (mean and sd, percentage, median and range) to describe demographic and clinical data. we illustrated the hearing status and otologic profile distribution based on sex and age using frequency distributions and computed the prevalence of hearing loss and common otologic diseases and conditions. the chisquare test was used to determine associations between, sex, presence of specific otologic conditions and presence of hearing lossfor both groups who underwent the pure tone audiometry and behavior hearing screening test; the kruskal-wallis test was used to determine presence of differences between hearing levels among those who underwent pure tone audiometry; and regression analysis was used to identify the relationship or correlation between factors associated with hearing loss odds ratio (or) for data of subjects who underwent pure tone philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery original articles audiometry screening. all p-values < .05 were considered significant. all data were encoded using ms excel version 2112 (microsoft 365®, microsoft corp., redmond wa, usa), and analyzed using stata 15.0 (stata corp llc, college station, tx, usa). results only 3258 out of 3452 datasets were analyzed in this study, with 194 records excluded due to missing, incomplete, erroneous encoding and/or repeated entries during screening. all pure tone audiometry measurements were obtained with surrounding median ambient noise of 55 db (ior: 14, [46 60 db]). our included population had a median age of 30 (iqr: 54 [12 to 64]) years old, composed of 42.20% children and 57.8% adults and dominated by females (62%). adults were further classified into adults aged 19 to 64 years old (51.84%) and elderly aged 65 years old above (5.95%). based on age, their ptas revealed that of the surveyed children > 4 years old to 18 years old, 24.30% had at least mild hearing impairment in their right ear and 23.21% in the left ear. for the adults, 46.99% had hearing loss in their right ear and 50.85% in their left ear. for sex, hearing loss of at least mild was higher in females in both ears (62.78% right ear, 63.24% left ear). the overall age prevalence of disabling hearing impairment was at 26.33%. in between age groups, the prevalence was identified as follows: 11.87% for ages 4 to 18 years old; 8.97% for those 19 to 64 years old; and 3.17% for ages 65 years old and above. representative graphs of each age group show that most hearing loss levels in all age groups were recorded as mild hearing loss. (figures 1 to 3) however, among the three groups, hearing loss levels were significantly associated with age among the elderly, 65 years old and above (h statistic = 41.840; df = 26; p = .02). (figure 3) figure 4 shows evaluations per province, with quezon ranked first as having the highest overall prevalence of disabling hearing loss (34.15%) among the five provinces, followed by rizal (23.24%) and laguna (21.92%). for pediatric residents, the disabling hearing impairment percentages were high in quezon (20.06%), cavite (12.32%) and rizal (12.16%). smaller percentages of the study population aged 65 years old and above were noted to have disabling hearing loss: quezon (3.83%), rizal (3.24%), and laguna (1.97%). as for ear symptoms and ear examination findings, 50 of the participants complained of ear pain. on otoscopy, the top three ear findings were: presence of ear wax (18.17%), tympanic membrane perforation (3.96%) and otorrhea (3.60%). these three findings, together with hyperemic tympanic membrane (df = 1, p = .008), were found to have significant association with presence of hearing loss in our study population (df = 1, p < .05). (table 1) as for pertinent history, any identified length of time that these participants suffered difficulty of hearing was associated with the presence of hearing loss regardless of duration: 0-4 years, 1.26% (chisquare test: observed value = 38.523, df = 1; p < .001), 5-59 years, 2.27% (chi-square test: observed value = 14.997; df = 1; p < .001) and 60 years and above, 1.14% (chi-square test: observed value = 34.160; df = 1; p < .001). in addition, information regarding recall of previous ear consultations or report of existing ear diagnoses revealed that ear occlusion with wax, 14.06% (chi-square: observed value = 37.786, df = 1, p < .001) , non-infectious causes presbycusis and noise-induced hearing loss (nihl), 4.51% (chi-square: observed value = 46.316; df = 1, p < .001), chronic suppurative otitis media (csom), 2.05% (chi-square: observed value = 12.247, df = 1, p < .001), and chronic otitis media (com), 0.86% (chi-square: observed value = 11.227, df = 1, p = .001), were also found to be significantly associated with decline in hearing in this population. (table 1) assessment and management data also revealed that 32.55% needed aural toilette, 30.61% needed medications, and 11.17% required hearing aid fitting. about 11% would be needing further diagnostic tests for hearing and 6% would require further investigation for hearing loss causes. among all the otologic and clinical characteristics analyzed in this population (table 2), we found that as they reached adulthood, they were more likely to start experiencing decline in hearing [or 1.010, 95% ci 1.005-1.014, p < .001]. on the contrary, male sex [or 0.539; 95% ci 0.393 0.738; p < .001]; absence of otologic findings such as inflamed ear canal [or 0.365, 95% ci 0.191 to 0.698, p < .002), earwax [or 0.619, 95% ci 0.504 to 0.759; p < .001], dry perforated ear drums [or 0.326, 95% ci 0.218 to 0.487, p < .001] and otorrhea in the middle ear [or 0.452, 95% ci 0.308 to 0.665, p < .001] of both ears during examinations decreased the risk of developing hearing loss by 39 to 68% compared to the normal hearing individuals in our study population. those who were not previously or currently diagnosed with serous otitis media [or 0.362, 95% ci 0.167 to 0.782, p = .010], csom [or 0.407, 95% ci 0.236 to 0.703, p = .001] com [or 0.229, 95% ci 0.106 to 0.494, p < .001] could lessen the chances of hearing impairment by 50% to 77%. prevention of noise-induced hearing loss or delay in the manifestation of presbycusis could reduce the risk of having hearing loss by as much as 75% [or 0.253, 95% ci (0.180 to 0.355), p < .001]. sub-analysis of records of the 260 pediatric participants subjected to behavioral tests revealed an almost equal distribution of males and females suspected to suffer from hearing loss (36.03% versus 35.48%), with no significant difference noted (kruskal-wallis test: h statistic: 3.429, df = 2, p = .180). philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery original articles table 1. clinical profile of subjects* (n=3258) * subjects whose hearing status were measured using behavioral tests were also included in this analysis. † all clinical characteristics in bold letters were found to have significant association with presence or absence of hearing loss (chi-square test: df=1, p-value <.05). hearing loss defined as having disabling hearing loss as determined by pure tone audiometry, and hearing loss as detected by the behavioral screening test recommended by who/peb ear and hearing disorders examination form version 7.1a clinical characteristics without hearing loss with hearing loss† frequency (%) symptom ear pain ear findings inflamed ear canal presence of ear wax presence of otorrhea presence of tympanic membrane perforation presence of dull tympanic membrane presence of hyperemic tympanic membrane diagnoses ear canal occlusionear wax chronic suppurative otitis media serous otitis media chronic otitis media non-infectious causes a. presbycusis b. noise-induced hearing loss 32 (0.98) 21 (0.65) 362 (11.11) 65 (2.00) 62 (1.90) 40 (1.23) 21 (0.65) 272 (8.35) 35 (1.07) 15 (0.46) 12 (0.37) 68 (2.09) 18 (0.55) 28 (0.86) 230 (7.06) 51 (1.60) 67 (2.06) 21 (0.65) 19 (0.58) 186 (5.71) 32 (0.98) 13 (0.39) 16 (0.49) 79 (2.42) table 2. factors associated with disabling hearing loss* in this study population (n=2998) * disabling hearing loss: >31db for children5 and >41db for adults6 on the better ear † the clinical characteristic is present in at least one ear ‡ non-infectious causes include presbycusis and noise-induced hearing loss § subjects analyzed here were those who underwent pure tone audiometry. logistic regression, df=1, p-values are significant if <.05 identified factors odds ratio (95% ci) p-value§ demographics age male sex clinical characteristics † symptom, ear pain absence of the following otologic examination findings -inflamed ear canal -ear wax in the canal -otorrhea (ear canal) -tympanic membrane findings: a. perforation b. dullness c. hyperemia -otorrhea in the middle ear absence of the following otologic diagnoses a. otitis externa b. otitis media c. serous otitis media d. chronic suppurative otitis media e. chronic otitis media f. non -infectious ‡ g. genetic causes 1.010 (1.005 to 1.014) 0.539 (0.393 to 0.738) 0.816 (0.433 to 1.535) 0.365 (0.191 to 0.698) 0.619 (0.504 to 0.759) 0.940 (0.510 to 1.733) 0.326 (0.218 to 0.487) 0.713 (0.412 to 1.234) 0.541 (0.265 to 1.105) 0.452 (0.308 to 0.665) 0.619 (0.243 to 1.576) 0.551 (0.237 to 1.282) 0.362 (0.167 to 0.782) 0.407 (0.236 to 0.703) 0.229 (0.106 to 0.494) 0.253 (0.180 to 0.355) 0.328 (0.063 to 1.704) <.001 <.001 .528 .002 <.001 .844 <.001 .227 .09 <.001 .314 .167 .010 .001 <.001 <.001 .185 discussion our study population, composed of mostly female adults aged 19 to 64 years old, had an overall prevalence of hearing loss of 71.29% for the right ear and 74.06% for the left ear, with the majority having at least mild hearing loss in either or both ears. the disabling hearing loss was recorded at 26.33% with the province of quezon having the highest percentage. they had common otologic symptoms of ear pain, and findings of earwax, perforated tympanic membrane and otorrhea. their most frequently diagnosed otologic diseases were ear occlusion due to ear wax, csom, com and non-infectious diseases namely, presbycusis and nihl. duration of their complaint of hearing loss was highly associated with presence of hearing loss. among those with identified hearing difficulties and otologic problems, most were advised to have ear cleaning, medical treatment, hearing aid fitting and to undergo further testing to identify the etiology of their conditions. as we compare our findings with local studies and with those among other lmics, our pediatric hearing disabling impairment prevalence was higher compared to the national prevalence obtained by newall et al. in 2020 of 7.5%1 and the prevalence recorded in india in 2018 of 4.5%.7 however, it was low compared to the ghana reported rate of 12.5%.8 we did not come across any recent studies where behavioral tests were utilized to compare with our subset of the pediatric population screened using alternative behavioral tests. the 2018 study in india by bright et al. screened the age group lower than 4 years old using otoacoustic emission testing and had a failure rate of 1.8% for both ears.7 although a comparison cannot be made due to differences in screening methods used, we can only approximate that the 5.69% prevalence of hearing loss in our pediatric subset population was higher compared to that reported from india. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery original articles figure 2. frequency distribution of hearing loss in the right ear, among adults aged 19 to 64 years old, n=1689 (kruskal-wallis test; h statistic: 10.101; df: 45; p = 1.00). figure 3. frequency distribution of hearing loss in the right ear among adults aged 65 years old and above, n=194 (kruskal-wallis test; h statistic= 41.840; df = 26; p = .02). figure 1. frequency distribution of hearing loss in the right ear among pediatric age group (>4 to 18 years old), n=1115 (kruskal-wallis test; h statistic= 10.104; df = 15; p = .813). philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery original articles our adult population, on the other hand, had a lower prevalence of hearing loss compared to the 63.8% prevalence reported in the previous 2020 nationwide study.1 it was higher than the prevalence of 8.5% reported for thailand,7 but lower than the 48.8% prevalence in india7 or 26% prevalence in malawi.10 comparing our findings with upper middle to high income countries, our 26.33% overall prevalence for disabling hearing impairment was higher than the 14.3% estimated bilateral hearing loss in the united states of america by goman et al. in 2016,11 and the 22.73% overall prevalence reported for south korea in 2015.12 our mentioned otologic findings and having been previously or currently diagnosed with diseases affecting the ear canal and the middle ear were also strongly associated with possibly developing poor hearing levels. these findings and diseases cause faulty function of the diseased middle ear that affect the conduction of sound waves and its translation.13 any conditions that hamper sound wave travel and its conversion to electrical stimulus modify the quality of sound for interpretation, causing variation or deviation of hearing acuity from normal.14 these findings were similar to the review of evidence by leach et al. in 2020 that these diseases were very much related to hearing loss in lmics especially among disadvantaged populations.15 similarly, otologic examination findings in our study (otorrhea in the middle ear and presence or absence of defects in the tympanic membrane) are significantly associated and evidently strengthen our earlier claim on their association with hearing difficulty. our study also showed that noninfectious causes such as noise-induced hearing loss significantly linked to poor effects on the cochlear function of the ear.16 among the items under pertinent medical history, we found an association between disabling hearing impairment and the duration of hearing loss regardless of the number of years affected. prolonged untreated and/or unaided hearing problems can cause an increased risk in disability.17 furthermore, it aggravates the hearing acuity of the stricken individual and affects language development17 if it involves children (11.87% of our study population) and doubles the risk for dementia and cognitive decline18 among adults (8.97% as mentioned earlier), especially the elderly. although the association between family members who are also hearing impaired and the development of hearing loss in an individual was not significant in our study, familial hearing status or having family members with hearing loss, regardless of the level of impairment was a high-risk indicator for developing unilateral, asymmetrical, or bilateral hearing loss.19 in addition, the advent of genetic studies has exploded into various investigations and produced evidence about possible genetic reasons for hearing loss that run through a family or community. approximately 50 to 60% of hearing loss in developed countries is rooted in genetic errors,20 and some genetic coding has been detected among filipinos that may explain possible causes of hearing loss, particularly the scl26a4 c.706c>g (p.leu236val) found among hearing impaired filipinos with cochlear implants21 and the a2ml1 genotype making the indigenous filipinos of central luzon at risk for developing otitis media.22 since wax occlusion and middle ear disease remained to be the most associated causes of hearing loss in our study population, it was not surprising that removal of ear wax and medications for middle ear infections were the management most recommended by physicians who conducted this survey. these findings were similar to those of studies in india,7 ghana8 and malawi.10 our study identified increasing age as detrimental to the development of hearing loss. on the other hand, the absence of earwax in the ear canal and otorrhea, having an intact tympanic membrane, being cleared from csom, com, serous otitis media, and non-exposure figure 4. distribution of disabling hearing impariment by percentage among provinces in region iva (n=2998). philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery original articles to noise, and delay in presbycusis factors lessen the risk for having hearing loss of at least mild severity. these findings were also reported in the previous nationwide study wherein age is a significant factor and having ear conditions of the outer or middle ear can aggravate hearing loss.1 in fact, that same study stated that the philippines had the highest number of hearing loss cases associated with wax occlusion and middle ear disease in the south east asia region.1 furthermore, studies in the lmics revealed same risk factors.1,7-10 however, unlike the newall et al. study,1 csom was a common finding in our study population, similar to the results of bright et al.5 where the disease ranked as the top otologic diagnosis among their indian study population subset with hearing loss. in studies across the globe, noise-induced hearing loss was also identified to be the one of the most common culprits11 which was also found to be significantly associated and a risk for developing hearing loss in our study population. however, compared to studies in lmics that usually identify infectious causes in the middle and outer ears as contributory factors for developing hearing loss, studies in highincome countries mostly associate hearing loss with factors such as age and noise exposure.11,12 on the other hand, some european studies still consider the status of middle ear function among the key factors in developing hearing problems23,24 and the 2017 cohort study by le clercq et al. in the netherlands still identified exposure to recurrent otitis media during childhood as a huge influence on hearing acuity25 making hearing care and ear health an utmost priority. the world health organization has always stressed the need for community-based screening for hearing loss to address its rising burden. however, similar to the experience in other lmics, the stents collaborators survey teams that collected these data encountered difficulties that can be attributed to infrequent data gathering process evaluation, logistical problems, and poor regional representation.15 thus, there are several limitations to our study. although the survey group uniformly followed the who/pbd ear and hearing disorders examination form and methods in conducting community-based hearing screening, the infrequent data gathering process evaluation and on-site data validation may have caused errors and missing data leading to exclusion of the other charts and records. this was the first time for the team to conduct a community-based hearing survey in a relatively large setting. to further improve the process of data quality checking, we recommend assignment of trained personnel per set of data collectors, adept with the who/pbd ear and hearing disorders examination form and methods, who can handle routine periodic data validation and checking to decrease missing data and errors of data encoding. a second limitation is the conduction of audiometric hearing screening in areas with a median ambient noise of 55db (iqr 46 to 60db) and the absence of a validated correction factor for ambient noise that may have caused an overor under-estimation of hearing loss levels. the who has recommended that the ambient noise be at a maximum of 40db. however, we failed to maintain or even attain this requirement for precise and accurate recording of the hearing acuity of our subjects. our recorded ambient noise value was similar to recorded values among the other community-based studies7-10 conducted in lmics. however, to improve the results of future community-based hearing acuity studies, we recommend studies determining validated correction factors for hearing screening procedures be conducted in communities where it is impossible to control ambient noise to less than 30db. a third major limitation is poor regional representation of the subjects included in our study. we had a relatively low yield of subjects to represent the actual number of residents in each area for us to determine the real hearing status of the communities. we attributed this to the few members of the survey team and limits in logistics and financial capacity. we failed to reach other areas of these regions. region iv-a has at least 14.4m residents based on the 2015 philippine statistics authority survey. to give a clear generalizable hearing and otologic condition or status of its constituents, the sample size must be increased, as well as the number of research team members. fourth, the hearing level classification and cutoff values for disabling hearing impairment used during data gathering were based on the 2008 and 2016 guidelines of the who. for future studies, we recommend that the recently released 2021 who guidelines be used. in conclusion, the prevalence of hearing loss among surveyed residents of the region iv-a: calabarzon provinces in southern tagalog, philippines was high compared to the previous nationwide study but low compared to other lowand middle-income countries. the top otologic conditions of this population (ear occlusion with ear wax, chronic suppurative otitis media, chronic otitis media, presbycusis, noise-induced hearing loss) were associated with hearing loss and their absence decreased the risks for hearing impairment. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery original articles references 1. newall jp, martinez n, swanepoel dw, mcmahon cm. a national survey of hearing loss in the philippines. asia pac j public health. 2020 jul;32(5):235-241. doi: 10.1177/10105395209370786; pubmed pmid: 32608243. 2. suen jj, bhatnagar k, emmett sd, marrone n, robler sk, swanepoel dw, et al. hearing care across the life course provided in the community. bull world health organ. 2019 oct 1; 97(10):681-690. doi: 10.2471/blt.18.227371; pubmed pmid: 31656333; pubmed central pmcid: pmc6796676. 3. ekmann b, borg j. provision of hearing aids to children in bangladesh: costs and cost -effectiveness of a community-based and centre-based approach. dis rehab assist technol. 2017 aug;12(6):625-630. doi: 10.1080/1743107.2016.1204631. 4. smith aw, mackenzie ij. who ear and hearing disorders survey protocol. for a populationbased survey of prevalence and causes of deafness and hearing impairment and other ear diseases. world health organizationprevention of blindness and deafness (pbd). geneva, switzerland: who; 1999. 5. olunsaya bo, davis ac, hoffman hj. hearing loss grades and the international classification of functioning, disability and health. bull world health organ. 2019 oct 1;97 (10):725-728. doi: 10.2471/blt.19.230367; pubmed pmid: 31656340; pubmed central pmcid: pmc6796665. 6. world health organization. childhood hearing loss. strategies for prevention and care. world health organization; 2016. [cited 2022 september 17]. available from: https://apps.who.int/iris/ handle/10665/204632. 7. bright t, mactaggart i, kuper h, murthy gv, polack s. prevalence of hearing impairment in mahabubnagar district, telangana state, india. ear hear. 2019 jan-feb;40(1):204-212. doi: 10.1097/aud.0000000000000599; pubmed pmid: 29782444. 8. larsen-reindorf r, otupiri e, anomah je, edwards bm, frimpong b, waller b. et al. pediatric stents 2012-2107 hearing survey collaborators* acosta, emilio romel g. alcira, ramon carmelo v alcira, winma athena l. alonzo, eugenio tomas a. aragon, rodney oliver j. arceo, roy o. azurin, eunice a. billones, william u. burgos, fidel p. (+) cabungcal, alexander c. canlas, rowena a. carmona, ramon jr v. carpiso, olma c. cayetano. leonides p. cordova, ma.ignatius e. cornista, josefa andrea g. cruz-durian, rosario m. de jesus, arvin l. destriza, waynn nielsen c. diaz, kathrina a. dimayuga, maria elaine m. duran, cecile trisha b. eslava, erwin m. ferrolino, brendan r. galicia, michael jr f. garing, athony vincent v. gasacao, ryan a. go-gasacao, rosemarie c. gutierrez, herbert q. holgado, jan warren a. imperial, mark ray t. lagrosa-saguiguit, pamela a. laki-pillas, maria rosario constancia r. nofuente, carlo a. olveda, mildred b. pajarillo, pio r. papa, enrique ii c. pascual, theresa paz g. perez, medwin d. perez-chua, abegayle machelle m. peteza, martin d. ramos, ramon iii p. remulla, felicidad m. rosanes, michael m. reyes, ana maria m. rosanes, michael m. rosas, juan lucas l. sampelo, angelo ian a. samson, aurelio c. sebastian, omar carlo t. siasoco, ramon gerardo albino e. talanay, deo h. victoria, roderic p. villanueva, maria elaine d. villaroman, felipe a. zavalla, mario angelo s. acknowledgements the authors would like to thank the stents 2012-2017 hearing survey collaborators* for allowing us to analyze their survey results. ms whyla amon aquino for her help with data screening and evaluation and mr rhalp jaylord valenzuela for performing the statistical analysis. hearing loss: a community-based survey in peri-urban kumasi, ghana. j laryngol otol. 2019 aug:10-9. doi: 10.1017/50022215119001658. 9. yiengprugsawan v, hogan a, harley d, seubsaman s, sleigh ac, thai cohort study team. epidemiological associations of hearing impairment and health among a national cohort of 87, 134 adults in thailand. asia pac j public health. 2012 nov; 24(6): 1013–1022. doi: https://doi. org/10.1177/1010539511408712. 10. bright t, mulwafu w, phiri m, ensink rjh, smith a, yip j, et al. diagnostic accuracy of nonspecialist versus specialist workers in diagnosing hearing loss and ear disease in malawi. trop med int health. 2019 jul;24(7):817-828. doi: 10.1111/tmi.13238; pubmed pmid: 31001894. 11. goman am, lin fr. prevalence of hearing loss by severity in the united states. am j public health. 2016 oct;106(10):1820-1822. doi: 10.2105/ajph.2016.303299; pubmed pmid: 27552261; pubmed central pmcid: pmc5024365. 12. jin hj, hwang sy, lee sh, lee je, song jj, chae s. the prevalence of hearing loss in south korea: data from a population-based study. laryngoscope. 2015 mar; 125(3):690-694. doi: 10.1002/ lary.24913; pubmed pmid: 25216153. 13. de zinnis lor, campovecchi c, parrinello g, antonelli ar. predisposing factors for inner ear hearing loss association with chronic otitis media. int j audiol. 2005 oct; 44(10):593-8. doi: 10.1080/14992020500243737; pubmed pmid: 16315450. 14. cai t, mcpherson b. hearing loss in children with otitis media with effusion: a systematic review. int j audiol. 2017 feb; 56(2):65-76. doi: 10.1080/14992027.2016.1250960; pubmed pmid: 27841699. 15. leach aj, homee p, chidzvia c, gunasekera h, kong k, bhutta mf, et al. panel 6: otitis media and associated hearing loss among disadvantaged populations and low to middle income countries. int j pediatr otorhinolaryngol. 2020 mar; 130(suppl 1): 109857. doi: 10.1016/j. ijporl.2019.109857; pubmed pmid: 32057518; pubmed central pmcid: pmc7259423. 16. le tn, straatman lv, lea j, westerberg b. current insights in noise-induced hearing loss: a literature review of the underlying mechanism, pathophysiology, asymmetry, and management options. j otolaryngol head neck surg. 2017 may 23;46(1):41. doi: 10.1186/s40463-017-0219-x; pubmed pmid: 28535812; pubmed central pmcid: pmc5442866. 17. gbd 2019 hearing loss collaborators. hearing loss prevalence and years lived with disability, 1990-2019: findings from the global burden of disease study 2019. lancet. 2021 mar 13; 397(10278):996-1009. doi: 10.1016/s0140-6736(21)00516-x; pubmed pmid: 33714390; pubmed central pmcid: pmc7960691. 18. lin fr, albert m. hearing loss and dementia-who’s listening? aging ment health. 2014aug; 18(6): 671-673. doi: 10.1080/13607863.2014.915924; pubmed pmcid: omc 4075051; pubmed central pmid: 24875093. 19. gouveia fn, jacob-corteletti lcb, silva bcs, araujo es, amantini rcb, oliveira eb, et al. unilateral and asymmetric hearing loss in childhood. codas. 2020 jan 27;32(1): e20180280. doi: 10.1590/2317-1782/20192018280; pubmed pmid: 31994593. 20. omichi r, shibata sb, morton cc, smith rjh. gene therapy for hearing loss. hum mol genet. 2019 oct 1;28(r1): r65-r79. doi: 10.1093/hmg/ddz129; pubmed pmid: 31227837; pubmed central pmcid: pmc6796998. 21. chiong cm, reyes-quintos mrt, yarza tkl, tobias-grasso cam, acharya a, leal sm et al. the slc26a4. c.706c>g (p.leu236val) variant is a frequent cause of hearing impairment in filipino cochlear implantees. otol neurotol. 2018 sept;39(8): e726-e730. doi: 10.1097/ mao.0000000000001893; pubmed pmid: 30113565; pubmed central pmcid: pmc6097524. 22. santos-cortez rlp, reyes-quintos mrt, tantoco mlc, abbe i, llanes egdv, ajami nj, et al. genetic and environmental determinants of otitis media in an indigenous filipino population. otolaryngol head neck surg. 2016 nov; 155(5):856-862. doi: 10.1177/0194599816661703; pubmed pmid: 27484237; pubmed central pmcid: pmc5093071. 23. pilka e, jedrzejczqak ww, kochanek k, pastucha m, skarzynski h. assessment of the hearing status of school-age children from rural and urban areas of mid-eastern poland. int j environ res public health. 2021 apr 18;18(8):4299. doi: 10.3390/ijerph18084299; pubmed pmid: 33919574; pubmed central pmcid: pmc8073182. 24. paping de, vroegop jl, le clercq cpm, baatenburg de jong rj, van der schroeff mp. a 4 year follow -up study of hearing acuity in a large population-based cohort of children and adolescent. laryngoscope investig otolaryngol. 2021 feb 9;6(2):302-309. doi: 10.1002/lio2.529; pubmed pmid: 33869762; pubmed central pmcid: pmc8035936. 25. le clercq cmp, van ingen g, ruytjens l, goedegebure a, moli ha, raat h, et al. prevalence of hearing loss among children 9 to 11 years old. the generation r study. jama otolaryngol head neck surg. 2017 sep 1;143(9):928-934. doi: 10.1001/jamaoto.2017.1068; pubmed pmid: 28750130; pubmed central pmcid: pmc5710286. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 passages ibarra r. crisostomo, md (1958-2021) rosalina a. bautista, md a tribute to our colleague hns of the armed forces medical center. he was the residency training officer for six years from 2002-2006. his humility and dedication to work was exemplary. he will be remembered by his residents and colleagues as an affectionate and beloved teacher who gave his best to his students and as a person of integrity, honesty and sincerity. he also started his private practice as an otolaryngologist in marikina. he was also a successful entrepreneur and managed various businesses. barry was an expert in multitasking by combining his medical practice with business. i admire him because he was indeed a good father and a good provider, always thinking about the welfare of his family. he felt proud and fulfilled that he was able to send his children to schools abroad. i shall always remember him as a thoughtful and loyal friend. he was a genuinely warm and wonderful individual. years after our residency, he would send text messages and greetings almost every year during my birthdays and holidays like christmas. he even greeted me on my birthday in the year 2020, not knowing he was already ill. barry, a caring and loving family man, a cherished colleague, and an ent-hns specialist, a good friend, will be missed by many, but never will he be forgotten by those who were fortunate enough to have known him. it is my privilege to write this tribute to dr. ibarra crisostomo, a friend, colleague, otolaryngologist, devoted husband, and a loving father. we honor him by expressing our loss but also by remembering how he has somehow touched our lives. i first met barry, as we all called him by his nickname, when i was a 1st year resident at the department of otolaryngology-head and neck surgery of east avenue medical center. he was my senior then, among the six 2nd year residents that year. that first encounter marked the beginning of our longstanding friendship. as a senior and a mentor, he was very supportive and patient in imparting his knowledge and experience to his juniors. never did he strike fear, but gained our respect with his simple and pleasant ways in dealing with us and our work. during our duties, he would make a difficult and toxic situation seem lighter due to his composure, humor, and caring attitude. in addition to his devotion to his work, i learned about his love for his family. they were never far from his thoughts. he was always in contact with them even when he was on duty at the hospital. he made certain to bring them a special little something when he went home. he was indeed a selfless person. after his residency, he was committed to teaching and became a staff at the department of entphilippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery from the viewbox philipp j otolaryngol head neck surg 2022; 37 (2): 53-54 c philippine society of otolaryngology – head and neck surgery, inc. can i diagnose a vestibular schwannoma using non-contrast imaging? nathaniel w. yang, md department of otolaryngology-head and neck surgery college of medicine philippine general hospital university of the philippines manila department of otolaryngology -head and neck surgery far eastern university nicanor reyes medical foundation institute of medicine correspondence: : dr. nathaniel w. yang department of otolaryngology – head and neck surgery university of the philippines manila ward 10, philippine general hospital, taft avenue ermita, manila 1000 philippines phone: (632) 8526 4360 fax: (632) 8525 5444 email: nwyang@up.edu.ph the author declared that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. “i have an adult patient with new-onset unilateral sensorineural hearing loss. i would like to rule out a vestibular schwannoma by performing an mri exam. however, the patient has a kidney problem that prevents him from receiving contrast material. can i still diagnose a vestibular schwannoma using a non-contrast imaging study?” the answer to this question is … yes! at the current time, gadolinium-enhanced t1-weighted magnetic resonance imaging (mri) is considered the gold standard for the diagnosis of vestibular schwannomas.1 however, the use of gadolinium-based contrast material may be contraindicated in patients with impaired renal function, in those who have had an allergic reaction to such contrast material, and in patients who are or may be pregnant. high-resolution t2-weighted mr sequences as a means of visualizing the fluid-filled inner ear and the 7th and 8th cranial nerves in the internal auditory canal and cerebellopontine angle cistern was described in the early 1990’s.2 these steady-state imaging sequences currently include various manufacturer-specific sequences such as ciss (constructive interference into steady state, siemens), fiesta-c (fast imaging employing steady-state acquisition cycled phases, ge), drive (driven equilibrium radiofrequency reset pulse, philips), bffe (balanced fast field echo, philips) and space (sampling perfection with application optimized contrasts using different flip angle evolutions, siemens).3 the submillimeter-resolution images from these sequences can be manipulated on computer-based dicom imaging software to provide reformatted images in non-orthogonal planes that allow visualization of the entire 8th cranial nerve, from the brainstem to the fundus of the internal auditory canal. in these sequences, cerebrospinal fluid (csf) displays a high signal intensity that provides an excellent contrasting background to the inherent low signal intensity of the 7th and 8th cranial nerves. (figure 1) similar to the nerves, a vestibular schwannoma will appear as a low-intensity (dark) filling defect that may be nodular, oblong, or ice cream cone-shaped, and located in the internal auditory canal and/or the cerebellopontine angle cistern immediately adjacent to it. (figure 2) creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery from the viewbox in evaluating a patient for the presence of a vestibular schwannoma, the current medical literature indicates that high-resolution t2weighted imaging sequences have a high sensitivity and specificity compared to gadolinium-enhanced t1-weighted imaging. however, t2-weighted imaging alone may not detect inflammatory, infectious or malignant conditions that may also present with sensorineural hearing loss.1 as such, a gadolinium-enhanced t1-weighted sequence will be needed when such conditions are suspected. figure 2. axial drive image at the level of the internal auditory canal showing a nodular low-intensity filling defect (white arrow) in the medial portion of the internal auditory canal that is characteristic of a vestibular schwannoma finally, local experience with institutions that perform imaging of the internal auditory canal and cerebellopontine angle shows that not all centers routinely perform the high-resolution t2-weighted imaging sequences. therefore, it would be prudent to specifically indicate the need for “a t2-weighted imaging sequence with submillimeterresolution, such as the ciss or fiesta-c sequence” in the imaging request, in order to ensure the performance of the appropriate imaging strategy. references 1. dang l, tu nc, chan ey. current imaging tools for vestibular schwannoma. curr opin otolaryngol head neck surg. 2020 oct;28(5):302-307. doi: 10.1097/moo.0000000000000647; pubmed pmid: 32833884. 2. casselman jw, kuhweide r, deimling m, ampe w, dehaene i, meeus l. constructive interference in steady state-3dft mr imaging of the inner ear and cerebellopontine angle. figure 1. axial ciss image at the level of the internal auditory canal showing the normal configuration of the 7th and 8th cranial nerves (white arrows) ajnr am j neuroradiol. 1993 jan-feb;14(1):47-57. pubmed pmid: 8427111; pubmed central pmcid: pmc8334438. 3. currie s, saunders d, macmullen-price j, verma s, ayres p, tait c, harwood c, scarsbrook a, craven ij. should we be moving to a national standardized non-gadolinium mr imaging protocol for the surveillance of vestibular schwannomas? br j radiol. 2019 apr;92(1096):20180833. doi: 10.1259/bjr.20180833; pubmed pmid: 30633539; pubmed central pmcid: pmc6540864. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 6362 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 6362 philippine journal of otolaryngology-head and neck surgery under the microscope philipp j otolaryngol head neck surg 2018; 33 (2): 62-63 c philippine society of otolaryngology – head and neck surgery, inc. respiratory epithelial adenomatoid hamartomajose m. carnate jr., mdagustina d. abelardo, md department of pathology college of medicine university of the philippines manila correspondence: dr. jose m. carnate, jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st. ermita, manila 1000 philippines phone (632) 526-4450 telefax (632) 400-3638 email: jmcjpath@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. a 65-year-old man consulted with a history of chronic snorting with a sensation of obstruction on the left side of the nasopharynx particularly when in supine position. a few days prior to consult, the patient had blood-tinged nasal discharge, thus this admission. no other symptoms were reported. nasal endoscopy showed a sessile exophytic lesion with a vaguely nodular surface seen as a polypoid nasopharyngeal mass on computed tomography scan. (figure 1) excision of the mass was performed. received in the surgical pathology laboratory was a 1.8 x 1.5 x 0.6 cm red to brown, rubbery to firm, vaguely ovoid mass with a nodular external surface. cut section showed a light gray solid surface. microscopic examination shows a broad-based exophytic mass with invaginations of the surface epithelium and proliferated glands within the stroma. (figure 2) the glands are tubular or variably dilated many are lined by a respiratory-type epithelium with goblet cells and a thickened basement membrane while the tubular glands are lined by a monolayered cuboidal epithelium. (figure 3) based on these features, we signed the case out as a respiratory epithelial adenomatoid hamartoma (reah). reah is a benign proliferation of sinonasal tract glands derived from the surface epithelium.1 it occurs primarily in male adults with a median age in the sixth decade of life. most cases arise in the posterior nasal septum while less common sites of involvement include other parts of the nasal cavity, the nasopharynx, and paranasal sinuses.2 common symptoms include nasal obstruction, stuffiness and epistaxis.1,3,4 reah presents as a polypoid lesion and may measure up to 6 cm in widest diameter.1 microscopically, there is a proliferation of small to medium-sized glands dispersed in abundant stroma. invagination of the glands from the surface epithelium may be seen.3 the glands are creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. vaguely nodular sessile nasopharyngeal mass on paranasal endoscopy (dotted area). inset shows the mass on ct scan (arrow). philippine journal of otolaryngology-head and neck surgery 6362 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 6362 philippine journal of otolaryngology-head and neck surgery under the microscope figure 2. sessile exophytic mass with invaginations of the surface epithelium and proliferated glands within the stroma. (hematoxylin-eosin, 40x magnification). figure 3. proliferated glands and stroma. (hematoxylin-eosin, 100x magnification). high power (400x magnification) shows glands lined by respiratory-type epithelium with goblet cells (inset a, arrow), monolayered cuboidal epithelium (inset b, double arrow), and thickened basement membrane (inset b, asterisk). references 1. weng bm, franchise a, ro jy. respiratory epithelial adenomatoid hamartoma. in: el-naggar ak, chan jkc, grandis jr, takata t, slootweg pj. who classification of head and neck tumors. iarc: lyon 2017. p.31. 2. zulkepli sz, husain s, gendeh bs. respiratory epithelial adenomatoid hamartoma of the nasal septum. philipp j otolaryngol head neck surg. 2012 jan-jun;27(1):28-30. 3. ramadhin ak. respiratory epithelial adenomatoid hamartoma: a rare cause of nasal obstruction – case report. glob j oto. 2017 may; 7(5):1-3. doi:10.19080/gjo.2017.07.555723. 4. saniasiaya j, shukri nm, ramli rr, abdul wahab wnnw, zawawi n. sinonasal respiratory epithelial adenomatoid hamartoma: an overlooked entity. egyptian journal of ear, nose, throat and allied sciences. 2017 jul;18(2):191-193. https://doi.org/10.1016/j.ejenta.2016.12.014. round to oval, lined by respiratory-type epithelium with admixed goblet cells. thickened basement membranes surround some of the glands, and smaller seromucinous glands lined by cuboidal epithelium may also be admixed among the latter. other alterations may include squamous, chondroid and osseous metaplasia.1,4 rarely, reah may occur synchronously with inverting sinonasal papillomas or inflammatory polyps.1 it may be mistaken for these two entities along with sinonasal low-grade adenocarcinomas. careful attention to the typical morphology including absence of an infiltrative growth pattern and atypia allow distinction from these entities particularly the malignant mimics.3 a related entity is a seromucinous hamartoma with which reah is believed to form a morphological spectrum.1 reah is benign and complete excision confers cure.1 malignant transformation has not been reported.1,3,4 (hematoxylin – eosin , 40x) (hematoxylin – eosin , 100x) (hematoxylin – eosin , 400x) philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 65 under the microscope philipp j otolaryngol head neck surg 2016; 31 (2): 65-66 c philippine society of otolaryngology – head and neck surgery, inc. low-grade cribriform cystadenocarcinoma of the parotid gland jose m. carnate, jr., md department of pathology college of medicine university of the philippines manila correspondence: dr. jose m. carnate, jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st. ermita, manila 1000 philippines phone (632) 526 4550 telefax (632) 400 3638 email: jmcjpath@gmail.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to conflict of interest. this is the case of a 44-year-old woman with a one-year history of a left pre-auricular mass. the surgical specimen is a 5 centimeter diameter tan-brown irregularly-shaped tissue whose cut surfaces are brown with cystic spaces. microscopic sections show cystic and dilated ductal spaces lined by cells forming irregular, variably-sized secondary spaces. these spaces are arranged in a cribriform pattern that is reminiscent of breast ductal hyperplasia. (figure 1) the ductal cells lining the spaces are small, multilayered, and generally bland. the superficial cells show apocrine-type cytoplasmic snouting. there is no significant nuclear atypia or mitotic activity noted. necrosis is also absent. (figure 2) based on these features, we signed the case as a low-grade cribriform cystadenocarcinoma (lgccc). creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. dilated ductal spaces with cribriform structures reminiscent of breast ductal hyperplasia (hematoxylin-eosin, 100x magnification) (hematoxylin – eosin , 100x) philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 under the microscope 66 philippine journal of otolaryngology-head and neck surgery lgccc is an uncommon tumor presenting primarily as cystic parotid masses in elderly females. the histologic hallmark of this tumor is its morphologic resemblance to the spectrum of breast lesions ranging from ductal hyperplasia to low-grade ductal carcinoma-in-situ.1-4 microscopic sections show an unencapsulated tumor consisting of single or multiple cysts lined by proliferated small and bland ductal cells with fine chromatin and small nucleoli. within the cystic spaces, the cells are often arranged in a cribriform pattern with anastomosing intracystic micropapillae lining the cavity. many superficial cells show apocrinetype secretions. thus, the over-all appearance is quite comparable to breast lesions that are termed atypical ductal hyperplasia and low-grade ductal carcinoma-in-situ.1-4 focal invasion into the surrounding tissue can be seen. perineural or vascular invasion however is typically absent. cellular pleomorphism and mitoses are also usually absent and necrosis is rare. occasional tumors however may demonstrate a transition to an intermediate or high-grade cytology with the appearance of scattered mitoses and focal necrosis.1,2 this tumor needs to be distinguished from a conventional cystadenocarcinoma. the latter is a more frankly invasive tumor with smaller duct-like structures that infiltrate into the salivary parenchyma and surrounding connective tissue. a papillary-cystic variant of acinic cell carcinoma will have areas of acinar differentiation and a greater degree of epithelial proliferation.1,5 a high-grade salivary duct carcinoma will have a high-grade cytology with more frequent necrosis, references 1. brandwein-gensler ms, gnepp dr. low-grade cribriform cystadenocarcinoma. in: barnes l, eveson jw, reichart p, sidransky d. (editors) world health organization classification of tumours. pathology and genetics of head and neck tumors. 2005; lyon: iarc press. p. 233. 2. wenig bm. atlas of head and neck pathology. 2nd ed. philadelphia. saunders elsevier, 2008, p. 664. 3. wang l, liu y, lin x, zhang d, li q, qiu x, wang eh. low-grade cribriform cystadenocarcinoma of salivary glands: report of two cases and review of the literature. diagn pathol. 2013 feb;8:28. epub 2013 feb 18. doi: 10.1186/1746-1596-8-28 pmid: 23419146 pmcid: pmc3598350. 4. kokabu s, nojima j, kayano h, yoda t. low-grade cribriform cystadenocarcinoma of the palatal gland: a case report. oncol lett. 2015 oct; 10(4):2453-2457. epub 2015 jul 23. doi: 10.3892/ ol.2015.3528 pmcid: pmc4580038 . 5. auclair pl. cystadenocarcinoma. in: barnes l., eveson jw, reichart p, sidransky d. (editors) world health organization classification of tumours. pathology and genetics of head and neck tumors. 2005; lyon: iarc press. p. 232. 6. gnepp dr. diagnostic surgical pathology of the head and neck. 2nd ed. 2009; philadelphia: saunders elsevier. p. 497. mitoses, and pleomorphism.6 special stains that help in the differential diagnosis include periodic acid-schiff (pas) stain with diastase digestion (diastase-resistant cytoplasmic granules in an acinic cell carcinoma), and s100 (strong diffuse positivity in lgccc).1 lgccc is treated by complete surgical excision. although there are only a few reported cases with follow-up, to our knowledge, none, to date, have recurred.1-4 figure 2. bland ductal cells forming cribriform spaces. superficial cells display apocrine-type snouting (arrows) (hematoxylin-eosin, 400x magnification). (hematoxylin – eosin , 400x) philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial that murmur, soon replies, “god doth not need either man’s work or his own gifts; who best bear his mild yoke, they serve him best. his state is kingly. thousands at his bidding speed and post o’er land and ocean without rest: they also serve who only stand and wait.”1 1john milton, sonnet 19 the covid-19 pandemic has brought out most of the best (and some of the worst) in us. much has been said, shared, even sung about health care workers as frontline heroes. whether we indeed form the frontline, or man the last line of defense, due credit is being given to all “front-liners” – essential-service workers, drivers and delivery personnel, security guards, the military and police who literally serve in the trenches of this invisible war. indeed, it is heartening to read the inspiring messages, hear the encouraging words, listen to the uplifting (sometimes funny) music and songs, witness the moving memes and cartoons, watch the refreshing dances and tributes, and receive the healing blessings and prayers on various media and social media platforms. indeed, we are motivated to continue to work, so that others may safely stay home. some of us have even been called upon to die, so that others may live. but so much less is and has been said about those who make our battle possible, who selflessly and silently took it upon themselves to clothe us with personal protective equipment, feed us, transport us, and even shelter us as we engage the unseen enemy. it is these heroes i wish to thank today. i certainly cannot thank them all, but i sincerely hope that those i do mention will represent the many others i cannot. early on, my brother elmer lapeña and his team twilight group of “golfing enthusiasts and friends” (“company owners, executives, managers, engineers, technicians, entrepreneurs, and expats in the electronics, semiconductor, metalworking, automotive, aerospace, and packaging manufacturing industries”) responded to the call for better protection for frontliners with door-todoor deliveries of personal protective equipment (ppe) to over 40 hospitals in the national capitol region, rizal, cavite, laguna and batangas including the philippine general hospital (pgh).2 on a personal note, elmer and my sister-in-law annette were closely monitoring our situation, going out of their way to obtain difficult-to-find ppes for my wife josie and myself, and our respective departments of family and community medicine (dfcm) and otorhinolaryngology (orl) at the pgh. for her part, our very dear friend gigi bautista rapadas organized project #helpcovid19warriors(hcw), to “go where the virus goes” and “help where help is needed and requested,” harnessing donations from ‘family, friends, and friends of friends” to procure ppe (as well as disinfectants, even canned goods) that were distributed “from metro manila to the provinces: tuguegarao, bataan, bulacan, la union, nueva vizcaya, cavite,” moving from hospitals and health centers to correctional institutes.3 it is because of them that our pgh department of orl obtained very expensive but essential respirator hoods for added protection from correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 telefax: (632) 8524 4455 email: lapenajf@upm.edu.ph, jflapena@up.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr. ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines people giving hope in the time of covid-19: they also serve who care and share philipp j otolaryngol head neck surg 2020; 35 (1): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial aerosolized virus when conducting airway procedures, in addition to head-to-foot ppes for use of the pgh dfcm in attending to pgh staff at the up health service. meanwhile, without fanfare, our dear friends popot and agnes (also my dlsu ’79 classmate) lorenzana provided cooked meals for 1,000 persons daily. working with on-the-ground social workers and with the 2kk tulong sa kapwa kapatid foundation, their feeding program “a thousand meals for poor communities” reached payatas, talayan, pinyahan, smokey mountain, maisan, bagong silang, old balara, tatalon, sta. teresita, sampaloc, and sta. ana, among more than 50 other communities. they generously responded to my wife’s request to provide meals for her community patients of the canossa health center in tondo. they have also provided meals for hospital staff of amang rodriguez memorial medical center, the medical city hospital, veterans memorial medical center, dr. jose fabella memorial hospital, dr. jose rodriquez memorial hospital, quezon city general hospital, the san lazaro hospital, valenzuela city emergency hospital and lung center of the philippines. they continue this service which to date has provided for more than 32,000 meals, with corporate partners and private individuals joining the effort.4 other de la salle university (dlsu) college ‘79 batchmates who wish to remain anonymous obtained board approval of their endorsement to channel all the social development funds of their maritime multipurpose cooperative for the next 3 years to the philippine general hospital. adding their personal funds (and those solicited by their daughter and nephew), they took on the daunting task of sourcing and providing powered air purifying respirators (paprs) for our use. another dlsu batchmate has been distributing ppes to various hospitals including pgh through their family corporation, nobleland ventures, inc. even their high school batch ’75 of saint jude catholic school has donated boxes and boxes of ppes to the pgh and other hospitals. other dlsu ’79 classmates bel and bong consing and timmy, joy (and tita linda) bautista have personally donated ppes and funds for our covid-19 operations, while classmate fritz de lange even sent over sweet mangoes for us to enjoy with our fellow frontliners. generous donations also poured in from la salle greenhills (lsgh) high school ’76 friends cris ibarra, norman uy, class 4e, and batchmates tito and pepper who wish to remain anonymous, as well as menchit borbon and her st. theresa’s college quezon city (stcqc) batch ‘76 section 1 classmates. we even received overseas support from my lsgh 4b classmate bingo pantaleon from yangon; my mom libby, brother bernie and lilli, and friend soyanto from singapore; and sister sabine from germany. and how can we forget the regular frozen food deliveries of jollibee chicken drumsticks and home-made bulgogi and tapa from our dear friends ed and aning go? perhaps the most touching gifts of all came from my eldest and youngest daughters melay and jica, who lovingly prepared and delivered much-appreciated meals to us, and middle child ro-an, who with our son-in-law reycay serenaded us with beautiful music that was appreciated by no less than vice president leni robredo and featured by the philippine philharmonic orchestra.5 their musical fundraising campaign started with another haunting piece featuring my sister nina and brother-in-law kiko.6 as if that were not enough, ro-an bakes happy wolf choco chip cookies to raise funds for our ongoing covid-19 operations at pgh, while melay and jica keep asking us what we want to eat next. because they themselves do not have much, their gifts are most precious, as they exemplify the proverbial widow who had the least, yet “put in everything she had.”7 these are but a few examples of those known personally to memy family and friends. and there are many more. in the same way, every other doctor and front liner will have their own stories to tell, of friends, family even mere acquaintances who have come out of the shadows to help, to care, to share in whatever way they can, in fighting this battle with us. let this be their tribute as well. those of us who serve in the philippine general hospital have been called people giving hope.8,9 i believe that we do give hope because others give us hope in turn. i would like to think that the inscription in the pgh lobby “they also serve who care and share” honors these others in a special way who go over and beyond the call of duty. with apologies to john milton, our heroes go way over and beyond “they also serve who only stand and wait.” maraming salamat po sa inyong lahat. references 1. milton j. sonnet 19: when i consider how my light is spent. chicago: the poetry foundation 2020 [cited 2020 may 12] available from: https://www.poetryfoundation.org/poems/44750/ sonnet-19-when-i-consider-how-my-light-is-spent 2. lapeña ebf. team twilight bayanihan na fight covid19 philippines. [internet] 2020 mar 28 [cited 2020 may 8]. available from: https://youtu.be/flu2tyczws4 3. rapadas mab. #helpcovid19warriors (hcw) project update #10. [internet] 2020 may 3 [cited 2020 may 8]. available from: https://m.facebook.com/story.php?story_fbid=102071135217923 94&id=1712078668 4. lorenzana aab. a thousand meals for poor communities. 2kk tulong sa kapwa kapatid foundation. [internet] [cited 2020 may 11]. available from: bit.ly/2kkonlzd 5. lapeña-concepcion rav. “may it be” by enya, arranged by rey casey concepcion. violin rosa lapeña concepcion, viola – rey casey concepcion. 2020 april 11 [cited 2020 may 14]. available from: https://www.facebook.com/532526836/posts/10156869813371837/?d=n and https://www.facebook.com/philippinephilharmonic/videos/vb.485712851781922/2382 96100613076/?type=2&theater 6. lapeña-concepcion rav. “nearer my god to thee” violin 1 – corinna lapeña llorin, violin 2 – rosa lapeña concepcion, viola – rey casey concepcion, cello – francisco llorin. 2020 april 5 [cited 2020 may 14]. available from https://www.facebook.com/532526836/ posts/10156850534476837/?d=n 7. mark 12:42-44. the bible with the apocryphal/deuterocanonical books. new revised standard version. copyright ©1989, division of christian education of the national council of the churches of christ in the united states of america. 8. legaspi gd. to the people giving hope (pgh). [letter on the internet] 2020 march 26 [cited 2020 may 14]. available from: https://www.facebook.com/philippinegeneralhospitalofficial/ photos/a.2554926417871915/3107212802643271/?type=3&theater 9. philippine general hospital. people giving hope – pgh [personal blog] 2020 april [cited 2020 may 14]. available from: https://www.facebook.com/peoplegivinghope/ https://www.poetryfoundation.org/poems/44750/sonnet-19-when-i-consider-how-my-light-is-spent https://www.poetryfoundation.org/poems/44750/sonnet-19-when-i-consider-how-my-light-is-spent https://youtu.be/flu2tyczws4 https://m.facebook.com/story.php?story_fbid=10207113521792394&id=1712078668 https://m.facebook.com/story.php?story_fbid=10207113521792394&id=1712078668 https://www.facebook.com/532526836/posts/10156869813371837/?d=n https://www.facebook.com/philippinephilharmonic/videos/vb.485712851781922/238296100613076/?type=2&theater https://www.facebook.com/philippinephilharmonic/videos/vb.485712851781922/238296100613076/?type=2&theater https://www.facebook.com/532526836/posts/10156850534476837/?d=n https://www.facebook.com/532526836/posts/10156850534476837/?d=n https://www.facebook.com/philippinegeneralhospitalofficial/photos/a.2554926417871915/3107212802643271/?type=3&theater https://www.facebook.com/philippinegeneralhospitalofficial/photos/a.2554926417871915/3107212802643271/?type=3&theater https://www.facebook.com/peoplegivinghope/ philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2019; 34 (1): 20-25 c philippine society of otolaryngology – head and neck surgery, inc. the use of bony septum as an extended spreader graft in primary and secondary rhinoplasty candice que ansorge, md eduardo c. yap, md metropolitan medical center department of otorhinolaryngology head and neck surgery correspondence: dr. candice que ansorge metropolitan medical center department of otorhinolaryngology head and neck surgery 1357 g. masangkay st, santa cruz, manila 1012 philippines phone: 0947-7474007 email: candiceque@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual, passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the cesar f. villafuerte sr. research contest (3rd place). november 30, 2017, maynila ballroom, manila hotel. presented at the antonio l. roxas international research contest (3rd place). december 1, 2017, maynila ballroom, manila hotel. presented at the 10th international academic conference in otology, rhinology and laryngology. march 2, 2018, fairmont hotel. abstract objective: to describe a surgical technique using bony septum specifically vomer or perpendicular plate of the ethmoid (ppe) as an extended spreader graft (esg) for securing septal extension graft (seg) and for correcting internal nasal valve dysfunction. methods: design: descriptive case series setting: tertiary private hospital participants: thirty-two (32) patients who underwent aesthetic rhinoplasty from may 2016 to october 2017 were evaluated and ten (10) patients presenting with symptomatic obstruction were considered for inclusion. the surgical technique was applied in patients with weak seg for control of nasal length and tip projection who had inadequate septal cartilage for seg and esg intraoperatively. results were evaluated grossly under direct vision intra-operatively and post-operatively to check the patency of the internal valve. results: bony septum was used as an esg in five (5) patients (1 male, 4 females, ages 35 to 50-years-old) with inadequate septal cartilage. intraoperative evaluation under direct vision showed anterior caudal septal deviation in all 5 patients in whom correction was confirmed after placement of seg and esg. immediate post-operative evaluation confirmed bilaterally patent nasal valve in all 5, who reported subjectively improved breathing at 2 and 4 weeks postoperatively. post-operative photographs showed improvement of nasal length and tip. conclusion: the use of the bony septum (vomer and ppe) as an esg for primary or secondary rhinoplasty is a potentially effective means of supporting and securing the seg for control of nasal length, preventing tip deviation or rotation and for improving internal valve function. further trials are needed to establish its reliability and long-term effectivity. keywords: rhinoplasty; vomer; perpendicular plate of the ethmoid (ppe) rhinoplasty is an old procedure in the field of facial plastic surgery yet it has become increasingly popular in recent years. most asians have a relatively low nasal dorsum and nasal tip as well as a broad bony vault compared to caucasians. hence, the technique in rhinoplasty has greatly evolved, reconstructing the nose structurally, serving its purpose aesthetically and functionally. consequently, different types of grafts have been developed and are being developed to address the challenges of the asian nose. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles the septal extension graft is frequently used to lengthen the tip of the nose among filipinos. the relatively larger portion of harvested cartilage is allotted as septal extension graft. to compensate for lack of support, a small reinforcing batten graft is usually added on the contralateral side, allowing further stabilization of the septal extension graft and preventing the gradual deviation of the graft.1 it is commonly encountered in filipinos that the fixation strength seems insufficient and additional extension is needed. more often than not, internal valve dysfunction is also encountered in primary and secondary rhinoplasty. in both instances, an extended spreader graft may be used. our literature search showed the use of bony septum as a batten graft2,3 or as a septal extension graft4 but to the best of our knowledge, no study has yet described the use of bony septum as an extended spreader graft. this study aimed to describe a surgical technique using bony septum, specifically vomer and perpendicular plate of the ethmoid, as an extended spreader graft (esg) to secure the septal extension graft (seg) in selected patients that needed overcorrection, to control the nasal length and to avoid post-operative nasal shortness, to avoid tip deviation or rotation, as well as to improve the breathing of the patient. methods this is a descriptive case series of a surgical technique using the bony septum (specifically vomer and perpendicular plate of the ethmoid) as an extended spreader graft in a tertiary private hospital with irb approval from the manila central university filemon d. tanchoco sr. medical foundation institutional review board (mcufdtmf irb). a total of thirty-two (32) private patients of the authors seeking aesthetic rhinoplasty (primary and secondary cases) that were operated from may 2016 to october 2017 were screened. with informed consent, 10 patients with nasal obstruction were evaluated by the authors for inclusion. inclusion criteria for this technique were (1) presence of symptomatic nasal obstruction on initial consultation and (2) inadequate septal cartilage harvested for seg and esg usage. exclusion criteria were (1) patients with no symptoms of obstruction, and (2) symptomatic patients who had adequate septal cartilage harvested for seg and esg intraoperatively. the nasal obstruction was pre-operatively evaluated under direct vision via anterior rhinoscopy and by cottle maneuver. all rhinoplasties were performed via an open approach. conchal cartilage was harvested for tip reconstruction. as previously described, a modified alar lift procedure via “sail” excision was done in patients with hanging ala, which is commonly seen in southeast asian noses.5 the alar rim was lifted by removing a triangular piece of tissue in the inner lateral vestibular skin.5.6 dissection of the lower lateral cartilage was approached at the medial crura, then at the lower lateral cartilage beneath the superficial muscular aponeurotic system (smas) and finally at the dome.5 the skin and soft tissue envelope of the septum was dissected in the subperichondrial plane anteriorly until subperiosteal elevation of the nasal bone. the dorsal septum was dissected along the submucoperichondrium layer until the bony-cartilaginous junction was reached. membranous septum was dissected to access the caudal edge of the septum. harvesting of the nasal septum via an anterior septal approach caudally was done using a freer septum d-knife 5mm x 8mm blade (storz n2252, karl storz, germany) or a freer septum elevator, leaving sufficient septum dorsally and caudally for the l-shaped strut. the bony septum, which was either vomer or perpendicular plate of the ethmoid, was cut using septal scissors along the dorsal septal strut and maxillary crest (figure 1) and fractured using freer elevator or takahashi forceps. if septal scissors were not available, mayo scissors could be used. using 1mm ophthalmic burr tip, 0.5mm holes were drilled on both sides, anteriorly and posteriorly, about 2mm from the edge for anchoring. (figure 2) if a burr tip was not available, a g20 peripheral intravenous needle could be used instead to produce holes. the septal extension graft was anchored on one side of the caudal septum with three or four sutures using polydioxanone pds ii 5.0 with 13mm reverse cutting needle (ethicon, somerville, nj, usa) for fixation while the vomer or perpendicular plate of the ethmoid was fixed on the contralateral side. (figure 3 and 4) tip grafts (such as shield, onlay and backstop) were placed according to the needs of the patient. osteotomy was done in patients with an inverted-v deformity or broad bony vault. dorsal implants were designed using a sheet of preformed expanded poly tetra fluoro ethylene eptfe, inserted and fixed such that no depression or irregularities were noted. closure of incisions were done meticulously. as a last step, alarplasty was performed when needed. the results were evaluated grossly under direct vision intraoperatively and immediately post-operatively to check the patency of internal valve. the patients were asked at 2 and 4 weeks postoperatively to rate the results as  worse (more obstructed), same, or improved (better breathing). preand post-operative photographs at 2 weeks were evaluated for improvement in lengthening of nose and projection of nasal tip. all patients were jointly and simultaneously evaluated by both co-authors. results of the thirty-two (32) patients who underwent rhinoplasty from may 2016 to october 2017, twenty-two (22) presented with no symptoms of obstruction and were excluded from this series. ten (10) presented with philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles planning. parameters such as rotation and nasal projection should be carefully evaluated. the amount that the tip of the nose is turned up or down is referred to as “rotation” and is evaluated with the nasolabial angle. in females, the angle must be obtuse, from 95-105 degrees, whereas for a male, the ideal is nearly forming a right angle, from 90figure 1. septal scissors used figure 2. vomer with burred holes symptomatic obstruction and were considered for inclusion. among the symptomatic patients, five (5) had adequate septal cartilage for seg and esg and were further excluded, while bony septum was harvested and used as an esg in five (5) patients with inadequate septal cartilage who were finally included in this series. these five (5) included 1 male and 4 females whose ages ranged from 35 to 50-years-old (mean age 41.8 + 5.3 years). intraoperative evaluation under direct vision showed the anterior caudal septum was deviated in all 5 patients at the area of the internal valve, and correction was confirmed after placement of seg and esg. the use of bony septum (specifically vomer and perpendicular plate of the ethmoid) as an extended spreader graft was able to secure and strengthen the septal extension graft in patients that needed overcorrection of nasal tip. the tip was adequately lengthened and derotated, which prevented post-operative nasal shortness. immediate post-operative evaluation further confirmed the nasal valve was bilaterally patent in all 5 patients and all 5 patients reported subjectively improved breathing or relief of obstructive symptoms when asked to rate the breathing as worse, same, or improved, 2 and 4 weeks post-operatively. post-operative photographs showed improvement of nasal length and tip. (figure 5) discussion our small series demonstrated that the bony septum (vomer and perpendicular plate of the ethmoid) was able to act as an extended spreader graft to stabilize the septal extension graft, correcting anterior septal deviation and nasal valve obstruction. it improved breathing, nasal length. since the new nasal tip is secure, this should prevent long term tip rotation. in rhinoplasty, facial aesthetic analysis is critical for proper surgical figure 3. a. placement of seg b. fixation of seg and c. placement and securing of vomer as extended spreader graft (esg) a b c philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles dorsal support, its advantage is to correct the lack of dorsal support to lateral walls in internal nasal valve dysfunction and to restore a normal dorsal profile in narrowed or collapsed nasal vault.10 extended spreader grafts are frequently used to enhance nasal tip support. acting as a splint graft, they may be placed on each side of seg to stabilize it and to ensure that the caudal septum is straight. these grafts are placed between the dorsal septum and the medial edge of the upper lateral cartilage and fashioned to extend into the tip-lobule complex to help alter tip position and definition. this ensures figure 4. illustration showing use of bony septum as esg and cartilaginous septum as seg 95 degrees.7 it becomes unattractive when too much of the nostril is visible from the frontal view. in rhinoplasty, rotation means turning the tip of the nose up while counter-rotation means turning the tip down. counter-rotation is more commonly done in filipino noses and presents a much greater surgical challenge. it has the effect of lengthening a shortened nose. cartilage is used to fashion grafts for this purpose. the commonly used grafts for tip repositioning and recontouring of the dorsal nasal vault are septal extension graft, caudal septal extension graft, spreader graft, extended spreader graft and a variety of onlay grafts. septal extension graft (seg) is used as a standard method for asian nasal tip surgery for tip projection, tip rotation or counterrotation, and better tip shape. kim et al1 cited that the graft is a suitable method to extend the asian nose and to maintain the thick skin since it provides both a direct extension of the framework and maintains a strong support. byrd et al.8 were the first to introduce 3 types of septal extension grafts (paired spreader grafts, paired batten grafts and direct extension grafts), depending on the nasal tip position. these overlapping grafts provide more support and prevent deviation. disadvantages are having a stiff nasal tip and a thick membranous septum postoperatively. this graft is the workhorse used in filipino noses. a modification popularized by toriumi et al. was the use of a caudal extension graft that is longer along the superior margin to push the nasal tip down for counter-rotation.9 this is also commonly used in filipino noses since it makes the graft longer along the inferior margin, increasing tip rotation and blunting the nasolabial angle, which are common problems with filipino noses. in 1984, sheen first introduced the use of spreader graft, widely used for functional and cosmetic purposes.10 since a lot of filipinos lack a b c figure 5. a 36-year-old woman with oriental nose who underwent primary rhinoplasty, preand post-operative photos: a. frontal b. lateral; and c. left oblique views (photos published with permission). philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles the dorsal septum is strengthened and straightened, internal valve is widened and tip projection is improved.11 it also aids in preserving nasal length subsequently avoiding the development of a short nose deformity post-operatively.12 in 1903, mink first described the nasal valve, dividing it into external and internal portions. it is important to know its anatomy to recognize if the nasal obstruction is from the external valve or internal valve. the external nasal valve (figure 6) is formed by the columella, the nasal floor and the nasal rim or caudal border of the lower lateral cartilage.13  the internal nasal valve area superolaterally is the caudal border of upper lateral cartilage, medially the septum, inferiorly the floor of pyriform aperture and posteriorly the head of inferior turbinate. the internal nasal valve (figure 7) is the specific structure within the internal nasal valve area between the caudal border of upper lateral cartilage and septum. it is 10 to 15 degrees in caucasian nose and wider in african or asian nose. if the angle is less than 10 degrees, nasal obstruction may ensue.11 a ct scan study by suh et al.14 confirmed the internal nasal valve angle in asians to be significantly larger than in caucasians with a measurement of 21.6 degrees +/-4.5 degrees. relief of nasal obstruction is another concern in this study. in patients with internal nasal valve collapse, unilateral or bilateral nasal obstruction is the primary complaint. some present without nasal obstruction and just evidence of aesthetic asymmetry. other factors to be considered are septal deviation, inferior turbinate hypertrophy and external nasal valve collapse. according to helinski,11 examination may reveal an asymmetric brow tip aesthetic line or pinched middle vault seen on frontal view. he also mentioned that in cases of prior reductive rhinoplasty, patients may present with an inverted v deformity. in developed countries, acoustic rhinometry is performed and is considered the objective standard to detect obstructions in specific sites of the nasal cavity. sound waves are used to determine whether the valve area in the nasal cavity is too narrow. in less developed figure 6. external valve illustration where nasal obstruction might occur figure 8. area where spreader graft is applied as shown in dorsal and caudal view figure 9. vomer used as batten graft to correct caudal septal extension figure 7. internal valve illustration where nasal valve collapse might occur philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles references 1. kim jh, park sw, song jw, oh ws, lee jh. effective septal extension graft for asian rhinoplasty. arch plast surg. 2014 jan; 41(1):3-11. doi: 10.5999/aps.2014.41.1.3; pmid: 24511488 pmcid: pmc3915153. 2. dini gm, iurk lk, ferreira mc, ferreira lm. grafts for straightening deviated noses. plast reconstr surg. 2011 nov;128(5): 529e–537e.  doi: 10.1097/prs.0b013e31822b6989; pmid: 22030515. 3. jang yj, kim jm, yeo nk, yoo jh. use of nasal septal bone to straighten deviated septal cartilage in correction of deviated nose.   ann otology rhinol laryngol.  2009 jul; 118(7):488–494. doi: 10.1177/000348940911800706; pmid: 19708487. 4. kim gr,   park k, md, kim t. use of nasal septal bone for septal extension graft after jaw surgery. plast reconstr surg glob open. 2013 dec; 1(8): e76. doi: 10.1097/gox.0000000000000016; pmid: 25289271; pmcid: pmc4186304. 5. baladiang de, olveda mb, yap ec. the “sail” excision technique: a modified alar lift procedure for southeast asian noses. philipp j otolaryngol head neck surg. 2010 jan-jun; 25(1): 31-37. 6. yap ec. aesthetic rhinoplasty for southeast asians. in: jin hr (editor). aesthetic plastic surgery of the east asian face. new york: thieme; 2016. p. 109-110. 7. lee kj. essential otolaryngology: head and neck surgery, 10th ed. new york: mc graw hill; 2008. p745. 8. courtiss eh, goldwyn rm. the effects of nasal surgery on airflow. plast reconst surg. 1983 jul; 72(1):9-21. pmid: 6867182. 9. kim yh, jang ty. porous high-density polyethylene in functional rhinoplasty: excellent longterm aesthetic results and safety.  plast surg (oakv). 2014 spring; 22(1):14-7. pmid: 25152641 pmcid: pmc4128427. 10. sheen jh. spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty.  plast reconst surg. 1984 feb; 73(2):230-9. pmid: 6695022. 11. hilinski jm, byrne p. spreader grafts rhinoplasty. medscape. updated: 2016 feb 05. 12. palacín jm,  bravo fg,  zeky r,  schwarze h. controlling nasal length with extended spreader grafts: a reliable technique in primary rhinoplasty. aesthetic plast surg.   2007 nov-dec; 31(6):645-50. doi: 10.1007/s00266-007-0065-8; pmid: 17876658. 13. schlosser rj, park sp. surgery for the dysfunctional nasal valve. cadaveric analysis and clinical outcomes. arch facial plast surg. 1999 apr-jun; 1(2):105-110. pmid: 10937087. 14. suh mw, jin hr, kim jh. computed tomography versus nasal endoscopy for the measurement of the internal nasal valve angle in asians. acta otolaryngol.  2008 jun; 128(6):675-9. doi: 10.1080/00016480701663391; pmid: 18568504. 15. heinberg ce, kern eb. the cottle sign: an aid in the physical diagnosis of nasal airflow disturbances.  rhinology. 1973; 11:89-94. countries, diagnosis is with visualization of the valvular area, ideally with the use of a zero-degree nasal endoscope. it can also be visualized with anterior rhinoscopy or the use of a nasal speculum as was performed in the patients. application of nasal decongestant can be performed to aid in identifying reversible mucosal edema. however, helinski stated that examining the valve without disturbing it with a nasal speculum is important because the speculum usually distorts the relationship of the septum and the caudal edge of the upper lateral cartilage and opens the valve artificially.11 a practical method that would not alter this anatomical relationship is to elevate the tip of the nose gently with the examiner’s finger with inspection using a good light source.11 a quick and easy test, the cottle maneuver is used to evaluate internal nasal valve stenosis or disorder.15 the cheek of the evaluated side is gently pulled laterally with 1-2 fingers and the patient is asked to breathe. a positive test result is when the obstruction is relieved. a more specific and reliable test is the modified cottle maneuver wherein a thin instrument such as cotton swab or cerumen curette is placed at the level of the external nasal valve and internal nasal valve. this is an accurate method to identify the level of obstruction the purpose of the spreader graft is to open the internal valve and to correct the septal deviation. (figure 8) an extended spreader graft on the other hand is used as support or reinforcement for the septal extension graft and for securing it, as well as to address internal nasal valve dysfunction. in this study, patients in a tertiary private hospital needing additional support of the l-strut and presenting with internal valve problems were included. this was done in both primary and secondary rhinoplasty. the bony septum was used as extended spreader graft. vomer or perpendicular plate of the ethmoid was harvested approximately one centimeter. some studies2.3 have used septal bone, commonly vomer or perpendicular plate of the ethmoid, as batten graft in dorsal and caudal strut, aimed mostly at correction of caudal septal deviation (figure 9). another study4 used the bony septum as septal extension graft in cartilage-depleted patients. no study has yet described the use of bony septum as extended spreader graft. bone is more difficult to shape than cartilage and can be easily fractured while being shaped. we were able to obtain grafts with the aid of septal scissors. in settings where septal scissors is not available, mayo scissors maybe used taking into account its bulkiness and difficulty in manipulation in a small area. fixation of bone grafts to the l-strut also poses a challenge. hence, burring of holes was done on either end of the graft to allow a precise and secure fixation of the graft. these holes also allow rapid ingrowth of vascularized tissue. the perpendicular plate of the ethmoid is thin, flattened and straighter while the vomer is more irregular. in this study, a septal extension graft using the central harvested septal cartilage is fixed to one side while an extended spreader graft on the contralateral side using bony septum. (figure 4) a seg is best secured with esg because of its firm nature to hold the seg in the desired vector. the bony septum widens the internal valve as well as supports the weak seg although it is known to resorb in a year. postoperatively, the patients were evaluated via anterior rhinoscopy. there was improvement in breathing noted subjectively by the patients. as evident in the preand post-operative photographs taken for evaluation (figure 5), control of the nasal length was achieved and tip deviation or rotation was corrected. avoidance of post-operative nasal shortness is another long-term advantage. the use of the bony septum (vomer and perpendicular plate of the ethmoid) as an extended spreader graft during primary or secondary rhinoplasty is a potentially effective method of supporting and securing the septal extension graft for preventing tip deviation or rotation and short-nose deformity, and for improving internal valve dysfunction. in our small series, it stabilized the septal extension graft and improved breathing, serving its purpose aesthetically and functionally. further trials with a larger population and longer follow-up are needed to establish its reliability and long-term effectivity. the use of a zerodegree nasal endoscope is likewise recommended to facilitate assessment of internal valve collapse and post-operative improvement. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 8180 philippine journal of otolaryngology-head and neck surgery letters to the editor on the representative ct image of an otic-disrupting fracture dear editor: in the article entitled “facial paralysis in longitudinal versus oblique and otic-sparing versus non otic-sparing temporal bone fracture” published in the vol 34 no 2 issue of the philippine journal of otolaryngology head and neck surgery, the authors included an image (figure 4) that was representative of an otic-disrupting fracture. the arrow clearly shows the fracture line running through the mastoid air cell system nearly parallel to the posterior external auditory canal wall and ending just posterior to the ossicular chain. references 1. juliano af, ginat dt, moonis g. imaging review of the temporal bone: part i. anatomy and inflammatory and neoplastic processes. radiology. 2013 oct; 269(1):17-33. doi:10.1148/ radiol.13120733. pmid: 24062560. yours sincerely, nathaniel w. yang, md associate professor and section head for otology, neurotology and lateral skull base surgery department of otorhinolaryngology college of medicine philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines figure 4. representative plain temporal bone ct scan, axial view, bone window at the level of the otic capsule showing an oticdisrupting fracture (arrow). however, the fracture line does not unequivocally appear to proceed medially towards the otic capsule, which is the densest portion of the temporal bone that surrounds the osseous labyrinth, and includes the cochlea, vestibule and semicircular canals. the otic capsule likewise is located within the petrous portion of the temporal bone.1 the otic capsule lies within the oval ring in the smaller figure above which is an enlarged image of the original figure in the article. this issue is relevant because the authors are classifying subjects according to the visual presence of a fracture that may or may not involve the otic capsule. misidentification of the type of fracture in a representative image raises the question of a systematic misidentification in the entire data set, thus rendering the results of the study invalid. philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery case reports abstract objective: to describe a unique case of extrapulmonary tuberculosis (tb) of the temporomandibular area focusing on its insidious and destructive course over a 2-year period with insights into the diagnostic and therapeutic pitfalls encountered throughout its clinical development. methods: design: case report setting: tertiary government hospital patient: one results: a 33-year-old man initially presented with right pre-auricular swelling and trismus that were unresponsive to antibiotic therapy. on subsequent follow-ups, initial symptoms were accompanied by a non-healing right pre-auricular wound, right ear discharge, trismus and right facial paralysis (house-brackmann iii). cranial and temporal bone computed tomography scans revealed osteolytic destruction of the right temporomandibular region extending to the auditory canal and of the right mastoid bone extending to the right mandibular condyle and parotid. infected malignancy of the parotid, mandible and temporal bone were considered but definitive diagnosis from an incision biopsy revealed caseating granulomatous inflammation consistent with tuberculosis. he was started on anti-tuberculosis medications with significant resolution of pre-auricular swelling, non-healing pre-auricular wound, facial paralysis and ear discharge but minimal improvement in mouth opening. conclusion: tuberculosis of temporomandibular region is rare and is associated with nonspecific manifestations. delay in diagnosing and initiating appropriate treatment can lead to morbidity and serious complications involving destruction of the temporal bone, middle ear, mandible and parotid gland over its progression. a high index of suspicion by the physician and awareness of the patient’s health seeking behaviors could have aided in the early diagnosis and treatment of this extrapulmonary tb. keywords: tuberculosis, temporomandibular region, pre-auricular swelling, trismus, antituberculosis therapy, facial paralysis, chronic mastoiditis, ear discharge tuberculosis of the temporomandibular regionjesusa m. santos, mdelias t. reala, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. elias t. reala department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 711-9491 local 320 e-mail: eliboy_entdoc@yahoo.com the authors declare that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. verbal consent was obtained from the patient for publication of this case report and accompanying images. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery interesting case contest (2nd place). may 12, 2018. citystate asturias hotel, puerto princesa, palawan. philipp j otolaryngol head neck surg 2018; 33 (2): 41-44 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery case reports tuberculosis (tb) remains a major public health problem worldwide and the impact of its magnitude can be felt by the continuing burden in the philippines spanning centuries of high prevalence. globally, there were an estimated 10.4 million new tb cases with 1.3 million tb deaths; estimates in the philippines report an incidence rate of 554 per 100,000 and death rate of 21 per 100,000 population.1 it is common medical knowledge that tb most commonly affects the lungs. extra-pulmonary tb comprises 15~20% of the total tb infection burden. of all cases of extrapulmonary tb, it is estimated that only 10% involve the head and neck region with predominance of cervical lymph node affectation (more than 90% of cases).2,3 temporomandibular tb is rare4 and we found no previous reports in herdin, the philippine journal of internal medicine and philippine journal of otolaryngology head and neck surgery. this report aims to describe a case of extrapulmonary tb of the temporomandibular area, its clinical course over a 2-year period and provide insights into the diagnostic and therapeutic pitfalls encountered during its clinical development. case report a 33-year-old man initially presented with 6-month history of initially non-painful right pre-auricular swelling and a 2-month history of gradual limitation of mouth opening. physical examination showed a 2x2cm, tender soft tissue swelling over the pre-auricular area, limitation of the mouth opening, palpable bilateral cervical lymph nodes and intact tympanic membranes. no cough nor afternoon fevers were reported. initial clinical impression was acute bacterial parotitis versus infected first branchial cleft cyst prompting treatment with oral coamoxiclav for 1 week, shifted to clindamycin for another week with no resolution of the swelling. imaging of the parotid area was requested but the patient was lost to follow-up. after 16 months, the patient consulted with a general practitioner due to increasing limitation of mouth opening and extension of the pre-auricular swelling to the right temporal and infra-auricular areas. the patient also reported a 1-month history of right ear discharge and appearance of a non-healing wound over the right pre-auricular area. plain cranial computed tomography (ct) scan was interpreted as “soft tissue swelling and abscess formation in the scalp overlying the right temporal bone, chronic mastoiditis with no intracranial pathology and intact parotid glands.” the patient followed up at our institution with these results. aside from the extended temporomandibular swelling, discharging ulcerations over the right pre-auricular area were noted on physical examination. (figure 1a, b) no symptoms referable to pulmonary pathology were elicited at this time except for intermittent figure 1a. right pre-auricular swelling, and b. non-healing right pre-auricular wound a b figure 2. note deviation of mouth opening to the right with limitation of mouth opening (maximum inter-incisor distance of 26 mm) undocumented fever. he denied any previous history of ear infection or discharge, diabetes mellitus, trauma to the affected areas and pulmonary tuberculosis. physical examination also showed deviation of mouth opening to the right with trismus documented as maximum inter-incisor distance of 26mm. (figure 2) he also had ipsilateral peripheral facial nerve figure 3. otoscopic view showing right external auditory canal granulation tissue philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery case reports paralysis (house-brackmann iii). otoscopy revealed granulation tissue with yellowish discharge occupying the right external auditory canal. (figure 3) an infected malignant neoplasm involving the temporal bone was highly considered when a repeat contrast-enhanced ct scan showed a large lobulated heterogeneously enhancing mass with bony lytic changes in the right temporomandibular region, with extension to the right buccal, masticator spaces, right parotid gland, mastoid air cells, middle and outer ear cavities. osteolytic destruction of the right mandibular condyle, coronoid process, neck and ramus, the tympanic, horizontal and zygomatic part of the right temporal bone, right mastoid bone, and erosion of the tegmen mastoideum and tegmen tympani were also evident. (figure 4 a-c) punch biopsy of the external auditory canal mass, fine needle aspiration biopsy (fnab) of the pre-auricular area and temporal area swellings revealed granulation/necrotic tissue and the absence of malignant cells. subsequently, a deeper incision biopsy over the non-healing wound in the pre-auricular area was read as caseating granulomatous inflammation consistent with tuberculosis. (figure 5) he was referred to our tb direct observed treatment, shortcourse (dots) clinic and started on anti-tuberculosis medications. one month into taking anti-tb medications, the patient reported complete resolution of the right ear discharge, skin ulcerations and swelling on the temporal and pre-auricular area. however, only partial resolution of the facial muscle weakness, and minimal resolution of trismus / difficulty of opening of the mouth was reported. unfortunately, after these improvements, our patient subsequently went home to samar province and was lost to follow-up. figure 5. histopathologic slide, hematoxylin-eosin, low-power view (10x) showing caseating granulomatous inflammation consistent with tuberculosis (hematoxylin – eosin , 10x) figure 4 a. cranial and temporal contrast-enhanced ct scan, coronal view revealing a large lobulated heterogeneously enhancing mass with bony lytic changes in the right temporomandibular region b. bone window showing osteolytic destruction of right temporal bone (arrow) and c. osteolytic destruction of the right mandibular condyle, neck and ramus (arrow) a b c discussion we described a patient with extrapulmonary tb of the temporomandibular area, its insidious natural course over 2 years, and aim to provide insights into the diagnostic and therapeutic pitfalls encountered throughout its clinical development. it is generally thought that most extrapulmonary tb results from hematogenous dissemination of the mycobacterium.5 other modes of dissemination are direct transfer, regional extension of soft tissue lesions, lymphatic routes, or a combination of these modes. the patient’s tb probably started in a pre-auricular lymph node outside the parotid. how the mycobacteria arrived in the area cannot be singled philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery case reports references 1. world health organization. global tuberculosis report 2017: executive summary. [cited 2017 nov 13]. available from: http://www.who.int/tb/publications/global_report/exec_ summary_13nov2017.pdf. 2. nalini b, vinayak s. tuberculosis in ear, nose, and throat practice: its presentation and diagnosis. am j otolaryngol. 2006 jan-feb; 27(1): 39–45. doi: 10.1016/j.amjoto.2005.07.005; pmid: 16360822. 3. prasad kc, sreedharan s, chakravarthy y, prasad sc. tuberculosis in the head and neck: experience in india. j laryngol otol. 2007 oct; 121(10): 979–85. doi: 10.1017/s0022215107006913; pmid: 17367564. 4. kreiner m. tuberculosis of the temporomandibular joint: low prevalence or missed diagnosis? cranio. 2006 oct; 24(4):234. pmid: 17086851. 5. sharma sk, mohan a. extrapulmonary tuberculosis. indian j med res. 2004 oct: 316–53. pmid: 15520485. 6. harisinghani mg, mcloud tc, shepard ja, ko jp, shroff mm, mueller pr. tuberculosis from head to toe. radiographics. 2000 mar-apr; 20(2): 449–470; quiz 528–529, 532. doi: 10.1148/ radiographics.20.2. g00mc12449; pmid: 10715343. 7. world health organization. global tuberculosis control: who report 2011. geneva: world health organization, 2011:1–258. [cited 2017 nov 13]. available from: http://www.who.int/iris/ handle/10665/44728. 8. patel m, scott n, newlands c. case of tuberculosis of the temporomandibular joint. br j oral maxillofac surg. 2012 jan; 50(1): e1–3. doi: 10.1016/j.bjoms.2011.05.012; pmid: 21676508. out although the presence of palpable multiple bilateral nontender cervical nodes does provide clues to this. the late administration of effective anti-tb medications allowed us to describe the path of spread and destruction the disease took in this patient. from the subcutaneous, superficial parotid pre-auricular node, the disease manifested as a slow growing 6-month swelling which spread to involve the structures surrounding the temporomandibular joint, hence the 2-month history of trismus. from there, and over the course of 15 months, the lesion spread to involve the mastoid air cells and middle ear resulting in a discharging ear. the skin over the initial site followed next and manifested as scrofuloderma. just a few weeks after the initial ct scan reported the parotid being intact, the disease breached the parotid fascia and penetrated the parotid gland thereby affecting the upper branches of the facial nerve. the repeat ct scan also revealed widespread involvement of adjacent bony structures, obliterating parts of the mandibular ramus and condyle, infiltrating the mastoid on the verge of breaching the intracranial space. while anti-tb therapy reversed many manifestations of the disease, the long-term or permanent impact of tb on the patient’s mastication and upper facial nerve functions remains to be seen. tuberculosis can affect any organ system in the body. it has been called “the great mimicker” because of its ability to simulate a number of other disease entities depending on the organ involved.6 diagnosing extrapulmonary tuberculosis is often difficult since many patients present with nonspecific symptoms, negative purified protein derivative skin test and negative culture of specimens.5 the nonspecific signs and symptoms presented by our patient were trismus, ear mass, ear discharge, and facial nerve paralysis which are similar to those of inflammation or infection, benign neoplasm and malignancy of the involved structures, hence, the diagnosis of tb was initially missed. a high index of suspicion and familiarity with the local incidence is needed in order to facilitate the diagnosis of extrapulmonary tb. the clues were there and can be deduced relatively easily on hindsight. the multiple cervical lymphadenopathies, intermittent fever and appearance of scrofuloderma. the indolent nature of this disease led to a burst of hurried deterioration. it is important to consider tuberculosis of temporomandibular region in a patient with unusual presentation of pre-auricular swelling and trismus despite the absence of classic symptoms associated with pulmonary tb7 since we are living in a country with high tb prevalence. the diagnostic tests that should have been employed earlier consist of culture of mycobacterium from bone tissue, afb smear, fine-needle aspiration cytology and tissue biopsy.5 however, almost 40-50% of patients will have no evidence of tuberculosis elsewhere6 and the repeated biopsies of our patient were inconclusive. histopathologic examination is needed to make a definitive diagnosis. the ct scan was also helpful in showing the extent of disease but imaging alone is insufficient in reaching a conclusive diagnosis. the patient was lost to follow up early in the clinical management of his complaints and returned only after 16 months had passed with a plethora of rapidly deteriorating new complaints. indeed, socioeconomic issues bear greatly on a patient’s consults and follow-up. in fact, following the clinical improvements reported in this case, he went back to his hometown and was again lost to follow up. needless to say, experience has yet again taught us that prompt recognition and treatment is key to reverse the symptoms and arrest the progression of tb. any delays in treatment may allow progression to significant tmj destruction, total facial nerve paralysis, intracranial infection and irreversible hearing loss. anti-tuberculosis therapy should be started and completed for at least 6 months, identical to the treatment of pulmonary tb.7 surgical interventions in the absence of appropriate medical therapy may result in complications such as fistula, non-healing suture lines and failure of surgery. since our patient presented with large abscess formation and osteolytic changes in the temporomandibular region, possible surgical excision, decortication and joint reconstruction8 may have been considered if anti-tuberculosis therapy failed.8 together with all these, socio-economic determinants of health must be addressed on a systematic level, or we risk the relapse of our patient, and occurrence in others. in summary, we described a rare case of extrapulmonary tb of the temporomandibular area manifested by trismus, right pre-auricular swelling, scrofuloderma, right ear discharge and right facial paralysis that developed over a span of 2 years. these are common findings in otolaryngology with a multitude of differential diagnoses covering the parotid, mandible and temporal bone. a thorough clinical history, physical examination and high index of suspicion are needed for the diagnosis and treatment of this elusive but very common disease in an uncommon location. philippine journal of otolaryngology-head and neck surgery 45 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports philipp j otolaryngol head neck surg 2016; 31 (1): 45-47 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to present a rare case of post-traumatic recurrent epistaxis in an elderly woman. methods: design: case report setting: tertiary private hospital patient: one result: a 93-year-old woman had multiple admissions for recurrent life threatening nosebleeding that was not controlled until a post-traumatic pseudoaneurysm of the infraorbital artery was diagnosed and embolized. conclusion: the diagnosis of pseudoaneurysm should be considered in such cases, and treatment involving surgeons and interventional radiologists should be initiated to minimize morbidity and mortality. keywords: recurrent epistaxis, post-traumatic pseudoaneurysm, right infraorbital artery, right internal maxillary artery, embolization epistaxis is a common medical condition, with about 60% of the adult population having at least one episode during their lifetime.1 eighty to ninety percent are idiopathic, with about 80% occurring from the highly vascularized anterior nasal septum.2 bleeding from this area is usually easily managed conservatively. however, when epistaxis is massive and intractable, differentials for possible sources include bleeding originating from the ethmoidal and sphenopalatine artery, facial and skull base trauma and post-traumatic aneurysms.3 we present an even rarer cause of such epistaxis. recurrent epistaxis from a post-traumatic infraorbital artery pseudoaneurysm ma. victoria p. pascual, md daniel m. alonzo, md department of otorhinolaryngology head and neck surgery the medical city, ortigas city correspondence: dr. daniel m. alonzo department of otorhinolaryngology-head and neck surgery the medical city ortigas avenue, pasig city 1600 philippines phone: (632) 635 6789 local 6250 fax: (632) 687 3349 email: ent@themedicalcity.com the authors declare that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest presented at the philippine society of otolaryngology-head and neck surgery clinical case report contest (3rd place), menarini office, 4/f w bldg. 11th ave. cor. 28th st. bonifacio high st. bgc taguig, june 2, 2015. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports 46 philippine journal of otolaryngology-head and neck surgery case report a 93-year-old woman consulted for bilateral epistaxis after falling and hitting her face and left shoulder on the ground. on examination, only blood clots in both nasal cavities and swelling and bruising of the right zygomatic area were noted. a facial ct scan showed a comminuted, depressed fracture of the right orbital floor, and hemoantrum of bilateral maxillary and right sphenoid sinus. the ear nose throat – head and neck surgery, ophthalmology, and emergency room (er) services determined that no immediate intervention was warranted, and discharged her with a nasal spray and antibiotics, advising outpatient follow-up. later that afternoon, she had right sided epistaxis amounting to approximately 2 cups while straining during defecation. the bleeding eventually stopped after cold compress, ice chips by mouth, and digital pressure. she was nevertheless admitted for observation and discharged a few days later with no recurrence of epistaxis during her hospital stay. one week later, she was seen at the er for right maxillary pain and numbness over the right nostril and upper lip. there had also been intermittent epistaxis at home of about 1/2 cup per episode but spontaneously relieved each time. she was reevaluated and again sent home with an oral decongestant. but that evening, she was readmitted for post-tussive epistaxis amounting to 2 cups of blood. during this admission, the patient was noted to have decreasing hemoglobin levels, attributed to intermittent episodes of right sided epistaxis of about 10ml per episode, relieved spontaneously. after dismissing a hematologic etiology, a pns ct scan revealed a comminuted, depressed fracture of the right orbital floor, hemoantrum within both maxillary and right ethmoid sinuses, and an ill-defined soft tissue density in the right middle meatus. (figure 1) she was then scheduled for surgical exploration. intraoperative endoscopy revealed a hematoma in the maxillary ostium. uncinectomy was performed for better visualization but was abandoned due to persistent bleeding. the approach was converted to a caldwell incision, but profuse bleeding amounting to 700ml within 2 minutes was immediately encountered upon entry into the maxillary sinus. hemostasis was achieved with application of gauze impregnated with petroleum jelly into the sinus, and insertion of polyvinyl alcohol sponge (merocel®) into the anterior nasal cavity. she was then referred to interventional radiology, and diagnostic angiography was carried out the following day in the hopes of locating the bleeding vessel. the procedure revealed a pseudoaneurysm (pa) of the inferior orbital branch of the right internal maxillary artery (figure 2), which was subsequently embolized using polyvinyl alcohol (pva). follow-up arteriography (figure 3) still showed flow into the pa, and repeat embolization (figure 4) was figure 1. pns ct scan with contrast (3 weeks post trauma). comminuted, depressed fracture of the right orbital floor, hemoantrum of both maxillary and right ethmoid sinuses, and obstructed ostiomeatal units and right nasofrontal recess. figure 2. ct angiography. leftsagittal view. rightcoronal view. catheter inserted into the right common femoral artery and advanced into the right external carotid artery. superselective arteriography performed, identifying a pseudoaneurysm from the inferior orbital artery branch of the right internal maxillary artery. bleeding vessel symbolized by the extravasation of the dye. initial embolization done using pva. performed until the pa was occluded. the patient tolerated the procedure well with no noted complications or recurrence of epistaxis. the maxillary sinus and nasal packs were removed the next morning, and she was subsequently discharged 2 days later asymptomatic. on follow-up one week from discharge, she reported complete resolution of epistaxis. she has better appetite and decreased right maxillary tenderness. figure 3. arteriography after initial embolization. note slower flow into the pseudoaneurysm but still with filling. further selective arteriography performed until occlusion of the pseudoaneurysm was achieved. philippine journal of otolaryngology-head and neck surgery 47 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports discussion pseudoaneurysm (pa) or false aneurysm is an outpouching of a blood vessel that results from disruption of one or more layers of its wall, rather than expansion of all wall layers as seen in a true aneurysm.4 asymmetries, neurological deficits, and thromboembolism are the main signs and symptoms.4,5 pseudoaneurysms can arise from the branches of the external carotid artery (eca) or the internal carotid artery (ica) system.5 pseudoaneurysms of the eca are rare. in a series of over 8,000 aneurysms, mccollum et al. reported only 21 pas of the eca, and 19 of them occurred after carotid surgery.6 this places its incidence at about 0.02%. its rarity might be attributed to the small size of the branches of the eca. due to its superficial course and its position as it crosses bony structures, the superficial temporal, distal facial and distal internal maxillary arteries are the most commonly involved vessels.3 the internal maxillary artery (ima) is the largest terminal branch of the eca, and bleeding from this site is mainly caused by bone fractures5 from direct penetrating or blunt trauma often fracturing the maxilla.6 other possible causes include post-irradiation vasculopathy, tumor invasion in patients with head and neck cancers who received composite treatment, or maxillomandibular surgery.6,7 the hallmark of post-traumatic pseudoaneurysm (ptsa) is delayed, progressively more severe and sometimes fatal bleeding.1 it can occur as early as four hours after the injury and as late as eight hours. angiography is the most confirmatory test in diagnosis and is considered the gold standard investigation.5,6 it is characterized by residual contrast media retention in the lesion long after the arterial phase of diagnostic angiogram is done.6 studies have shown that as many as 89% of untreated pa resolve in 5 to 90 days.3 however, in those with profuse life-threatening oronasal bleeding, initial management includes application of tight nasal and oral packing, followed by blood transfusion to maintain hemodynamic stability. more definitive treatments include emergent open surgical references 1. willems pwa, farb ri, agid r. endovascular treatment of epistaxis. ajnr am j neuroradiol. 2009 oct: 30(9):1637-1645. 2. haroon y, saleh ha, al-azzazy mz, abou-issa ah. embolization for control of refractory posterior epistaxis. ejrnm. 2012: 43(3):407–411. 3. masooni a, fazlipour a, davoodi m. traumatic pseudoaneurysm of internal maxillary artery: a case report. vascular & interventional. iran j radiol. 2009:6(1):37-39. 4. barbalho jcm, santos es, menezes jms jr, goncalves fr, chagas ol jr. treatment of pseudoaneurysm of internal maxillary artery: a case report. craniomaxillofac trauma reconstruc. 2010 jun: 3(2):87-89. 5. zhang cw, xie xd, you c, mao by, wang ch, he m, sun h. endovascular treatment of traumatic pseudoaneurysm presenting as intractable epistaxis. korean j radiol. 2010 nov-dec: 11(6):603611. 6. luo cb, teng mm, chang fc, chang cy. role of ct and endovascular embolization in managing pseudoaneurysms of the internal maxillary artery. j chin med assoc. 2006 jul; 69(7):310-16. 7. karanth sk, jagannathan m, mahesh sg, devale m. internal maxillary artery pseudoaneurysm in a case of mandibular fracture. indian j plast surg 2007:40(1):51-53. ligation of the ima6 via arterial ligation methods, transantral approach to the maxillary artery, or external carotid artery ligation. however, these have high failure rates due to extensive anastomosis distal to the site of ligation.2 current management of epistaxis includes angiography and embolization of the bleeding vessels.2 endovascular embolization is the most successful way to manage pa of the ima with rapid relief of symptoms. it causes reduction in blood flow, retrograde filling of the proximally occluded vessel and eventual obliteration of the pa.1 it has gained considerable clinical recognition because of its capability for super-selective localization of the bleeding, allowing preservation of all the other branches of the eca.6 it allows more distal access to bleeding points, is less invasive, requires a shorter time for the procedure, and is faster than open arterial ligation.2 the common permanent embolic agents employed for endovascular embolization of vascular lesions in the head and neck region are polyvinyl particle (pva) foam, microcoils, and liquid adhesives.1,3 pva has been widely used for the treatment of idiopathic epistaxis and for preoperative tumor embolization1 since it is the easiest to handle and has a higher capacity for vascular occlusion compared to metal coils.3 however, there is the risk of developing recurrent pas with bleeding after embolization.1 other complications range from minor transient adverse events like headache, facial pain or fever, to persistent complications such as monocular blindness, peripheral facial nerve paralysis or cerebral infarction.2 epistaxis is an expected sequelae of trauma. however, persistent or recurrent bleeding and excessive blood loss are not usual. ptpa is rare but should raise a high index of suspicion when a patient presents with intractable epistaxis.1 especially with geriatric patients whose clinical status may quickly deteriorate4 even with subtle changes from normal bodily functions, early diagnosis and treatment of a pa is imperative to minimize morbidity and mortality. as seen in our case, recurrent epistaxis should not be taken lightly. figure 4. repeat embolization. after the second attempt, no spillage of dye noted. no residual contrast media retention. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery commentary magandang gabi po sa inyong lahat lalo na sa mga bagong specialista (o diplomate) ng ating samahang pbo-hns na pinararangalan natin ngayon; ganuon din sa kanilang mga kabiyak, at mga magulang, mga marangal nating panauhin at syempre sa mga dati kong kasama sa pso at pbohns. itong samahang ito ang hindi tumitigil na paunlarin ang mga patakaran ng society at para ang ent diplomate ay maging tunay na specialist at hindi “ispecialista daw.” for the single ones among you, let’s give your parents special citation for having sacrificed not only once during your medical student days but twice-during your residency days. their encouragement and material aid are phenomenal. likewise to those married, your spouses either had a more challenging housewife’s role or became “housebands” during your busy training days. so in this talk of mine which you may consider “unsolicited advice,” i will mention some idealistic-even bordering on the philosophical -reminders of some of our pillars in the specialty and my own experience as a budding practitioner. also my personal pitfalls and how to possibly solve them. after all, when we reach our sunset years, we can discuss such topics ad infinitum. success in your practice is more or less guaranteed. after all, our specialty is still relatively young and in demand and our membership is still wanting in proportion to the needs of a 100-million population. i still have to see an ent practitioner unhappy in his chosen field. the only factor that may be unfavourable is your questionable attitude towards your patient, your colleagues in the profession and the hospital administrators in the institution where you belong. in an article by the multi-awarded neurotologist dr. michael glasscock entitled “the lost art of medicine,”1 he enumerated the basic principles of the time-honored physician-patient relationship which are: 1. “the science of medicine” which you have just endured by passing the board so i will not elaborate on it. 2. “the art of medicine” which is multifaceted approach to patient care that takes into consideration the patient’s emotional as well as his physical well-being. i remember a patient, my own cousin, who fainted in front of me when he learned from the histopath that he had cancer. i miscalculated his intelligence against his anxiety, which brings me to the next topic; 3. “the art of full disclosure” a most important aspect of good patient care is keeping the patient fully informed. a well-informed patient is an understanding patient who may think twice or more before suing you after a surgical complication, because you have explained that possibility to him. a dvd or disc on the surgical procedure, showing its advantages, indications, and possible complications can be a good source of informed consent. an anatomic picture in your laptop can explain the pathophysiology and help prevent problems in the lifestyle of -let’s say-a chronically allergic patient. 4. “the art of listening” studies have shown that during the initial interview an average doctor interrupts the patient’s story within 17-20 seconds. this frustrates the patient. true, the patient can be a poor historian so you can prompt him-but not to the point of leading the story. remember 40 to even 60% of his story can be the source of the diagnosis. 5. “the art of compassion” postoperatively make rounds twice a day and even more if the case is a difficult one. this lets the patient and family know that you are on top of the on shoulders of giants: a message from an elder fellow to new diplomates teodoro p. llamanzares, md department of otolaryngology head and neck surgery makati medical center department of otolaryngology head and neck surgery uerm-memorial medical center correspondence: dr. teodoro p. llamanzares department of otorhinolaryngology head and neck surgery 2nd floor, tower 1, makati medical center #2 amorsolo st., legaspi village, makati city 1229 philippines phone: (632) 888 8999 local 2282 email: tllamanza@gmail.com reprints will not be available. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. this inspirational talk was originally delivered during the philippine board of otolaryngology – head and neck surgery graduation ceremonies held on november 28, 2015 at the unilab bayanihan annex, pasig city, philippines. philipp j otolaryngol head neck surg 2016; 31 (2): 6-7 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery commentary situation and are concerned about their well-being. a secure physician will suggest a second opinion before the patient and/or family ask for one.1 and again will not even consider a malpractice suit if a complication happens. those are the emotionally-charged problems you may encounter. so it’s not only the 3a’s of good practice, namely: ability, availability, acceptability that can ensure success. maybe add two more – accessibility and affordability for obvious reasons, when inefficiency is very palpable, such as in this unfortunate place known as metro manila with its horrendous traffic and other problems. there is a clamour for the next president to create a “department of common sense.” as to affordability, you may be the best ent doctor but if your pf is preposterous, that will be a definite turn-off for the patient. here are few reminders for a starter: 1. recruit a “smiling staff ” from the secretary in the reception room, your clinic nurse and/or clinic assistant. nothing can be a better welcome scene for a sick, depressed patient than a smiling, assuring face. 2. be always on time as posted. working patients have to rush back to work and get disappointed with errant doctors, and seek one who is available. a few red flags in practice: 1. beware of a secretary who may be a cheat, charging your pro bono patients without your knowledge and pocketing the money. 2. a colleague who captures “walk-in” patients by socializing with personnel from the admitting section, opd-er nurses and residents. no wonder inspite of “on call” scheduling you never received any patient from these departments. these events really happen. one of the fastest ways for a quick fix to accumulate patients is to join hmos. financial returns may not be as great as private patients but in the long run an hmo-satisfied patient is eventually your recruiter of his relatives and friends. some downsides on joining hmos: 1. controlling your wor k-ups such as refusing necessar y, thorough but expensive requests. 2. delayed payments 3. defining what is pre-existing illness in this day and age of social media, here are some do’s and don’ts: never refuse an invitation to tv forums. during my time the two popular ones were: kapwa ko, mahal ko and damayan. i was invited a few times to guest in these fora. as a result, my telephone lines became busy answering calls about my schedule. i felt like a superstar. the availability of information about your practice at a click of a mouse will allow you to reduce your marketing budgets. you can even create your own website or through the services of facebook, twitter, etc. as long as your statements in your ads are not false, misleading and deceptive you can’t go wrong. some examples of false statements: 1. statements of ability to do subspecialty procedures where in fact he did it with a “ghost surgeon.” 2. has had fellowship in a well-known medical center abroad but actually spent just a few days of observation. example of deceptive claims: paid testimonials by prominent patients about his greatness. still some other tricks of the trade: 1. practice in the provinces where you grew up. people there are very familiar with you, a returning professional, who will appreciate your humanitarian services. you will be the pride of your family. a very rewarding feeling indeed. 2. accept speaking engagements from other medical groups, and socio-civic clubs. again, they become your sources of referral. the philhealth is a noble undertaking by the government for those who have less in life should have more in law. it is a law and we are all bound to abide by it. let us not abuse it as is happening with one of the other specialties. i understand there is also an ongoing controversy between lgus and provincial hospitals about philhealth returns. thinking of academic medicine and research? you don’t have to be in a classroom or in the laboratory. remember even the ancient oath of hippocrates mentioned this art of sharing knowledge and experience with others, when it states: “i will impart this knowledge of the art to my own sons and those of my teachers and to other disciples…”2 teaching can also be self-serving since it forces one to study more and updated. masama naman na mas marunong pa sa iyo ang estudyante mo. in closing, let me remind you about the past. while you are in a solitary moment savouring the thought of your enormous professional success, please remember the toils, the sacrifices, the idealism of the “heroic nine” who founded our specialty society, and the board and the subsequent leaders who nourished it. don’t forget your department chairmen, training officers and consultant staff who shared their time and expertise with you. they are part and parcel of your success. so there goes the remark of a french philosopher, bernard de charter: “we are like dwarfs seated on giants shoulders. if we can see far, it’s not because we are tall but because we are seated on giant’s shoulders.”3 and most of these giants are with us tonight and they are all very proud of you. good evening and thank you for the pleasure of sharing these ideas with you today. references 1. glasscock me, kraus em. the lost art of medicine: patient care is paramount in practice. ent today. 2011 aug 2. [cited 2016 sep 27]. available from:: http://www.enttoday.org/article/thelost-art-of-medicine-patient-care-is-paramount-in-practice/3/?singlepage=1. 2. greek medicine-the hippocratic oath [internet]. u.s national library of medicine. 2002 sep 16 [updated 2012 feb 07; cited 2016 sep 27]. available from: https://www.nlm.nih.gov/hmd/ greek/greek_oath.html. 3. bernard de chartres quotes [internet]. goodreads c2016. [cited 2016 sep 27]. available from: http://www.goodreads.com/author/quotes/4072421.bernard_de_chartres. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery featured grand rounds oblique facial clefts (tessier clefts) are severe orofacial clefts beyond the lip and palate that count among the rare congenital malformations “with an incidence of 1.43 to 4.85 per 100,000 births.”1,2 the tessier classification system devised by paul tessier in 1976 assigned specific caudocranial numbers to clefts involving the “soft tissue and underlying bones of the mouth, maxilla, nose, eyes and forehead” in relation to the sagittal midline of the face.1,3,4 the midline is designated 0 – 14, and adjacent clefts are numbered 1-13, 2-12 and so on, depending on the location and axis of the malformation. we present a patient with a bilateral tessier 5 cleft. case report a 4-month-old baby boy was referred to our outpatient clinic due to facial deformity. he had been born full-term via normal spontaneous vaginal delivery to an 18-year-old g1p0 mother, assisted by a mid-wife at a lying-in clinic with no fetal or maternal complications, and no history of trauma or prenatal drug intake (except for amoxicillin for urinary tract infection during pregnancy). the facial deformity was noted at birth. neither parent nor any other family member up to the second degree had a similar condition. although there was no difficulty feeding or developmental delay, incomplete closure of the right eye with reddening of the sclera and frequent tearing when asleep eventually prompted consult. on physical exam he had a right tessier facial cleft 5, originating as a lip furrow approximately 5mm medial to the right labial commissure extending upward and laterally as a groove on the cheek, ending at the junction of the middle third and lateral third of lower eye lid with ectropion and downward displacement of the lateral canthus compared with the left side. (figure 1a) the bony maxillary cleft involved the ipsilateral alveolar ridge and hard palate. (figure 1b) the soft palate was intact. there was also a mild tessier 5 on the left, beginning 10mm medial to the left commissure extending superiorly along the nasolabial area ending midway at the level of the ala, mildly involving the alveolar ridge on the same side. the facial computed tomography (ct) scan revealed a thin bony defect in the right alveolus at the premolar region extending and widening posteriorly to the lateral aspect of the hard palate. (figure 2a) an apparent thin linear defect was likewise appreciated between the left canine and first premolar mildly involving the alveolar ridge. (figure 2a) the right skeletal cleft also involved the body of the maxilla lateral to the infra-orbital foramen (figure 2b), through the infra-orbital rim and the orbital floor. (figure 2c). cleft beyond the lip and palate: a bilateral tessier cleft correspondence: dr. laurice ann b. canta department of otorhinolaryngology head and neck surgery 6th floor, east avenue medical center east avenue, diliman, quezon city 1100 philippines phone: (632) 928 0611 loc. 324 fax: (632) 435 6988 email: eamc_enthns@yahoo.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery inter hospital grand rounds. august 30, 2017. st. luke’s medical center, quezon city. laurice ann b. canta, md department of otorhinolaryngology head and neck surgery east avenue medical center philipp j otolaryngol head neck surg 2018; 33 (2): 56-59 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery featured grand rounds ba figure 1a. right facial cleft originating medial to the right labial commissure extending upward and laterally, ending at the lateral third of lower eye lid and a mild tessier 5 cleft on the left beginning medial to the labial commisure going superiorly and laterally as furrow ending midway on the cheek at the level of the ala (arrows). note ectropion and downward displacement of the lateral canthus on the right compared with the left side; b. palatal component of right maxillary cleft (dotted circle) with left facial cleft beginning medial to the lateral commissure (dashed circle). photos published in full, with permission. figure 2. ct scan a. axial view showing the thin defect between the right first molar and second premolar extending and widening posteriorly to the lateral aspect of the hard palate (oval) and an apparent thin linear defect between the left canine and first premolar mildly involving the alveolar ridge (rectangle); b. bony defect in the right maxilla lateral to the infraorbital foramen (arrowhead); and c. coronal view revealing the defect in the right maxillary bone at the inferolateral orbital wall and orbital floor (arrow). a b c philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery featured grand rounds the patient was referred to the department of pediatrics – genetics clinic for further evaluation, and karyotyping at the national institutes of health ruled out any chromosomal disorder. colleagues from the co-managing department of ophthalmology prescribed ophthalmic drops and advised lid taping while waiting for definitive surgical management. discussion facial clefts may be described as “a gap (hypoplasia), misshapen face (dysplasia), interruption or deficiency in the continuity of a soft tissue (coloboma) or fissure in the soft tissue, bone or a combination of both.”1 these craniofacial defects may be classified under the tessier classification which designates numbers to the site of the cleft. based on this classification, the patient in this report has a bilateral tessier 5 but an incomplete or mild one on the left. the etiology of tessier clefting especially tessier 5 cleft is not well understood because it cannot be explained by genetics or known processes of craniofacial fusion and embryologic development.2,3,5-7 factors that may contribute include interplay of the environment, like exposure to radiation or infection, intake of teratogens, vitamin or folate deficiency and metabolic or hematologic disorders.1,7 some postulate that it is developmental and might be due to primary stop of development,1,5 neurovascular insufficiency1-3,5 and amniotic bands.2,3,5,6 cannistra and others concluded that these defects can occur late in development when they observed that agenesis of the maxillary nerve in a 24-week-old fetus resulted in tessier no. 5 cleft.2 another theory states that facial clefts are due to genetic aberrances and that they are usually associated with congenital syndromes.1,2,6,7 a study by gfrerer et al.6 demonstrated that facial clefts can be traced to disruption in the human genome specifically to specc1l which encodes a cytoskeletal protein and its deficiency leads to failure of cell adhesion and migration. it is hypothesized that this genetic sequence is required for normal chondrocyte assemblage and molecular signaling processes leading to the fusion of frontonasal and maxillary processes and convergence of mandibular prominences.6 the many theories proposed with regard to the origin of orofacial clefting attests that this condition has no single cause; tessier 5 cleft may be due to genetic disorder, neurovascular agenesis or amniotic bands. we are not aware of any existing surgical protocol for repairing tessier 5 clefts. nevertheless, the objectives of surgery for this type of orofacial cleft are to reconstruct the lower eyelid and reposition the lateral canthus, repair the labiomaxillary cleft, and “reconstruct the orbital floor, the malar bone, and the body of the maxilla with bone grafts.”5,8 most patients also need serial surgical reconstruction to correct significant scarring and persistent facial deformity due to lack of development of the facial structures.1,5,8,9 commonly used surgical procedures include z-plasty, transposition or advancement flaps, canthopexy, commissureplasty and bone grafting.1,5,8 since tessier 5 clefts involve the eyelid region with ectropion and corneal exposure, reconstruction of the lower eyelid must be undertaken as soon as possible to prevent keratitis. a lateral tarsal strip is the traditional technique however in severe loss of lower eyelid tissue an advancement flap may be utilized which also has a more favourable scarring.5,8 multiple z-plasties can redirect and correct the cheek fissure and labial cleft in a tessier 5 cleft.1,2,5,8 there should be enough vertical length and tensionless closure in the area between the lower eyelid and upper lip to prevent asymmetry and displacement of eyelid and vermillion border when scar maturation occurs.8,9 when there is no viable soft tissue bulk left, free flaps or regional flaps and tissue expanders may be used.5,8 bone grafts from the iliac crest, ribs and calvarial bone are used reconstruct the orbital floor, malar bone and body of the maxilla.5,8 although bone failure rate is unpredictable, this is recommended to restore skeletal continuity, prevent globe prolapse and achieve facial symmetry. for this patient, the initial procedures that can be done include lateral canthopexy and repair of ectropion using lateral tarsal strip or advancement flap from the superolateral side to elevate the lateral canthus (eutrapio s. guevara, jr., expert opinion presented at the psohns inter-hospital grand rounds, august 30, 2017) and address the most immediate problem which is corneal exposure. great attention must be given during this stage to prevent disproportionate stripping or advancement leading to a narrower palpebral fissure compared to the left side (eduard m. alfanta, personal communication, august 29, 2017). (figure 3a). either side of the cheek can be repaired using multiple z-plasties to redirect and correct the continuity of the cheek fissure. (figure 3b). philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery featured grand rounds acknowledgements the author would like to acknowledge dr. eduard m. alfanta for his inputs in the surgical recommendation for the patient and his guidance during the inter-hospital grand rounds; and dr. alfred peter justine e. dizon for his continued support for this case. references rances ka, cruz et, pascual a, tinaza j. a case series of tessier 3, 4, 7 and combined 4, 7 1. craniofacial clefts. philipp j otolaryngol head neck surg. 2015; 30 (1): 34-38. cannistra` c, bontemps c, valero r, ianneti g, barbet jp. orbitofacialcleft number 5: 2. radiographic, anatomical, and histologic study of a 24week-old fetus. plast reconstr surg. 2006 dec; 118(7):1538-42. doi: 10.1097/01.prs.0000240818.64018.2a; pmid: 17102725. abdollahifakhim s, shahidi n, bayazian g. a bilateral tessier number 4 and 5 facial cleft and 3. surgical strategy: a case report. iran j otorhinolaryngol. 2013 sep; 25(73): 259-62. pmid: 24303450 pmcid: pmc3846247. tessier, p. anatomical classification of facial, cranio-facial and latero-facial cleft. 4. j maxillofac. surg. 1976 june; 4(2): 69-92. doi: 10.1016/s0301-0503(76)80013-6; pmid: 820824 da silva freitas r, alonso n, shin j, busato l, dall’ oglio tolazzi ar, de oliveria e cruz ga. the 5. tessier number 5 facial cleft: surgical strategies and outcomes in six patients. cleft palate craniofac j. 2009 mar; 46 (2): 179-186. doi: 10.1597/07-192.1; pmid: 19254060. gfrerer l, shubinets v, hoyos t, kong y, nguyen c, pietschmann p. functional analysis of specc1l 6. in craniofacial development and oblique facial cleft pathogenesis. plast reconstr surg. 2014 oct; 134(4): 748–759. doi: 10.1097/prs.0000000000000517; pmid: 25357034 pmcid: pmc4430087. demke jc, tatum iii sa. craniofacial surgery for congenital and acquired deformities. in flint 7. pw, haughey bh, lund vj, niparko jk, thomas robbin k, regan thomas j, et al. (editors). cummings otolaryngology head and neck surgery. philadelphia: saunders; 2015. p. 28912914. afifi am, djohan r, sweeney w, brooks s, connolly j, gordon cr, 8. et al. long-term follow-up of a tessier number 5 facial cleft. craniomaxillofac trauma reconstr. 2011 mar; 4 (1): 35-42. doi: 10.1055/s-0031-1272900; pmid: 22379505 pmcid: pmc3208340. galante g, dado d. the tessier number 5 cleft: a report of two cases and a review of literature. 9. plastic and reconstructive surgery. 1991 july; 88 (1): 131-135. pmid: 2052642. the incision and dissection should be brought down to the subperiosteal plane since the infraorbital nerve is spared of the bony cleft and can be preserved. soft tissue dissection should be made along the dermal fat and subcutaneous plane to allow layered closure. the periosteum and all soft tissues can be carried medially to cover the bony defect. another z-plasty might be used to reconstruct and correct the upper lip commissures and vermillion border. since the soft palate is intact, there would be no immediate problem in feeding and language development. an alveolar moulding or feeding plate can reshape the developing alveolus and palate and eventually narrow the gap of the cleft (eduard m. alfanta, personal communication, august 29, 2017). second stage reconstruction with palatoplasty and bone grafts or use of a 3-d printed bioresorbable medical grade polycaprolactone scaffold such as osteopore™ for the infraorbital and maxillary bony cleft may be postponed until conditions are optimal. factors such as bone growth and maturation must be taken into consideration to decrease the need for serial reconstruction and to come up with a better outcome as the pediatric patient grows. (eutrapio s. guevara, jr., expert opinion presented at the pso-hns inter-hospital grand rounds, august 30, 2017). figure 3. proposed surgical reconstruction for the eyelid and cheek fissure: a. lateral canthopexy either through lateral tarsal strip or advancement flap from the superolateral area; and b. multiple z-plasties to correct the cheek fissure and redirect the labial commissures and vermillion border. photos printed in full, with permission. a b as mentioned previously, there is no single surgical plan for tessier clefts and although most patients with tessier 5 cleft need serial and multiple surgical reconstructions to correct significant scarring or persistent facial deformity, a pleasing and balanced aesthetic result is achievable. aside from surgical management, proper advice for post-operative monitoring, therapy and rehabilitation may also be recommended to achieve the best aesthetic outcome for this kind of congenital deformity. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 philippine journal of otolaryngology-head and neck surgery 61 featured grand rounds laryngeal scca usually presents with hoarseness when the glottis is involved, dysphagia if the supraglottis is involved, and difficulty of breathing and stridor in subglottic invovlement. a neck mass as an initial presentation of laryngeal carcinoma is commonly linked to the involvement of the supraglottis due to its rich lymphatic drainage. about 70% of supraglottic tumours present with advanced disease (stages iii-iv),1 while 75% of glottic tumours present with localized disease (stages i-ii).1 smoking and alcohol consumption are considered highly significant etiologic factors but evidence has suggested a possible role for human papilloma virus (hpv) infection, ras oncogene activation, and gastroesophageal reflux as well.2 to the best of our knowledge, laryngeal squamous cell carcinoma has not been associated with herpes simplex virus (hsv). we report a case of laryngeal squamous cell carcinoma with an unusual presentation and peculiar histopathology, and discuss its potential association with herpes simplex virus. case report a 67-year-old man consulted for a right lateral neck mass that gradually started enlarging eight months prior to consult. there was no fever, cough, nasal discharge or congestion, hoarseness, dysphagia, difficulty of breathing, weight loss, oral ulcers, difficulty opening and closing the mouth, or facial asymmetry, and he did not consult a health professional or take any medication. he was a smoker but did not drink alcoholic beverages. he finally consulted due to the gradual increase in size of the neck mass. physical examination revealed a 6 x 7 cm hard, fixed, right neck mass involving levels ii, and iii. flexible endoscopy showed an enlarged right arytenoid with normal-looking mucosa. (figure 1 a, b). a ct scan of the neck revealed a 2.8 x 3.8 x 6.3 cm supraglottic/ glottic soft tissue mass and right-sided cervical lymphadenopathies suggestive of metastasis. (figure 2 a, b) direct laryngoscopy with biopsy of the (arytenoid) supraglottic mass and panendoscopy surprisingly revealed only an enlarged right arytenoid and no lesions in the false and true vocal folds or oral, nasopharyngeal, oropharyngeal, tracheal, and esophageal mucosa. histopathology showed focal moderate dysplasia with cytopathic changes probably herpes simplex virus infection with probable involvement of the submucosal layer requiring deeper bites for further diagnosis. at this point, although the working impression was a benign lesion, we still considered the possibility that this was a malignancy because of the dysplastic changes noted on the histopathology report. a repeat laryngoscopy with biopsy of cytopathologic herpes simplex virus features in laryngeal squamous cell carcinoma correspondence: dr. jimmy v. chang department of otolaryngology head and neck surgery saint luke’s medical center 279 e. rodriguez ave., quezon city 1102 philippines phone: (632) 727 5543 fax: (632) 723 1199 (h) email: slmcearnosethroat@yahoo.com the authors declare that this represents original material. that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. donalee d. devilleres-mendoza, m.d. jimmy v. chang, m.d. department of otolaryngology head and neck surgery st. luke’s medical center, quezon city philipp j otolaryngol head neck surg 2016; 31 (1): 61-64 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 featured grand rounds 62 philippine journal of otolaryngology-head and neck surgery figure 1b. laryngoscopy revealed slightly edematous vocal folds, with no visualized masses. figure 1a. hypopharyngeal examination showing an enlarged right arytenoid (black arrow) with no apparent mucosal involvement. figure 3. posterior view of cut larynx showing submucosal and paraglottic space involvement. figure 2a. contrast ct scan of the neck, a, axial view and figure 2b. b, coronal view, showing almost complete obliteration of the paralaryngeal space with thickening of the right false and true vocal folds. the supraglottic mass and fine needle aspiration biopsy of the neck mass yielded a histopathologic diagnosis of moderately differentiated squamous cell carcinoma and level ii lymph node metastatic scca. with a diagnosis of laryngeal scca stage iva (t3 n2b m0), a total laryngectomy with bilateral neck dissection (radical on the right and modified radical on the left) and total thyroidectomy was performed. there was a submucosal lesion confined to the supra and glottic area on the right side of the posterior aspect of the cut larynx. (figure 3) final histopathology showed moderately differentiated, keratinizing invasive squamous cell carcinoma with viral cytopathic changes. (figure 4) philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 philippine journal of otolaryngology-head and neck surgery 63 featured grand rounds discussion in this case, the patient initially presented with a lateral neck mass without associated signs and symptoms. this made it more difficult to diagnose, since neck masses can have varying etiologies involving a large number of different structures of the head and neck. squamous cell carcinoma on physical examination usually presents with an ulcerative, exophytic, or polypoid lesion.2 this patient initially showed an enlarged right arytenoid with normal-looking mucosa and no involvement of the false and true vocal folds, consistent with the absence of symptoms of hoarseness or dysphagia. considering the patient’s age and the history of smoking, a malignant neoplasm was still the most plausible explanation for the lateral neck mass and supraglottic bulge. imaging was important to evaluate deeper structures that might be involved. computed tomography is an indispensable tool for evaluating submucosal laryngeal masses or otherwise unexplainable symptoms (usually hoarseness) that might herald such a mass.3 ct scans showed involvement of the supraglottis and glottis, inconsistent with the patient’s history and physical examination findings. our patient was diagnosed to have transglottic scca with paraglottic space (pgs) involvement. paraglottic space involvement in either a glottic or supraglottic tumor is staged as t3 and is significant because the extent of the pgs means that tumors in this space may spread to involve any or all of the three regions of the larynx.2 the pgs lies lateral to the true and false vocal folds and extends laterally to the thyroid cartilage.2 anteriorly, each pgs is continuous with the paraepiglottic space, and tumors may spread along this pathway.2 transglottic tumors are an important subset of laryngeal tumors with aggressive behavior and high risk of lymphatic metastasis. the term transglottic was first used by mcgavran and associates in 1961.4 it is not used in the american joint commission and associates for cancer (ajcc) staging system and is defined by kirchner and colleagues as a tumor that crosses the ventricle in a vertical direction.4 tumors can become transglottic in four ways: by crossing the ventricle directly; by crossing at the anterior commissure; by spreading through the paraglottic space; and by spreading along the arytenoid cartilage posterior to the ventricle. the latter form of spread does not predict deep invasion: in kirchner’s series of 50 transglottic tumors studied in whole organ preparations, none of the 8 tumors with transglottic spread along the arytenoid demonstrated laryngeal cartilage invasion.4 in the same series, invasion of the laryngeal framework was seen in over half of transglottic tumors over 2 cm. cervical metastases were seen in 30% of cases; and in primary tumors greater than 4 cm in dimension, 55% of tumors had nodal metastases.4 the biopsy showed moderate dysplasia with viral cytopathic changes suggestive of submucosal rather than mucosal involvement, and this was consistent with our intraoperative findings. in general, squamous cell carcinomas histologically involve the epithelial layer of a certain structure. however, in a specific type of laryngeal carcinoma -ventriculosaccular squamous cell carcinoma -epithelial lesions are not visibly apparent.2 our case may have been similar to ventriculosaccular scca in this regard. the histopathologic slides of our patient revealed multinucleated giant cells, which resulted from fusion of cell membranes bearing viral glycoproteins. (figure 4) alterations in the cell nuclei and cytoplasmic tails between the cells were seen. these cytopathic effects (cpe) are seen in hsv-infected cells. this is another issue because herpes viruses are less likely linked to laryngeal malignancies. herpes simplex virus (hsv) is less strongly correlated with the development of oral carcinomas than ebv or hpv.5 on the other hand, serologic studies have shown that patients with head and neck cancer have higher levels of igm antibody to hsv type one than control ‘subjects.6,7 hsv can transform cells in vitro to a malignant phenotype. this may be due to an hsv-encoded peptide that increases mutagenicity of infected cells. in one series of 31 young adults with head and neck cancer, antipeptide antibody levels were significantly higher in the patients than in control subjects.8 however, most of the studies generalized the association of viruses with malignancies of the oral cavity in general, not with laryngeal carcinoma alone. the question regarding which caused which is left; did the figure 4. histopathologic section of laryngeal specimen, (hematoxylin and eosin high power magnification 40x) showing multinucleated giant cells that result from fusion of cell membranes bearing viral glycoproteins. (hematoxylin – eosin , 40x) philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 featured grand rounds 64 philippine journal of otolaryngology-head and neck surgery herpes virus cause the laryngeal scca or was it a superimposed infection due to the patient’s immunocompromised state? head and neck carcinomas are closely linked to epsteinbarr and human papilloma viruses, particularly carcinoma of the nasopharynx and the oral cavity respectively. at present, accepted causal associations between viruses and human cancer include hpv and cervical cancer; human t-lymphotrophic virus type-1 (htlv-1) and adult t-cell leukemia and lymphoma; hepatitis b and c and liver cancer, epstein–barr virus (ebv) and nasopharyngeal cancer, burkitt’s and hodgkin’s lymphomas, and some non-hodgkin’s lymphomas; and human herpes virus 8 (hhv-8) and kaposi’s sarcoma.9 there may or may not be an association between herpes simplex virus and laryngeal scca, but our experience suggests that the matter is worth investigating. the clinical history and physical examination findings may not always reveal the true extent of disease, and imaging modalities may mislead, but the complementary nature of all these should be considered vis-àvis intraoperative findings and final histopathologic results. acknowledgements we thank dr. ronaldo g. soriano for providing case details and intraoperative photos; dr. ann margaret v. chang for interpreting the slides and raising the possible association between laryngeal scca and herpes simplex virus; and dr. cecilia gretchen navarro-locsin for help with the literature review and final editing. we also thank dr. christian neil f. romero for help with editing, and our chairs dr. ray casile (qc) and dr. william lim (bgc) and residency training officers dr. joseph arañas (qc), and dr. keith aguilera (bgc) for their continued support. references 1. koufman ja, burke aj. the etiology and pathogenesis of laryngeal carcinoma. otolaryngol clin north am j. 1997 feb; 30(1): 1-19. 2. armstrong wb, vokes de, verma sp. malignant tumors of the larynx. in: flint pw, haughey bh, lund v, niparko jk, robbins kt, thomas jr, lesperance mm, editors. cummings otolaryngology head and neck surgery, 6th edition, volume 2. philadelphia: saunders. 2015. p. 1601-1633. 3. saleh em, mancuso aa, stringer sp. ct of submucosal and occult laryngeal masses. j comput assist tomogr. 1992 jan-feb;16(1):87-93. 4. kirchner ja, cornog jr jl, holmes re. transglottic cancer: its growth and spread within the larynx. arch otolaryngl. 1974 apr: 99(4):247-251. 5. stenson km. epidemiology and risk factors for head and neck cancer. uptodate® 2016 june [cited june 2016] available from: http://www.uptodate.com/contents/ epidemiology-and-risk-factors-for-head-and-neck-cancer. 6. shillitoe ej, greenspan d, greenspan js, silverman s jr. five-year survival of patients with oral cancer and its association with antibody to herpes simplex virus. cancer 1986 nov; 58(10): 2256-9. 7. larsson pa, edström s, westin t, nordkvist a, hirsch jm, vahlne a. reactivity against herpes simplex virus in patients with head and neck cancer. int j cancer. 1991 aug 19; 49(1):14-8. 8. das cm, schantz sp, shillitoe ej. antibody to a mutagenic peptide of herpes simplex virus in young adult patients with cancer of the head and neck. oral surg oral med oral pathol. 1993 may; 75(5):610-4. 9. brower v. connecting viruses to cancer: how research moves from association to causation. j natl cancer inst. 2004 feb 18; 96(4): 256-257. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery case reports abstract objective: to describe a surgical technique in the treatment of arteriovenous malformations of the mandible methods: design: case report setting: tertiary national university hospital participants: one result: a 16-year-old boy underwent resection, extracorporeal curettage and immediate replantation of the hemimandible for intraosseous arteriovenous malformation. postoperative follow up and imaging  at oneand six-months showed no signs of recurrence, new bone formation and consolidation of the replanted right mandible with good symmetry and function. conclusion: extracorporeal curettage followed by immediate replantation of the resected mandible seems to have yielded good early results in our case and may be a viable alternative especially when access to highly specialized microvascular surgical services is limited. keywords: arteriovenous malformation; mandible, abnormalities; extracorporeal curettage intraosseus arteriovenous (av) malformations of the mandible are extremely rare and can cause significant morbidity and even mortality. arriving at the correct diagnosis is oftentimes difficult due to the nonspecific signs and symptoms and absence of pathognomonic radiographic features. we present the case of a boy with a chronic history of on-and-off bleeding from and a unilateral swelling of the mandible that was misdiagnosed, causing morbidity and delay in treatment. case report a 16-year-old boy presented in our emergency room for intraoral bleeding and an expanding mass at the angle of the right mandible. the condition started 6 years prior to consult when the then 10-year-old patient developed spontaneous intraoral bleeding of the right mandible around the area of the second molar. he was brought to a hospital where tranexamic acid stopped the bleeding. a dentist extracted the tooth with profuse bleeding that was again controlled by tranexamic acid. over the next 4 years progressive swelling was noted on the right angle of the intraosseus arteriovenous malformation of the mandible: extracorporeal curettage and immediate replantation erik a. tongol, md alfredo q.y. pontejos, jr., md phillip b. fullante, md arsenio claro a. cabungcal, md kimberly mae c. ong, md department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: dr. alfredo q.y. pontejos, jr. department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 554 8400 local 2152 email: orl.up.pgh@gmail.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery interesting case contest (3rd place). may 12, 2018. citystate asturias hotel, puerto princesa, palawan. philipp j otolaryngol head neck surg 2019; 34 (1): 56-59 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery case reports mandible with intermittent bleeding that resolved spontaneously. the patient eventually developed a depressed mood and suicidal ideations which affected his schooling and social relationships. two years prior to consult, the mandibular mass was assessed to be an odontogenic cyst at another hospital but an attempted biopsy was deferred due to profuse bleeding. he underwent emergency tracheostomy due to the bleeding and impending respiratory failure and was subsequently sent home. except for the mandibular mass and tracheostomy, he remained apparently well and asymptomatic until a day prior to consult when intraoral bleeding finally brought them to our institution. on examination, there was a soft, pulsating, movable non-tender 6 x 6 x 5cm mass over the angle of the right mandible with audible bruits. (figure 1) the overlying skin was normal in color and there was no paresthesia. contrast-enhanced computed tomography (ct) scans showed an expansile lytic lesion with cortical thinning involving the right mandibular angle and ramus. axial and coronal ct images showed tortuous arterial vessels arising from the right external carotid artery supplying the enhancing mandibular av malformation with extension to the right masseter. (figures 2a, b and 3a) angiography showed feeding arteries arising from the right external carotid artery (facial and maxillary branches) with draining tributaries from the anterior and internal jugular veins (common facial vein). the nidus was measured to be 7 x 5 x 6 cm. (figure 3b) the patient was diagnosed with av malformation of the mandible and underwent preoperative embolization and surgical treatment under general anesthesia the following day. surgical technique through a submandibular incision with lip split, the aberrant branch of the right internal jugular vein and the right external carotid artery were ligated. the soft tissue component of the arteriovenous malformation was excised before exposing the mandible. the proximal and distal extent of the intraosseus component of the right mandible was identified, followed by pre-bending of the reconstruction plate to conform to the mandible. segmental mandibulectomy using a gigli wire was done at the ascending ramus and at the junction of the right canine and first premolar. using an extracorporeal technique, the teeth in the involved segment were extracted followed by curettage and hollowing of the mandible. (figures 4a and 4b) replantation of the cortical shell was achieved with a 17-hole titanium reconstruction plate and 7 screws. (figure 4c) maxillo-mandibular fixation was applied with erlich arch bars on the contralateral side. the postoperative course figure 1. preoperative facial photograph of patient. note the mass on the right mandible (solid arrow). (photo published with permission). was uneventful and the patient was decannulated and subsequently sent home. on follow up after three weeks, there was still soft tissue swelling but no more episodes of oral bleeding, allowing him to return to school and slowly readjust to his normal daily activities. (figure 5a) a panoramic radiograph at oneand 6-months post operation showed no signs of recurrence, new bone formation and consolidation of the replanted right mandible with good symmetry and function. (figures 5b and 5c) discussion vascular malformations of the mandible have been referred to as “great radiologic imitators” and can look like any lesion, ranging from a cyst to a malignancy, with no pathognomonic radiographic features of its own.7 it can be mistaken for odontogenic cysts or ameloblastoma because it most commonly appears as a poorly defined, multilocular radiolucent image, often with the appearance of honeycomb or soap bubbles.8 this case was initially mistaken to be an odontogenic cyst and a biopsy was attempted leading to significant morbidity. physician awareness of this clinical entity as a differential diagnosis may lessen such morbidities. ct angiography remains the gold standard to delineate the location and number of feeding vessels and the pattern of drainage. in this case, with the help of the patient’s ct angiography the feeding arteries from philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery case reports figure 4. intraoperative photos a. showing extraction of teeth and curettage of lesion from resected mandibular segment b. resected right mandibular cortical shell after extracorporeal tumor resection of the malformation c. showing replantation of mandibular segment and fixation with 17hole reconstruction plate. (s, superior; i, inferior; r, right; l, left) b a c figure 2. ct images a. axial bone window and b. axial soft tissue window, showing cortical thinning (arrow) and arterial feeders from the right external carotid artery (arrow). a b figure 3. ct images a. coronal soft tissue window b. angiogram of the right external carotid artery showing feeding arteries from right external carotid artery (arrow) and a nidus measuring 7x5x6cm (arrow) a b the right external carotid artery were identified. this is helpful to the surgeons as the goal of treatment is to identify and remove the nidus of the av malformation which represents the core of the pathological process of these malformations.2 the current recommended treatment for such large field defects with extensive collateral circulation is hemimandibulectomy, resulting in a major cosmetic and functional deformity which only can be repaired by immediate primary or secondary reconstruction. the conventional figure 5. postoperative photos a. 3 weeks, showing swelling of the right mandibular area, with good alignment of lower mandibular border b. panoramic radiograph of patient at 1-month showing good symmetry c. panoramic radiograph of patient at 6-months showing good symmetry and take of graft. (photo published with permission). a b c philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery case reports references 1. kohout mp, hansen m, pribaz jj, mulliken jb. arteriovenous malformations of the head and neck: natural history and management.  plast reconstr surg. 1998 sep;  102(3): 643-654. pmid: 9727427. 2. kaderbhai j, breik o, heggie aa, penington aj. high-flow paediatric mandibular arteriovenous malformations: case reports and a review of current management.  int j oral maxillofac surg. 2017 dec; 46(12): 1650-1655. doi: 10.1016/j.ijom.2017.06.011; pmid: 28705626. 3. theologie-lygidakis, n., schoinohoriti, o., tzermpos, f., christopoulos, p., iatrou, i., & petersson, a. (2015). management of intraosseous vascular malformations of the jaws in children and adolescents: report of 6 cases and literature review. j oral maxillofacl res. 2015 jun 30; 6(2): e5. doi: 10.5037/jomr.2015.6205; pmid: 26229584 pmcid: pmc4516857. 4. fowell c, jones r, nishikawa h, monaghan a. arteriovenous malformations of the head and neck: current concepts in management.  br j oral maxillofac surg. 2016 jun; 54(5): 482-7. doi: 10.1016/j.bjoms.2016.01.034; pmid: 27020371. 5. fahrni jo, cho ey, engelberger rp, baumgartner i, von kanel r. quality of life in patients with congenital vascular malformations [abstract]. j vasc surg venous lymphat disord. 2014 jan; 2(1): 46-51. doi: 10.1016/j.jvsv.2013.09.001; pmid: 26992968. 6. shum jw, clayman l. resection and immediate reconstruction of a pediatric vascular malformation in the mandible: case report.  oral surg oral med oral pathol oral radiol endod. 2010 apr; 109(4), 517-524. doi: 10.1016/j.tripleo.2009.10.020; pmid: 20097586. 7. dwivedi an, pandey a, kumar i, agarwal a. mandibular arteriovenous malformation: a rare life threatening condition depicted on multidetector ct angiography. j oral maxillofac pathol. 2014 jan; 18(1): 111-3. doi: 10.4103/0973-029x.131930; pmid: 24959049 pmcid: pmc4065426. 8. noreau g, landry p, morais d. arteriovenous malformation of the mandible: review of literature and case history. j can dent assoc. 2001 dec; 67(11): 646-651. pmid: 11841745. 9. behnia h, motamedi mh. treatment of central arteriovenous malformation of the mandible via resection and immediate replantation of the segment: a case report. j oral maxillofac surg. 1997 jan; 55(1): 79-84. doi:10.1016/s0278-2391(97)90453-5; pmid: 8994473. 10. behnia h, ghodoosi i, motamedi, mh, khojasteh a, masjedi a. treatment of arteriovenous malformations: assessment of 2 techniques—transmandibular curettage versus resection and immediate replantation.  j oral maxillofac surg. 2008 dec; 66(12): 2557-2565. doi: 10.1016/j. joms.2008.06.056; pmid: 19022136. 11. singh v, bhardwaj p. arteriovenous malformation of mandible: extracorporeal curettage with immediate replantation technique.  natl j maxillofac surg. 2010 jan; 1(1), 45-49. doi: 10.4103/0975-5950.69168; pmid: 22442550 pmcid: pmc3304184. 12. schneider c, wagner a, hollmann k. treatment of intraosseous high flow arteriovenous malformation of the mandible by temporary segmental ostectomy for extracorporal tumour resection: a case report. j craniomaxillofac surg., 1996 oct; 24(5): 271-275. doi:10.1016/s10105182(96)80057-6; pmid: 8938507 13. shum jw, clayman l. resection and immediate reconstruction of a pediatric vascular malformation in the mandible: case report.  oral surg oral med oral pathol oral radiol endod., 2010 apr; 109(4): 517-524. doi: 10.1016/j.tripleo.2009.10.020; pmid: 20097586. 14. gallagher dm, hilley d, epker bn. surgical treatment of an arteriovenous malformation of the mandible in a child. j maxillofac surg. 1983 dec; 11(6): 279-283. doi:10.1016/s03010503(83)80066-6; pmid: 658. surgical option of resection, reconstruction and bone grafting entails prolonged operative time, more blood loss, donor site disfigurement, possible disruption of growth and dependence on highly specialized microvascular surgeons. a surgical option that addresses the morbidities associated with the conventional method is radical tumor resection, extracorporeal curettage with immediate replantation of the resected mandibular segment after removal of the pathologic tissue.9-13 this method was first described by schneider, et al. in 1996 where they reported that this technique does not adversely affect anatomical morphology, mandibular growth nor neuromuscular function.12 they claimed that this method maintained the continuity of the mandible and return to normal mandibular function was possible sooner.12 this method is appropriate in this case because of the patient’s very young age and its potential of not significantly disrupting mandibular growth and function. the use of immediate reconstruction with the patient’s own free mandibular segment preserved facial symmetry and avoided the additional morbidity associated with a second operation for reconstruction of the resection site and at the donor site for the bone graft.13 further, this method enabled removal of all abnormal vascular tissue, thereby minimizing the problem of postoperative recurrence.10 theoretically, the hollowed cortical shell acts as an autogenous osteoinductive and osteoconductive medium, providing a structural graft which acts as a scaffold for bony ingrowth, at the same time, inducing local growth factors to stimulate bone healing.9 should the replanted segment succeed in the long term, maintaining mandibular form and masticatory function provide the best physiological matrix for favorable growth and development.14 this technique of resection, extracorporeal curettage and immediate replantation may be a viable option for treating such lesions without need for free tissue or bone transfers. it seems to have yielded good early results in our case and may be a viable alternative especially when access to highly specialized microvascular surgical services is limited. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 51 surgical innovations and instrumentation philipp j otolaryngol head neck surg 2016; 31 (2): 51-53 c philippine society of otolaryngology – head and neck surgery, inc. true congenital macroglossia surgically managed using a modified kole technique jenifer c. smith, md gil m. vicente, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. gil m. vicente department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 711 9491 local 320 email: gmvicentemd@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery surgical innovation and instrumentation poster contest, december 2, 2014. sofitel philippine plaza hotel, manila. abstract objective: to describe a 2-year-old boy with true congenital macroglossia surgically managed using a modified kole technique. methods: design: surgical innovation setting: tertiary government hospital patient: one results: a 2-year-old boy presented with congenital macroglossia, associated with difficulty feeding and phonating. on physical examination, the massive tongue had both increased length and width. at rest, it protruded between the upper and lower teeth with drying and fissuring of the tip. dribbling of saliva and mandible prognathism were also noted. the child was surgically treated with a modified kole technique, wherein the apex of the anterior wedge resection was extended to the posterior third midline. final histopathology was consistent with cavernous hemangioma. conclusion: the modified kole technique proved viable as the postoperative results were considered satisfactory. tongue volume was uniformly reduced in length and width enabling mouth and jaw closure while tongue sensation and mobility were preserved. feeding, speech intelligibility and cosmesis were markedly improved. future application of this modification may prove its usefulness. keywords: macroglossia; glossectomy; congenital macroglossia macroglossia is an enlargement of the tongue that leads to functional and aesthetic problems. although uncommon, this disorder has a variety of etiologies and cause significant morbidity.1 macroglosia may be defined as either true macroglossia or relative macroglossia. in true macroglossia, the tongue size is larger than normal, whereas in relative macroglossia, the oral cavity is not large enough to accommodate the tongue.1,2 vascular anomalies encompass vascular tumors and malformations, which involve the head and neck 70% to 80 % of the time. treatment depends on the site, size, and appearance of the lesion and the functional and aesthetic problems. in general, medical therapy is ineffective for congenital hemangiomas.3 functional and aesthetic problems were the main indication for surgery in this case. glossectomy approaches include peripheral and midline resections providing either reduction in length and/or width.4 among these, the kole technique reduces the length and thickness of the anterior third of the tongue but does not address the base leaving it thick and wide.4 we present a modified kole technique to solve this problem in a child with macroglossia. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 surgical innovations and instrumentation 52 philippine journal of otolaryngology-head and neck surgery case report a 2-year-old boy presented to us with a congenitally enlarged tongue and associated difficulty feeding and phonating. on physical examination, the tongue was enlarged, increased in both length and width. in its resting state, protruded between the upper and lower teeth, with drying and fissuring at the tip. (figure 1) dribbling of saliva and a prognathic mandible were also present. no other physical abnormalities were noted. a ct scan of the oral cavity revealed a markedly enlarged tongue involving at least the anterior 2/3 with outward protrusion. surgical technique the objectives of surgery were to enable mouth and jaw closure while maintaining tongue mobility and sensation. the tongue was maintained in place using silk sutures at the tip and on each side of the tongue. an outline of the glossoplasty incision and neurovascular bundle were made. (figure 2) using an evac™ 70 xtra hp coblation™ wand (arthrocare corp., austin, tx, usa), a wedge-shaped partial glossectomy of the anterior 1/3 of the tongue was performed followed by an extended midline triangular incision with the apex pointing posteriorly over the middle 1/3. tongue margins were approximated using polyglactin 910 sutures (vicryl 3.0, ethicon, johnson & johnson, nj, usa). (figure 3) surgical outcomes tongue volume was uniformly reduced in both length and width. blood loss was minimal and no dessication or charring of tissues was noted. his tongue healed uneventfully. the final histopathologic result was consistent with cavernous hemangioma. one week postoperatively, the patient still had habitual mouth opening but could close his mouth and jaw on conscious effort. there was marked improvement in phonation intelligibility and feeding. (figure 4) on follow-up at 9 months, there was no limitation in tongue movement. he did not have any feeding problems. his habit of keeping his mouth open had already disappeared. no general and taste sensation problems were noted. speech was intelligible, however he had difficulty producing the “r” speech sound and there was still prognathism of the mandible. (figure 5) discussion the decision to surgically treat macroglossia should be based in part on assessment of the level of functional debility and cosmetic problems. indications for surgery include airway obstruction, speech difficulties, feeding problems and cosmesis. the basis for surgical success include proper position of the tongue in the oral cavity, functional tongue mobility, mouth opening and closure, improvement in feeding, articulation, preservation of sensation and taste, and airway improvement.2,4-6 in this case, indications for surgery included speech difficulties, feeding problems and cosmesis. figure 5. nine months follow up with no more habitually-open mouth and no limitation in tongue movement. figure 1. (front view) tongue in resting position figure 2. outline of glossoplasty incision figure 4. one week post operatively, still with habitual mouth opening but able to close mouth on conscious effort. figure 3. wedge-shaped partial glossectomy of anterior third a. followed by extended midline triangular incision b. and reapproximation c, d. a c b d philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 53 surgical innovations and instrumentation a number of different approaches for tongue reduction have been advocated. rather than using one approach for all patients, each case should be evaluated and the appropriate surgical approach chosen.6 the techniques are subdivided into median line and peripheral glossectomies.2 regardless of the approach taken, the initial resection should be conservative to prevent permanent problems from overly aggressive resection.6 in 1950, edgerton described a technique consisting of an elliptical excision along the center of the tongue with a view to spare the nerves, figure 6. edgerton figure 7. dingman and grabb figure 8. gupta figure 9. morgan figure 10. kole references 1. murthy p, laing mr. macroglossia. bmj. 1994 nov;309(6966):1386-7. doi: http://dx.doi. org/10.1136/bmj.309.6966.1386 pubmed pmid: 7819836 pmcid: pmc2541322. 2. cymrot m, teixeira f, sales f, neto f. subtotal glossectomy by modified keyhole lingual resection technique for the treatment of true macroglossia. rev bras cir plást. 2012 jan-mar; 27(1):165-9. doi: http://dx.doi.org/10.1590/s1983-51752012000100028. 3. perkins ja, chen ey. vascular anomalies of the head and neck. in: flint pw, haughey bh, niparko jk, richardson ma, robbins kt, thomas jr, editors. cummings otolaryngology head and neck surgery, 5th ed. vol 3. philadelphia: mosby elsevier; 2010. p. 2822-25. 4. davalbhakta a, lamberty bg. technique for uniform reduction of macroglossia. br j plast surg. 2000 jun; 53(4): 294-97. doi: 10.1054/bjps.1999.3311 pubmed pmid: 10876252. 5. myers en. tongue reduction procedures. operative otolaryngology: head and neck surgery, 2nd ed. vol 1. philadelphia: saunders / elsevier; 2008. p.161-67. 6. taher a. surgical correction of the enlarged tongue. the internet journal of head and neck surgery. 2008;3(1). [cited 2013 nov]. available from: http://ispub.com/ijhns/3/1/5989#. 7. gard a, gilman l, goman, j. speech and language development chart, 2nd ed. austin tx:proed; 1993. [cited 2014 oct]. available from: http://www.ccr4kids.org/portals/0/pdfs/language%20 development%20chart.pdf. artery and papillae.4,5 (figure 6) the technique only reduces the width and does not reduce thickness and length.2,4 peripheral excision techniques described by dingman and grabb, and gupta suffer from the drawback of reducing the bulk of the tongue at the periphery while leaving the center and base bulky.4,5 (figures 7 and 8) to combat the problem of an ankylosed globular tongue seen in some anterior tongue reductions, morgan et al. described the keyhole subtotal glossectomy, wherein a posterior circular incision was added to the anterior wedge excision. (figure 9) keyhole glossectomy decreases both length and thickness of the anterior tongue.2,4,5 in 1965, kole proposed an anterior triangular wedge excision of the tongue. (figure 10) this technique reduced the length and thickness of the anterior third of the tongue but did not address the base of the tongue, leaving it thick and wide.4,5 in our case, the initial anterior wedge excision following the kole technique provided adequate reduction in tongue length but width reduction was unsatisfactory. hence, we modified the technique by extending the apex of the anterior triangular wedge to the posterior third midline providing additional and adequate reduction in tongue width. we preserved the neurovascular bundle that lies approximately midway between the lateral tongue margin and the tongue midline. further tongue width reduction via the posterior midline triangular wedge was achieved while sparing the proximal portion of the neurovascular bundle, as the excision did not encroach into the area of the bundle, thus sparing tongue mobility and sensation. our modification of the kole technique proved to be viable as the postoperative results were considered satisfactory. there was minimal blood loss. tongue volume was uniformly reduced in both length and width enabling mouth and jaw closure while tongue sensation and mobility were preserved. appearance, feeding, and speech intelligibility were markedly improved although difficulty in uttering “r” speech sound was noted. this could be attributed to the patient’s age, as the “r” speech sound is only accurately used by 75% of children by age 5 years.7 future application of this modification may demonstrate its usefulness. philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to compare surgical outcomes (operative time and tympanic membrane graft uptake) obtained by endoscopic transcanal tympanoplasty (et) and microscopic post-auricular tympanoplasty (mt) in patient with inactive chronic otitis media. methods: design: retrospective cohort setting: multicenter study in 3 private tertiary hospitals participants: 18 patients who underwent microscopic or endoscopic tympanoplasty for chronic otitis media. results: each group had 9 patients with median age of 43 (31-65 years) for the mt and 47 (29-59 years) for the et group. there was no significant difference in median age of the two groups (mann-whitney u=17, p=.22). male: female ratio was (5:4) and (6:3) for the et and mt group, respectively, with no significant difference in gender distribution (c2= 0.90, p=.34). mean operative time for the et and mt group was 86.7 minutes and 140.6 minutes, respectively, with significantly lower mean operative time for the et group (t= 3.57, p=.0025). there was complete tympanic membrane graft uptake in both groups. conclusion: regardless of technique, tympanoplasty is an effective surgical treatment among patients with inactive chronic otitis media. endoscopic tympanoplasty may be an alternative to conventional microscopic tympanoplasty that may use less operative time, producing similarly complete graft uptake. keywords: chronic otitis media, tympanoplasty, endoscopic tympanoplasty, microscopic tympanoplasty, perforation, tympanic membrane tympanoplasty is a surgical procedure that conventionally utilizes an operating microscope to visualize the tympanic membrane and middle ear and is commonly performed in the philippines. although the use of endoscopes has traditionally been limited to paranasal sinus surgeries,1 several reports have been made on endoscopic tympanoplasty worldwide.1-5 in our country, however, there is a scarcity of studies on endoscopic techniques for micro-otologic operative time and tympanic membrane graft uptake in endoscopic transcanal versus microscopic post-auricular tympanoplasty for chronic otitis media jenina rachel d.j. escalderon, md william l. lim, md department of otorhinolaryngology head and neck surgery university of santo tomas, manila, philippines correspondence: dr. william l. lim department of otorhinolaryngology head and neck surgery university of santo tomas hospital españa blvd., sampaloc manila 1015 philippines phone: (632) 731 3001 local 2411 email: ust_enthns@yahoo.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology – head and neck surgery 61st annual convention and 10th international symposium on recent advances in rhinosinusitis and nasal polyposis. free paper presentation. november 30, 2017. manila hotel, manila, philippines. presented at 2018 research fortnight: poster exhibition. february 20, 2018. cme auditorium, university of sano tomas, españa, manila. presented at the 10th international academic conference in otology, rhinology and laryngology. march 1-3, 2018. fairmont hotel, makati city presented at the 2nd international conference on ear, nose and throat disorders. may 14-15,2018. osaka, japan. philipp j otolaryngol head neck surg 20178; 33 (1): 25-29 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles surgery and the practice of endoscopic tympanoplasty is limited. while endoscopy opens more surgical access options for otologic surgery, it requires the surgeon to trade the binocular hands-free microscope for the monocular, technically more challenging endoscope;6 a technique with which most otologic surgeons may not be as familiar. our search of the english literature using the keywords “endoscopic” “tympanoplasty” “philippines” on medline (pubmed), cochrane, herdin and google scholar yielded no published reports on endoscopic tympanoplasty in the country. through this retrospective cohort, we attempt to evaluate the application of this approach among filipino patients by comparing with the conventional approach. specifically, this study aims to determine the operative time and tympanic membrane graft uptake of endoscopic endaural tympanoplasty compared to microscopic post-auricular tympanoplasty in patients with inactive chronic otitis media. methods with institutional board review (irb) approval (university of santo tomas hospital protocol irb-2017-06-120-tr) this retrospective cohort retrieved the medical records of all patients with inactive chronic otitis media who underwent endoscopic or microscopic tympanoplasty by a single surgeon (wl) in any of three tertiary hospitals -st. luke’s medical centerbonifacio global city (slmc-bgc), university of santo tomas hospital (usth) and hospital of the infant jesus (hij) from january 2015 august 2017. records with operative techniques and preand post-operative notes and video otoscopy findings were considered for inclusion. excluded were medical records with incomplete data, those of patients in whom cortical mastoidectomy or mastoid antrotomy with tympanoplasty was performed, or records of patients who had previous surgery for chronic otitis media and those with ossicular discontinuity. medical records were selected, assigned a reference number and data was de-identified by the principal investigator (je). demographics such as age and gender including surgical approach, duration of surgery and postoperative complications were tabulated by the same investigator. based on video otoscopic findings in hospital charts, preoperative tympanic membrane perforation was classified into 3 groups by je following the method of ambani et al.:7 25-50% perforation was classified as medium; 51 to 75% as large; and 76% or more as subtotal/ total. standard surgical techniques had been employed for microscopic post-auricular tympanoplasty (mt) and endoscopic transcanal tympanoplasty (et) by a single surgeon. surgical techniques microscopic tympanoplasty (mt) microscopic techniques utilized a post-auricular approach using an opmiò vario/s88 (carl zeiss, oberkochen, germany) or leica m720 oh5 (surgitech, usa) operating microscope. lidocaine 2% (xylocaine, aspen, france) with 1:100,000 epinephrine (adrenaline, par pharmaceutical inc, usa) was infiltrated subcutaneously over the post-auricular area and anterior external auditory canal (between tragus and triangular fossa). a post auricular skin incision using blade 15 (feather, germany) was carried down to the subcutaneous layer exposing fascia. a weitlaner sharp self-retaining retractor (bv206r, aesculap, usa) was placed and an approximately 2 x 2 cm superficial temporalis fascia graft was harvested and dried over a metal medicine glass. a t-incision was carried down through periosteum and periosteal flaps were developed using a langenbeck periosteal elevator (aesculap, usa). external auditory canal skin along with the first layer of tympanic membrane was elevated using a drum elevator. microcotton balls soaked in pure epinephrine were used to control mucosal bleeders. a rosen pick needle (bausch+lomb storz, n16901, tuttlingen, germany) was used in freshening the edges of the tympanic membrane perforation. the graft was then placed by underlay technique, the tympanomeatal flap was replaced and secured with gelfoam (ferrosan, soborg, denmark) packing. the post-auricular incision was closed in layers using absorbable sutures. endoscopic tympanoplasty transcanal approaches used endoscopes measuring 3.0 mm with both 0 and 30 degree angles (karl storz gmbh & co. kg tuttlingen, germany) connected to a camera connector, light source and high definition monitor (richard wolf, endocam performance hd and endolight led 1.1, knittlinge, germany). lidocaine 2% (xylocaine, aspen, france) and 1:100,000 epinephrine (adrenaline, par pharmaceutical inc, usa) was infiltrated in the facial side of the tragal cartilage followed by a 1.5 cm skin incision over the dome of the tragal cartilage with a no. 15 scalpel blade (feather, germany). the incision was extended through the skin and cartilage with the perichondrium. the subcutaneous tissue was dissected laterally from the perichondrium and the cartilage was retracted superiorly with forceps and incised using metzenbaum blunt scissors (bc277r, aesculap, usa). a vertical incision was made with a scalpel into the inferior part of the tragus to completely mobilize the tragal graft. the harvested graft was placed in a sterile water-filled medicine cup. using standard microotologic ear surgical instruments (n1705 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles ent surgery set, karl storz, tuttlingen, germany) the tympanomeatal flap was raised via underlay technique from 6 o’ clock to 12 o’ clock position. (figure 1a) the middle ear was inspected. (figure 1b) the harvested tragal cartilage graft was inserted into the middle ear and kept inferiorly at the handle of malleus, resting on the posterior canal wall. (figure 1c) the graft was then placed by underlay technique, the tympanomeatal flap was replaced and secured with gelfoam (ferrosan, soborg, denmark) packing. (figure 1d) post-operative procedures the microscopic group had sterile cotton placed in the cavum concha and a 2 mm elastic bandage was applied over the mastoid area while the endoscopic group had sterile gauze applied over the tragus secured with medical tape. all patients were given post-operative medications (analgesics, antibiotics and decongestants) and advised to avoid valsalva, forceful blowing of nose and straining. regular weekly follow up was done. sutures were removed one week post operatively, antibiotic otic drops were started at the third and fourth week post-operatively and tympanic membrane graft uptake was evaluated by the same surgeon (wl) at two months, and a video otoscopy recording was included in the medical record. data collection and analysis patients were divided according to operative technique into the microscopic tympanoplasty (mt) and endoscopic tympanoplasty (et) group by the principal investigator (je). outcome measures were operative time and tympanic membrane graft uptake. the mean operative time was defined as the time-marked incision to the timemarked end of surgery based on operating room records accomplished c d a b figure 1. representative images of transcanal endoscopic tympanoplasty in one patient. a. elevation of tympanomeatal flap; b. middle ear is inspected; c. graft placed in the posterior canal wall; and d. tympanomeatal flap secured with gelfoam. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles figure 2. bar graph showing distribution of pre-operative tympanic membrane perforation size for both groups. figure 3. a. the endoscopic view allows the surgeon to access the deep recesses with an angulated endoscope; b. the microscopic technique provides a magnified view with a linear focus. manipulation of the whole microscope is needed to visualize other parts of the middle ear. by operating room staff for all patients. successful graft take was defined as complete closure of the perforation documented at 2 months post operation with video otoscopy recorded by the surgeon utilizing a 3.0 mm 0° endoscope (karl storz gmbh & co. kg – tuttlingen, germany), based on review of video recordings by the investigator, je. statistical computations utilized ibm spss statistics for windows, version 19.0. (ibm corp., armonk, ny). the mann-whitney test was utilized to check the difference in median age between the two groups while the t-test was used to check the significant difference in the mean operative time between the two techniques. the chi-square test was then utilized to check the difference in sex and perforation between the mt and et groups. an alpha(a) of 0.05 or 95% level of confidence was assumed for this study. results a total of 18 patients fulfilled inclusion and exclusion criteria and were included, 9 in the transcanal endoscopic technique (et) group and 9 in the post-aural microscopic technique (mt) group. there were 10 males and 8 females overall, with 4 males (44%) and 5 females (56%) in the et group and 6 males (67%) and 3 females (33%) in the mt group. there was no significant difference in gender distribution of both groups (c2= 0.90, p=.34). the median age was 43 (31-65 years) for the mt and 47 (29-59 years) for the et group. there was no significant difference in median age between the two groups (mann-whitney u = 17, p =.22). of the 18 ears, 3 had medium perforation (2, 22% underwent et; 1, 11% underwent mt), 8 had large perforations (5, 56% underwent et; 3 33% underwent mt), and 7 had subtotal/total perforation (2, 22% underwent et; 5, 56% underwent mt). there was no significant difference in perforation between the two groups (c2=2.12, p=.35). (figure 2) the mean operative time for the et group was 86.7 (range 60105) minutes compared to 140.6 (range 90-240) minutes for the mt a b philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles references zollner f. the principles of plastic surgery of the sound-conducting apparatus. 1. j laryngol otol. 1955 oct; 69(10):637-52. pmid: 13263770. akyigit a, sakallioglu o, karlidag t. endoscopic tympanoplasty, 2. j otol. 2017 apr; 12: 62-67. doi: 10.1016/j.joto.2017.04.004. ayache s. cartilaginous myringoplasty: the endoscopic transcanal procedure. 3. eur arch otorhinolaryngol. 2013 mar;270(3):853-60. doi: 10.1007/s00405-012-2056-x; pmid: 22639200. tseng cc, lai mt, wu cc, yuan sp, ding yf. learning curve for endoscopic tympanoplasty: 4. initial experience of 221 procedures. j chin med assoc. 2017 aug; 80(8): 508-514. doi: 10.1016/j. jcma.2017.01.005; pmid: 28465109. choi n, noh y, park w, lee jj, yook s, choi je, et al. comparison of endoscopic tympanoplasty 5. to microscopic tympanoplasty. clin exp otorhinolaryngol. 2017 mar;10(1):44-49. doi: 10.21053/ ceo.2016.00080; pmid: 27334511 pmcid: pmc5327595. dundar r, kulduk e, soy fk, aslan m, hanci d muluk nb, et al. endoscopic versus microscopic 6. approach to type 1 tympanoplasty in children. int j pediatr otorhinolaryngol. 2014 jul; 78(7): 1084–1089 doi: 10.1016/j.ijporl.2014.04.013; pmid: 24816224. 7. ambani kp, bhavya bm, vakharia sd, khanna a, katarkar au. merits and demerits of endoscopic tympanoplasty. int j otorhinolaryngol head neck surg. 2017 apr; 3(2): 395-399. doi:10.18203/ issn.2454-5929.ijohns20171200. group. using unpaired t-test, the et group had significantly lower mean operative time than the mt group with a mean difference of 53.9 minutes (t= 3.57, p=.0025). there was complete tympanic membrane graft uptake in all patients for both groups and no dehiscence or surgical site infection was noted in any patients. discussion our study demonstrated 100% post-operative tympanic membrane graft uptake among both groups of patients with inactive chronic otitis media that underwent endoscopic transcanal tympanoplasty or microscopic post-auricular tympanolasty with significantly lower operative time for the former group. our findings are consistent with those of previous studies. dundar et al. noted tympanic membrane perforations in 4 (12.5%) of their endoscopic group and 2 (5.71%) in their microscopic group with no significant difference in tympanic membrane graft uptake and shorter operative time for endoscopic tympanoplasty (p=.000).6 choi et al. reported better results with tympanic membrane graft uptake of 100% in the endoscopic group and 95.8% in the microscopic group with no significant difference between the groups.5 endoscopic tympanoplasty also had a significantly shorter operative time with a mean of 88.9±28.5 minutes compared to the microscopic technique with a mean operative time of 68.2±22.1 minutes (p=.002). the reduction in operative time may be attributed in part to ample visualization of deeply located structures that cannot easily be visualized using the magnified view afforded by the linear focus of a microscope.2 (figure 3 a, b) the researchers hypothesized that technicality was not a factor due to adequate experience of the surgeon in utilizing endoscopes for sinus surgery. all endoscopic tympanoplasties were accomplished without conversion to microscopic tympanoplasty. limitations of this study include the retrospective design and limited sample size meeting inclusion and exclusion criteria within the short study period. to minimize confounding variables, we only included patients with inactive chronic otitis media who underwent tympanoplasty by a single surgeon with similarly-induced anesthesia, uniform surgical technique and instrumentation. other limitations are selection bias (from prior knowledge of disease and exposure among participants) and information bias (from assumed accuracy of archived data), but we tried to minimize these by not involving the surgeon in applying inclusion and exclusion criteria or in interpretation and analysis of recorded data. a future randomized prospective trial with more study participants and better follow-up may yield more robust conclusions and address the other sources of bias. preand postoperative audiometric findings (not included in this study because they were only available for the et group) should also be assessed. meanwhile, our findings suggest that regardless of technique, tympanoplasty is an effective surgical treatment for patients with inactive chronic otitis media. endoscopic transcanal tympanoplasty may be an alternative to conventional microscopic post-auricular tympanoplasty in our setting and may involve less operative time producing similarly complete graft uptake. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine if there is a difference in the duration of mechanical ventilation and hospitalization between patients who underwent early compared to late tracheostomy. methods: design: causal-comparative (ex post facto) chart review setting: tertiary national university hospital participants: records of 68 pediatric patients who underwent elective tracheostomy from january 1, 2013 to june 30, 2018 were considered for inclusion. patients were excluded if invasive mechanical ventilation was not done for at least a day prior to tracheostomy, if they underwent emergency tracheostomy or had incomplete records. selected patients were categorized in the early tracheostomy group if the procedure was performed within 14 days of mechanical ventilation and late tracheostomy group if performed beyond 14 days. early posttracheostomy weaning from mechanical ventilation was defined as less than 7 days from time of tracheostomy. results: a total of 21 patients were included, 6 in the early tracheostomy group and 15 in the late tracheostomy group. although early tracheostomy did not show significant association with shortened post-tracheostomy duration of mechanical ventilation (o.r. 6; c.i. 0.276 to 130.322; p = .476), two-sample t-tests showed the early tracheostomy group had a significantly shorter mean duration of mechanical ventilation and hospitalization compared to the late tracheostomy group (13.17 vs. 54.13 days, p = .0012; 21.17 vs. 66.67 days, p = .0032). conclusion: although early tracheostomy does not shorten post-tracheostomy mechanical ventilation support, there is a significant difference in the duration of mechanical ventilation and hospitalization between early and late tracheostomy groups and this may suggest potential benefits of performing tracheostomy earlier in children. keywords: tracheotomy; pediatric; mechanical ventilation; hospitalization historically, the common indication for tracheostomy in children was for relief of acute inflammatory airway obstruction, but this changed with the use of vaccines and development timing of tracheostomy, weaning from mechanical ventilation and duration of hospitalization among a sample of pediatric patients jose brian a. ferrolino, bs, md1 josé florencio f. lapeña jr., ma, md2 ryner jose d. carrillo, md, msc1,3 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila 3department of anatomy college of medicine university of the philippines manila correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 telefax: (632) 8524 4455 email: lapenajf@upm.edu.ph, jflapena@up.edu.ph the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2019; 34 (2): 16-19 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery original articles of modern neonatal intensive care units. these changes allowed increased survival of neonates and preterm babies with complex cardiopulmonary disease, shifting the main indication of tracheostomy to cases of prolonged intubation.1,2 for adults, it is generally recommended that patients who are on mechanical ventilation or expected to be on mechanical ventilation for > 2 weeks undergo tracheostomy.3 for pediatric patients, to the best of our knowledge, it seems there is currently no consensus as to when to perform tracheostomy4,5 although it is claimed that children can tolerate intubation for longer period than adults.6 a current institutional guideline7 recommends a safe period of 30 to 60 days intubation before considering elective tracheostomy in pediatric patients more than 1 year old. however, this prolongs hospital stay of patients, extends use of hospital resources, and increases expenses. this study aims to determine if there is a difference in the duration of mechanical ventilation and hospitalization between patients who underwent early compared to late tracheostomy. methods this causal-comparative chart review considered for inclusion records of all pediatric patients (age < 18) admitted in the philippine general hospital who were referred for tracheostomy to the department of otorhinolaryngology and underwent the surgical procedure between january 1, 2013 and june 30, 2018. the study was approved by the university of the philippines manila research ethics board (upmreb 2018-310-01). informed consent was waived by the board. data of tracheostomies performed on pediatric patients were reviewed from the departmental operating room (or) census, then in-patient records were retrieved from the hospital records section and the following variables were obtained: age, sex, indication for tracheostomy, date of hospital admission, date of intubation, date of tracheostomy, date of weaning from mechanical ventilation and date of hospital discharge. patients were excluded if they were not on mechanical ventilation for at least a day prior to tracheostomy, if they underwent emergency tracheostomy or had incomplete records. duration of mechanical ventilation was counted in days starting from the date of intubation up to the date of weaning. duration of hospitalization was counted in days starting from the date of admission up to the date of hospital discharge. the patients were categorized in the early tracheostomy group if the tracheostomy was performed within 14 days of mechanical ventilation and late tracheostomy group if performed beyond 14 days. this definition was based on a previous study.8 post-tracheostomy duration of mechanical ventilation was determined, with weaning from mechanical ventilation considered early if within < 7 days from the time of tracheostomy, and late if > 7 days from the time of tracheostomy. tests for association between early tracheostomy and shortened post-tracheostomy duration of mechanical ventilation among patients 3 years old or younger, and those above 3 years old (based on pediatric airway development) was performed. the deidentified data were recorded by the principal investigator in ms excel for mac v.16.20 (2018, microsoft corp., redmond, wa) and analyzed by a statistician using stata release 14 (2015, statacorp lp, college station, tx) software. descriptive summary measures (mean, standard deviation, range) were used and inferential statistics included a two-sample t-test for two means to compare the average difference of patients in the two treatment arms that were considered as independent samples. a p-value of less than .05 was considered statistically significant. odds ratios were computed to test for association between early tracheostomy and post-tracheostomy duration of mechanical ventilation. results records of a total of 68 pediatric patients who underwent tracheostomy between january 1, 2013 and june 30, 2018 were considered for inclusion. excluded were 47 patients: 34 who underwent emergency tracheostomy and 13 who had incomplete records. the records of 21 patients (13 male, 8 female) were finally included in the study. age range was 2 months to 12 years old with a mean age of 5 years. there were 6 in the early tracheostomy group and 15 in the late tracheostomy group, with a m/f ratio of 4:2 and 9:6 in the early and late tracheostomy group respectively. the indication for tracheostomy in most (n=19) was prolonged intubation while a minority (n=2) were due to airway obstruction. the minimum time before tracheostomy was 2 days while the maximum time was 93 days. the average pre-tracheostomy mv duration was 10.33 days in the early tracheostomy group and 46.13 days in the late tracheostomy group. table 1 presents the total duration of mechanical ventilation in the two tracheostomy groups. in the early tracheostomy group the mean duration of mechanical ventilation was 13.17 days while in the late tracheostomy group it was 54.13 days. there was a significant difference between the duration of mechanical ventilation in the early tracheostomy group compared to the late tracheostomy group (p = .0012) table 2 presents the hospital duration in the two groups. the mean hospital duration in the early tracheostomy group was 21.17 days while in the late tracheostomy group it was 66.67 days. comparing the two means showed a significant difference (p = .0032) philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery original articles however, the associations between early tracheostomy and shortened post-tracheostomy duration of mechanical ventilation across the population [o.r. 6 (0.276 to 130.322); p = .476], for patients 3 years old and below [o.r. 2.4 (0.079 to 72.896); p = .798], and those above 3 years old [o.r. 3.6 (0.13 to 99.424); p = .928] were not statistically significant. (tables 3, 4, 5) discussion our study showed that there was a statistically significant difference in the total duration of mechanical ventilation and hospitalization among early versus late tracheostomy groups of tracheotomized pediatric patients in our institution. in adult patients, tracheostomy is usually performed within two weeks of mechanical ventilation3 with some recommending adult tracheostomy at < 10 days4,9 or even as early as 72 hours on mechanical ventilation.10 in contrast, there is still seems to be no definite criteria with regards the timing of tracheostomy in pediatric patients.4,5 a survey of 28 pediatric intensive care units in the uk showed variation in answers with regards to the duration of invasive ventilation before considering tracheostomy: four units suggested less than 14 days of mechanical ventilation while other units suggested > 14 days or > 28 days with some respondents even considering more than 90 days.11 wakeham et al.12 reported a variation of pre-tracheostomy ventilation ranging from 4.3 days to 30.4 days. further analysis revealed that an infectious or cardiac diagnosis and 2 or more reintubations are associated with longer time to tracheostomy. our current institutional guidelines suggest 30 to 60 days before considering tracheostomy in patients more than one year old.7 in our current study, the range of pre-tracheostomy ventilation was 2 to 93 days. the cut-off of 14 days to delineate between early and late tracheostomy was extrapolated from adult studies cited by holloway et al.8 in their study of 73 pediatric patients, they determined that the total hospital length of stay was 4 weeks shorter in the early tracheostomy group. a similar study of 111 pediatric patients by lee et al.5 showed a significantly shorter duration of mv, and length of icu and hospital stay in the early tracheostomy group. in this study, a cut-off of 14 days was also used to classify patients into early and late tracheostomy groups.4 lin et al.1 also concluded that earlier tracheostomy can shorten total mv table 1. comparison of early and late tracheostomy with duration of mechanical ventilation n mean (day) std. err. std. dev. p-value95% conf. interval early late diff 6 15 13.17 54.13 -40.97 1.89 7.24 11.69 4.62 28.05 .0012 8.32 18.02 38.60 69.67 -65.43 -16.50 t = -3.50 degrees of freedom = 19 table 2. comparison of early and late tracheostomy with hospital duration n mean (day) std. err. std. dev. p-value95% conf. interval early late diff 6 15 21.17 66.67 -45.5 4.40 8.24 13.50 10.78 31.92 .0032 9.86 32.48 48.99 84.34 -73.76 -17.24 t = -3.37 degrees of freedom = 19 table 3. early tracheostomy vs early weaning from post-tracheostomy mechanical ventilation weaning from mv after tracheostomy for < or = 7 days weaning from mv after tracheostomy for > 7 days tracheostomy after intubation for <14 days tracheostomy after intubation for >= 14 days 6 10 0 (0.5) 5 odds ratio: 6 (0.276 to 130.322) p value .476 table 4. early tracheostomy vs early weaning from post-tracheostomy mechanical ventilation for pediatric patients less than or equal to 3 years old weaning from mv after tracheostomy for <or = 7 days age 3 years old or less weaning from mv after tracheostomy for > 7 days tracheostomy after intubation for <14 days tracheostomy after intubation for >= 14 days 3 5 0 (0.5) 2 odds ratio: 2.4 (0.079 to 72.896) p value .798 table 5. early tracheostomy vs early weaning from post-tracheostomy mechanical ventilation for pediatric patients greater than 3 years old weaning from mv after tracheostomy for <or = 7 days age above 3 years old weaning from mv after tracheostomy for > 7 days tracheostomy after intubation for <14 days tracheostomy after intubation for >= 14 days 3 5 0 (0.5) 3 odds ratio: 3.6 (0.13 to 99.424) p value: .928 philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery original articles acknowledgements we thank angelica anne e. latorre, mph, msph(candidate) of the university of the philippines manila college of public health for her assistance with statistical analysis. references 1. lin cy, ting tt, hsiao ty, hsu wc. pediatric tracheostomy: a comparison of outcomes and lengths of hospitalization between different indications. int j pediatr otorhinolaryngol. 2017 oct; 101: 75 – 80. pubmed pmid: 28964315 2. ozmen s, ozmen oa, unal of. pediatric tracheostomies: a 37-year experience in 282 children. int j pediatr otorhinolaryngol. 2009 jul; 73(7): 959 – 961. pubmed pmid: 19395057 3. rumbak mj, newton m, truncale t, schwartz sw, adams jw, hazard pb. a prospective randomized study comparing early percutaneous dilational tracheostomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. crit care med. 2004 dec; 32(12): 2566. pubmed pmid: 15286545. 4. adly a, youssef ta, el-begermy mm, younis hm. timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review. eur arch otorhinolaryngol. 2017 mar; 275(3): 679 690. pubmed pmid: 29255970. 5. lee jh, koo ch, yee sy, kim eh, song ik, kim hs, et al. effect of early vs late tracheostomy on clinical outcomes in critically ill pediatric patients. acta anesthesiol scand. 2016 oct; 60(9): 1281 1288. pubmed pmid: 27377041. 6. ertugrul i, kesici s, bayrakci b, unal of. tracheostomy in pediatric intensive care unit: when and where? iran j pediatr. 2016 feb; 26(1): e2283. pubmed pmid: 26848369; pubmed central pmcid: pmc4733285. 7. university of the philippines; philippine general hospital, department of otorhinolaryngology. clinical practice guidelines: tracheostomy and decannulation. manila: university of the philippines department of otorhinolaryngology; 2003.p53–60. 8. holloway aj, spaeder mc, basu s. association of timing of tracheostomy on clinical outcomes in picu patients. pediatr crit care med. 2015 mar; 16(3): e52 e58. pubmed pmid: 25581633. 9. veenith t, ganeshamoorthy s, standley t, carter j, young p. intensive care unit tracheostomy: a snapshot of uk practice. int arch med. 2008 oct; 1(1):21. pubmed pmid: 18950520; pubmed central pmcid: pmc2583967. 10. durbin cg jr, perkins mp, moores lk. should tracheostomy be performed as early as 72 hours in patients requiring prolonged mechanical ventilation? respir care. 2010 jan; 55(1):76 – 87. pubmed pmid: 20040126. 11. wood d, mcshane p, davis p. tracheostomy in children admitted to pediatric intensive care. arch dis child. 2012 oct;97(10): 866 869. pubmed pmid: 22814521. 12. wakeham mk, kuhn em, lee kj, mccrory mc, scanlon mc. use of tracheostomy in the picu among patients requiring prolonged mechanical ventilation. intensive care med. 2014 jun; 40(6):863 – 870. pubmed pmid: 24789618. and hospital duration although the study set their cut-off at < 30 days for early tracheostomy. there was no association between early tracheostomy and the post-tracheostomy duration of mechanical ventilation across the pediatric population in our study as shown in table 3-5. this suggests that overall duration of mechanical ventilation (pre-tracheostomy + post-tracheostomy) and hospital stay may be decreased by shortening the pre-tracheostomy period, i.e., performing an early tracheostomy. the possible relationship of early tracheostomy to early weaning is easy to posit. bypassing the upper airway with a tracheostomy decreases the work of breathing, which may in turn aid a patient with neurological or muscular disease or one experiencing difficulty in weaning.6 subsequently, earlier weaning can increase patient comfort, facilitate earlier ambulation and mobilization, improve tracheal toilette, oral feeding and rehabilitation and overall better quality of life for the patient5,6,11 while earlier hospital discharge can possibly reduce nosocomial infection.6 our study has several limitations. first, the small sample size prevented determination of correlations between variables. other possibly confounding or intervening variables were not accounted for, from which possible biases could arise. these include differences in underlying diseases and morbidities (such as concomitant neurological disease or cardiovascular disease) that may have influenced the timing of tracheostomy. another limitation is the bias from selection inclusion (inherent to our study design), where measurement of pretracheostomy time contributes to the outcome measurement of overall mechanical ventilation and hospital time. a prospective multi-center study with a larger sample size is recommended to obtain better correlations. such variables as early and long-term follow-up, early and late complications, concomitant diseases and decannulation rates that can better establish the optimum time for tracheostomy in individual pediatric patients, should be analyzed. in conclusion, our study found significant differences in the duration of mechanical ventilation and hospitalization between early and late tracheostomy groups and may suggest these benefits of performing tracheostomy early in children, although early tracheostomy does not shorten post-tracheostomy mechanical ventilation support. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles 10 philippine journal of otolaryngology-head and neck surgery abstract objectives: to evaluate the effects of dexamethasone-impregnated absorbable nasal pack versus saline-impregnated nasal packing on postoperative outcome of nasal cavities after endoscopic sinus surgery using the perioperative sinus evaluation scoring system (pose) and lund and kennedy endoscopic scoring system. methods: design: prospective, randomized, double blinded, placebo-controlled trial setting: single center tertiary government hospital participants: nineteen (19) patients aged 15 years old and above, diagnosed with chronic rhinosinusitis, with nasal polyposis grade 3, who underwent endoscopic sinus surgery from january 2015 to august 2015 results: nasal cavities that received postoperative dexamethasone-impregnated nasal packs showed significantly lower pose scores than placebo on post-op days 14 (p value 0.0022; 95% ci: -2.113 to -0.5116) as well as lower lund-kennedy scores on post-op day 14 (p value of 0.0180; 95% ci: -2.493 to – 0.2571) and day 28 (p value of 0.007; 95% ci: -1.56275 to -0.2832). conclusion: dexamethasone-impregnated absorbable nasal packing affords better postoperative outcomes: less edema, crusting, secretions, and synechiae, than saline-impregnated absorbable packing in later postoperative days. keywords: dexamethasone, endoscopy, nasal polyp, nasal cavity, intranasal absorption functional endoscopic sinus surgery (ess) has become the standard treatment for medically refractory chronic rhinosinusitis and nasal polyps.1 advancements in post-ess care include the use of nasal packing and steroids. new absorbable nasal packs provide less pain, bleeding, nasal blockage, and facial edema.2 intranasal steroids also decrease mucosal inflammation and minimize nasal secretory response, and triamcinolone acetonide and mometasone-impregnated absorbable nasal packing post-ess have shown promising postoperative results.3,4 however, further studies are needed, and we wanted to find out whether impregnating absorbable nasal effects of dexamethasone versus saline-impregnated nasal packing on the postoperative outcome of patients with chronic rhinosinusitis and nasal polyps after endoscopic sinus surgery: a randomized controlled trial shella may a. promentilla, md rubiliza dc. onofre, md, benjamin sa. campomanes, jr., md department of otorhinolaryngology head and neck surgery east avenue medical center correspondence: dr. shella may a. promentilla department of otorhinolaryngology head and neck surgery 6th floor east avenue medical center east avenue, quezon city 1100 philippines phone: (632) 928 0611 local 324 email: eamc_enthns@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosure: the nasal packs were provided by nasopore forte® (easmed sdn bhd 13th floor suite 13.05 & 13.06 menara summit persiaran kewajipan, usj 147600 uep subang jaya selangor darul ehsan, malaysia) for the course of this study. however, the company did not influence the conduct and results of this study since the primary objective was to determine the effects of dexamethasone as a topical corticosteroid in the management of post-ess nasal cavity, and not examine the characteristic of the pack as vehicle for the drug. presented at the philippine society of otolaryngology head and neck surgery analytical research contest (2nd place), plaza ibarra,quezon avenue, quezon city, november 10, 2015. philipp j otolaryngol head neck surg 2016; 31 (1): 10-13 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 11 packs with dexamethasone, a more widely available, long acting steroid,5 can similarly demonstrate better postoperative outcomes. this study aimed to objectively measure the effects of dexamethasone-impregnated packing versus saline-impregnated packing on post-ess nasal cavities. methods study design and setting this prospective, randomized, double blinded, placebo-controlled trial was conducted in a tertiary government hospital from january 1, 2015 to august 31, 2015. population and sample size the study was conducted among patients 15 years old and above, diagnosed with chronic rhinosinusitis with nasal polyposis grade 3, bilateral. patients with recurrent nasal polyposis; previous history of ess and medical co-morbidities were excluded from the study. informed consent and assent were obtained. the target population was computed based on proportion estimate outcomes. p1 .800 (8% chance of morbidity) and p2 .300 (3% chance of morbidity) with a margin of error of 5% and power of 90%. a minimum total of 32 nasal cavities, 16 in each treatment group, was needed to be 90% sure of being able to detect a 5% reduction in postoperative morbidity, which was felt to be clinically relevant. a table of random numbers was used in labeling patients. all odd numbered patients were given dexamethasone packing on their left nasal cavity, placebo saline packing on their right, and vice versa. the allocation of impregnated packs was not known to the participants, surgeons and postoperative evaluators. clinical trial nasal packs were composed of two equal dimensions of 8cm x 2cm x 1cm biodegradable synthetic polyurethane foam (nasopore forte®, easmed sdn bhd subang jaya selangor darul ehsan, malaysia), one soaked with 2ml of 4mg/ml dexamethasone and the other with 2 ml saline solution. after endoscopic sinus surgery, the surgeon placed the nasal packs in the assigned nasal cavity as dictated by the investigator. all patients were given co-amoxiclav 625mg/capsule, 1 capsule every 8 hours for 7 days as postoperative prophylaxis. saline nasal douching was commenced on the 4th postoperative day. nasal endoscopy was performed on postoperative days 3, 7, 14, and 28 before and after nasal saline irrigation and removal of blood clots. data collection a blinded otorhinolaryngology consultant who was not a coinvestigator assessed all nasal endoscopy videos in one sitting using the perioperative sinus endoscopic (pose)6 and lund-kennedy sinus endoscopy2 score sheets. these are objective endoscopic scoring tools used for assessing sinonasal cavities.2,6 crusting, mucosal edema, polyposis, secretions and scarring criteria for assessment are found in both tools. in addition, the pose system has middle turbinate, middle meatal antrostomy and secondary sinuses as additional assessments.6 fully accomplished scoring sheets were collated and tallied for analysis. statistical analysis descriptive statistics were described using mean, standard deviation, frequency and median. the difference between dexamethasone and placebo group scores on each evaluation day was determined using student paired t-test. repeated measurement analysis of variance, rmanova at <0.05 p-value was utilized for multivariate analysis between each evaluation day. stata 12.0 (statacorp lp., texas usa) was used for data encoding and analyses. ethical considerations the department research ethical board alone evaluated the study, since a hospital irb was not yet established at that time. the study sample size computation m (size per group) = c x p1(1-p1) + p2 (1-p2) (p1-p2)2 p1 = .800 margin of error 5% p2 = .300 power 90% m = 10.5 x .800(1-.800) + .300 (1-.300) (.800-.300)2 m = 10.5 x .800(0.2) + .300(0.7) 0.25 m = 10.5 x 0.16 + 0.21 0.25 m = 10.5 x .37 0.25 m =3.885/ 0.25 m = 15.54 ~ 16 sample size = 16 x 2 = 32 nasal cavities philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles 12 philippine journal of otolaryngology-head and neck surgery adhered with the ethical principles set out in relevant guidelines (declaration of helsinki 2008, who operational guidelines, ich-gcp and national ethics guidelines for health research). written and informed consent were obtained from all participants upon recruitment. patients aged 15 to 18 years old were asked for an assent form prior to their inclusion to the study. all identifiable information was deleted from the data obtained with each participant assigned with unique alphanumeric codes. all data were kept in an external hard drive accessible only to the investigators, and will be kept for five years. results this study comprised 19 patients, 9 females and 10 males, with a range of 15 to 33 years old (median age, 31 years). all underwent ess, however one of the participants was withdrawn from the study because of severe postoperative bleeding and revision of nasal packing, thus, only 18 patients or 36 nasal cavities, were considered for final evaluation. there were also follow-up irregularities accounting for the differences in population for each evaluation made. mean pose scores (table 1) of the saline group on days 3 and 7 were higher than the dexamethasone group. the scores of both groups improved on day 7 of evaluation, but the differences between the two groups were not statistically significant. the pose scores on day 14 generally improved for both groups. the dexamethasone nasal cavities had a 2-point lower score than the saline group with a p-value of 0.0022, which was statistically significant (confidence interval of -2.113 to -0.5116). the pose scores on day 28 showed greater general improvement with the dexamethasone group registering a mean score of 1.3077 against 1.7692 of the placebo group. however, the difference between the groups was not statistically significant (p-value of -0.8936, based on confidence interval of -1.5299 to 0.6069). a similar trend was seen using the lund-kennedy scoring system. (table 2) on postoperative days 3 and 7, the differences were not statistically significant. post-op days 14 and 28, however showed that the dexamethasone group scored 1 point lower than the placebo group, which was statistically significant with a p-value of 0.0180 based on confidence interval of -2.493 to -0.2571 (day 14) and a p-value of 0.007 based on the confidence interval of -1.563 to -0.2832 (day 28). the rmanova was performed separately on the scores of both groups obtained from the 4 evaluation days. the decreasing scores between each examination day obtained for both pose and lundkennedy scoring systems (figure 1 and 2) were all statistically significant with p-values of <0.05 (tables 1 and 2). discussion the effectiveness of performing ess in patients with chronic rhinosinusitis with nasal polyps is dependent on the reduction of postoperative complications: scarring, edema and crusting which hinders natural ciliary function and sinus drainage.3 several postoperative adjuncts developed include saline irrigation, meticulous nasal cavity cleaning as well as the use of topical steroid sprays. these practices have decreased the incidence of complications.1,7 to measure the postoperative improvements, this study utilized the table 1. perioperative sinus evaluation (pose) scores from day 3 to day 28 of post-ess patients (n=36 nasal cavities) population dexamethasone group placebo group p-value* day3 n= 34 mean (sd) 4.1765 ( +1.382) 4.6471 ( +1.6066) -0.9158 (-1.5186 to 0.5775) day 7 n= 34 3.0588 ( +1.2112) 3.7059 ( +0.8921) -1.77391 (-1.3932 to 0.09897) day 14 n=32 1.875 ( +1.0879) 3.1875 ( ±1.1302) 0.0022 # (-2.113 to -0.5116) day 28 n=26 1.3077 ( +1.2016) 1.7692 ( +1.4226) -0.893566 (-1.5299 to 0.6069) p-value+ <0.0001#a 0.000116#a # significance of p-value based on corresponding confidence intervals a significant also at p-value <0.05 * student t-test used in determining difference between two groups +rm-anova used in determining differences between each evaluation days table 2. lund-kennedy sinus endoscopy scores from postoperative day 3 to day 28 of post-ess patients (n=36 nasal cavities) population dexamethasone group placebo group p-value* day3 n= 34 mean (sd) 4.765 ( +1.262) 4.647 ( +1.326) 0.7921 (-0.7863 to 1.02235) day 7 n= 34 3.588 ( +1.325) 3.412 ( +0.771) 0.6399 (-0.5882 to 0.9403) day 14 n=32 mean (sd) 2.250 ( +1.854) 3.625 ( +1.130) 0.0180# (-2.493 to -0.2571) day 28 n=26 mean (sd) 0.462 ( +0.929) 1.385 ( +0.606) 0.007 # (-1.56275 to -0.2832) p-value+ <0.0001#a <0.0001 #a # significance of p-value based on corresponding confidence intervals a significant also at p-value <0.05 * student t-test used in determining difference between two groups +rm-anova used in determining differences between each evaluation days philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 13 acknowledgements the primary investigators would like to acknowledge the fourth year and first year resident physicians of the department of orl-hns east avenue medical center for helping them in the recruitment, screening, surgery and data gathering for this research paper. likewise, we also thank dr. dwight alejo for the review and interpretation of the nasal endoscopy videos of the participants. references 1. wang yp, wang mc, chen yc, leu ys, lin hc, lee ks. the effects of vaseline gauze strip, merocel, and nasopore on the formation of synechiae and granulation tissue in the middle meatus and the incidence of major postoperative bleeding after endoscopic sinus surgery. j chin med assoc. 2011 jan; 74(1):16-21. 2. vermin a, seneldir l, naiboglu b, karace ct, kulekci s, toros sz, oysu c. role of nasal packing in surgical outcome for chronic rhinosinusitis with polyposis. laryngoscope. 2014 jul; 124(7):1529-35. 3. cote dwj, wright ed. triamcinolone-impregnated nasal dressing following endoscopic sinus surgery: a randomized, double blind, placebo-controlled study. laryngoscope. 2010 jun; 120(6):1269-1273. 4. marple bf. smith tl. han jk. gould ar. jampel hd. stambaugh jw. mugglin as. advance ii: a prospective, randomized study assessing safety and efficacy of bioabsorbable steroid releasing sinus implants. journ oto rhino laryngol head neck surg. 2011; 146(6):1004-1011. 5. adrenal cortico steroids. in: drugs and facts companions. 5th edition. facts and companions inc.: st louis; 1997:122-128. 6. wright ed, agrawal s. impact of perioperative systemic steroids on surgical outcomes in patients with chronic rhinosinusitis with polyposis. evaluation with novel perioperative sinus endoscopy (pose) scoring system. laryngoscope. 2007 nov; 117 (suppl. 115):1-28. 7. hong sd, kin jh, dhing hj, kim hy, chung sk, chang ys. et al. systemic effects and safety of triamcinolone-impregnated nasal packing after endoscopic sinus surgery: a randomized, double-blinded, placebo-controlled study. am journ rhinol allergy. september-october 2013; 27(5):407-410. 8. more y, willen s, catalano p. management of early nasal polyposis using steroidimpregnated nasal dressing. int forum allergy rhinol. 2011 sep-oct; 1(5):401404. pose and lund-kennedy sinus endoscopic surgery scoring system, which incorporates crusting, mucosal edema, polyposis, secretions and scarring in their criteria.2,6 the benefit of postoperative packing was exemplified by the statistically significant progressive decrease in scores throughout the 28-day postoperative period. (figure 1) figure 1. comparison of post ess nasal cavities dexamethasone impregnated nasal pack versus saline impregnated nasal pack based on mean perioperative sinus evaluation scores figure 2. comparison of post ess nasal cavities dexamethasone impregnated nasal pack versus saline impregnated nasal pack based on mean lund-kennedy sinus endoscopy scores in our setting and inexpensive, but also because it has the longest half-life and highest anti-inflammatory effect among steroids.5 its use in this study revealed improved scores on postoperative days 14 to 28, suggesting a probable equivalence to triamcinolone in terms of effectiveness, but at a fraction of the cost. as for the drug safety, although steroid-impregnated absorbable nasal dressing may have transient systemic effects -serum cortisol and osteocalcin suppression6,7 -possible systemic side effects were not evaluated in this study. there is still a lack of consensus regarding optimal perioperative nasal dressing and steroid regimens, and this study may forge new ground in the search for an ideal postoperative standard of care based on effectiveness, economy and availability. the investigators recommend the use of dexamethasoneimpregnated absorbable nasal packing in the management of post-ess patients. a future non-inferiority study between dexamethasoneimpregnated nasal dressing and triamcinolone-impregnated dressing utilizing a bigger sample size, and safety studies covering local and systemic adverse effects and complications are also recommended. in the management of post-ess nasal cavities, steroids, both administered systemically or topically, had the widest range of studies regarding improved postoperative outcome.4,6,8 administration of systemic steroids is known to improve short-term post-ess outcomes.6 however, the risk of systemic side effects has led to the development of safer topical steroid sprays and steroidimpregnated nasal packs. two previous studies have shown that the delivery of triamcinolone through nasal packs showed statistically significant improvements in pose and lundkennedy scores from day 7 to day 28 postoperatively, with similar outcomes compared to the oral steroids while limiting the systemic harmful effects.3,8 we selected dexamethasone for this study not only because it is widely available philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 36 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2016; 31 (2): 36-40 c philippine society of otolaryngology – head and neck surgery, inc. rhinofacial conidiobolomycosis in a 16-year-old girl xirxiz vin c. parilla, md joseph e. cachuela, md department of otorhinolaryngology head and neck surgery southern philippines medical center correspondence: dr. xirxiz vin c. parilla department of otorhinolaryngology head and neck surgery southern philippines medical center davao city 8000 philippines phone: (+63) 932 279 0063; (+63) 917 705 9050 email: kaervek27@gmail.com, xirxizparilla@outlook.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery interesting case contest (1st place). june 30, 2016. unilab bayanihan center, pasig city. presented at spmc orl-hns annual interesting case contest (1st place). april 2016. jica building southern philippines medical center, davao city. abstract objectives: to present the case of a 16-year-old girl with progressive facial disfigurement spanning 11 months due to conidiobolomycosis. methods: design: case report setting: tertiary government hospital patient: one results: a 16-year-old girl presented with a severe facial deformity of 11 months duration. the lesion started as a swelling in the right nasal vestibule, which later involved the entire nose, forehead, cheeks, upper and lower lip. a series of tissue biopsies revealed varied results -chronic inflammation, chronic granulomatous inflammation with foreign body type giant cells, and eosinophilic granuloma—resulting in delayed provision of appropriate treatment. on the fourth biopsy using grocott methenamine silver staining technique, septate fungal hyphae were identified. with a diagnosis of rhinofacial conidiobolomycosis, she was started on itraconazole 100mg three times daily for eight months. her facial swelling subsided gradually during the course of treatment and no systemic drug-related complications were observed. conclusion: rhinofacial conidiobolomycosis is a rare chronic localized fungal infection that usually affects midline facial structures in immunocompetent hosts. early detection and diagnosis, and appropriate medication can give rapid resolution. to the best of our knowledge, this may be the first documented case of rhinofacial conidiobolomycosis in the philippines. keywords: conidiobolomycosis; conidiobolus; fungal infection; itraconazole, therapeutic use rhinofacial conidiobolomycosis (rfc), also known as rhinoentomophthoromycosis, is a rare, chronic, subcutaneous mycoses caused by conidiobolus.1 the fungal infection manifests as an indolent and painless swelling in the midfacial structures and commonly originates in the nasal cavity or sinuses from which the fungus extends to involve subcutaneous tissues of the nose and the face.1 we present a rare case of a 16-year-old girl with progressive facial disfigurement spanning 11 months due to such a fungal infection. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 case reports philippine journal of otolaryngology-head and neck surgery 37 case report a 16-year-old girl consulted with a complaint of progressive facial swelling. (figure 1) her condition started 11 months prior to consult when she noticed a slow growing papule on her right nasal vestibule. it was firm, painless and did not bleed during manipulation. there were no associated signs and symptoms. her past medical history was unremarkable. after one month, she noticed progressive swelling of her right nasal cavity. physical examination by an otorhinolaryngologist revealed an irregularly swollen right nasal vestibule and inferior turbinate. (figure 2) systemic examination was within normal limits. contrast enhanced paranasal sinus ct scans revealed soft tissue swelling and congested right inferior turbinate. (figure 3) nasal endoscopy showed a rough nasal vestibule mass and congested right inferior turbinate. punch biopsy of the right nasal mass only showed chronic inflammation. she was given unrecalled antibiotics for a week and intranasal steroid therapy for a month with no relief. seven months prior to consult, the swelling extended from the entire nasal area to the right cheek. biopsy of the nasomaxillary swelling via gingivobuccal approach showed chronic inflammation with giant cell reaction and fibrosis. she was advised a repeat biopsy due to the inconclusive result, but refused and was lost to follow-up. after a period of six months, she was admitted due to rapid increase in the facial swelling, now involving the entire nasal area, forehead, cheeks, upper and lower lip. it was associated with nasal congestion, foul smelling nasal discharge and epistaxis. due to the severity of the facial swelling she had obstructed vision and epiphora in the right eye. repeat ct scan showed marked involvement of bilateral maxillary soft tissues and the right nasal cavity. no bony lesions or erosions were figure 2. the right nasal cavity showed swollen inferior turbinate (star) and nasal septum (arrow). the mucosa is rough, irregular and granulomatous in appearance compared to the left nasal cavity with unremarkable findings. figure 3. a. paranasal sinus ct-scan with contrast in axial view (december 2013) showing a diffuse thickening of the soft tissue with heterogenous enhancement in the right nasal cavity (arrow). there is also a congested turbinate and bilateral maxillary sinusitis. b. craniofacial ct scan with contrast (august 2014) showing a heterogeneously enhancing soft tissue thickening over the entire maxilla (white arrow) in axial view; and right inferior turbinate (white arrow) in c. coronal view; no bony lytic lesions were noted. figure 1. anterior and antero-lateral views showing extensive facial swelling involving the entire nose, forehead, cheeks and lips. (photos published in full, with permission) anterior antero-lateral a b c philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 case reports 38 philippine journal of otolaryngology-head and neck surgery noted. (figure 3) repeat biopsy in two different sites, right glabellar and nasolabial area, both revealed eosinophilic granuloma. (figure 4) fungal culture on blood agar and bacterial cultures were also negative. laboratory work-ups were unremarkable except for elevated eosinophil count. she was discharged with an impression of an inflammatory reaction and prescribed cefuroxime 500mg capsule three times a day for 1 week, again without relief. after one month due to the persistent facial swelling, a repeat biopsy from the contralateral side of the forehead was sent to another institution for additional immunostaining, bacterial and fungal studies. tumor immunohistochemistry of cd1a and langerin were negative for langerhans cells while cd68 and cd163 stains were positive for histiocytes. histochemistry revealed dermal mycosis with septate fungal hyphae using grocott methenamine silver staining technique. figure 4. incision biopsy from two different sites. (top) glabellar (thin black arrow) and nasolabial area (thick black arrow). (above) actual nasolabial biopsy. figure 5. white to tan rubbery glabellar mass measuring 2x3x5cm. histopathological sections of the glabellar mass (hematoxylin & eosin, 40x magnification) showing a mixed granuloma with numerous neutrophils. note: splendor-hoeppli phenomenon characterized by the presence of thin walled septated hyphae (black arrow) characteristically enveloped by an eosinophilic sheath. (hematoxylin – eosin, 40x) (hematoxylin – eosin, 40x) (figure 5) considering the clinical features and histopathology report, a diagnosis of rhinofacial conidiobolomycosis was established. she was treated with itraconazole 100mg tablet three times a day for eight months with good response. the facial swelling showed marked improvement with significant reduction in extent and softening consistency of the swelling. (figure 6) philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 39 case reports discussion rhinofacial conidiobolomycosis is a chronic, progressive, indolent fungal infection which involves granulomatous changes in the subcutaneous tissue.1 these granulomatous changes eventually lead to a progressive swelling of the subdermal area. rhinofacial conidiobolomycosis presents as a painless swelling over the midline of the face and usually affects middle-aged men in tropical countries like africa and south-east asia.1 in this case, it occurred in a healthy young girl with no associated risk factors and an unremarkable past medical history. compared to other types of fungal infections, conidiobolomycosis most commonly occurs as a chronic infection in otherwise healthy hosts.2 rhinofacial conidiobolomycosis is caused by the saprophytic fungus conodiobolus coronatus or conidiobolus incongruous, under the class zygomycetes, order entomophthorale.3 the causative fungus is thick-walled with short hyphae that grow at temperatures between 30oc and 37oc.4 although the causative agents were not successfully grown and isolated in this case, specific laboratory tests such as grocott methenamine silver staining technique aided identification of the fungal pathogen with septate hyphae. the mode of transmission is nose-picking which causes traumatic inoculation of the nasal mucosa with contaminated dust or soil containing the spores.5 two genera of zygomycetes exist, basidiobolus and conidiobolus. in conidiobolus infection, the nasal mucosa below the inferior turbinate is commonly affected and appears as a uniform, progressive nasal swelling forming a midfacial deformity. in basidiobolus infection, the limb and limb girdle are predominantly affected.6 the initial presentation in the patient was nasal swelling limited to the nasal cavity, specifically the vestibule and inferior turbinate. eventually the swelling progressed and it involved the entire nasal dorsum, cheeks, forehead and lips leading to a severe facial deformity. the most common presentation of rfc is characterized by chronic, indolent and localized swelling of the nose, paranasal sinuses, cheeks, and upper lips.7 clinically, the extent of involvement can be divided into three phases. in phase i, involvement is limited to the nasal cavity, paranasal sinuses, and pharynx. in phase ii, infection extends to the surrounding subcutaneous tissues causing facial swelling with involvement of the lips. in phase iii, the muscles, bones, and viscera are affected.3 due to failure of early identification of the causative agent and inadequate follow-up with her physician, the infection eventually progressed to phase ii involving her entire face. the diagnosis of rfc is both clinical and histopathological. a history of nose-picking and physical findings of midfacial swelling should trigger a high index of suspicion. histological examinations are figure 6. clinical findings after 1 month of itraconazole treatment. a. reduction of facial swelling of the forehead, nose, cheeks and lips. b. decreased swelling and smoothening of the inferior turbinate. c. post-treatment for 8 months. the swelling has decreased and there is smoothening of the skin. a b c philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 case reports 40 philippine journal of otolaryngology-head and neck surgery acknowledgements we would like to thank the consultants of the department of ent-hns of the southern philippines medical center (spmc) who helped critique and appraise the paper, the resident physicians and nurses of the department of pediatrics for their support and input, and resident physicians of the department of ent-hns of spmc for their encouragement. references 1. martinson fd, clark bm. rhinophycomycosis entomorphthorae in nigeria. am j trop med hyg. 1967 jan; 16(1):40-7. pmid: 6021728. 2. geramizadeh b, foroughi r, keshtkar-jahromi m, malek-hosseini sa, alborzi a. gastrointestinal basidiobolomycosis, an emerging infection in the immunocompetent host: a report of 14 patients. j med microbiol. 2012 dec; 61(pt 12):1770-4. doi: 10.1099/jmm.0.046839-0. pmid: 22918871. 3. isa-isa r, arenas r, fernández rf, isa m. rhinofacial conidiobolomycosis (entomophthoramycosis). clin dermatol. 2012 jul-aug; 30(4):409-12. doi: 10.1016/j.clindermatol.2011.09.12. pmid: 22682189. 4. pérez ja, correa a, fuentes j, meléndez e. conidiobolomycosis: a case report with histopathologic findings. biomedica. 2004 dec; 24(4):350-5. pmid: 15678798. 5. sugar am. agents of mucormycosis and related species. in: mandell gl, bennett ge, dolin r, editors. mandell, douglas and bennett’s. principles and practice of infectious disease, 6th ed. new york: churchill livingstone, 2005: 2973–2984. 6. leopairut j, larbcharoensub n, cheewaruangroj w, sungkanuparph s, sathapatayavongs b. rhinofacial entomophthoramycosis; a case series and review of the literature. southeast asian j trop med public health. 2010 jul; 41(4):928-35. pmid: 21073068. 7. chander j. textbook of medical mycology. 3rd ed. new delhi: mehta publishers; 2009. p. 36186. 8. cherian lm, varghese l, panchatcharam bs, parmar hv, varghese gm. nasal conidiobolomycosis: a successful treatment option for localized disease. j postgrad med. 2015 apr-jun; 61(2):143-4. doi: 10.4103/0022-3859.153112. pmid: 25766357. pmcid: pmc4943445. 9. prabhu rm, patel r. mucormycosis and entomophthoromycosis: a review of the clinical manifestations, diagnosis and treatment. clin microbiol infect. 2004 mar; 10 suppl: 31–47. pmid: 14748801. 10. kim j, tang jy, gong r, kim j, lee jj, clemons kv, et al. itraconazole, a commonly used antifungal that inhibits hedgehog pathway activity and cancer growth. cancer cell. 2010 apr 13; 17(4): 388–399. doi: 10.1016/j.ccr.2010.02.027. pmid: 20385363. pmcid: pmc4039177. 11. agrawal s, meshram p, qazi ms. rhinoentomophthoromycosis: a rare case report. indian j med microbiol. 2013 oct-dec; 31(4):401-3. doi: 10.4103/0255-0857. pmid: 24064651. 12. jain a, rynga d, singh pk, chowdhary a. rhinofacial conidiobolomycosis due to conidiobolus coronatus: a case report and update of the disease in asia. seajcrr. 2015; 4(2): 1576-1589. essential for confirmation of the diagnosis. conidiobolus coronatus may grow on sabouraud’s dextrose agar but this medium was not utilized for the initial biopsy specimens. having said that, fungal cultures may be negative in more than 85% of cases.3 condiobolomycosis infection is characterized histopathologically by the presence of septate hyphae surrounded by an eosinophilic halo, the so-called splendore-hoeppli phenomenon.8 (figure 5) in this case, adding to the difficulty in establishing such diagnosis were the initial histopathological results of chronic inflammatory granulomatous cellular infiltrates composed of lymphocytes, epithelioid cells, giant cells, histiocytes and rich eosinophils which can be seen in various disease entities. the identification of the splendorehoeppli phenomenon together with the clinical presentation of midfacial swelling established rfc as the diagnosis. rhinofacial conidiobolomycosis should be included in the differential diagnoses of healthy patients who present with nasal symptoms and painless midfacial swelling.11 the treatment of rfc has not been well established because the disease is infrequently reported and studied. although a number of antifungals have been used and reported as effective, there is still lack of evidence to determine the antifungal of choice, its dosage and duration.3 daily high-dose antifungal therapy and months of continuous treatment are required for successful management, and this may sometimes be difficult due to poor compliance resulting from adverse effects and drug cost.9 our patient was treated with itraconazole 100mg three times a day for a period of eight months. besides its excellent antifungal activity, itraconazole also has anti-tumorigenic effects, inhibits angiogenesis, and plays a role in controlling inflammation and swelling in fungal infection.10 we noted good response to therapy as shown by a progressive decrease in facial swelling and smoothening of the skin. (figure 6) rhinofacial conidiobolomycosis is an endemic condition in asia but may be under reported due to lack of clinical suspicion and mycological facilities in hospitals. a number of rfc cases have been reported and publications are limited to case reports. to the best of our knowledge, this case is the 62nd reported in asia and the first in the philippines based on a 2015 case report and literature review of conidiobolomycosis in asia.12 we found no previous local reports in a search of the cochrane library, wiley online library, herdin, philippine e-journals, philippine journals online, and google scholar, using the keywords rhinofacial swelling, conidiobolomycosis, and philippines. in summary, rhinofacial conidiobolomycosis is a rare chronic localized fungal infection that usually affects midline facial structures in immunocompetent hosts. early detection and diagnosis, and appropriate medication can give rapid resolution. to the best of our knowledge, this may be the first documented case of rhinofacial conidiobolomycosis in the philippines. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial light one candle for the strength that we need to never become our own foe and light one candle for those who are suffering pain we learned so long ago light one candle for all we believe in that anger not tear us apart and light one candle to find us together with peace as the song in our hearts don’t let the light go out! it’s lasted for so many years! don’t let the light go out! let it shine through our hope and our tears. — peter yarrow (peter, paul and mary) 19821 the philippine elections of 2022 are over, and long before the official results were available (and despite the absence of an objectively credible count), presumptive winners were declared based on early returns.2 a supposed majority of results claimed a landslide victory within hours (in a country with one of the slowest internet speeds in the world), even as voting was still taking place in some precincts (several continuing on to the next day, delayed by mechanical and electronic glitches and other issues).2,3 as the incredible outcome was broadcast and disseminated, millions of people reacted in disbelief and denial.2,4 allegations of massive vote-buying and systematic manipulation, irregularities and fraud spread quickly amidst a growing groundswell of anger, as speculations and explanations were exchanged.4,5 the looming defeat of the leading (and sole, “last man standing is a woman”) lady contender, vice president ma. leonor “leni” gerona robredo, and inevitability of the return to power of the marcoses in the person of ferdinand “bongbong” romualdez marcos jr., son and namesake of the strongman ousted almost two score years ago, resulted in widespread despair and depression.2-5 indeed, it seemed (at least to the former’s supporters) that the darkness had finally succeeded in blanketing out the light. the previous months had seen a campaign period marked by the unprecedented rise of the biggest mass-based volunteer movement the country had ever seen.6 (cf. https://www.lenirobredo.com) without any funding of her own, leni robredo had kindled hope in the hearts of millions who rallied to her cause for good governance to achieve the upliftment of all (“sa gobyernong tapat, angat buhay lahat”), particularly the marginalized (“mga nasa laylayan”), heeding her admonition that it is more radical to love (“mas radikal magmahal”). doctors and lawyers rendered free medical and legal assistance (the former continuing on from the pandemic response mobilized and supported by her office of the vice president). artists composed songs (cf. https://open.spotify.com/artist/7see7czi72xhqbahteaqpt) and created artworks, and volunteer-funded murals, posters and placards, t-shirts and pink paraphernalia blossomed everywhere. even public transportation drivers gave free rides to fellow supporters who called each other “kakampinks” -a combination of “kakampi” (meaning ally) and the pink color that came to identify the rose-colored tomorrow (“kulay rosas ang bukas”) that her supporters envisioned. people donated resources in cash and in kind, prepared pink porridge (“lugaw,”) pink bread (“pan de sal,”) even pink hard-boiled eggs and shared them with anyone and everyone, in house-to-house campaigns as well as in the campaign rallies that mobilized hundreds of thousands of supporters that trooped to venues on foot or whatever means possible (despite multiple obstacles including unannounced road closures and sudden unavailability of previously arranged transportation). these rallies saw modern-day multiplications of the loaves and fish, as participants brought food and drink to share under drenching rain or burning sun. they also reverberated with a spirit of kindness, camaraderie and mutual respect, with participants feeling safe and secure amidst self-policed ranks without needing external law enforcement. moreover, rally sites were left as clean as they were before, the day after each gathering. flash mobs and spontaneous events sprung up in multiple places, as leni managed to visit every province in the country, including vote-poor areas never before visited by any presidential candidate. a pink tsunami loomed on the horizon from north to south, sweeping east to west as more and more like-minded people witnessed to the message of hope.6 indeed, these correspondence: prof. dr. josé florencio f. lapeña, jr. department of otolaryngology head and neck surgery ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 telefax: (632) 8524 4455 email: lapenajf@upm.edu.ph , jflapena@up.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr. ma, md department of otolaryngology head and neck surgery college of medicine, university of the philippines manila department of otorhinolaryngology head and neck surgery east avenue medical center, diliman, quezon city liwanag sa dilim: days of darkness, night of light! c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philipp j otolaryngol head neck surg 2022; 37 (1): 4-5 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial were moments of light providing a foretaste of and bearing witness to the possibility of a better future. suddenly, these hopes seemed dashed to the ground with the resounding victory of the marcos camp and their powerful propaganda machine that had systematically spewed massive misinformation and disinformation in the decades of calculated preparation for their return to rule over the country they had once been forced to flee in exile.7 it culminated in a blitzkrieg barrage that was a naked “in your face” flaunting of lies and falsehood over truth and justice, of thievery and plunder over honest labor and hard work, of wealth, entitlement and wanton excess over diligent study, legitimate qualifications8 and dutiful payment of due taxes.9 indeed, the triumph of the untouchable convict made it seem that it was “better to cheat than to repeat” reinforcing the golden rule as those who had the gold made the rules. in the words of a young academic, “what our youth bitterly learned, unfortunately, is that goodness doesn’t always win, at least not in each battle… why should they work hard on their studies when apparently qualifications don’t matter? why should they practice honesty when dishonesty helps you win?”5 for those who quixotically fought for the right, the dismal days after the elections were days of darkness indeed. and then a thanksgiving rally dubbed “we are the light” (“tayo ang liwanag”) was convened just four days after the elections, where leni acknowledged the collective grief, hurt and anger, then turned it around completely. allow me to paraphrase and translate:10 affirming these knotted-up, deep-seated pent-up emotions and even soaking in them can allow listening to your heart of hearts and remembering that this is what it really feels like to love. remember that there was good that blossomed within each one and that the rage we feel is rooted in love. we reached out to others, listened to them, helped them and promoted our vision in the past months, not to gather votes, but to value and uplift every filipino. regardless of who they were supporting. regardless of who they voted for. while unanswered questions should be answered and allegations addressed, we have to begin accepting results that differ from those we dreamed of and hoped for. the wrongdoings did not just take place on election day (in the form of broken vote counting machines or alleged vote-buying). the biggest adversary predated the polls, a powerful, vast machinery developed over decades with the capacity to sow disinformation and spread anger. it stole the truth, and therefore stole history, as well as the future. disinformation is one of our biggest foes. although systematic lying may prevail now, only we can say until when it will reign. it is up to us, whether the fight is over or just beginning. she then promised to devote her energy to fighting falsehood, inviting us to join her in a movement that would defend truth and explain how disinformation was spread, why it was believed in, and who was behind it. so that we do not lose the spirit behind the movement, that the aim of a faithful government is the upliftment of everyone’s life (“sa gobyernong tapat; angat buhay lahat”), she announced the launching of an angat buhay ngo (literally, lift life ngo) and invited all to continue working together in the largest volunteer network in the history of our nation:10 and as we continue reaching out to the marginalized, and contribute so that they can rise up, we must not choose who to help or turn our back on anyone as we demonstrate the full force of radical love (“radikal na pagmamahal”). our challenge is to move forward arm in arm to realize the aspiration that bound us together: one nation that is humane, truthful, and just, where government is accountable and no one is left behind in the fringes. so many are still grieving and sad, and hearts and minds are wrapped in gloom. your feelings are real, and important. but i have learned in such difficult times, that healing will not happen in solitude and sulking, but in resuming service to others, with eyes fixed on the horizon. allow yourself to weep, but when you are ready to dry your tears, shake it off and strengthen your heart because we have work to do. i am excited now, excited to continue to strive together with you. and i say to all: hope continues, there is still light. that light was not snuffed out in the elections, rather it grew brighter. how much further can we reach if we do not give up? let us use the coming days, months and years to advance the philippines we dream of. i repeat: nothing was wasted, we were not defeated. the eyes that have been opened will not be shut again! she ended by asking people to hug one another, as this day was not an ending, but the beginning of a new chapter – one that we would write together. as we lit up one another’s paths, so would we light up the lives of many others. in one speech on that may evening, a speech that reverberated throughout the country, she rekindled hope and brought light in the darkness. she magically and brilliantly transformed the preceding days of darkness and depression into one night of light! what is the memory that’s valued so highly that we keep it alive in that flame? what’s the commitment to those who have died that we cry out they’ve not died in vain? we have come this far always believing that justice would somehow prevail this is the burden, this is the promise this is why we will not fail! don’t let the light go out! don’t let the light go out! don’t let the light go out! — peter yarrow (peter, paul and mary) 19821 references 1. yarrow p. (peter, paul and mary). “light one candle” performed at the 1982 peter, paul and mary hanukkah / christmas concert at carnegie hall 1982 december 11; studio album “no easy walk to freedom” (gold castle records / polygram albums) 1986. new york: rca studios. [cited 2022 may 16]. available from: https://www.youtube.com/watch?v=bzuvwzuppj4. 2. nikkei staff writers. philippine presidential election: how the night unfolded. nikkei asia. may 9, 20022 18:00 jst (updated on may 10, 2022 18:10 jst). [cited 2022 may 16] available from: https://asia.nikkei.com/politics/philippine-elections/philippine-presidential-election-howthe-night-unfolded. 3. #phvote microsite. #wedecide: atin ang pilipinas. (comelec-accredited election live-update website). [cited 2022 may 16] available from: https://ph.rappler.com. 4. wee s-l. marcos win prompts protests in the philippines. the new york times. may 10, 2022. [cited 2022 may 16]. available from: https://www.nytimes.com/2022/05/10/world/asia/ philippines-election-protests.html. 5. tuazon ac. what do we tell our children? philippine daily inquirer. may 12, 2022. [cited 2022 may 18]. available from: https://opinion.inquirer.net/152880/what-do-we-tell-our-children. 6. doyo mcp. leni’s magnificat campaign moments. philippine daily inquirer. may 20, 2022. [cited 2022 may 21]. available from: https://opinion.inquirer.net/153138/lenis-magnificat-campaignmoments. 7. johnson h, simonette v. bongbong marcos: the man attempting to revive a corrupt political dynasty. bbc news, manila. 6 may 2022. [cited 2022 may 16]. available from: https://www.bbc. com/news/world-asia-61212659. 8. yap c, sayson ic. oxford university says marcos jr. did not complete degree. bloomberg asia edition. october 27, 2021. [cited 2022 may 16]. available from: https://www.bloomberg.com/ news/articles/2021-10-27/oxford-gets-pulled-into-philippine-row-over-marcos-jr-s-degree. 9. cnn philippines staff. court says ‘no record’ of bongbong marcos complying with tax ruling petitioners. cnn philippines. december 3, 2021. [cited 2022 may 16]. available from: https:// www.cnnphilippines.com/news/2021/12/3/bongbong-marcos-no-record-compliance payment-court-tax-case.html. 10. robredo l. address during “tayo ang liwanag: isang pasasalamat” thanksgiving speech at the ateneo de manila university bellarmine field. 2022 may 13. [cited 2022 may 16] available from: https://www.youtube.com/watch?v=2c0ihwxt-6k. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the profile of patients with oral cavity cancer seen at the ear, nose and throat – head and neck surgery (ent-hns) department of the bicol medical center from january 2018 to december 2020. methods: design: retrospective review of records setting: tertiary government training hospital participants: medical records of patients with oral cavity lesions with malignant biopsy results seen at the bicol medical center department of ent-hns from january 2018 to december 2020. results: records of 42 patients were included, 30 (71%) male; 12 (29%) female with the mean age of 62 ± 10.02 (range 34 to 80 years old). squamous cell carcinoma was the most common histopathologic diagnosis (38/42; 91%), mostly affecting the anterior tongue (16/42; 38%) and buccal regions (14/42; 33%). most tumors were in advanced stages: 25/42 (59%) in stage iva; 7 (17%) in stage ivb. a total of 61% (17) of 28 oral cavity cancer patients with recorded risk factors practiced a combination of two or three high risk habits (betel nut chewing, tobacco smoking, alcoholic beverage intake) and a third practiced all three (10/28; 36%). conclusion: the profile of oral cavity cancer patients in our study is different from the reported profiles in asia and european and us counterparts. our profile patient is a married male farmer in the 7th decade of life with poor dental hygiene and advanced stage iv squamous cell carcinoma of the tongue and buccal region, and combined habits of regular alcoholic beverage drinking, chronic tobacco smoking, and/or betel nut chewing, who lives in coastal or mountainous communities where access to health care may be limited. keywords: oral cavity cancer; demographic profile; squamous cell carcinoma; bicol region profile of patients with oral cavity cancer seen at the department of ear nose throat – head and neck surgery of the bicol medical center adrian d. alvarez, md marifee u. reyes, md, mdm department of ear nose throat head and neck surgery bicol medical center correspondence: dr. marifee reyes department of ear nose throat head and neck surgery bicol medical center, bmc rd., concepcion pequeña, naga city camarines sur 4400 philippines phone: (632) 54 472 6125 / +63 920 915 5988 email: bmc2017ent@gmail.com ampyreyes98@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by both authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2023; 38 (1): 35-38 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery original articles lip and oral cavity cancer is a disfiguring disease associated with high morbidity and mortality, and is known to be a serious public health dilemma.1,2 south-central asia has the highest incidence of lip and oral cavity cancer in the world according to the 2020 estimate by the global cancer observatory (globocan).3 oral cavity cancer (occ) ranks 16th in global incidence and has a prevalence of 3.56 per 100,000.3 in the philippines, cancer is the third leading cause of morbidity and mortality with oral cavity cancer ranking 19th among the most common cancers.3,4 the only local statistics available are from the time period of 1980-2007 in metro manila and the rizal province with incidences of  2.9 and 1.9 (per 100,000) for men and women, respectively.5 different risk factors have been identified and associated in the pathogenesis of occ. studies have established the synergistic relationship of tobacco and alcohol consumption as the most important risk factors.6,7 asian populations including the philippines have distinct cultural practices such as betel nut chewing with or without tobacco which have been implicated as strong etiologic factors.7 other factors that have been associated with the development of occ are genetics, poor oral hygiene, chronic trauma due to ill-fitting dentures or pointed teeth, wood dust exposure, lack of vegetables and fruits in the diet, maté leaf drinking, high red meat consumption, and high salted meat consumption.3,7 low socioeconomic status, diabetes mellitus type ii, and heavy metal exposure were also considered in the complex etiology of occ.8 unfortunately, there is very limited philippine data for occ, and to the best of our knowledge, no published data from the bicol region based on our search of herdin plus, google scholar, and medline (pubmed). this study intends to determine the profile of patients with occ seen at the ear, nose and throat – head and neck surgery department of the bicol medical center from january 2018 to december 2020. studying the risk factors and the epidemiology of occ from a regional perspective can help in understanding this disease as variation among populations and/or regions have been reported. this study can also be used to create baseline data for the institution and the region, to identify high risk populations, and to aid in developing programs for future advocacies. methods with approval of the bicol medical center – research ethics committee (bmc-rec-2021-14) and authorization for data collection by the chief of hospital and head of the records section, a retrospective review of records using purposive sampling was started last may 2021. all records of patients seen by the ent-hns department from january 2018 to december 2020 were considered for possible inclusion in the study. inclusion criteria were patients seen by the ent-hns department with oral cavity mass and confirmed histopathology of occ. excluded from the study were patients with oral cavity mass without histopathology results and those with missing records. data collected included the socio-demographic profile, histopathology report, tumor location, high risk lifestyle habits (smoking, alcohol, betel nut chewing), diet, occupation, dental status and clinical staging based on the american joint committee on cancer 8th edition.9 microsoft® excel for mac version 16.66 (microsoft corporation, redmond, wa, usa) was used for tabulating and collating data. patient records were assigned codes and anonymized. descriptive summary measures for continuous variables were analyzed in terms of mean ± standard deviation. categorical variables were summarized in terms of frequency counts and proportions. statistical analyses were also performed using microsoft® excel for mac version 16.66 (microsoft corporation, redmond, wa, usa). results there were a total of 48 medical records initially reviewed. six hospital charts were excluded from the study, four due to missing records, and two lost to follow up for biopsy. of the 42 remaining records of patients included, 30 (71%) were male and 12 (29%) were female with a ratio of 2.5:1. the population distribution was bell-shaped with mean age of 62 ± 10.02 (range 34 – 80 years old). most of the patients were married (34/42; 81%). primary occupations reported were farmers (12/42; 29%) and housewives or housekeepers (8/42; 19%). the municipalities of iriga and lagonoy accounted for 12% each of the study population. most of the patients were clustered in the southern portion of camarines sur. data on diet preferences were mostly absent (50%) and of those recorded the majority had no food preference (17/42; 40%). of the 30 available dental records of occ patients prior to chemo-radiation, 12 (40%) showed presence of multiple dental caries, calculi and soft debris, 11 (36%) had multiple dental caries, while four (13%) were edentulous. unfortunately, the dental records of twelve patients were not available in the hospital chart as dental records from private dental clinics are not usually brought in by the patients. squamous cell carcinoma was the most common histopathologic diagnosis (38/42; 91%). there were two cases of verrucous carcinoma and one spindle cell carcinoma. the most commonly affected anatomic sites were the anterior tongue (16/42; 38%), buccal (14/42; 33%), and lower lip (5/42; 12%). most of the tumors were in the advanced stages: 25/42 (59%) in stage iva, 7 (17%) in stage ivb and 3 (7%) in stage iii. seven cases were lacking in information for proper staging. tumor sizes were more than 4 cm and had invaded adjacent structures or skin of the face (t4a) in 60%, and had extended to either the masticator space, philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery original articles pterygoid plates, skull base, or encased the internal carotid artery (t4b) in 17%. a third (33%) had nodal metastasis of less than 3cm on bilateral sides of the neck (n2c), and 31% had nodal metastasis on the ipsilateral side (n2b). none of the patients had metastasis detected on chest radiographs. for the analysis of high risk habits, only 28 charts had recorded details on risk factors. a total of 61% (17) of the 28 occ patients practiced a combination of two or three of the mentioned high risk habits. of these, a third of the 28 occ patients practiced all three combined habits of betel nut chewing, smoking, and intake of alcohol (10/28, 36%), four combined betel nut chewing and alcoholic beverage intake, while three combined betel nut chewing with tobacco smoking. for single users, betel nut chewing was the most common habit (20/28, 71%), followed by alcoholic beverage drinking (17/28, 61%), and tobacco smoking (16/28, 57%). the history of betel nut chewing ranged from 5 to 43 years, smoking history ranged from 5 to 62 pack years, while reported frequencies of alcoholic beverage drinking ranged from occasional to monthly or weekly. quantity of use or intake was not available for all. discussion our local profile of occ patients is different from the reported profile in asia and european and us counterparts.6,7 european and us profiles show an elderly man in his 7th decade of life with the most common diagnosis and area as early-stage tongue squamous cell carcinoma whereas the asian profile is a man in his 5th decade of life afflicted with late-stage lesions of buccal mucosa squamous cell carcinoma.6,7 the profile of patients with occ seen by the department of ent in bicol medical center in our study is a married male farmer in the 7th decade of life (older than his asian counterpart) who most likely has combined habits of regular alcoholic beverage drinking, chronic tobacco smoking, and/or betel nut chewing. the profile patient also has poor dental hygiene with a primary tongue lesion, and lives in coastal or mountainous communities where access to health care may be limited. different studies have shown that oral cavity cancer was more common in patients between 51 and 70 years old.4,7,10 this is consistent with our findings of an overall mean age of 62 years, with the most affected groups between 60 – 69 years (36%) and 50 – 59 years (31%) of age.  according to a 2020 social survey, the average age of the filipino farmer is 59, which places them in the mean age of our study population.11 this implies a social emergency need to implement an effective program for early detection. despite health programs and advocacies on the consequences of cigarette smoking (e.g., yosi kadiri),12 alcoholic beverage drinking,13 and betel nut chewing,13,14 there are pockets in our local population (particularly the farming community) still practicing these high risk behaviors as evidenced in this study. a post hoc conversation with a farmer with occ revealed that betel nut chewing allegedly kept him warm while plowing rice fields which entails being submerged in water up to mid-calf for hours especially during the rainy season. another one claimed that betel nut chewing helps relieve him of fatigue as he does his manual laborious work while another claimed it makes her teeth strong. our occ population was already in the advanced stage of cancer when received in our institution. the reasons for the delay were not elicited, but according to sankaranarayana et al., delayed healthseeking behavior may be attributed to low socioeconomic status, low educational attainment, and the preference for folk medicine.3,7 another possible reason is that diagnosis may be further delayed by the inability to identify early lesions by the patients or by the health care workers in the primary health units.3 this is significant as the country shifts to universal health care where primary health units are the first line in medical consultation: are they capable of early detection for oral cancer? delay can also be associated with subsequent late referral to highly specialized facilities.3 our study has several limitations. first, our sample was limited to patients seen at the ent-hns department of the bicol medical center, overlooking patients seen by other departments, in private clinics and in other hospitals in region v. second, our study was a review of records only, and not of actual patients. hence, all our data was at best secondhand. third, incompleteness of data and inability to quantify details such as the amount of consumption by the examiner and/or the patient may lead to biased estimates. fourth, there were a lot of inferences due to lack of direct data which can be derived from direct questioning which was not possible for our study. finally, our sample was very small, even for our institution, and it was not possible to generate any inferences regarding associations among variables, beyond raw frequency counts and percentages. we recommend further studies that will include the occ patients seen in other departments and hospitals in the region as well as a more complete and detailed data collection, and to explore other risk factors possibly associated with the disease such as diet, viral etiologies among others which are not routinely inquired or tested in our institution. future researchers can also include behavioral surveys, treatment outcomes and survival rates of patients diagnosed with occ. because our purpose for obtaining a regional profile was to improve our regional cancer care as encouraged in the national integrated cancer control act,15 we recommend that even with our limited findings, the department of health regional office and bicol medical center consider a targeted program on the prevention and regular monitoring of oral philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery references 1. rao svk, mejia g, thomson kr, logan r. epidemiology of oral cancer in asia in the past decade – an update (2000-2012). asian pac j cancer prev. 2013;14(10):5567-77. doi: 10.7314/ apjcp.2013.14.10.5567; pubmed pmid: 24289546. 2. open database: national cancer institute. surveillance, epidemiology, and end results program. cancer statistics review, 1975-2018. age-adjusted seer incidence and us death rates and 5-year relative survival (percent) by primary cancer site, sex and tiime period all races [cited 2021 april 28]. available from: https://seer.cancer.gov/csr/1975_2018/browse_csr. php?sectionsel=1&pagesel=sect_01_table.04. 3. sankaranarayana r, ramadas k, amarasinghe h, subramanian s, johnson n. chapter 5 oral cancer: prevention, early detection, and treatment. in: gelband h, jha p, sankaranarayanan, r., horton, s, editors. disease control priorities third edition cancer. washington: the world bank; 2015. p. 85-99. 4. alves a, correa m, silva k, araújo l, vasconcelos a, gomes a. et al. demographic and clinical profile of oral squamous cell carcinoma from a service-based population. braz dent j. 2017 may-jun;28(3):301-306. doi: 10.1590/0103-6440201601257; pubmed pmid: 29297550. 5. open database: philippine cancer society. manila (phil): cancer in the phils vol 5 part 2. c2015 – [cited 2021 april 28]. available from: http://www.philcancer.org.ph/wp-content/ uploads/2017/07/cancer-in-the-phils-vol-5-part-2.pdf. 6. wein ro, weber rs. malignant neoplasms of the oral cavity. in: flint pw, haughey bh,lund v, niparko jk, robbins kt, thomas jr, lesperance mm, editors. cummings otolaryngology head and neck surgery sixth edition. philadelphia, pa: elsevier saunders; 2016. p.1359-87. 7. montero ph, patel sg. cancer of the oral cavity. surg oncol clin n am. 2015 jul; 24(3):491508; doi: 10.1016/j.soc.2015.03.006; pubmed pmid: 25979396; pubmed central pmcid: pmc5018209. 8. shenoi r, devrukhkar v, chaudhuri, sharma bk, sapre sb, chikhale a. demographic and clinical profile of oral squamous cell carcinoma patients: a retrospective study. indian j cancer. 2012 jan-mar;49(1):21-6. doi: 10.4103/0019-509x.98910; pubmed pmid: 22842164. 9. amin mb, edge s, greene f, byrd dr, brookland rk, washington mk, gershenwald je, compton cc, hess kr, et al., the eighth edition ajcc cancer staging manual: continuing to build a bridge from a population-based to a more «personalized» approach to cancer staging. doi: 10.3322/ caac.21388; pubmed pmid: 28094848. 10. palis f. aging filipino farmers and their aspiration for their children. philipp j sci. 2020 jun;149(2):351-361. doi: 10.56899/149.02.10. 11. republic act 9211. an act regulating the packaging, use, sale, distribution and advertisements of tobacco products and for other purposes. tobacco regulation act of 2003. [cited 2021 april 28]. available from: https://doh.gov.ph/sites/default/files/policies_and_laws/ra09211.pdf. 12. ngelangel ca, wang ehm. cancer and the philippine cancer control program. jpn j clin oncol. 2002 mar;32 suppl:s52-61; doi: 10.1093/jjco/hye126; pubmed pmid: 11959878. 13. presidential proclamation no. 1676, s.2008. declaring the fourth week of april and every year thereafter as head and neck consciousness week. [cited 2021 april 28]. available from: https:// www.officialgazette.gov.ph/2008/11/21/proclamation-no-1676-s-2008/. 14. republic act no. 11223. an act instituting universal health care for all filipinos, prescribing reforms in the health system, and appropriating funds therefor. [cited 2021 april 28]. available from: https://www.officialgazette.gov.ph/2019/02/20/republic-act-no-11223/. 15. republic act no. 11215. an act institutionalizing a national integrated cancer control program and appropriating funds therefor. [cited 2021 april 28]. available from: https://www. officialgazette.gov.ph/2019/02/14/republic-act-no-11215/. cavity lesions in farming communities. in addition, capacity building can be conducted among healthcare workers in local health units of the affected municipalities. the service delivery network involving our hospital should be reviewed and the referral system be improved, if necessary. in summary, our profile of occ patients is different from the reported profiles in asia and european and us counterparts. unlike european and us profiles of an elderly man in his 7th decade of life with early-stage tongue squamous cell carcinoma, or asian profiles of a man in his 5th decade of life with late-stage lesions of buccal mucosa squamous cell carcinoma, our profile patient is a married male farmer in the 7th decade of life with poor dental hygiene and advanced stage iv squamous cell carcinoma of the tongue and buccal region, and combined habits of regular alcoholic beverage drinking, chronic tobacco smoking, and/or betel nut chewing, who lives in coastal or mountainous communities where access to health care may be limited. original articles philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the association of thyroid malignancy and the following ultrasonographic findings: presence of solid hypoechoic nodule, irregular margins (infiltrative, microlobulated, or speculated), microcalcifications or disrupted rim calcifications with small extrusive hypoechoic soft tissue component, taller than wide shape of the thyroid nodule, and evidence of extrathyroidal extension. methods: design: cross-sectional study setting: tertiary government training hospital participants: records of patients admitted to the otorhinolaryngologyhead and neck surgery ward with a diagnosis of nodular non-toxic goiter, multinodular non-toxic goiter, and thyroid malignancy who underwent thyroid surgery between january 2017 and june 2018 were considered for inclusion. results: a total of 33 patients, 7 males and 26 females, were included in this study. patients’ age ranged from 26 to 69 years with an average of 46 years. thirteen (39.4%) had malignant while 20 (60.6%) had benign histopathologic results. there was a significant association between presence of solid hypoechoic nodule (fisher exact, n = 33, p = .0047), irregular margins and microcalcifications with malignant histopathology results (x2 (df = 1, n = 33) = 8.57, p = .003). no significant difference was noted in the proportion of subjects with malignancy according to taller than wide nodules (fisher exact, n = 33, p = 1.000) or presence of extrathyroidal extension nodules or presence of extrathyroidal extension (fisher exact, n = 33, p = .276). on multivariate analysis using logistic regression, only microcalcification was found to be a significant predictor of malignancy (or = 8.96, 95% ci: 1.02 – 87.19, p = .05). conclusion: there was a significant association between presence of solid hypoechoic nodule, margins and microcalcifications with thyroid carcinoma. only microcalcification was found to be a significant predictor of thyroid malignancy on ultrasound, although our confidence interval was broad. keywords: calcifications; thyroid; thyroid carcinoma; thyroid nodule; ultrasonography association of ultrasonographic findings and thyroid malignancy: a cross-sectional study clint s. trinchera, md emmanuel tadeus s. cruz, md quezon city general hospital department of otorhinolaryngology head and neck surgery correspondence: dr. emmanuel tadeus s. cruz department of otorhinolaryngology head and neck surgery quezon city general hospital seminary rd., bgy. bahay toro, quezon city 1106 philippines phone: (02) 8863 0800 local 401 email: orl_hns_qcgh@yahoo.com the authors declared that this is an original manuscript that has not been published or accepted for publication locally or elsewhere, in print or in electronic media. the manuscript has been approved by all the authors, and that the requirements for authorship have been met. authors practiced honesty and integrity in this work. disclosures: the authors signed disclosures that there are no financial grants or relationships, intellectual passion, religious, cultural, or political beliefs, and institutional affiliations that may bring about conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery, analytical research contest (2nd place). october 23, 2018. roma salon, the manila hotel. manila. presented at the 62nd pso-hns annual convention & ifhnos world tour manila analytical research contest (2nd place), december 2018. marquee tent, edsa shangri-la hotel, manila. philipp j otolaryngol head neck surg 2019; 34 (2): 24-28 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles thyroid cancer accounts for approximately 0.5% of all malignancies.1 though most palpable nodules are benign, there is a 5-10% risk of having a malignancy.2 the american thyroid association (ata) strongly recommends thyroid ultrasonography (utz) for patients with suspected or incidentally-detected nodules. this modality is able to determine the presence of suspicious nodules, their character and location, and guide the accuracy of fine needle aspiration biopsy.3 a number of studies have been published associating specific sonographic findings with thyroid malignancy.1,2,4-9 many elucidate the role of nodule size and presence of microcalcifications.2,4-9 the ata listed presence of disrupted rim calcifications with small extrusive hypoechoic soft tissue component, evidence of extrathyroidal extension, nodule shape and features as determinants of malignancy. we initiated this study to determine whether these ultrasonographic features of malignancy are also present in, or if they differ in the local setting. this study aims to determine the association of thyroid malignancy and the following ultrasonographic findings: presence of solid hypoechoic nodule, irregular margins (infiltrative, microlobulated, or speculated), microcalcifications or disrupted rim calcifications with small extrusive hypoechoic soft tissue component, taller than wide shape of the thyroid nodule, and evidence of extrathyroidal extension. methods with institutional review board approval, this cross-sectional study was conducted from may to july 2018. records of patients who were admitted to the otorhinolaryngologyhead and neck surgery ward with a diagnosis of nodular non-toxic goiter, multinodular non-toxic goiter, or thyroid malignancy and underwent thyroid surgery from january 2017 to june 2018 were considered for inclusion. the following were excluded: post-surgery patients previously diagnosed with thyroid malignancy who were managed for tumor recurrence or relapse, and those with no ultrasonographic result or final histopathology results on record. a sample size of 24 was computed using this formula: where: z α = 95% confidence level= 1.96 z β = 80% power of study= 0.84 p 1 = estimated proportion of malignant histopathological results among those with malignant ultrasound findings= 30/51 = 58.8 = 0.588 q1= 1p 1 = 10.588 = 0.412 p 2 = estimated proportion of malignant histopatholigical results among those with benign ultrasound findings = 15/75= 20.0= 0.20 q 2 = 1 p 2 = 10.20 = 0.80 q= 1p = 1 0.394 = 0.606 the clinical histories, physical examination, and histopathologic results recorded in the hospital charts were extracted by the researcher and collated using ms excel for mac 2011 version 14.4.2 (microsoft corp., redmond, wa, usa). a senior radiology resident blinded to the final histopathology viewed each ultrasound image and reviewed each printed report to ascertain the presence or absence of the parameters which may not be covered in the official interpretation of the ultrasound results. this was done to standardize the interpretation. if the feature/s were absent on the printed report, the image was reviewed; if both the printed report and the image was absent, then the parameter/s were ruled out. we tabulated the consolidated data using the same software. the presence and type of malignancy were included in the tabulation. analysis of data data were encoded and tallied in statistical package for social sciences (spssx 3) version 10 for windows (spss corp., chicago, il, usa). descriptive statistics were generated for all variables. for nominal data frequencies and percentages were computed. for numerical data, mean ± sd were generated. analysis of the different variables was done using the following test statistics: chi-square test was used to compare/associate nominal (categorical) data, fisher exact test was used when there were expected frequencies <5, logistic regression was used in predicting a dichotomous outcome variable (i.e. malignant histopathology result). results out of 45 records retrieved, a total of 33 were included in the study. of the 12 excluded records, 9 had no histopathology result while 8 had no ultrasound report. of the 33 included, 7 (21.2%) were males and (zα √ 2pq + ζβ √ p1q1 + p2q2) 2 (p1-p2) 2 n = p1+p2 0.588+0.20 2 2 p= = = 0.394 (1.96 √ 2(0.394)(0.606) + 0.84 √ (0.588 (0.412) + 0.20 (0.80)) 2 (0.588 0.20) 2 n = (1.35 + 0.53)2 0.15 n = = 24 philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles 26 (78.8%) were females. the age ranged from 26 to 69 years with an average of 46 ± 13.6 years. the age of patients with malignant results (52.6 ± 15.6 years) was significantly higher (t (df = 31) = 2.42, p = 0.02) than those with benign histopathology (41.7 ± 10.4 years). on the other hand, no significant difference was noted in the proportion of males and females according to histopathology result (fisher exact, n = 33, p = .58). a solid hypoechoic nodule was present in 21 (63.6%), irregular margins in 9 (27.3%), microcalcifications in 15 (45.5%), taller than wide nodules in 29 (87.9%), and extrathyroidal extension in 4 (12.1%). (table 2) of the 33 patients, 13 (39.4%) had thyroid carcinoma while 20 (60.6%) had benign lesions. malignant histopathologies included 12 with papillary thyroid carcinoma and one with medullary carcinoma while benign lesions comprised 20 colloid adenomatous goiters. there were significant associations noted between histopathology results and the following ultrasonographic findings: 1. presence of solid hypoechoic nodule (fisher exact, n = 33, p = .047), irregular margins and 2. microcalcifications (x2 (df = 1, n = 33) = 8.57, p = .003). a significantly higher proportion (fisher exact, n = 33, p = .047) of subjects with solid hypoechoic nodule had malignant histopathology results compared to those with nodules that were not solid with 11 (52.4%) and 2 (16.7%), respectively. similarly, significantly higher proportions of nodules with irregular margins were malignant compared to those with regular margins with 6 (66.7%) and 7 (29.2%), respectively. moreover, a significantly higher proportion (x2 (df = 1, n = 33) = 8.57, p = .003) of nodules with microcalcifications yielded malignant results compared to those without microcalcifications with 10 (66.7%) and 3 (16.7%), respectively. on the other hand, no significant difference was noted in the proportion of subjects with malignancy according to taller than wide nodules (fisher exact, n = 33, p = 1.000) or presence of extrathyroidal extension (fisher exact, n = 33, p = .276). on multivariate analysis using logistic regression, only microcalcification was found to be a significant predictor of malignancy. the risk of patients with microcalcification for thyroid malignancy was almost 9 times higher than those without microcalcification (or = 8.96; 95% ci = 1.02 – 87.19; p = .05). (table 4) discussion this study revealed a significant association between malignant histopathologic results of the thyroid and the presence of solid hypoechoic nodules, irregular margins and microcalcifications on ultrasound. conversely, no significant association was found between thyroid malignancy and taller than wide nodules or presence of extrathyroidal extension on ultrasound. table 2. distribution according to ultrasonographic findings frequency (n=33) percentage presence of solid hypoehoic nodule solid not solid margins irregular regular microcalcifications with without taller than wide nodules taller than wide not taller than wide extrathyroidal extension with extension without extension 21 12 9 24 15 18 29 4 4 29 63.6 36.4 27.3 72.7 45.5 54.5 87.9 12.1 12.1 87.9 table 1. comparison of demographic characteristics according to histopathology results histopath result malignant benign (n=13) (n=20) total p-value* age (in years) mean ± sd sex male female 52.62 ± 15.61 3 (42.9%) 10 (38.5%) 41.70 ± 10.41 4 (57.1%) 16 (61.5%) 46.00 ± 13.60 7 26 .02 (s)† 1.00 (ns)‡ * p>0.05not significant; p ≤0.05-significant data presented as mean ± sd, (medians) were computed as needed; or as frequency (%) † t-test; ‡fisher exact test * ssignificant; (ns)not significant these findings are similar to those of anil and colleagues wherein solid nodules on utz had the highest sensitivity (69-75%) for malignancy in comparison to cystic or spongiform appearance.7 cystic nodules were more likely benign (with only about 2% malignant),8 similar to our findings. solid nodules are a common ultrasound feature of papillary thyroid carcinoma in around 70% of cases,4 anaplastic and medullary thyroid carcinoma also display this feature.4 irregular margins may be infiltrative, microlobulated or spiculated.3 irregularity of margins is attributed to the nodule losing its pseudocapsule of fibrous connective tissues making the tumor and philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles malignancy (>90%). in a study by ren and colleagues (2015), taller than wide shape is a good predictor of papillary thyroid carcinoma in small nodules with high sensitivity and specificity (81.4% and 96.8%, respectively).9 however, the sensitivity was significantly low and odds ratios were smaller (1.6-2.9) when assessed separately from other features.3 in contrast, in this study, no significant association was observed between taller than wide shape and malignancy. the size of the nodule was excluded because this was not included in the parameters set by ata. no qualifications were made as to large (>1cm) or small (<1); only the anteroposterior to transverse ratio was considered. extension to adjacent structures and metastasis to lymph nodes are specific signs of thyroid cancer.7 papillary thyroid cancer is known to metastasize to the pre/paratracheal group of lymph nodes.4,7 anaplastic carcinoma displays extracapsular and vascular spread (33%). medullary carcinoma may present with lymph node and distant organ metastasis.7 in this study, 3 had extrathyroidal invasion; 2 with extension to lateral cervical lymph nodes, and 1 to the submandibular region. however, no significant association was found between extrathyroidal invasion and malignancy. this may be due to the small number of subjects with extrathyroidal invasion which may differ in a larger population since sample size is inversely proportional to p value and ci. in this study, only microcalcification proved to be a significant predictor of malignancy using multivariate analysis. the risk of those with microcalcifications for having malignancy was almost 9x higher than those without microcalcification. microcalcifications were noted to have strong association with malignancy.1,2 in a study by sio et al., 86% of papillary thyroid carcinoma cases displayed microcalcification on thyroid utz.2 this feature had the highest accuracy (76%), specificity (44-95%), and predictive value (77.9%) in detecting malignancy.1 these sonographic findings are consistent with hyperechoic foci with or without shadowing, corresponding histopathologically to psammoma body clusters.1,7 the american thyroid association recommends ultrasonography in patients with known or suspected thyroid nodules. asymptomatic nodules can be found in as many as 50% of adults1,6 while thyroid malignancy affects 1/10,000 people annually.1 the challenge lies in identifying whether a nodule is benign or malignant, and who among the population would necessitate early aggressive management or avoidance of unnecessary investigation.4 at present, the ata categorized nodules to be of high suspicion (malignancy risk >70% to 90%) if the following are present in thyroid ultrasonography: solid hypoechoic nodule, irregular margins (specified as either infiltrative, microlobulated, or speculated), microcalcifications or disrupted rim table 3. distribution according to ultrasonographic findings and histopath results histopath result malignant benign (n=13) (n=20) total p-value* presence of solid hypoehoic nodule solid not solid margins irregular regular microcalcifications with without taller than wide nodules taller than wide not taller than wide extrathyroidal extension with extension without extension 11 (52.4%) 2 (16.7%) 6 (66.7%) 7 (29.2%) 10 (66.7%) 3 (16.7%) 11 (37.9%) 2 (50.0%) 3 (75.0%) 10 (34.5%) 10 (47.6%) 10 (83.3%) 3 (33.3%) 17 (70.8%) 5 (33.3%) 15 (83.3%) 18 (62.1%) 2 (50.0%) 1 (25.0%) 19 (65.5%) 21 12 9 24 15 18 29 4 4 29 .05 (s)‡ .05 (s)‡ .003 (s)§ 1.00 (ns)‡ .28 (ns)‡ * p>0.05not significant; p ≤0.05-significant data presented as mean ± sd, (medians) were computed as needed; or as frequency (%) ‡ fisher exact test; §chi-square test * ssignificant; (ns)not significant table 4. multivariate analysis of the different ultrasonographic findings predictive of malignant histopath results variable or 95% ci p value age sex (male) solid nodule irregular margins microcalcifications taller than wide nodules extrathyroidal extension 1.08 0.53 2.03 1.83 8.96 0.07 9.50 0.99 – 1.18 0.03 – 9.79 0.14 – 28.05 0.17 – 19.79 1.02 – 87.19 0.002 – 2.91 0.49 – 182.82 .07 (ns) .67 (ns) .60 (ns) .62 (ns) .05 (s) .16 (ns) .14 (ns) logistic regression analysis the thyroid parenchyma indistinct.7 results of this study showed that significantly higher proportions of nodules with irregular margins were malignant compared to those with regular margins. this feature may also be found in benign nodules with a low sensitivity (48.355%) but with high specificity (83-91%) and predictive value (60-81.3%).7 the ata guidelines also implicated taller than wide thyroid nodules measured in transverse view having high specificity for detecting philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles references 1. smith-bindman r, lebda p, feldstein va, sellami d, goldstein rb, brasic n, et al. risk of thyroid cancer based on thyroid ultrasound imaging characteristics: results of a population-based study. jama intern med. 2013 oct; 173(19): 1788-1796. doi: 10.1001/jamainternmed.2013.9245; pmid: 23978950 pmcid: pmc3936789. 2. sio mcd, uy jau, soriano rg. calcifications in thyroid ultrasonography and thyroid carcinoma. philipp j otorhinolaryngol head neck surg. 2014; 29(2): 15-18. 3. haugen br, alexander ek, bible kc, doherty gm, mandel sj, nikiforov ye, et al. 2015 american thyroid association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. the american thyroid association guidelines task force on thyroid nodules ad differentiated thyroid cancer. thyroid. 2016 jan; 26(1): 1-133. doi: 10.1089/ thy.2015.0020; pmid: 26462967 pmcid: pmc4739132. 4. wong kt, ahuja at. ultrasound of thyroid cancer. cancer imaging. 2005 dec 9; 5: 157-166. doi: 10.1102/1470-7330.2005.0110; pmid: 16361145 pmcid: pmc1665239. 5. hershman jm. malignancy of a thyroid nodule can be predicted by ultrasonography if it has microcalcifications and is solid and larger than 2cm. clin thyroidol. 2013 nov; 25(11): 256-258. 6. vera mi, merono t, urrutia ma, parisi c, morosan y, rosmarin m, et al. differential profile of ultrasound findings associated with malignancy in mixed and solid thyroid nodules in an elderly female population. j thyroid res. 2014; 2014: 761653. doi: 10.1155/2014/761653; pmid: 25050189 pmcid: pmc4094854. 7. anil g, hegde a, chong fh. thyroid nodules: risk stratification for malignancy with ultrasound and guided biopsy. cancer imaging. 2011 dec 28; 11: 209-223. doi: 10.1102/14707330.2011.0030; pmid: 22203727 pmcid: pmc3266587. 8. hoang j. thyroid nodules and evaluation of thyroid cancer risk. australas j ultrasound med. 2010 nov. 13(4): 33-36. doi: 10.1002/j.2205-0140.2010.tb00177.x; pmid: 28191095 pmcid: pmc5024877. 9. ren j, liu b, zhang ll, li hy, zhang f, li s, et al. a taller-than-wide shape is a good predictor of papillary thyroid carcinoma in small solid nodules. j ultraosund med. 2015 jan; 34(1):19-26. doi: 10.7863/ultra.34.1.19; pmid: 25542935. calcifications with small extrusive hypoechoic soft tissue component, taller than wide shape of the thyroid nodule and evidence of extrathyroidal extension. our study has several limitations. although the required number of subjects of 24 was met, the study sample may not fairly represent the larger population because of our convenience sampling technique. random or consecutive sampling with clearer inclusion and exclusion criteria in future studies may address this. because this is an observational non-randomized study, our benign and malignant “groups” may also vary in prognosis due to different demographics, illness severity or other baseline characteristics. moreoever, we have at least two potential sources of measurement or observer bias – the histopathologic readings (taken at face value from available reports), and the ultrasonographic readings (despite verification by a blinded senior radiology resident). future studies can improve on this with random and concealed allocation of participants to groups and prospectively-obtained masked outcome assessment using objective and validated measures by independent, blinded observers. in conclusion, our study found a significant association between malignant histopathologic results of the thyroid and presence of solid hypoechoic nodule, margins and microcalcifications but noted no significant difference with taller than wide nodules or presence of extrathyroidal extension on ultrasound. only microcalcification was found to be a significant predictor of malignancy using multivariate analysis. the risk of patients with microcalcification for malignant result was almost 9 times higher than those without microcalcification, but this requires careful scrutiny, as our confidence interval was broad. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 case reports 44 philippine journal of otolaryngology-head and neck surgery philipp j otolaryngol head neck surg 2017; 32 (1): 44-46 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to present an atypical case of a live fish lodged in the throat of a pediatric patient and discuss its management. methods: design: case report setting: tertiary government hospital patient: one result: an 8-year-old girl swallowed a live fish when she accidentally fell in a body of water. failed attempts to remove the live fish prompted consult in the emergency room of our hospital, where removal of the foreign body was successfully done using mixter right angle forceps assisted with a gloved finger. transient cyanosis and unresponsiveness during extraction was overcome with oxygen by mask and she regained consciousness. she was allowed to go home as no other untoward events or complications were observed. conclusion: all ingested foreign bodies particularly in children require immediate attention. the survival of patients with upper aerodigestive and airway foreign bodies depends on early recognition and prompt multidisciplinary management. keywords: foreign body, endoscopy, foreign body ingestion, impaction, oropharynx while swimming in the river, a person can accidentally swallow water. but how often do we see a fish enter the mouth and get lodged in the oropharyngeal inlet? we report a rare case of live fish impaction in the oropharynx of a pediatric patient and discuss its removal. case report an 8-year-old girl was brought to the emergency room of our hospital with severe throat discomfort. her parents claimed that she was walking along the banks of a river in bulacan in central luzon, philippines, when she slipped and accidently fell into the water. a live fish swam towards her and accidentally entered her mouth. attempts to remove the fish from her mouth were unsuccessful and she was rushed to our hospital where she arrived approximately 8 hours after the incident. an impacted live fish in the oropharynx of an 8-year-old child soraya n. joson, md natividad a. almazan, md melanie grace y. cruz, md department of otorhinolaryngology head and neck surgery east avenue medical center correspondence: dr. melanie grace y. cruz department of otorhinolaryngology head and neck surgery 6th floor, east avenue medical center east avenue, diliman, quezon city 1100 philippines phone: (632) 928 0611 local 324 fax: (632) 435 6988 email: eamc_enthns@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery interesting case contest (3rd place), june 30, 2016. unilab bayanihan center, pasig city creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 philippine journal of otolaryngology-head and neck surgery 45 case reports she was received conscious and was able to follow commands but noted to have dysphagia, odynophagia, drooling of saliva and a muffled voice. oral examination revealed abrasions and hyperemia over the soft palate, with the dark-colored fin of the fish visible in the oropharynx. (figure 1) this was better visualized with depression of the tongue. extraction of the foreign body was initially planned under sedation, but the anesthesiologist was concerned about the risk of complete airway obstruction from the tongue falling back against the already-obstructed airway in our patient who was becoming cyanotic and lethergic. consent was obtained to remove it while she was awake and a jennings mouth gag was applied to hold her mouth open. (figure 2) initial attempts to remove the fish using mixter right-angle forceps were unsuccessful, as were subsequent attempts made by palpating the fish with a gloved finger. the fish was eventually grasped mid-body using mixter right-angle forceps assisted by a gloved finger and finally extracted, measuring 8 x 5 cm. (figure 3) immediately prior to extraction of the foreign body, the child became cyanotic and unresponsive. oxygen was administered by mask and she immediately regained consciousness. there was no bleeding noted in the oropharynx. they declined admission for observation, and were eventually allowed to go home, as there were no other untoward events or complications. discussion foreign body ingestion among children is not uncommon in the emergency room. majority of these were ingested accidentally among children aged between six months and six years.1,2 foreign bodies may be aspirated or impacted. common sites of impaction include the tonsils, base of the tongue, piriform fossae and the cricopharynx.3 however, a bigger foreign body in the throat may block both the trachea and esophagus and result in death. with impaction, our patient had dysphagia, odynophagia, drooling of saliva and muffling of the voice. in most cases of foreign bodies in children, diagnosis may be difficult because a clear history cannot be obtained due to the lack of characteristic clinical features and radiologic findings.3 it was different in our patient. oral examination revealed a large fish obstructing the entire oropharynx. impaction of live fish in the laryngopharynx has been previously reported in adults and in children,4,5 but to the best of our knowledge not in our institution. an impacted foreign body in the oropharynx should be immediately removed as the chance of spontaneous passage is less likely. a delay in the procedure causes edema of the mucosa which lodges the object more firmly, making later manipulation extremely difficult.6 more serious and potential life-threatening complications include esophageal perforation, mediastinitis, cervical or mediastinal abscess, emphysema, esophageal-tracheal fistula and septic complications.2 removal should be performed promptly as no foreign body should remain in the aerodigestive tract beyond 24 hours after presentation.7 most importantly, the procedure should be performed under conditions of maximum safety and minimum trauma.6 live fish entering the pharynx while bathing in a stream of water is not commonly reported. in a search of herdin, pubmed and google scholar using the keywords “foreign body,” “impaction,” “oropharynx,” figure 1. abrasions over the soft palate with the fish’s tail seen in the oropharynx. figure 2. application of jennings retractor, and depression of the tongue with a gloved finger reveals more of the fish. figure 3. 8 x 5 cm fish. a part of the tail was detached during initial extraction attempts. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 46 philippine journal of otolaryngology-head and neck surgery case reports references 1. mevio e, mevio n. unusual esophageal foreign body: a table fork. case rep otolaryngol. [internet]. 2013; 2013:987504: 1-20 [cited 2015 dec 15]. available from: https://www.hindawi. com/journals/criot/2013/987504/. doi: 10.1155/2013/987504; pmid: 23634316; pmcid: pmc3619629. 2. sardana p, bais as, singh vp, arora m. unusual foreign bodies of the aerodigestive tract. indian j otolarygol head neck surg. 2002 apr; 54(2): 123-126. doi: 10.1007/bf02968730; pmid: 23119872; pmcid: pmc3450538. 3. vadhera r, gulati sp, garg a, goyal r, ghai a. extraluminal hypopharyngeal foreign body. indian j otolarygol head neck surg. 2009 mar; 61(1):76-78. doi: 10.1007/s12070-009-0039-z; pmid: 23120609; pmcid: pmc3450132. 4. aggarwal mk, singh gb, dhawan r, tiwari a. an unusual case of live fish impaction in hypopharynx in an infant. int j pediatr otorhinolaryngol. 2006 jun; 1(2): 154–156. 5. senthilkumaran s, sweni s, ganapathysubramanian, suresh p, thirumalaikolundusubramnian p. live fish impaction in hypopharynx in an elderly patient. int j gerontol. 2011 dec; 5(4): 225-226. doi:: http://dx.doi.org/10.1016/j.ijge.2011.12.003. 6. murty p, ingle vs, ramakrishna s, shah fa, varghese p. foreign bodies in the upper aero-digestive tract. j sci res med sci. 2001 oct; 3(2): 117-120. pmid: 24019718; pmcid: pmc3174712. 7. loh ks, tan lk, smith jd, yeoh kh, dong f. complications of foreign bodies in the esophagus. otolaryngol head neck surg. 2000 nov; 123(5):613–616. doi: 10.1067/mhn.2000.110616; pmid: 11077351. “hypopharynx,” “esophagus,” and “fish” the authors did not find any similar cases reported in the philippines. however, live fish impaction in the hypopharynx in both children and adults have been reported elsewhere.4,5 most notable was the report of a live fish successfully removed in toto from the hypopharynx of a 7-month-old child.4 removal was done under general anesthesia inside the operating room. although we operated under less-controlled circumstances, we also obtained a successful outcome. ideally, patients should be relaxed, well ventilated and unconscious as these factors afford the best prospects for the successful removal of the foreign body. our decision to remove the foreign body promptly in the emergency room was further necessitated because the patient was becoming cyanotic and lethargic. the possible complications of awake foreign body removal in this case were deemed to outweigh the risk of her possible impending demise. this interesting rare case of impacted live fish in the oropharynx was, to the best of our knowledge, the first in our institution and the first reported in the philippines. the decision to extract the fish was urgent and straightforward because of the risk of total airway obstruction. all ingested foreign bodies, particularly in children, require immediate attention, and impacted oropharyngeal foreign bodies in particular should be removed. the survival of patients with upper aerodigestive and airway foreign bodies depends on early recognition and prompt multidisciplinary management. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 26 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to describe the clinical profile of patients with laryngotracheal stenosis over a 7-year period and discuss strategies for its prevention. methods: design: retrospective case series setting: tertiary government hospital participants: thirteen (13) patients with laryngotracheal stenosis confirmed by laryngoscopy and/or bronchoscopy. results: twenty-one patients were evaluated for laryngotracheal stenosis from january 2008 to june 2015, but only 13 with complete data were included in this study. of the 13 patients, nine (69.2%) belonged to the pediatric age group. ten (77%) were males and three (23%) were females. laryngotracheal stenosis following endotracheal tube (et) intubation was seen in 11 (84.6%) while 2 had thyroid masses and no history of prior et intubation. presenting symptoms or reasons for referral were wheezing (n=4), stridor (n=4), failure to decannulate the tracheostomy tube (n=3), and dyspnea (n=2). duration of et intubation was four to 60 days. the highest frequency of et reintubation was 5 times. among those intubated, stenosis was glottic in one, subglottic in five and tracheal in five patients. three had cotton-myer grade i stenosis, two had grade ii, three had grade iii and three had grade iv stenosis. those with thyroid masses had tracheal stenosis. conclusion: strategies for prevention of laryngotracheal stenosis should include routine airway endoscopy for patients with longstanding neck masses and for those with prolonged et intubation, for whom the option of early prophylactic tracheostomy is worth considering. otherwise, immediate post-extubation endoscopy may facilitate documentation and appropriate intervention. keywords: acquired laryngeal stenosis; tracheal stenosis; endoscopy; intubation, intratracheal; tracheostomy laryngotracheal stenosis is a challenging airway problem, most often from sequelae of local tumors, infection, trauma and intubation.1 laryngotracheal stenosis is an umbrella term, encompassing luminal compromise of the larynx, subglottis and trachea.2 injury is initiated by ischemic necrosis of the mucosa, leading to ulceration of cartilage, inflammation with granulation and fibrous contraction.3 although numerous studies describe various treatment modalities, there is no standard approach to laryngotracheal stenosis.4 successful treatment clinical profile of patients with laryngotracheal stenosis in a tertiary government hospital anna carlissa p. arriola, md antonio h. chua, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. antonio h. chua department of otorhinolaryngology-head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 711 9491 local 320 email: entjrrmmc@yahoo.com the authors declare that this represents original material. that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest (2nd place), natrapharm, the patriot building, km18 slex, paranaque city, september 25, 2015. philipp j otolaryngol head neck surg 2016; 31 (1): 26-30 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 27 despite various options remains a challenge to the otolaryngologist, and prevention is still the best way to overcome laryngotracheal stenosis. understanding the etiologies of stenosis and avoidance of instigating factors may help prevent its development. to the best of our knowledge, no local data has been published on the profile of patients with laryngotracheal stenosis. an initial survey may thus be used to explore prevention strategies. this study describes the clinical profile of patients with laryngotracheal stenosis over a 7-year period and discusses strategies for its prevention. methods with institutional review board approval, a retrospective chart review of patients with laryngotracheal stenosis who were seen at a tertiary government hospital from january 2008 to june 2015 was conducted. patients with incomplete data were excluded. diagnosis of laryngotracheal stenosis was confirmed by laryngoscopy and/ or bronchoscopy. age, sex, causal factors for stenosis, presentation of stenosis, history of endotracheal tube (et) intubation (including indication for intubation, size of et tube used, duration of intubation, frequency of re-intubation, interval from latest extubation until stenosis diagnosis), and grading of stenosis based on cotton-myer classification and location of stenosis were recorded. results a total of 21 patients were evaluated for laryngotracheal stenosis from january 2008 to june 2015, but only 13 patients with complete data were included in this study. table 1 shows the age, sex, causal factors of stenosis, presentation of stenosis, history of et intubation, table 1. clinical profile of patients with laryngotracheal stenosis from 2008-2015 age 24 days 52 days 22 mos 3 yrs 6 yrs 8 yrs 12 yrs 14 yrs 16 yrs 32 yrs 35 yrs 41 yrs 63 yrs frequency of et reintubation 2 5 2 1 1 2 3 1 1 1 1 interval from latest extubation to stenosis diagnosis (days) 2 29 5 4 3 378 3 7 217 128 68 sex m m m m m m f m m m f f m et size used 3.0 3.0 4.5 4.5 5.5 4.0 5.5 6.0 6.0 6.0 6.0 stenosis grade i iii ii i iii ii i i iv iv iv iii iii stenosis location subglottis subglottis trachea subglottis subglottis subglottis glottis trachea trachea trachea trachea trachea trachea probable cause of stenosis intubation due to pneumonia intubation due to pneumonia, failure to thrive intubation due to congenital diaphragmatic hernia intubation due to pneumonia intubation due to blunt abdominal trauma due to vehicular accident intubation due to pneumonia intubation due to acute gastroenteritis,hypokalemia, multinodular nontoxic goiter, compression intubation due to craniectomy due to vehicular accident intubation due to cardiopulmonary arrest intubation due to ectopic pregnancy multinodular nontoxic goiter, compression intubation due to altered sensorium, due to vehicular accident presentation of stenosis stridor stridor stridor stridor wheeze failure to decannulate wheeze wheezing dyspnea failure to decannulate failure to decannulate wheezing dyspnea total duration of et intubation (days) 5 33 4 60 15 42 converted to tracheostomy 22 9 23 converted to tracheostomy 18 converted to tracheostomy 28 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 28 philippine journal of otolaryngology-head and neck surgery original articles grading and location of stenosis. of the 13 patients, nine (69.2%) belonged to the pediatric age group. ten (77%) were males and three (23%) were females. laryngotracheal stenosis following et intubation was seen in 11 (84.6%) of the patients. the indications for et intubation were diverse. two patients had thyroid masses with no history of prior et intubation. presentations of stenosis were wheezing (n=4), stridor (n=4), failure to decannulate (n=3), and dyspnea (n=2). all 11 patients who had a history of et intubation had endotracheal tubes compatible with the ideal size for age. the duration of et intubation ranged from 4 to 60 days. five patients had a history of being intubated more than once. the highest frequency of et re-intubation was five times. among the eight patients who did not undergo conversion to tracheostomy, stenosis diagnosis was established 2 to 68 days after et extubation. three patients were diagnosed very late (378, 216, and 128 days respectively) when they were referred due to failure of tracheostomy tube decannulation. among those intubated, three had grade i stenosis, two had grade ii, three had grade iii and three had grade iv stenosis. the stenosis location was glottic in one patient, subglottic in five patients and tracheal in five patients. those with thyroid masses had tracheal stenosis. discussion laryngotracheal stenosis is a term implying the presence of airway compromise resulting from healing by secondary intention resulting in submucosal fibrosis and scar contraction involving the larynx, trachea or both.4 probable causes of laryngotracheal stenosis in this study were et intubation and neck mass compression. an iatrogenic cause of laryngotracheal stenosis is usually et intubation. nearly 10% of intubated patients subsequently develop laryngotracheal stenosis1 with a 0-2% incidence of subglottic stenosis5 and 6% to 21% incidence of tracheal stenosis.4 in our study, stenosis following et intubation was seen in 11 patients. the cuff of the et tube can cause ischemic necrosis leading to stenosis in the trachea and/or subglottic region.4 tracheal stenosis was seen in adults and adolescents which may be due to the cuffed et usually used in this agegroup. the tube itself can cause pressure injury to the glottis that can result in severe commissural scarring and necrosis especially if et tube was excessively wide.4 however, appropriateness of et tube size was probably not a factor causing stenosis in our study since all patients had appropriate et tube sizes. there is no consensus regarding the limits for safe periods of intubation.6 longer intubation periods correlated with broader and deeper ulcers, injury in the subglottis and posterior glottis. in neonates, perichondrium of the cartilage was exposed when intubation was longer than 8 days.7 in adults, orotracheal intubation for more than 96 hours has been associated with permanent damage.6 stenosis was seen in 2% of patients who were intubated between three to five days while stenosis increased to 5% in patients intubated between six to ten days.8 in our study, the duration of et intubation associated with stenosis was 4 to 60 days. based on this limited experience, the authors suggest that patients may be evaluated as early as 4 days after et intubation for possible stenosis. tracheostomy may be contemplated based on the clinical features on endoscopy, particularly in those unlikely to be extubated early.5 the highest frequency of intubation was five times in a patient. stenosis was seen even in patients who had been intubated only once, including those with grade iv stenosis. this may suggest that intubated patients should be evaluated regardless of the times intubated. in our study, diagnosis of stenosis was made 2 to 68 days after et extubation. delays in diagnosis may be due to symptoms not manifesting immediately or due to symptoms that presented immediately but were treated as asthma or pneumonia before eventual referral to our larynx clinic. the diagnosis may be missed if the patient exhibited airway symptoms and was immediately re-intubated without stenosis evaluation. in this study, the diagnosis was as late as 378 days after et extubation for patients who were referred after failure of decannulation. wittekamp et al. found that post-extubation laryngeal edema developing symptoms within 30 minutes after extubation was the cause of 15% of all reintubations.9 laryngeal edema, once diagnosed, can be prevented by giving corticosteroids.9 by preventing laryngeal edema, reintubations and in turn stenosis may be prevented. all the reasons for delayed diagnosis were related to failure to evaluate patients immediately post-extubation. a study by smith et al reports that fiber-optic laryngoscopy may be performed in the first hours after extubation, with few minor complications.10 flexible endosopy is rapidly performed and provides accurate conditions of the larynx that may be useful for the diagnosis of lesions due to intubation. this would be less aggressive compared to direct laryngoscopy under general anesthesia.10 the cotton-myer system, originally developed for congenital subglottic stenosis, is currently the generally used classification in evaluating laryngotracheal stenosis severity.11 grade i is 0 to 50% obstruction of the lumen, grade ii 51-70%, grade iii 71-99% and grade iv is no detectable lumen.12 among our patients, grade i, iii and iv stenosis were mostly seen but the exact etiopathology cannot be determined. figure 1 shows examples of the grading of stenosis from our study subjects. the combination of factors such as age, infection, duration and multiple extubations-reintubations may have led to stenosis. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 29 pneumonia, an indication for intubation in four of our patients, could have predisposed the previously injured laryngotracheal framework to bacterial contamination. age could be contributory. subglottic stenosis was seen in 11.38% of intubated children.13 majority of laryngotracheal stenosis in this study was in the pediatric group where subglottic stenosis was common. the subglottis is the most vulnerable area of the pediatric airways because it is the only site surrounded by a complete cartilage ring, the narrowest anatomic site, and the site most exposed to intubation trauma.10 our study could not account for other factors that may have been potential risk factors for injury such as et cuff inflation, inadequate sedation and less cooperation on the part of the patient, technique of et intubation, number of attempts and difficulty scale, movement of the tube from ventilator motion or manual suctioning and gastric reflux.14,15 tracheal injury was seen in patients with thyroid masses. this may be due to the anatomic location of the thyroid gland causing extrinsic compression and compromising the patency of the trachea.16 in our study, two patients had benign goiter measuring 3 and 4 cm, presenting 3 and 2 years, respectively. consequent tracheal stenosis was diagnosed warranting prophylactic tracheostomy. tracheal stenosis is often misdiagnosed as asthma.8 respiratory distress develops in patients with more than 50% narrowing of the tracheal lumen.10 in our study, three patients were treated as having asthma. two of them presented with wheezing and neck masses and upon routine laryngoscopy for the neck mass were suspected to have tracheal stenosis. laryngoscopy and bronchoscopy confirmed the diagnosis. another patient presented with stridor after extubation. since there was no resolution of stridor after 28 days of bronchodilator, referral to our larynx clinic was made which confirmed subglottic stenosis. history of prolonged et intubation with respiratory symptoms unresponsive to bronchodilators should be an index of suspicion for stenosis. the limitation of the study is the sparse number of cases that have been well documented. in 7 years, there were only 13 cases confirmed to have laryngotracheal stenosis with complete records, out of only 21 patients referred for evaluation. deficiency of referrals due to lack of awareness of possibility of stenosis, failure to evaluate patients postextubation, missed and misdiagnosis of patients may explain the small number of reported patients. figure 1. representative stenoses seen in our patients graded according to the cotton-myer system. grade i (a). grade ii (b). grade iii (c). grade iv (d). philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 30 philippine journal of otolaryngology-head and neck surgery original articles this study observed the varied frequency of intubation and intervals from latest extubation to stenosis diagnosis. the exact time when stenosis developed cannot be identified. future research can be geared toward elucidation of stenosis evolution among the general population of intubated patients. correlation of frequency and duration of intubation to the grading of stenosis can also be explored. best time of intervention can then be determined. awareness of potential endotracheal intubation-related injuries is critical for early diagnosis and appropriate treatment.7 a systematic laryngeal examination after extubation decreases the chances of morbid sequelae by initiating appropriate measures.13 strategies for prevention of laryngotracheal stenosis should include routine airway endoscopy for patients with longstanding neck masses and for those with prolonged et intubation, for whom the option of early prophylactic tracheostomy is worth considering. otherwise, immediate postextubation endoscopy may facilitate documentation and appropriate intervention. references 1. janssen l.m. laryngotracheal stenosis and reconstruction [internet]. erasmus university rotterdam; 2010. available from: http://hdl.handle.net/1765/19828. 2. gelbard a, francis do, sandulache vc, simmons jc, donovan dt, ongkasuwan j. causes and consequences of adult laryngotracheal stenosis. laryngoscope. 2015 may; 125(5): 1137-43. 3. lahav y, shoffel-havakuk h, halperin d. acquired glottis stenosis-the ongoing challenge: a review of etiology, pathogenesis and surgical management. j voice. 2015 sept; 29(5):1-10. 4. gallo a, pagliuca a, greco a, martellucci s, mascelli a, fusconi m, de vincentiis m. laryngotracheal stenosis treated with multiple surgeries:experience,results and prognostic factors in 70 patients. acta otorhinolaryngol ital.2012 jun; 32(3):182-8. 5. tantinikorn w, sinrachtanant c, assanasen p. how to overcome laryngotracheal stenosis. j med assoc thai. 2004 jul; 87(7):800-9. 6. sato k, nakashima t. histopathologic changes in laryngeal mucosa of extremely low-birth weight infants after endotracheal intubation. ann otol rhinol laryngol. 2006 nov; 115(11):816823. 7. wei jl, bond j. management and prevention of endotracheal intubation injury in neonates. curr opin otolaryngol head neck surg. 2011 dec; 19(6):474-7. 8. mota la, de cavalho gb, brito va. laryngeal complication by orotracheal intubation: literature review. int arch otorhinolaryngol. 2012 apr; 16(2):236-45. 9. wittekamp bh, van mook wn, tjan dh, zwaveling jh, bergmans dc. clinical review: postextubation laryngeal edema and extubation failure in critically ill patients. crit care. 2009 dec; 13(6):233. 10. smith mm, kuhl g, carvalho pr, marostica pjc. flexible fiber-optic laryngoscopy in the first hours after extubation for the evaluation of laryngeal lesions due to intubation in the pediatric intensive care unit. int j pediatr otorhinolaryngol. 2007 sep; 71(9):1423-8. 11. brigger mt, boseley me. management of tracheal stenosis. curr opin otolaryngol head neck surg. 2012 dec; 20(6):491-6. 12. myer cm, o’connor dm, cotton rt. proposed grading system for subglottic stenosis based on endotracheal tube sizes. ann otol rhinol laryngol. 1994 apr; 103(4 pt 1):319-23. 13. schweiger c, marostica pj, smith mm, manica d, carvalho pr, kuhl g. incidence of postintubation subglottic stenosis in children: prospective study. j laryngol otol. 2013 apr; 127(4):399-403. 14. tadie jm, behm e, lecuyer l, benhmamed r, hans s, brasnu d, diehl jl, fagon jy, guerot e. postintubation laryngeal injuries and extubation failure: a fiberoptic endoscopic study. intensive care med. 2010 jun; 36(6):991-8. 15. rangachari v, sundararajan i, sumathi v, krishna kumar k. laryngeal sequelae following prolonged intubation: a prospective study. indian j crit care med. 2006 jul-sept; 10(3):171-5. 16. machado n. thyroidectomy for massive goiter weighing more than 500 grams, technical difficulties, complications and management review. surgical science. 2011 jan; 2 (5): 278-84. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: this study aimed to determine the prevalence of nasopharyngeal tuberculosis among patients who were initially assessed to have a nasopharyngeal mass and subsequently underwent biopsy in a philippine tertiary general hospital from year 2013 to 2015. methods: design: case series setting: tertiary national university hospital participants: all patients with nasopharyngeal mass identified from january 2013 to december 2015 from a hospital wide census who underwent biopsy were investigated using chart and histopathology review. the prevalence of tuberculosis, malignancies and other findings were determined. results: among 285 nasopharyngeal biopsies done between 2013 and 2015, 33 (11.6%) were histologically compatible with nasopharyngeal tuberculosis, 177 (62.1%) were different types of nasopharyngeal carcinoma, 59 (20.7%) were chronic inflammation, 4 (1.4%) were lymphoma, 5 (1.8%) were normal, and 7 (2.5 %) had diagnoses other than those above.. conclusion: this study suggests a relatively high prevalence rate (11.6%) of nasopharyngeal tuberculosis in patients who have a nasopharyngeal mass. this indicates that nasopharyngeal tuberculosis should always be a differential when confronted with a mass in the nasopharynx especially in tuberculosis endemic areas. keywords: nasopharyngeal tuberculosis; prevalence; censuses; tertiary care centers; philippines; carcinoma; nasopharynx; biopsy; tuberculosis; lymphoma while the majority of tuberculosis infection is found in the lungs, tuberculosis can manifest in the head and neck region including cervical lymph nodes, parotid, the larynx, middle ear and tonsils.1-4 nasopharyngeal tuberculosis (nptb) is rarer and to the best of our knowledge, has been characterized in only a few case reports and series worldwide. there has only been one published case report in the philippines.5 nasopharyngeal tuberculosis in a philippine tertiary general hospital mark anthony t. gomez, md, mpm-hsd1 romeo l. villarta, jr., md, mph1,2 ruzanne m. caro, md3 criston van c. manasan, md4 jose m. carnate, jr., md5 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2department of epidemiology and biostatistics college of public health university of the philippines manila 3department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila 4department of laboratories philippine general hospital university of the philippines manila 5department of pathology college of medicine university of the philippines manila correspondence: dr. jose m. carnate, jr. department of pathology philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8400 local 3200 email: jmcjpath@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery annual convention free paper forum, december 2, 2017, the manila hotel. philipp j otolaryngol head neck surg 2019; 34 (2): 7-10 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery original articles years old. the mean age of patients with nasopharyngeal carcinoma was 47.84 years old while the mean age of patients with nasopharyngeal tuberculosis was younger at 29.15 years old. the mean age of patients with chronic inflammation and lymphoma were 38.82 and 40.5 years old, respectively. the youngest patients with npca, chronic inflammation, nptb and lymphoma were 15, 15, 14 and 17 years old, respectively. the oldest patients with npca, chronic inflammation, nptb and lymphoma were 78, 70, 60 and 66 years old, respectively. the patients had variable distributions among different age groups. the distribution of disease according to age group is shown in table 1. in terms of sex, the ratio of nasopharyngeal carcinoma and chronic inflammation were almost the same at 3:1. on the other hand, the sex ratio for nasopharyngeal tuberculosis and lymphoma were the same and equal at 1:1. the distribution of patients is shown in table 2. of the 33 patients with nptb, only seven complete patient charts were retrieved. most of the records of other patients had been transferred to their local tuberculosis treatment center or were missing. among the seven patients whose complete charts were reviewed, two had a previous history of pulmonary tuberculosis and had been treated with anti-tuberculosis chemotherapy and one had a history of unrecalled chronic lung illness which could also be pulmonary tuberculosis. all the seven patients had presence of cervical lymphadenopathy which prompted the initial medical consult. there was no mention of history of human immunodeficiency virus infection, multidrug resistant tuberculosis infection or diabetes mellitus in the charts of the seven nptb patients. table 1. distribution of disease according to age group age group (years) nasopharyngeal carcinoma (%) n=177 nasopharyngeal tuberculosis (%) n=33 chronic inflammation (%) n=59 lymphoma (%) n=4 14-20 21-55 56-70+ 5 (2.8%) 127 (71.8%) 45 (25.4%) 10 (30.3%) 20 (60.6%) 3 (9%) 9 (15.3%) 38 (64.4%) 12 (20.3%) 1 (25%) 2 (50%) 1 (25%) based on available literature, nptb usually presents with nasopharyngeal mass associated with cervical lymphadenopathy as well as nasal, ocular and otologic symptoms.6-10 these findings overlap with the clinical presentation of nasopharyngeal malignancies, posing important diagnostic and therapeutic issues.6,11-15 the study aimed to determine the prevalence of nasopharyngeal tuberculosis among patients who underwent nasopharyngeal biopsy in the philippine national university hospital from january 2013 to december 2015. methods with institutional ethical and technical review board approval (upmreb orl 2016-387-01), this descriptive case series sought to review records of patients of any age who were previously assessed to have a nasopharyngeal mass on endoscopy and who eventually underwent nasopharyngeal mass biopsy at the philippine general hospital from january 1, 2013 to december 31, 2015. patients who underwent nasopharyngeal mass biopsies were initially identified from the department of otorhinolaryngology census and logbooks of the in-patient and out-patient operating rooms. records were retrieved by the first author and basic demographic (age and sex) and histopathologic data were collated and recorded using microsoft office professional plus 2010 for windows (microsoft corporation, redmond, wa usa). excluded were patients whose biopsies were deferred due to other health reasons, who underwent intranasal (instead of nasopharyngeal) mass biopsies and those with incomplete entries. patients who had previous recurrences of the condition and appeared twice in the registry were considered as one patient. the final histopathological diagnoses were retrieved from the database of histopathology results at the department of laboratories. full hospital chart reviews were attempted on all patients with nptb. descriptive statistics were used to define demographics and summarize and describe the data. the prevalences of each of the diagnosis were computed based on the data. the different prevalences were then described. results among the 285 nasopharyngeal biopsies we identified between 2013 and 2015, 33 (11.6%) were histologically compatible with nasopharyngeal tuberculosis (nptb), 177 (62.1%) were different types of nasopharyngeal carcinoma (npca), 59 (20.7%) were interpreted as chronic inflammation, four (1.4%) were lymphoma, five (1.8%) were normal, and seven (2.5 %) were diagnosis other than those mentioned. the mean age of all patients with nasopharyngeal mass was 43.47 table 2. distribution of disease according to sex diagnosis male (%) female (%) sex npca (n=177) nptb (n=33) chronic inflammation (n=59) lymphoma n=4 132 (74.6%) 17 (51.5%) 45 (76.3%) 2 (50%) 45 (25.4%) 16 (48.5) 14 (23.7%) 2 (50%) philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery original articles‰ discussion nasopharyngeal tuberculosis (nptb) has been described prior to the advent of the anti-tuberculosis antibiotics in 1936 by graff who identified a high presence (82%) of nasopharyngeal tuberculosis by histology in 118 pulmonary tuberculosis cases.16 after the emergence of anti-tuberculosis medications, there was a dramatic decrease in cases of nasopharyngeal tuberculosis. a 1976 survey of 843 cases of pulmonary tuberculosis by rohwedder found 16 patients with tuberculosis of the upper respiratory tract and only one of these had nasopharyngeal tuberculosis.17 the recent worldwide upsurge in the incidence of nasopharyngeal tuberculosis in the literature could be due to increased awareness of disease, improvement of knowledge regarding the entity, improved diagnostic techniques and of course, increase in incidence of the disease itself.6 most of the literature on the topic is only in the form of case reports and series that were gathered over many years and are not enough to give a clear picture of the prevalence of the illness. as of this writing, we could find no other studies detailing its prevalence. based on our study, the prevalence of nptb can reach as high as 1.1 for every 10 nasopharyngeal biopsies. this prevalence of nasopharyngeal tuberculosis is second only to nasopharyngeal carcinoma and even higher than lymphoma. there are several important implications of the results of our study. first, clinicians usually have two main differential diagnoses when faced with a nasopharyngeal mass –nasopharyngeal carcinoma or lymphoma. the results of our study would add nasopharyngeal tuberculosis to the differentials especially in areas where tuberculosis is endemic. these three diagnoses each entail totally different managements and accurate diagnosis is necessary to provide proper treatment. the additional differential should guide other medical specialists. pathologists must thoroughly analyse histopathologic slides especially those with chronic inflammatory patterns because hidden in the sea of inflammatory cells might be islands of tuberculosis or granulomatous lesions that may be overlooked. pathologists should also be careful in making diagnosis because concomitant tb infection of the nasopharynges of patients with nasopharyngeal carcinoma may be present.18 radiologists should consider the possibility of nasopharyngeal tuberculosis in interpreting ct scans of patients with a nasopharyngeal mass. the possibility of nasopharyngeal tuberculosis should also be mentioned in patient education, and patient anxiety may be decreased by the knowledge that not all nasopharyngeal masses are cancer. there are also important implications related to the safety of clinicians. although it is the usual practice for otorhinolaryngologists to wear standard personal protective equipment in performing nasopharyngeal biopsies, the high prevalence of tuberculosis in patients with nasopharyngeal mass will require additional precautions such as wearing n95 masks instead of regular masks and ultraviolet disinfection after surgery. as patients with nasopharyngeal tuberculosis may have other co-morbidities such as hiv infection, these additional precautionary measures mentioned are well-justified. diagnosis of nptb in previous reports were done initially by nasal endoscopy, biopsy and culture of tuberculous bacilli from secretions and nasopharyngeal tissue. histopathology of the biopsied nasopharyngeal may also be helpful since results of tb culture may cause delays in diagnosis up to 6 weeks.6 additional radiologic examinations may also be helpful such as ct scan and mri.6 a study in china reported that a presence of necrosis and striped pattern in nasopharyngeal lesions and lack of invasion of regional structures as seen in ct and mri of 36 nptb patients may suggest the diagnosis of nptb instead of malignancy.19 in terms of management, previous reports differed in the duration of anti-tuberculosis treatment. some had the minimal six-month course of triple combination therapy that included isoniazid, rifampicin and ethambutol. others were treated with nine months of quadruple therapy (adding an initial short course of pyrazinamide). there is even a study in china which used an oral anti tuberculosis regimen of 3hrzs(e)/9hr(e) for one year combined with nasal spray combination medication of isoniazid, rifampicin and streptomycin injection solution for 3 months.20 however, to the best of our knowledge, there have been no published recommendations on the proper diagnosis, treatment and monitoring of response to treatment specifically for nasopharyngeal tuberculosis. while this may reflect the global rarity of the disease, further studies must be performed in tuberculosis endemic countries like the philippines to evaluate the means of diagnosis and treatment response of nasopharyngeal tuberculosis so that management can be optimised to prevent development of multiple drug resistance. there were at least two patients in our study with a past history of previously treated pulmonary tuberculosis. although it is not known whether the nasopharyngeal tuberculosis appeared before or after pulmonary tuberculosis treatment, this finding could mean that the nasopharyngeal tuberculosis in these patients may not have been affected by the initial treatment given or may have developed despite treatment. although there have been no studies that state the clear association between disseminated tuberculosis and development of multi-drug resistant tuberculosis, having multiple sites in a patient might trigger the development of resistance especially if the other sites are not known or undiagnosed. for example, a known pulmonary tuberculosis patient with a hidden or undiagnosed nasopharyngeal component will only be given six months of initial pulmonary tuberculosis treatment. because an extrapulmonary site is involved, nasopharyngeal tuberculosis might need a longer anti philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery original articles tuberculosis treatment regimen or additional medications on top of the usual medications for pulmonary tuberculosis. the treatment for such a hypothetical patient may only be enough for the pulmonary involvement but insufficient for the nasopharyngeal disease which may lead to development of drug resistance. moreover, should nasal endoscopy be recommended to search for nasopharyngeal masses in patients with pulmonary tuberculosis prior to treatment? further studies are needed in this regard. there are several limitations of our study. the purely observational and descriptive study design makes it only a preliminary study to generate epidemiological knowledge and local information among filipinos. the study only involved a database review and it is possible that not all data were available. the study only sought to establish a local picture of nasopharyngeal tuberculosis using the limited data gathered within a tertiary general hospital. even if it is the national university hospital, many other regions of the country were not represented by the study population and our findings may not be generalizable to them. in conclusion, this study suggests a relatively high prevalence rate of nasopharyngeal tuberculosis (11.6%) in patients who have a nasopharyngeal mass. although nasopharyngeal carcinoma (62.1%) remains to be the most common diagnosis, nasopharyngeal tuberculosis should always be a differential aside from lymphoma (1.8%) when confronted with a mass in the nasopharynx in areas with high tuberculosis endemicity. acknowledgements we would like to thank dr. cristina c. arcinue gomez for assistance with data collection and initial editing of the manuscript. we would also like to express our gratitude to dr. jose florencio f. lapeña jr. for helping us rewrite the manuscript. lastly, we are also immensely grateful to the nurses of the tb-dots office and personnel of the records section at the philippine general hospital for their time and effort in helping us retrieve the patient records within their respective offices. references 1. menon k, bem c, gouldesbrough d, strachan dr. a clinical review of 128 cases of head and neck tuberculosis presenting over a 10-year period in bradford, uk. j laryngol otol. 2007 apr;121(4):362-8. doi: 10.1017/s0022215106002507. pmid: 16923320. 2. choudhury n, bruch g, kothari p, rao g, simo r. 4 years’ experience of head and neck tuberculosis in a south london hospital. j r soc med. 2005 june; 98(6): 267–269. doi: 10.1258/ jrsm.98.6.267 pmid: 15928377 pmcid: pmc1142231. 3. das s, das d, bhuyan ut, saikia n. head and neck tuberculosis: scenario in a tertiary care hospital of north eastern india. j clin diagn res 2016 jan;10(1): mc04-7. doi:10.7860/ jcdr/2016/17171.7076 pmid: 26894099 pmcid: pmc4740627. 4. vayisoglu y, unal m, ozcan c, görür k, horasan es, sevük l. [lesions of tuberculosis in the head and neck region: a retrospective analysis of 48 cases]. kulak burun bogaz ihtis derg 2010 marapr;20(2):57-63. [turkish] pmid: 20214547. 5. nieves cs, onofre rd, aberin-roldan fca, gutierrez rlc. nasopharyngeal tuberculosis in a patient presenting with upper airway obstruction. philipp j otolaryngol head neck surg.  2010 jan-jun;25(1):20-22. doi: 10.32412/pjohns.v25i1.653. 6. srivanitchapoom c,  sittitrai p. nasopharyngeal tuberculosis: epidemiology, mechanism of infection, clinical manifestations, and management. int j otolaryngol. 2016; 2016:4817429 doi: 10.1155/2016/4817429 pmid: 27034677 pmcid: pmc4789561. 7. kim ks. primary nasopharyngeal tuberculosis mimicking carcinoma: a potentially false-positive pet/ct finding. clin nucl med. 2010 may;35(5):346-8. doi: 10.1097/rlu.0b013e3181d624ff pmid:20395711. 8. basal y, ermişler b, eryilmaz a, ertuğrul b. two rare cases of head and neck tuberculosis. bmj case rep. 2015 oct 23;2015. doi: 10.1136/bcr-2015-211897 pmid: 26498669 pmcid: pmc4620213. 9. richardus ra, jansen jc, steens sc, arend sm. two immigrants with tuberculosis of the ear, nose, and throat region with skull base and cranial nerve involvement. case rep med. 2011; 2011:675807. doi: 10.1155/2011/675807 pmid: 21541186. pmcid: pmc3085480. 10. zhang y, chen y, huang z, cai l, wu j. nasopharyngeal tuberculosis mimicking nasopharyngeal carcinoma on (18)f-fdg pet/ct in a young patient. j.clin nucl med. 2015 jun;40(6):518-20. doi: 10.1097/rlu.0000000000000656. pmid: 25546210. 11. takagi a, nagayasu f, sugama y, shiraishi s. primary nasopharyngeal tuberculosis. kekkaku. 2013 may;88(5):485-9. pmid: 23882729. 12. sithinamsuwan p, sakulsaengprapha a, chinvarun y. nasopharyngeal tuberculosis: a case report presenting with diplopia. j med assoc thai. 2005 oct;88(10):1442-6. pmid: 16519394. 13. taş a, yağiz r, koçyiğit m, karasalihoğlu ar. primary nasopharyngeal tuberculosis. kulak burun bogaz ihtis derg. 2009 mar-apr;19(2):109-11. pmid: 19796011. 14. kuran g, sagit m, saka c, saka d, oktay m, hucumenoglu s, et al. nasopharyngeal tuberculosis: an unusual cause of nasal obstruction and snoring. b-ent. 2008;4(4):249-51. pmid: 19227032. 15. prstačić r, jurlina m, žižić-mitrečić m, janjanin s. primary nasopharyngeal tuberculosis mimicking exacerbation of chronic rhinosinusitis. j laryngol otol. 2011 jul;125(7):747-9. doi: 10.1017/s0022215110002835 pmid: 21481293. 16. graff s. [die bedeutung des epipharynx for die menachlidie pathologie]. klin wochenschr. 1936; 15:953-7. 11. [german] doi: 10.1007/bf01777670. 17. rohwedder jj. upper respiratory tract tuberculosis. sixteen cases in a general hospital. ann intern med 1974; 80:708-13. doi:10.7326/0003-4819-80-6-708. pmid: 4832158. 18. zalesska-krecicka m, krecicki t, morawska-kochman m, mosiniak-trajnowicz k, kuliczkowski. [nasopharyngeal carcinoma coexistent with lymph node tuberculosis, diagnostic difficulties-case report]. k.otolaryngol pol. 2005;59(4):607-9. [polish] pmid: 16273871. 19. cai pq, li yz, zeng rf, xu jh, xie cm, wu yp, et al. nasopharyngeal tuberculosis: ct and mri findings in thirty-six patients. eur j radiol. 2013 sep;82(9):e448-54. doi: 10.1016/j. ejrad.2013.04.015 pmid: 23689055. 20. jian y, liu b, guo l, kong s, su x, lu c. pathogeny and treatment of 50 nasopharyngeal tuberculosis cases. lin chung er bi yan hou tou jing wai ke za zhi. 2012 dec;26(24):1138-40. pmid: 23477122. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery president’s page the philippine journal of otolaryngology-head and neck surgery has transformed into a bastion of original local researches related to our specialty. it has gained international prestige for the past years and at present it is included at the directory of open access journals (doaj), asean citation index, health research and development network (herdin) and western pacific region index medicus (wprim). both the editorin-chief dr. jose florencio f. lapeña, jr. and managing editor dr. erasmo gonzalo d.v. llanes are working it out for our journal to be included at scopus and pubmed central. our commitment to the academic community and global exchange of information are the touchstones of our publications. hence, the philippine society of otolaryngology-head and neck surgery is committed to support and invest on activities pertaining to quest for knowledge and one of the best tool is through research contests and workshops. the society’s 10 academies representing the various subspecialty tracts are at the forefront of augmenting the research output of various training institutions. with our fellows’ global collaborations, researches done by our foreign colleagues are published in our journal. with our converging efforts, the pjo-hns will continuously soar high in the scientific community. the greater challenge now is for the society to be one in research as one pso-hns. mabuhay ang pjo-hns! danilo a. poblete, md, fpso-hns president philippine society of otolaryngology-head and neck surgery one in research as one pso-hns philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial the great enemy of communication, we find, is the illusion of it. — william hollingsworth whyte, 19501 on september 6, 2022, a combined investigation by research integrity experts, data and analytics experts, publishing and operational teams, and legal counsels from hindawi and its parent company wiley, led to the initial recommendation to retract 511 articles that were compromised based on reviewer activity alone.2 that same month, the physics publisher institute of physics (iop) announced the retraction of 494 papers after investigation indicated they “may have been created, manipulated, and/or sold by a commercial entity” (or paper mill).3 this october, the elsevier journal thinking skills and creativity retracted 47 papers that appear to have been generated by a paper mill because they were each accepted on the “positive advice of one illegitimate reviewer report.”4 paper mills and phony peer reviews5 undermine the soundness of science, because they are based on illusion rather than truth. truth (veritas) is only verifiable if it is transparent. the committee on publication ethics (cope), the directory of open access journals (doaj), the  open access scholarly publishing  association  (oaspa), and the  world association of medical editors (wame) have been collaborating to identify principles of transparency and best practice for scholarly publications.6 the fourth version of this work in progress was published on september 15, 2022 and is available from: https://publicationethics.org/files/principlestransparency-best-practice-scholarly-publishing.pdf. the philippine journal of otolaryngology head and neck surgery upholds these principles of transparency and continues to strive to implement these best practices. in a related development, the international association of scientific, technical and medical publishers (stm) has proposed a standard taxonomy for peer review,7 recognizing a need to identify and standardize definitions and terminology in peer review practices to help align nomenclature as more publishers use open peer review models. this peer review taxonomy will help make the peer review process for articles and journals more transparent and will enable the community to better assess and compare peer review practices between different journals. according to stm, peer review should be described using four components:7 1. identity transparency: • all identities visible: reviewers, authors, decision-making editor [editor] all visible to each other • single anonymized: reviewer identity is not visible to the author, author and editor identities are visible to everyone (also known as single masked, formerly single blinded, review) • double anonymized: reviewer identity is not visible to the author, author identity is not visible to the reviewer, editor identity is known to both (also known as double masked, formerly double-blinded, review) correspondence: prof. dr. josé florencio f. lapeña, jr. department of otolaryngology head and neck surgery ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 telefax: (632) 8524 4455 email: lapenajf@upm.edu.ph , jflapena@up.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr. ma, md department of otolaryngology head and neck surgery college of medicine, university of the philippines manila department of otorhinolaryngology head and neck surgery east avenue medical center, diliman, quezon city truth and transparency, compromise and climate change c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philipp j otolaryngol head neck surg 2022; 37 (2): 4-5 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial • triple anonymized: reviewer identity is not visible to the author or editor, author identity is not visible to the reviewer or editor, editor identity is not visible to reviewer or author (also known as triple masked, formerly triple-blinded, review) 2. who the reviewer interacts with: the editor only (traditional review), direct interaction with the other reviewers (with or without their identities visible), and/or directly with the authors (with or without identities visible) 3. what information about the review process is published: options include no information, review summaries, review reports, review reports if the reviewer opts to have review published, review reports if the author opts to have review published, the submitted manuscript (can be posted as a preprint), the submitted manuscript if the author opts in, the editor’s correspondence with the author, the authors’ response (rebuttal) letter, reviewer identities, reviewer identities if the review opts in, editor identities 4. whether post-publication commenting takes place: online comments may be either open (commenters may be anonymous or required to sign comments; could also include whether comments are moderated) or invited only; this item does not include letters to the editor. this item is not mentioned if no commenting is allowed. using stm terminology, the philippine journal of otolaryngology head and neck surgery may be described as follows: • identity transparency: double anonymized • reviewer interacts with: editor • review information published: none we are updating our instructions to authors and about the journal to reflect these developments. -----------------------------------------------------------------on another front, the philippine journal of otolaryngology head and neck surgery has agreed to co-publish an editorial calling on wealthy countries to do more to support africa and other vulnerable nations in mitigating the impact of climate change on health.8    the guest editorial in this issue is authored by the editors of 16 african health journals, and is co-published by 259 international journals, including the lancet, british medical journal, new england journal of medicine, national medical journal of india, and medical journal of australia and the philippine journal of otolaryngology head and neck surgery (see http://press.psprings.co.uk/bmj/october/journals.pdf). never have so many journals come together to make the same call, reflecting the severity of the climate change emergency now facing the world. the authors, say, africa has suffered disproportionately although it has done little to cause the crisis and urges wealthy nations to step up support for africa and vulnerable countries in addressing past, present and future impacts of climate change.8 they explain that the climate crisis has had an impact on the environmental and social determinants of health across africa, leading to devastating health effects. in west and central africa, for example, severe flooding resulted in mortality and forced migration from loss of shelter, cultivated land, and livestock, while extreme weather damages water and food supply, increasing food insecurity and malnutrition, which causes 1.7 million deaths annually in africa.8 changes in vector ecology brought about by floods and damage to environmental hygiene has also led to increases in malaria, dengue fever, ebola virus, and other infectious diseases across sub-saharan africa.8 in all, it is estimated that the climate crisis has destroyed a fifth of the gross domestic product (gdp) of the countries most vulnerable to climate shocks.8 the damage to africa should be of supreme concern to all nations, they write, because in an interconnected world, leaving countries to the mercy of environmental shocks creates instability that has severe consequences for all nations.8 we call on participants of the 2022 united nations climate change conference (cop27) to take concrete steps towards achieving our collective climate goals by turning their commitments under the paris agreement into action, without falling short as they did in cop26 glasgow.9 without compromise; in truth, transparently. references 1. whyte wh. “is anybody listening?” fortune. 1950 september. new york: time, inc. verified on microfilm by quote investigator (start page 77, quote page 174), [cited 2022 october 19], available from: https://quoteinvestigator.com/2014/08/31/illusion/ 2. kincaid e. “exclusive: hindawi and wiley to retract over 500 papers linked to peer review rings.” retraction watch. september 28, 2022. [cited 2022 october 17] available from: https:// retractionwatch.com/2022/09/28/exclusive-hindawi-and-wiley-to-retract-over-500-paperslinked-to-peer-review-rings/#more-125719 3. oransky i. “physics publisher retracting nearly 500 likely paper mill papers” september 9, 2022. [cited 2022 october 17] available from: https://retractionwatch.com/2022/09/09/physicspublisher-retracting-nearly-500-likely-paper-mill-papers/#more-125630 4. marcus a. “elsevier journal retracts nearly 50 papers because they were each accepted on the positive advice of one illegitimate reviewer report.” retraction watch october 18, 2022. [cited 2022 october 17] available from: https://retractionwatch.com/2022/10/18/elsevier-journalretracts-nearly-50-papers-because-they-were-each-accepted-on-the-positive-advice-of-oneillegitimate-reviewer-report/#more-125838 5. marcus a, oransky i. “phony peer review: the more we look, the more we find.” stat. april 28, 2017. [cited 2022 october 17] available from: https://www.statnews.com/2017/04/28/phonypeer-review/ 6. committee on publication ethics (cope), directory of open access journals (doaj), open access scholarly publishing association (oaspa), world association of medical editors (wame). principles of transparency and best practice in scholarly publishing — english. doi: https://doi. org/10.24318/cope.2019.1.12 https://doi.org/10.24318/cope.2019.1.12 [cited 2022 october 21] available from: https://wame.org/principles-of-transparency-and-best-practice-in-scholarlypublishing#journal%20practices 7. jones l, van rossum j, mehmani b, black c, kowalczuk m, alam s, moylan e, stein g, larkin a. a standard taxonomy for peer review. osf. center for open science. may 10, 2022. [cited 2022 october 21] available from: https://osf.io/68rnz/ 8. atwoli l, erhabor ge, gbakima aa, haileamlak a, ntumba jk, laybourn-langton l et al. cop27 climate change conference: urgent action needed for africa and the world. bmj 2022 oct 19; 379:o2459 doi:10.1136/bmj.o2459 co-published in philipp j otolaryngol head neck surg. 2022 jul-dec;37(2):6-7. 9. united nations environment program (unep). cop26 ends with agreement but falls short on climate action. news, stories & speeches. 15 november 2021. [cited 2022 october 21]. available from: https://www.unep.org/news-and-stories/story/cop26-ends-agreement-falls-shortclimate-action philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery review article abstract objective: to systematically review the available evidence on the association of hba1c levels and development of sensorineural hearing loss and to quantitatively analyze the available data on hba1c levels in patients with type 2 diabetes mellitus and sensorineural hearing loss to determine an hba1c level that may be associated with the risk of having sensorineural hearing loss. methods: design: systematic review and meta-analysis eligibility criteria: cross-sectional studies, or cohort studies which were limited to english language that investigated the correlation of glycemic index using hba1c and sensorineural hearing loss among adult type 2 diabetic patients which were done from january 2010 to december 2021. studies with no published outcome, incomplete data or that were ongoing as of august 1, 2022 were also excluded. information sources: medline (through pubmed), cochrane library, scopus, embase (through ovid@journal), directory of open access journals (doaj), google scholar and herdin plus risk of bias: risk of bias was assessed using the guidelines for cochrane collaboration synthesis of results: results were presented using forest plots for representation. results: a total of 8 studies were reviewed with 2,103 participants in all. six articles compared hearing loss incidence between diabetic and non-diabetic patients. overall, there were a total of 881 diabetic patients and 1222 non-diabetic patients. there was a significantly lower incidence of sensorineural hearing loss in non-diabetic patients with a risk ratio of 1.89, 95% ci [1.65, 2.16]. three articles compared the hba1c levels of diabetic patients with or without sensorineural hearing loss. diabetic patients without sensorineural hearing loss had significantly lower hba1c levels compared to those with sensorineural hearing loss with mean difference of 1.04, 95%ci [0.82, 1.25]. conclusion: in conclusion, this meta-analysis showed a higher prevalence rate of sensorineural hearing loss among patients with diabetes mellitus compared to non-diabetic patients. moreover, poor glycemic control among diabetic patients with a glycemic index based on hba1c of more than 8.3 (6.97-9.6) is associated with sensorineural hearing loss. keywords: diabetes mellitus; t2dm; hba1c; glycemic index; sensorineural hearing loss; pure tone audiometry; deafness association of glycemic index using hba1c and sensorineural hearing loss in diabetes mellitus type 2 patients: a systematic review and meta-analysis mark randell r. quines, md cristopher ed c. gloria, md department of otorhinolaryngology head and neck surgery university of santo tomas hospital correspondence: dr. cristopher ed c. gloria department of otorhinolaryngology head and neck surgery university of santo tomas hospital españa blvd, sampaloc, manila 1015 philippines phone : +63 927 371 0690 email : cristopheredgloria@gmail.com the authors declared that this represents original material, that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosure: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. funding: the study was funded by the investigators. registration: the study is not registered. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philipp j otolaryngol head neck surg 2023; 38 (1): 10-16 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery review articlereview article diabetes mellitus (dm) is a multiple-etiology metabolic disorder characterized by chronic hyperglycemia and other metabolic abnormalities which result in absolute or relative insulin deficiency and is associated with other health disorders such as atherosclerosis manifested in cardiovascular disease, kidney disease, retinopathy, and neuropathy.1 hearing impairment is an under-recognized complication of type 2 diabetes mellitus (t2dm); the insulin/glucose signaling pathology that characterizes t2dm may lead to inner ear pathology and accompanying hearing loss.2 cochlear changes, such as an increased thickness of the basal membrane and stria vascularis vessel walls, internal auditory artery sclerosis, and inner ear neural system degeneration, are responsible for hearing impairment among dm patients.3 the prevalence of hearing loss in type 2 diabetic patients varies from 34.4 to 60.2%.4 the published literature has conflicting results with regards to the association of sensorineural hearing loss and glycemic index reflected in hba1c levels in terms of levels of glycemic control and their effects in hearing loss.1,2,5although there is still no consensus on the level of hba1c at which patients with type 2 dm are predisposed to developing sensorineural hearing loss, different studies have demonstrated that sensorineural hearing loss was associated with control of diabetes mellitus.6-8 our study aims to systematically review the available evidence on the association of hba1c levels and development of sensorineural hearing loss and to quantitatively analyze the available data on hba1c levels in patients with t2dm and sensorineural hearing loss to determine an hba1c level that may be associated with the risk of having sensorineural hearing loss. data from studies on patients with t2dm diagnosed and assessed with laboratory results of hba1c with assessment of hearing using pure tone audiometry done will be included and the association of their hba1c results and pure tone audiometry will be qualitatively analyzed. methods this systematic review and meta-analysis were conducted from august 1, 2021 to august 20, 2022 with university of santo tomas hospital research ethics committee exemption number rec-2022-10136-tr. eligibility criteria studies eligible for inclusion were randomized controlled trials (rcts), cross-sectional studies, or cohort studies in english language that investigated the correlation of glycemic index using hba1c and sensorineural hearing loss among adult type 2 diabetic patients and had data on the number of hearing-impaired and non-hearingimpaired patients with diabetes, with hearing impairment assessed using pure-tone audiometry that included a frequency range of at least 2khz. case reports and case series were excluded. studies with no published outcome, incomplete data or ongoing as of august 1, 2022 were also excluded as well as studies whose full text was not available through our institutional library. only studies after january 1, 2010 to december 31, 2021 were included in the search. information sources a search of clinical trials that investigated the correlation of glycemic index using hba1c and the development of sensorineural hearing loss among adults diagnosed with t2dm were independently performed by the primary investigator (mrrq) and co-investigator (cecg) using medline (through pubmed), the cochrane library, scopus, embase (through ovid@journal), the directory of open access journals (doaj), google scholar and herdin plus. these online databases were accessed from february 2022 to august 2022. a final search of each database was done from july 21 to august 20, 2022, to assess if new articles that might be eligible for meta-analysis had been added. search strategy the citations were identified with the use of a combination of the following text mesh terms: “hba1c”, “glycemic index”, “type 2 diabetes mellitus”, “t2dm”, “sensorineural”, “hearing loss” “sensorineural hearing loss”, “deafness” “hypoacusis” and “randomized”. a sample search included a line search of the mesh term “diabetes mellitus” and other terms related to diabetes mellitus (type 2 diabetes mellitus; t2dm) under the filter of title/abstract using the conjunction “or”. a second line search of the mesh term “glycemic index” and “hba1c” using the conjunction “or” was made. these two lines were joined together in one search combined by the conjunction “and” to obtain all possible articles with this intersection of search terms. all trials that matched the terms set by the researchers were retrieved. titles and research abstracts were reviewed individually. no restriction for geographic location was applied but the search was limited to english language articles. other studies were sought by searching for previous or ongoing trials registered in clinicaltrials.gov to determine if any unpublished but relevant studies existed. the final database search for each was conducted from july 21 to august 20, 2022. only studies after january 1, 2010 to december 31, 2021 were included in the search. selection process prior to data abstraction, review of data from article abstracts were done by the primary and co-investigator to assess eligibility of papers philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery review article to be included in the analysis. those eligible for inclusion were then individually analyzed by the investigators. the researchers settled any inconsistencies by discussion or mediated by a statistician who acted as an arbiter. data collection process standard data extraction templates and operational definitions of outcomes and explanatory variables were prepared prior to abstraction. the researchers independently abstracted data for each study prior to pooling of results. information on participant characteristics (study inclusion and exclusion criteria), diagnosis and study duration were collected. information on each of these outcomes were extracted whenever available: incidence of sensorineural hearing loss and incidence of control of diabetes based on hba1c. data items the researchers extracted the number of events of interest and total number to be analyzed in each group for dichotomous data namely the presence and absence of sensorineural hearing loss in patients with and without dm and extracted the mean and standard deviations (sd) for continuous data such as the levels of hba1c for those with sensorineural hearing loss. however, in case mean change and sd were not available, calculations were made from presented data such as standard error, confidence intervals, baseline and follow up means and sd to obtain the mean change and sd values. risk of bias assessment in individual studies guidelines for cochrane collaboration were used to assess the risk of bias using the review manager (revman) version 5.3, 2014 (the nordic cochrane centre, the cochrane collaboration, copenhagen, denmark). the statistician reviewed the methods of random sequence generation and allocation concealment, which became the authors’ basis for evaluation of selection bias. the methods of blinding among the participants and investigator of each trial were noted for performance bias. blinding for outcome assessment was used to calculate detection bias. completeness of the outcome data was used to evaluate attrition bias. lastly, publication bias was evaluated using funnel plots. effect measures risk ratio was used to represent the effect of the number of patients with sensorineural hearing loss among total patients with dm compared to those with sensorineural hearing loss without dm. mean difference was used to present the data between hba1c levels of dm patients presenting with or without sensorineural hearing loss. synthesis methods the inclusion of studies for the systematic review and meta-analysis were based on the assessment of the primary investigators in the studies’ completeness in terms of data on the levels of hba1c and results of pure tone audiometry by tabulating the studies included with the outcomes to be used for comparison and analysis. data included in the studies which had incomplete or missing data were either excluded or supplemented from other meta-analytic studies and review articles previously done. the complete data of studies included were placed in a table for representation. studies included on data abstraction were placed in a software to aid in analysis where review manager (revman) version 5.3, 2014 (the nordic cochrane centre, the cochrane collaboration, copenhagen, denmark) was used to produce the forest plots to represent the data for the analysis. overall effect was determined using odds ratios (ors) with 95% confidence intervals set for each parameter. publication bias was also evaluated by visual inspection of the funnel plots and egger’s tests which were generated using revman and comprehensive metaanalysis program version 3.3.070, 2014 (bio stat, englewood, nj, usa). lastly, to summarize information on individual studies and give a visual suggestion of the amount of study heterogeneity and show the estimated common effect, forest plots were used for representation. a fixed effect model was used to represent data granted that the outcome which was sensorineural hearing loss was present in diabetic and nondiabetic patients. the mantel-haenzsel method was used to calculate odds ratio in the presence of confounders. test of heterogeneity was done via visual inspection of results and formal computation using chi2 testing. results study selection initial literature search from january 1, 2010 to december 31, 2021 yielded 51 citations. duplicates were eliminated by selecting only the more complete article for each duplicated study. after screening for completeness of the article, case and control groups and final data analysis, 15 full-text articles were screened and 8 articles were included for qualitative and quantitative study. studies meeting all the requirements were included in the meta-analysis and reported using prisma (preferred reporting items for systematic reviews and metaanalysis) flowchart. (figure 1) study characteristics a total of 2,103 study subjects from 8 different articles were included in the study. one thousand seventy-four (1,074) were case subjects and 1,029 were control subjects. one out of the 8 included studies had no philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery review article controls9 while 6 out of the 8 studies had subjects less than 60 years old.9-12,14,15 duration of diabetes for subjects were included in 6 out of 8 studies with most of the subjects having more than 10 years of disease process.9-12,15,16 other confounding factors such as gender and environmental exposures were not included in the analysis. all studies utilized pure tone audiometry as assessment of sensorineural hearing loss and level of glycemic control was assessed based on laboratory determination of hba1c. the studies included are described in table 1. risk of bias in studies the cochrane risk of bias assessment tool was used to assess methodological quality and bias in the included studies. the following biases were assessed: selection bias, performance bias, detection bias, reporting bias, attrition bias and other author reported bias. each criterion was assessed as having low, unclear or high-risk bias. there was low risk of selection bias for studies in references 9,12,13,14,15,16, and an unclear risk of bias for studies 10 and 11 as the blinding were not explicitly included in the methodology. performance bias was also low for studies 14,15 and 16. attribution and reporting bias were all low in all studies. figure 2 shows that the included studies fall within the symmetrical curve of the funnel plot which means the studies included have a low risk for publication bias. results of individual studies the results of individual studies are described in table 2. results of synthesis there were 6 articles comparing hearing loss incidence between diabetic and non-diabetic patients. figure 3 compared the incidence of sensorineural hearing loss between diabetic and non-diabetic patients. there were a total of 305 cases of sensorineural hearing loss out of 1,222 non-diabetic patients compared to 321 cases of sensorineural hearing loss out of 881 diabetic patients. based on the forest plot, the incidence favors non-diabetic patients. therefore, the analysis shows that the incidence of sensorineural hearing loss is significantly lower in non-diabetic patients with risk ratio of 1.89, 95% ci [1.65, 2.16]. figure 4 compared the mean hba1c levels between diabetic patients with hearing loss vs. those without hearing loss. among diabetic patients, the mean hba1c levels of patients with sensorineural hearing loss ranges from 7.88 to 12.2 whereas diabetic patients table 1. summary of included studies 1. hearing loss among patients with type 2 diabetes mellitus: a cross-sectional study 2. effect of diabetes mellitus on hearing 3. prevalence of sensorineural hearing loss and its association with glycemic control in filipino patients with diabetes at the philippine general hospital 4. sensorineural hearing loss – a common finding in early-onset type 2 diabetes mellitus 5. diabetes mellitus and sensorineural hearing loss: is there an association? baseline of the brazilian longitudinal study of adult health (elsa-brasil) 6. correlation between sensorineural hearing loss and hba1c in diabetes mellitus patients 7. a one year prospective study of hearing loss in diabetes in general population 8. alterations in hearing function of patients with glucose disorders 1-5 years: 21.7% 6-10 years: 17.8% >10 years: 60.5% 0-5 years: 38.2% 6-10 years: 25.5% >10 years: 32.7% 13.27 ± 7.57 years 11 ± 6 years not stated not stated >5 years: 79% first time diagnosis: 42% 9.4 ± 8.7 years 51 (47-54) <60 57.52 ±11.1 dm: 42 ± 6 control: 39 ± 8 dm: 57.4 ± 9 control: 51.2 ± 8.9 10-50 dm: 60.9 ± 10.9 control: 56.5 ± 15.7 157/0 55/28 120/8 93/47 191/710 150/150 87/105 221/278 2021 2019 2016 2012 2017 2022 2012 2019 al-rubeaan k, al momani m, al gethami a, darandari j, alsalhi a, al naqeeb d, almogbel e, almasaari f, youssef a ghosh u, fakir a, osmany h, lodh d, islam z, islam m gutierrez j, jimeno c, labra p, grullo p, cruz t lerman-garber i, cuevas-ramos d, valdes s, enriquez l, lobato m, osornio m, escobedo a, pascual-ramos v, mehta r, ramirezanguiano j, gomez-perez f samelli a, santos i, moreira r, rabelo c, rolim l, bensenor i, lotufo p sharma r, choudhary r, teharia r thimmasettaiah n, shankar r, ravi g, reddy s vergou z, paschou s, bargiota a, koukoulis g reference, title authors duration of diabetesage (years) sample size (diabetic/ control) year philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery review article table 2. results of individual studies effect of diabetes mellitus on hearing prevalence of sensorineural hearing loss and its association with glycemic control in filipino patients with diabetes at the philippine general hospital diabetes mellitus and sensorineural hearing loss: is there an association? baseline of the brazilian longitudinal study of adult health (elsa-brasil) correlation between sensorineural hearing loss and hba1c in diabetes mellitus patients a one year prospective study of hearing loss in diabetes in general population alterations in hearing function of patients with glucose disorders 2019 2016 2017 2022 2012 2019 24 54 108 42 76 17 55 120 191 150 87 278 4 4 227 14 43 13 28 8 710 150 105 221 ghosh u, fakir a, osmany h, lodh d, islam z, islam m. gutierrez j, jimeno c, labra p, grullo p, cruz t. samelli a, santos i, moreira r, rabelo c, rolim l, bensenor i, lotufo p. sharma r, choudhary r, teharia r. thimmasettaiah n, shankar r, ravi g, reddy s. vergou z, paschou s, bargiota a, koukoulis g. title incidence of sensorineural hearing loss among patients with and without diabetes mellitus type 2 authors with diabetes mellitus with sensorineural hearing loss with sensorineural hearing loss total number of patients total number of patients without diabetes mellitusyear hearing loss among patients with type 2 diabetes mellitus: a cross-sectional study effect of diabetes mellitus on hearing sensorineural hearing loss – a common finding in early-onset type 2 diabetes mellitus 2021 2019 2012 8.8 7.88 12.2 1.7 0.49 3.2 104 24 10 8.2 6.79 9.8 1.8 0.37 2.6 53 31 36 al-rubeaan k, almomani m, algethami a, darandari j, alsalhi a, alnaqeeb d, almogbel e, almasaari f, youssef a. ghosh u, fakir a, osmany h, lodh d, islam z, islam m. lerman-garber i, cuevas-ramos d, valdes s, enriquez l, lobato m, osornio m, escobedo a, pascualramos v, mehta r, ramirezanguiano j, gomez-perez f. title mean glycemic index using hba1c of diabetes mellitus type 2 patients with or without sensorineural hearing loss authors with sensorineural hearing loss mean meansd sdtotal total without sensorineural hearing lossyear without sensorineural hearing loss have mean hba1c levels of 6.79 to 9.8 (m=8.3). based on the forest plot, the results favor the group without sensorineural hearing loss. significantly lower hba1c levels are observed in diabetic patients without sensorineural hearing loss compared to those with sensorineural hearing loss, with mean difference of 1.04, 95%ci [0.82, 1.25]. this means that diabetic patients without sensorineural hearing loss have better glycemic control. reporting biases risk of publication bias was reported using funnel plot. based on figure 2, all the studies fall within the triangle of the funnel plot showing that the included studies had low risk for reporting bias. discussion the current meta-analysis of observational studies shows a 1.8-fold prevalence of sensorineural hearing loss in patients diagnosed with dm than those without, showing a significant association between glycemic control and sensorineural hearing loss. this is comparable with the study done by horikawa et al. in 2013 with a relative risk of 2.1.7 based on the combined results of studies, diabetic patients without sensorineural hearing loss have better glycemic control. with the current meta-analysis, glycemic control as represented by glycosylated hemoglobin (hba1c) in known diabetic patients was studied and associated with sensorineural hearing loss. a limited number of observational studies directly show continuous data philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery review article figure 1. prisma (preferred reporting items for systematic reviews and meta-analysis) flowchart figure 2. funnel plot for publication bias. this funnel plot shows that the articles included in the review had low risk of publication bias falling equally within the curve of the funnel plot. x-axis represents the effect size represented by the relative risk value obtained from each study. the y-axis represent the standard error of effect estimate which is the log of the relative risk for each study. each study within the article is plotted using a circle. regarding the use of hba1c to represent glycemic control in diabetic patients and associated these with the degree of sensorineural hearing loss.3,8,13 in the studies included in the meta-analysis, those with diagnosed dm with hba1c levels greater than 8.3 (6.79-9.8) had higher incidence of sensorineural hearing loss. moreover, poor glycemic control is associated with a higher incidence of sensorineural hearing loss, with a mean difference of 1.04. glucose levels within the endolymph may affect homeostasis and cause strial damage leading to hearing impairment.7-9 although stratified and meta-regression analyses were not done on individual demographic profiles of the included population, the confounding factor of aging was mitigated based on the demographic profiles of patients included in the study. the duration of disease process was also stated in the data abstracted from the study, which showed those with disease process of more than 10 years have higher risk of developing sensorineural hearing loss compared to patients with the disease process less than 10 years.9-13,16 limitations of this meta-analysis should be considered. first, the meta-analysis includes data from mostly observational studies and control of confounding factors within each study which associate impairment of glucose control and the risk of hearing impairment cannot be fully mitigated (i.e., exposure to noise, intake of ototoxic drugs, presence of other comorbidities predisposing subjects to end-organ complications particularly the cochlea). second, with the literature review done, the dose-response relationship between level of glycemic control in dm patients and their degree of sensorineural hearing loss was not fully established. ideally, to give weight and supplement the result of the meta-analysis, a stratification of subjects’ demographics complete with meta-regression analysis should be done to qualify the results and to produce a stronger association of the outcome based on patient’s overall demographic and clinical picture. it is recommended for further studies, given that there are already ample amounts of data showing the association of glycemic control and sensorineural hearing loss, to quantify the dose-response relationship between these two variables to be able to create a standardized data for clinicians, ultimately to push for strict glycemic control for prevention of hearing loss. dose-response associations between severity of dm and sensorineural hearing loss may give a clearer association between the disease and its long-standing effect which may be shown via the relationship of hyperglycemia, glycemic control, duration of disease and the prevalence of sensorineural hearing loss. philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery vol. 38 no. 1 january june 2023 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery review article figure 3. comparison of incidence of sensorineural hearing loss between diabetic and non-diabetic patients. note that the size of the squares on the forest plot reflects the statistical weight of each study. the pooled risk ratio is indicated by the shaded diamond which falls within the 95% ci calculated. figure 4. comparison of hba1c levels of diabetic patients with or without sensorineural hearing loss. note that the size of the squares on the forest plot reflects the statistical weight of each study. the pooled mean difference is indicated by the shaded diamond which falls within the 95% ci calculated, favoring the diabetic group with lower glycemic index and no sensorineural hearing loss. references 1. samocha-bonet d, wu b, ryugo dk. diabetes mellitus and hearing loss: a review. ageing res rev. 2021 nov;71:101423. doi: https://doi.org/10.1016/j.arr.2021.101423; pubmed pmid: 34384902. 2. bainbridge ke, hoffman hj, cowie cc. diabetes and hearing impairment in the united states: audiometric evidence from the national health and nutrition examination survey, 1999 to 2004. ann int med, 2008 jul 1;149(1): 1-10. doi:10.7326/0003-4819-149-1-200807010-00231 pubmed pmid: 18559825 pubmed central pmcid: pmc2803029. 3. dosemane, deviprasad, et al. association between type 2 diabetes mellitus and hearing loss among patients in a coastal city of south india. indian journal of otolaryngology and head & neck surgery 71 2019: 1422-1425. doi: https://doi.org/10.1007/s12070-018-1499-9. 4. gadag  rp, nayak  ps, j  t. clinical assessment of sensorineural hearing loss among diabetes mellitus patients. bengal j otolaryngol head neck surg. 2020 aug 31;28(2):112-9. doi: https:// doi.org/10.47210/bjohns.2020.v28i2.297. 5. li y, liu b, li j, xin l, zhou q. early detection of hearing impairment in type 2 diabetic patients. acta otolaryngol. 2020 feb;140(2):133-139. doi:  10.1080/00016489.2019.1680863; pubmed pmid: 31961256. 6. horikawa c, kodama s, tanaka s, fujihara k, hirasawa r, yachi y, et al. diabetes and risk of hearing impairment in adults: a meta-analysis.  j clin endocrinol metab. 2013 jan;98(1):51-58. doi: 10.1210/jc.2012-2119; pubmed pmid: 23150692. 7. hirose k. hearing loss and diabetes: you might not know what you’re missing. ann intern med. 2008 jul 1;149(1):54-55. doi:  10.7326/0003-4819-149-1-200807010-00232; pubmed pmid: 18559823. 8. austin df, konrad-martin d, griest s, mcmillan gp, mcdermott d, fausti s. diabetes-related changes in hearing. laryngoscope. 2009 sep;119(9):1788-96. doi: 10.1002/lary.20570; pubmed pmid: 19593813; pubmed central pmcid: pmc5576137. 9. al-rubeaan k, almomani, m, algethami ak, darandari j, alsahi a, alnaqeeb d, et al. hearing loss among patients with type 2 diabetes mellitus: a cross-sectional study. ann saudi med 2021; 41(3):171-178. doi: 10.5144/0256-4947.2021.171. 10. ghosh uc, fakir ma, osmany hq, lodh d, islam mz, islam mn. effect of diabetes mellitus on hearing. bangladesh j otorhinolaryngol. 2020 jan;25(2):116-124. doi:10.3329/bjo.v25i2.45210. 11. gutierrez j, jimeno c, labra pj, grullo pe, cruz tl. prevalence of sensorineural hearing loss and its association with glycemic control in filipino patients with diabetes at the philippine general hospital. j asean fed endoc soc. 2016 nov;31(2):137-143. doi:10.15605/jafes.031.02.09. 12. lerman-garber i, cuevas-ramos d, valdés s, enríquez l, lobato m, osornio m, et al. sensorineural hearing loss-a common finding in early-onset type 2 diabetes mellitus. endocr pract. 2012 jul-aug;18(4):549-57. doi: 10.4158/ep11389.or; pubmed pmid: 22440999. 13. samelli ag, santos is, moreira rr, rabelo cm, rolim l, bensenõr i, et al. diabetes mellitus and sensorineural hearing loss: is there an association? baseline of the brazilian longitudinal study of adult health (elsa-brasil). clinics (sao paulo). 2017 jan 1;72(1):5-10. doi:  10.6061/ clinics/2017(01)02; pubmed pmid: 28226026; pubmed central pmcid: pmc5251196. 14. sharma, rukmini, raghuveer choudhary, and rajendra k. teharia. correlation between sensorineural hearing loss and hba1c in diabetes mellitus patients. european journal of molecular and clinical medicine 9.1 (2022): 958-964. pii: issn 2515-8260. 15. thimmasettaiah nb, shankar r, ravi gc, reddy s. a one year prospective study of hearing loss in diabetes in general population. trans biomed. 2012 jan;3(2):1-7. doi: 10.3823/433. 16. vergou z, paschou sa, bargiota a, koukoulis gn. alterations in hearing function of patients with glucose disorders. hormones (athens). 2019 sep;18(3):281-287. doi: 10.1007/s42000-01900120-w; pubmed pmid: 31338751. 17. fukushima h, cureoglu s, schachern pa, paparella mm, harada t, oktay mf. effects of type 2 diabetes mellitus on cochlear structure in humans. arch otolaryngol head neck surg. 2006 sep;132(9):934-8. doi: 10.1001/archotol.132.9.934; pmid: 16982969. 18. sachdeva k, azim s. sensorineural hearing loss and type ii diabetes mellitus. int j otorhinolaryngol head neck surg. 2018 mar-apr;4(2):499. doi: https://doi.org/10.18203/issn.2454-5929.ijohns20180714. in conclusion, this meta-analysis showed a higher prevalence rate of sensorineural hearing loss among patients with dm compared to nondiabetic patients. moreover, poor glycemic control among diabetic patients with a glycemic index based on hba1c of more than 8.3 (6.979.6) is associated with sensorineural hearing loss. clinicians should be advised of this finding in managing patients with diabetes mellitus and its chronically debilitating end-organ effects within the inner ear. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to compare the radiographic features of the nasal septal swell body (nsb) with the laterality of nasal septal deviation and investigate whether there is a correlation between the severity of the septal deviation and difference in nsb size. methods: design: retrospective observational study setting: tertiary private university hospital participants: 30 paranasal sinus computerized tomography scans from january to october 2017 results: a septal deviation was present in 60% of the subjects. in 78% of cases with septal deviation, the nsb was noted to be significantly larger on the side opposite the nasal septal deviation (p < .05). conclusion: the correlation between the severity of the septal deviation and difference in nsb size had a value of (r = 0.37) therefore, no positive correlation was established. subjects with almost symmetric nsb measurements tend to have no septal deviation. on the other hand, the nsb is more prominent contralateral to a septal deviation. keywords: nasal septal swell body; septal deviation; inferior turbinate hypertrophy the nasal septal swell body (nsb) is a distinct and widened region of the anterior nasal septum composed of septal cartilage, bone and a thick mucosal lining.1,2 this structure is located superior to the inferior turbinate and anterior to the middle turbinate and can be identified on anterior rhinoscopy, nasal endoscopy and on sinonasal imaging studies.2-4 the nsb has been said to have similar characteristics and physiologic properties to the inferior turbinate (it).2-6 it contains vasoactive tissue that may behave in a manner similar to that of the inferior turbinate, hence the term, septal turbinate.2-7 the relationship of inferior turbinate hypertrophy and septal deviation has been discussed in the literature wherein inferior turbinate hypertrophy occurs compensatory to the presence of nasal septal deviation.1,3 both the nasal septum and inferior turbinate have been studied well with regards to its function in nasal airflow regulation.3 however, the nsb receives little attention in the clinical setting and can be confused with a high septal deviation.4,5 in order to explore a possible relationship between the nasal septal body and nasal septal deviation (and whether there is a correlation between the severity of the septal deviation and radiologic study of the nasal septal swell body and its relationship to septal deviation veronica marie m. mendoza, md1 january e. gelera, md1 christen-zen i. sison, md1 francis aaron d. dizon, md2 juan miguel l. manalo, md2 1department of otorhinolaryngology head and neck surgery university of santo tomas hospital 2department of radiology university of santo tomas hospital correspondence: dr. january e. gelera department of otorhinolaryngology head and neck surgery university of santo tomas hospital españa blvd., sampaloc, manila 1015 philippines phone: (632) 8731 3001 local 2411 email: vignettejan@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine academy of rhinology antonio l. roxas international research contest, december 1, 2017. manila hotel, one rizal park, manila. philipp j otolaryngol head neck surg 2020; 35 (1): 30-32 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles difference in nsb size), this study aims to compare the radiographic features of the nasal septal swell body with the laterality of nasal septal deviation using paranasal sinus ct scans. methods with institutional review board approval (irb-2017-10-194-tr), this retrospective study serially selected 30 paranasal sinus computerized tomography (ct) scans of patients aged 18 to 80 years old from the radiology department database of our hospital between the months of january and october 2017. the scans had been obtained using a siemens somatom sensation 64 slices (siemens healthcare gmbh, erlangen, germany). coronal and axial images with a maximum of 1.0-millimeter thickness were included. excluded from the study were ct scan images with evidence of nasal bone or nasal septum fracture and records of those with previous surgical intervention to the nasomaxillary area. the sample size of 30 was computed using the fleiss et al. and kelsey formula.8,9 the nsb was identified and the epicenter (the area of the greatest width) was marked as reference. the width of the septal body was separately measured from the widest lateral aspect of the nasal septal swell body up to the nasal septal cartilage on each side.1 (figure 1) the difference in septal body size on each side was measured and recorded. the presence of septal deviation was also obtained from these images. the presence, laterality and degree of septal deviation were recorded.3 two lines at an angle were used to assess the degree of septal deviation. the first line was drawn between the crista galli and the premaxillary area. the second line was from the crista galli to the most prominent portion of the nasal septum.3 (figure 2) the degree of septal deviation was classified as: mild (≤ 8o), moderate (9-15o) and severe (≥ 16o).10 clearcanvas workstation version 13.1 (synaptive medical, toronto, canada) was used to measure the width and angles. data was collected and tabulated using microsoft excel for mac version 16.7 (microsoft corp. redmond, wa, usa). data analysis was performed using ibm spss statistics for windows version 20.0 (ibm corp., armonk, new york). student’s ttest was used to correlate the mean difference in the size of the nsb and the degree of septal deviation. simple regression analysis using a linear model was utilized to show the correlation between the degree of severity of septal deviation and nsb size difference. a value of p < .05 was considered statistically significant. results a total of 30 patient records (15 males and 15 females) met inclusion and exclusion criteria. ages ranged from 18 to 80 years old (mean age 38 years old). the average total width of the septal body measured by adding the width of the septal body on each side of the septal cartilage was 9.5 mm (sd 1.5). the degree of septal deviation gnm was classified figure 1. representative axial computerized tomography (ct) image showing the measurement of the nasal septal swell body on both sides. figure 2. representative coronal computerized tomography (ct) image showing the measurement of the degree of nasal septal deviation. the angle between the two lines was used to quantify the degree of septal deviation. figure 3. scatter plot of difference in septal body size by degree of septal deviation. a linear regression model shows that there are inconclusive findings in the relationship between the degree of septal deviation and septal body size. as mild (≤ 8°) in 13 cases and severe (≥ 16°) in 5 cases. no cases were classified as moderate (9-15°). a distinct nasal septal swell body was identified in all 30 cases. the presence of septal deviation was noted in 18 out of the 30 (60%). in 14 of the 18 with septal deviation (78%), the septal body was noted to philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles references 1. costa dj, sanford t, janney c, cooper m, sindwani r. radiographic and anatomic characterization of the nasal septal swell body. acrh otolaryngol head neck surg. 2010 nov; 136(11): 1107-1110. doi: 10.1001/archoto.2010.201; pmid: 21079165. 2. lapeña jf. tuberculum septi. brunei int med j. 2011 aug; 7(4): 239. 3. setlur j, goyal p. relationship between septal body size and septal deviation. am j rhinol allergy. 2011 nov-dec; 25(6): 397-400. doi: 10.2500/ajra.2011.25.3671; pmid: 22185743. 4. elwany s, salam sa, soliman a, medanni a, talaat e. the septal body revisited. j laryngol otol. 2009 mar; 123(3):303–308. doi: 10.1017/s0022215108003526; pmid: 18796179. 5. wotman m, kacker a. should otolaryngologists pay more attention to nasal swell bodies? laryngoscope. 2015 aug; 125(8):1759-1760. doi: 10.1002/lary.25144; pmid: 25600033. 6. arslan m, muderris t, muderris s. radiological study of the intumescentia septi nasi anterior. j laryngol otol. 2004 mar; 118(3): 119-201. doi: 10.1258/002221504322927964; pmid: 15068516. 7. wexler d, braverman i, amar m. histology of the nasal septal swell body (septal turbinate). otolaryngol head neck surg. 2006 apr; 134(4): 596-600. doi: 10.1016/j.otohns.2005.10.058; pmid: 16564379. 8. kelsey jl, whittemore as, evans as, thompson wd. methods in observational epidemiology. oxford: oxford university press; 1996. 9. fleiss jl. statistical methods for rates and proportions. hoboken, new jersey: john wiley & sons; 1981. 10. elahi mm, frenkiel s, fageeh n. paraseptal structural changes and chronic sinus disease in relation to the deviated septum. j otolaryngol. 1997 aug; 26(4): 236–240. pmid: 9263892. 11. san t, muluk nb, saylisoy s, acar m, cingi c. nasal septal body and inferior turbinate sizes differ in subjects grouped by sex and age. rhinology. 2014 sep; 52(3): 231-237. doi: 10.4193/ rhin13.138; pmid: 25271528. 12. wong e, deboever n, chong j, sritharan n, singh n. isolated topical decongestion of the nasal septum and swell body is effective in improving nasal airflow. am j rhinol allergy. 2020 february. doi: 10.1177/1945892420902913. 13. akoglu e, karazincir s, balci a, okuyucu s, sumbas h, dagli as. evaluation of the turbinate hypertrophy by computed tomography in patients with deviated nasal septum. otolaryngol head neck surg. 2007 mar; 136(3):380–384. doi: 10.1016/j.otohns.2006.09.006; pmid: 17321863. 14. egeli e, demerici l, yazycy b, harputluoglu u. evaluation of the inferior turbinate in patients with deviated nasal septum by using computed tomography. laryngoscope. 2004 jan; 114(1):113–117. doi: 10.1097/00005537-200401000-00020; pmid: 14710005. 15. estomba cc, schmitz tr, echeverri co, reinoso fa, velasquez ao, hidalgo cs. compensatory hypertrophy of the contralateral inferior turbinate in patients with unilateral nasal septal deviation. otolaryngol pol. 2015 april; 69 (2): 14-20. doi: 10.5604/00306657.1149568. be significantly larger on the side opposite the nasal septal deviation (p < .05). no significant asymmetry of the nasal septal swell body was identified in the 12 cases with absence of septal deviation. the mean difference in septal body size was 1.58 mm in cases with severe septal deviation and 0.98 mm in cases with mild septal deviation. there was no statistically significant difference found between the septal body size of patients with severe septal deviation and those with mild septal deviation (p < .05). the correlation between the severity of the septal deviation and difference in the septal body size on the two sides of the septum was not classified as high (r = 0.37). a positive r value signifies that there is a positive relationship between the severity of septal deviation and difference in the septal body size. figure 3 shows the result of a simple regression analysis using a linear model for which r2 = 0.138 was obtained. this denotes that only 13.8% of the variance in the septal body size difference is due to the severity of septal deviation. discussion nasal airflow is regulated predominantly by the nasal turbinates. on the other hand, the nsb has been said to have similar characteristics and properties as the inferior turbinate.1,11 it contains vasoactive tissue that may behave in a manner similar to the inferior turbinate wherein arteriovenous congestion would cause nasal airway obstruction.4,12 however, its role in nasal airflow regulation remains unclear. several sources in the literature observe that patients with septal deviation are often found to have significant inferior turbinate hypertrophy on the side opposite the septal deviation as a counterbalance mechanism.13,14 this compensatory hypertrophy of the inferior turbinate protects the more spacious nasal side from crusting, drying, altered air filtration and mucociliary flow due to the excess air.13,14,15 the results of our study suggest that the nsb is more prominent contralateral to a septal deviation. these findings echo those seen with inferior turbinate hypertrophy11 and may corroborate those of setlur and goyal who concluded (based on the similarities of the nsb and inferior turbinate) that the nsb may have a role in regulating nasal airflow and contribute to nasal obstruction.3 recent evidence has shown that direct decongestant application isolated to the nsb resulted in a reduction in nasal obstruction symptoms as well as improved scores on anterior rhinomanometry, acoustic rhinometry and peak nasal inspiratory flow.12 unfortunately, there was no statistically significant correlation between the severity of the septal deviation and difference in the septal body size in our study, differing from the theoretical results obtained from previous studies.3,4,5 this may be due to the small sample size used for the study, and the subsequent number of subjects with septal deviation (18 out of 30). since this study focused mainly on radiographic characteristics of the nsb and septal deviation and not on its histologic composition, it is recommended that the vascular and glandular structures of the nsb be investigated further, in order to elucidate the physiologic properties of the nsb and how they might affect nasal airflow. furthermore, the emphasis on the nsb as a distinct and separate structure may direct novel surgical procedures or medical therapies specific to its management in the future. our study showed that those with almost symmetric septal body measurements tend to have no septal deviation, while patients with asymmetric nsb hypertrophy tend to have septal deviation contralateral to the side with hypertrophy, but our results are not conclusive. whether this relationship may be similar to that of septal deviation and compensatory contralateral inferior turbinate hypertrophy, and whether it can suggest that the nsb may have an impact on nasal airflow regulation similar to that of the inferior turbinate, needs further study. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2022; 37 (2): 26-29 c philippine society of otolaryngology – head and neck surgery, inc. quality of sleep among shift work nurses at the baguio general hospital: a pilot cross sectional study kathrynne endenna s. andaya, md department of otorhinolaryngology head and neck surgery baguio general hospital and medical center correspondence: dr. kathrynne endenna s. andaya department of otorhinolaryngology head and neck surgery baguio general hospital and medical center governor pack road, baguio city 2600 philippines phone: (+63) 916 269 1945 email: kathrynne_solang@yahoo.com the author declares that this is an original material and is not being considered for publication or has not been published elsewhere; that the final manuscript has been read and approved by the author, and that the requirements for authorship have been met by the author. disclosures: the author discloses that there are no financial or personal relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the 2021 annual research presentation at the bghmc secretary’s cottage, governor pack road baguio city. march 11, 2021. abstract objective: the primary objective of this study was to determine the quality of sleep among 12hour shift-work nurses at the baguio general hospital using the pittsburg sleep quality index (psqi). methods: this was a preliminary cross-sectional study with a primary endpoint of assessing the sleep quality of the participants using the psqi. the association of sleep quality with individual and work factors was also determined. design: cross sectional study setting: tertiary government training hospital patient: 154 12-hour shiftwork nurses results: the majority (88.96%) of the participants self-reported having poor sleep quality. among the components of the psqi, current shift was significantly associated with habitual sleep efficiency (fisher exact test p < .049). no significant associations were found between demographic characteristics and psqi global score, with most respondents having poor sleep quality regardless of participant characteristics. conclusion: majority of nurses working in 12-hour shifts had poor sleep quality. night shift nurses had higher habitual sleep efficiency scores compared to day shift nurses indicating that those working in the night shift had poorer habitual sleep efficiency. keywords: sleep quality; shift worker; psqi; nurse; night shift; day shift; workplace health; 12-hour shift shiftwork means employment outside the established workday, which is typically 8 am 4 pm.1 essential for the successful functioning of institutions requiring 24-hour operation (such as hospitals), it requires employees to work outside of physiologic sleep hours. a shift worker is defined as a person who does not work a standard daytime schedule.2 shift work affects sleep quality: current or past performance of shift work was significantly associated with poor sleep quality among shift-working nurses in shanghai, china;3 18% of shiftwork nurses at the lung center of the philippines had shift work disorder (swd);4 and swd had a prevalence of 32.1% among night workers and 10.1% in day workers in a random population study.5 poor quality of sleep also negatively impacts ability to work which is crucial in healthcare settings.3 the baguio general hospital and medical center (bghmc) currently employs 380 nurses. among these, 308 are shift workers who work twelve-hour shifts daily. at the moment, there is creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles no fixed policy dictating shift changes every seven days. these changes are dependent only on the preferences of the nurses in each unit, without regard to how it may affect quality of sleep. the aim of this study was to determine the quality of sleep among 12-hour shift-work nurses in this institution using the pittsburgh sleep quality index (psqi). methods this cross sectional study sought to determine the quality of sleep among consenting 12-hour shiftwork nurses using the pittsburgh sleep quality index (psqi) from november 1 to 30, 2020.    the psqi is a widely used self-rated questionnaire to assess sleep quality. having a diagnostic sensitivity of 89.6% and a specificity of 86.5%,6 it showed strong reliability and validity with moderate structural validity in a variety of samples, suggesting that it fulfills its intended use to screen for sleep dysfunction.7 the protocol for this study was approved by baguio general hospital and medical center research ethics committee (bghmc-erc-2020-36). considered for inclusion were staff nurses employed at the bghmc who were directly involved in patient care and who followed shift schedules: seven days of 7am-7pm followed by 7 days of 7pm-7am after a sevenday-off; seven days of 7pm-7am followed by 7 days of 7am-7pm after a seven-day-off. nurses who were not directly involved in patient care, who were in the ancillary services, on duty during office hours only or head nurses assigned to administrative roles, were excluded. additionally, staff nurses directly involved in patient care who were promoted to administrative roles, or transferred to ancillary services during the study period, or those who converted from shift schedules to office-hour schedules during the study period were excluded. similarly, nurses undergoing psychiatric or psychological care or who were diagnosed with or treated for serious medical conditions (such as severe covid-19) during the study period were excluded. we used the openepi version 3.01 formula of sample size n = [deff*np(1-p)]/ [(d2/z2 1-α/2 *(n-1)+p*(1-p)] where: population size (for finite population correction factor or fpc) (n): 352 hypothesized % frequency of outcome factor in the population (p): 50%+/-5 confidence limits as % of 100(absolute +/%)(d): 5% design effect (for cluster surveys-deff): 1 accordingly, the calculated sample size was 172. stratified random sampling was used for the distribution of subjects into two shifts. a sampling frame was constructed based on a complete list of nurses meeting inclusion and exclusion criteria, with their respective assigned departments and shift schedules. this full list was subdivided into the two shift categories: 7am-7pm followed by 7pm-7am after a seven-day off; or 7pm-7am followed by 7am-7pm after a seven-day off. using a random number generator, participants were chosen at random with a 20% adjustment for attrition. test questionnaires included the psqi and demographic (age, sex, marital status, comorbidities) and work factor (length of employment, shift schedule) data. selected participants were contacted through the nursing division office and informed consent was obtained individually by a research assistant before participants responded to the questionnaire. potential participants were briefed on the nature and objectives of the study, possible risks and benefits, and were informed that participation was fully voluntary, with withdrawal being possible at any point. the participants were also given the choice to skip any questions they preferred to. test questionnaires were distributed to consenting participants, and answered at their leisure one day after completion of their shift, then retrieved seven days after distribution. data analysis data was encoded and tabulated using the 2019 version of microsoft excel version (microsoft corp., redmond, wa, usa) following a coding manual that was prepared prior to statistical analysis. the data was then statistically analyzed using ibm statistical package for the social sciences (ibmò spssò statistics) v.17 (ibm corp., armonk, ny, usa) and r project for statistical computing version 4.0.3 (https://www.r-project. org/). a fisher exact test statistic was computed to explore the association of the demographic profile of the shift nurses to the participants’ quality of sleep.  descriptive and inferential statistics were used in describing, comparing and analyzing data.  significance was determined as a p-value of ≤ .05. the effects of possible confounders were also determined and controlled. results out of 308 participants who consented to participate and were given test questionnaires, only 154 nurses returned the questionnaires, for a response rate of 50%. respondents were predominantly female (67.53%) with a mean age of 32.2 years (range 23-60 years old). less than half (42.21%) of the nurses were single. overall, almost all nurses were part of the 12-hour shift for 8 months, wherein more than half (62.34%) were currently on day shift. majority (89.61%) of the participants had no known comorbidities. (table 1) a majority (88.96%) of the participants self-reported having poor sleep quality with a global psqi score greater than or equal to 5. based on the fisher exact test, the association between components of psqi (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication and daytime dysfunction) and current shift (day shift and night shift), current shift was significantly associated with habitual sleep efficiency (p < .049). (table 2) philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles table 1. distribution of participants by current shift and by pittsburgh sleep quality index components component n n% % p-value day shift night shift subjective sleep quality (n=151) 0 1 2 3 sleep latency (n=154) 0 1 2 3 sleep duration (n=153) 0 1 2 3 habitual sleep efficiency (n=147) 0 1 2 3 sleep disturbances (n=154) 0 1 2 3 use of sleeping medication (n=151) 0 1 2 3 daytime dysfunction (n=154) 0 1 2 3 10 70 14 1 5 14 37 40 7 17 58 13 43 23 14 12 3 54 37 2 81 5 4 4 24 56 16 0 6.62 46.36 9.27 0.66 3.25 9.09 24.03 25.97 4.58 11.11 37.91 8.50 29.25 15.65 9.52 8.16 1.95 35.06 24.03 1.30 53.64 3.31 2.65 2.65 15.58 37.09 10.39 7 33 15 1 3 13 19 23 11 7 28 12 17 12 9 17 0 25 32 1 50 2 2 3 15 31 8 4 4.64 21.85 9.93 0.66 1.95 8.44 12.34 14.94 7.19 4.58 18.30 7.84 11.56 8.16 6.12 11.56 16.23 20.78 0.65 33.11 1.32 1.32 1.99 9.74 20.13 5.19 2.60 .199* .652 .071 .049 .154* .973* .084* *computed using fisher exact test table 2. relationship of demographic characteristics of 12-hour shift nurses and their psqi scores demographic characteristics psqi score 0-4 pts (n=17) 5-21 pts (n=137) p-value age-group (n=154) 20-29 y/o 30-39 >40 no answer sex male female civil status single married no answer current shift day shift night shift shift change changers to night shift changers to day shift maintained shift length of time employed as an 12-hour shift worker 0-12months no answer comorbidities with any comorbidities no known comorbidities 6 8 1 2 8 9 7 6 4 11 6 2 4 11 16 1 3 14 50 57 5 25 42 95 58 35 44 85 52 25 39 73 136 1 13 124 .726* .173 .555 .831 .829* na** .389* *computed using fisher exact test **no test applicable as all answers were one-sided (8 months) getting 5-6 hours of actual sleep. low scores in habitual sleep efficiency were observed to be more frequent in day shift nurses (29.25% scored 0, equivalent to >85% habitual sleep efficiency) than those among night shift nurses, of whom 11.56% had >85% habitual sleep efficiency and 11.56% had <65% sleep efficiency. fairly good sleep quality was reported by 46.36% of day shift nurses and 21.85% of night shift nurses. only 5.97% of day shift nurses and 14.94% of night shift nurses had high scores in sleep latency, while 37.91% of day shift and 18.30% of night shift nurses reported a 5 to 6-hour duration of sleep. most respondents were within the mid ranges of the sleep disturbance score and a great proportion (86.75%) reported non-use of sleeping medication in the past month. more day shift (37.09%) than night shift (20.13% ) nurses had low scores for daytime dysfunction. overall, most respondents (88.96%) had poor sleep quality, regardless of participant characteristics. mean hours of sleep for all participants were 5.69 hours, ranging from 1.5 hours to 10 hours, wherein 55.2% of the total sample reported philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles discussion our survey found that 88.96% of the participants self-reported having poor sleep quality (psqi global score > 5), with an overall mean score of 8.75 + 3.17. only 11.04% of the group reported having good sleep quality. among the components of the psqi, only habitual sleep efficiency was associated with current shift (p < .049), with lower scores observed among day shift nurses than night shift nurses. in comparison to a study among nurses working in acute hospitals in south korea, the results of the present study show a higher prevalence of poor sleep quality (79.8%), and a higher mean psqi global score (6.52 + 4.23).8 these findings are also similar to a cross-sectional study in a tertiary hospital in shanghai wherein psqi scoring was found to be significantly associated to sleep efficiency, sleep quality and daily dysfunction.9 however, in the current study, sleep quality and daily dysfunction were not statistically significant. while the present study was able to determine that the majority of shiftwork nurses in the bghmc had poor sleep quality, it was not able to identify which individual characteristic of nurses nor which work factor was associated with poor sleep quality. additionally, only a total of 154 respondents were included and due to limitations in time and resources, the minimum sample size requirement was not fulfilled. almost all reported to have been in 12-hour shifts for eight months. this corresponds to the hospital mandate of having staff nurses go into 12hour shifts from the previous eight-hour-shifts to allow for a quarantine period in between shift changes. prior to the covid-19 pandemic, nurses were assigned one of the following shifts: 7 am-3 pm, 3 pm -11 pm and 11 pm-7 am. the assigned shift for 15 days was followed by another 15 days in another shift, depending on their arrangement with their immediate supervisor. the change in schedule was due to the emergence of the covid-19 virus and need to provide a dedicated area of the hospital for infected patients. while the psqi was originally intended for psychiatric patients6 and although there are other tools available to assess sleep, only the psqi was used in this study. the psqi was the most appropriate tool for this population during the peak of the pandemic as it is a self-reported, easy to administer and requires a brief time for completion. the psqi was intended to identify the good sleepers and the bad sleepers, which this study was able to achieve. despite its limitations, the current study concurs with what other studies have concluded, that shift work is associated with sleep quality. early screening of sleep quality should be done among shift workers. programs to improve sleep quality should be designed and implemented among the nurses employed in the institution. improvement of sleep quality has the ultimate intention of positively impacting work judgement and performance, resulting in less errors and accidents. although other studies have shown that the other components of the psqi were associated with shift work, these were not shown in the present study. this may be attributable to the suboptimal sample size. future studies with larger sample sizes may reveal such acknowledgements the author acknowledges the invaluable contributions of beverly carbonell, md, fpso-hns, fpssm for her guidance and insight, and of mr. roy revilla and ms. karell calpito who provided advice and statistical support for this study. references 1. puerta y, garcía m, heras e, lópez-herce j, fernández sn, mencía s, et al. sleep characteristics of the staff working in a pediatric intensive care unit based on a survey. front pediatr. 2017 dec 22;5:288. doi:  10.3389/fped.2017.00288; pubmed pmid:  29318135; pubmed central pmcid: pmc5748084. 2. tepas di, armstrong dr, carlson ml, duchon jc, gersten a, lezotte dv. changing industry to continuous operations: different strokes for different plants. behavior research methods.1985 nov;17(6):670-6. doi:10.3758/bf03200980. 3. neidhammer i, lert f, marne mj. effects of shiftwork on sleep among french nurses. a longitudinal study. j occup med. 1994 jun: 36(6):667-674. pubmed pmid: 8071731. 4. jocson mc, de los reyes v. prevalence and consequences of shift work disorder among nurses at lung center of the philippines. phil j chest dis. 2015 apr-jun:16(2):10-18. available from: http://philchest.org/v3/wp-content/uploads/2013/05/pjcd-vol-16-issue-2_final.pdf. 5. di milia l, waage s, pallesen s, bjorvatn b. shift work disorder in a random population sample– prevalence and comorbidities. plos one. 2013 jan 25;8(1):e55306. doi:  10.1371/journal. pone.0055306; pubmed pmid: 23372847; pubmed central pmcid: pmc3555931. 6. buysse, dj, reynolds iii cf, monk th, berman sr, kupfer dj. the pittsburgh sleep quality index: a new instrument for psychiatric practice and research. psychiatry res. 1989 may;28(2):193-213. doi: 10.1016/0165-1781(89)90047-4; pubmed pmid: 2748771. 7. mollayeva t, thurairajah p, burton k, mollayeva s, shapiro cm, colantonio a. the pittsburgh sleep quality index as a screening tool for sleep dysfunction in clinical and non-clinical samples: a systematic review and meta-analysis. sleep med rev. 2016 feb ;25:52-73. doi:  10.1016/j. smrv.2015.01.009; pubmed pmid: 26163057. 8. park e,  lee hy,  park cs-y.  association between sleep quality and nurse productivity among korean clinical nurses.  j nurs manag. 2018 nov;26(8):1051-1058. doi:  10.1111/jonm.12634; pubmed pmid: 29855101. 9. zhang l, sun d, li c, tao m. influencing factors for sleep quality among shift-working nurses: a cross-sectional study in china using 3-factor pittsburgh sleep quality index. asian nurs res (korean soc nurs sci). 2016 dec;10(4):277-282. doi:  10.1016/j.anr.2016.09.002; pubmed pmid: 28057314. relationships. this study was limited by the covid-19 pandemic. the change in shifts and ward assignments of the nurses, as well as quarantine protocols made it more difficult for them to participate in the research. the pandemic also increased stress levels of all hospital workers in our institution which could have contributed to the poor sleep of nurses. this study was only done on nurses working in 12-hour shifts, as the schedule of nurses were adjusted from the usual three shifts in 24 hours to two shifts to accommodate the needs of the hospital during the pandemic. in the future, this study may also be done on shift workers working in three shifts to assess if shorter shifts, or rotating in between three shifts provide better sleep quality for shift-workers. also, this study was conducted in a single institution in the northern philippines, thus, the results may not be generalizable to other institutions. other tools to assess sleep quality and work quality may be used in future to look for associations between these. in conclusion, this current study found that the majority of the nurses at the bghmc report low sleep quality. given that shift work remains indispensable, this finding is worthy of further consideration in order to identify ways of addressing it. a future direction of this study is assess sleep quality in other departments and with other workers in the hospital such as resident physicians who go on 24-hour duty, paramedical staff such as radiology technicians, and medical technologists. further studies should be conducted to identify the drivers of sleep quality, as well to identify comprehensive strategies to improve them among shift workers. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery letters to the editor otitic hydrocephalus or obstructive hydrocephalus? dear editor: i came across the article entitled “fatal otitic hydrocephalus due to sinus thrombosis : a case report”, and i would like to thank the authors for sharing their experience with this case. in their discussion, the authors state that otitic hydrocephalus “is characterized by increased intracranial pressure with clear csf, transient sixth nerve palsy, headache, vomiting, papilledema with no other detectable cns signs and no actual dilation of ventricles.” they go on to state that “otitic hydrocephalus is a misnomer according to some because it may occur in the absence of otitis and because patients do not show the ventricular dilatation seen in true hydrocephalus.” lastly, they state that “the diagnosis of oh is made by exclusion and a brain abscess should be ruled out by ct scan.” however, in the description of their case, the authors state the following: 1) “lumbar tap showed elevated cerebrospinal fluid (csf) opening pressure of 270 mm h2o, decreased glucose and increased protein content” 2) “repeat ct scan on the second post-op day showed marked dilatation of the third and lateral ventricles due to compression of the fourth ventricle...” 3) “he underwent ventriculostomy and evacuation of abscess on the fourth post-operative day.” these statements contradict the main diagnostic features of otitic hydrocephalus, and thus call into question the diagnosis of otitic hydrocephalus in this particular case. in fact, the clinical data points to the presence of an obstructive hydrocephalus. there is no doubt that the patient has evidence of lateral sinus thrombophlebitis. however, not all cases of lateral sinus thrombophlebitis are associated with otitic hydrocephalus. nathaniel w. yang, md, fpsohns associate professor department of otolaryngology head and neck surgery college of medicine philippine general hospital university of the philippines manila ward 10, philippine general hospital, taft avenue ermita, manila 1000 philippines phone: (632) 8526 4360 fax: (632) 8525 5444 email: nwyang@up.edu.ph creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery letters to the editor response from the authors dear editor, herewith is our reply to the letter sender. thank you for your interest in our article “fatal otitic hydrocephalus due to sinus thrombosis: a case report” published in the philippine journal of otolaryngology – head and neck surgery vol. 37 no. 1 jan – jun 2022. we analyzed the case, consulted specialists, reviewed the ct scans, and did further research to answer the issues raised in the inquiry. most of the references and content in this reply were not included in the article. first, we would like to correct our discussion statement that the fixed lateral gaze to the right was a conjugate gaze deviation that was due to abducens palsy; we now know that it may have been caused by compression of either the frontal or pontine gaze center or its interconnection which may have been affected by the enlarged ventricle.1 conjugate gaze deviation was also observed in an 18-yearold young man diagnosed with otitic hydrocephalus reported in the british medical journal in 1932.2 in the same article,2 symonds said that the average normal cerebrospinal fluid (csf) pressure is 150 mmh2o, in brain abscess the pressure is normal up to 250 mmh2o while in hydrocephalus it is around 300 mmh2o. by the time symptoms of increased intracranial pressure (icp) are evident, cerebellar abscess will manifest with “localizing signs” of which the most important is nystagmus and limb incoordination ipsilateral to the lesion. in left temporal lobe abscess, “word forgetfulness,” weakness of the opposite face, and homonymous defect in the opposite visual field may be manifested.2 in our case, the csf pressure was 270 mmh2o prior to mastoidectomy which doubled to 543 mmh2o four days later when ventriculostomy was done. there were no localizing signs except for meningeal irritation and slight weakness on the right upper (4/5) and lower extremities (3/5) which improved with antibiotics. after vp shunt, conjugate gaze was relieved while icp and csf normalized. however, the gcs continued to decline and central herniation due to hydrocephalus and bacterial meningitis were considered for his demise. in 1939, gardner reported a case of otitic sinus thrombosis in a 9-year-old girl where postmortem examination showed a fibrous cord on the left lateral sinus that caused increased icp, acute thrombophlebitis of the left superior petrosal and sagittal sinuses and fibrinopurulent leptomeningitis.3 he said these findings led symonds to consider that otitic hydrocephalus may be due to thrombosis of the intracranial sinuses which by partially obstructing the outflow of venous blood, causes cerebral venous engorgement and consequent rise in icp.3 the thrombus is a protective measure and is not infected from the beginning. it is nature’s way of blocking the blood channel in an effort to prevent further spread of infection, but it is the secondary infection of the clot and not the thrombus that constitutes the danger.3 a 7-year-old girl diagnosed with otitic hydrocephalus presented with subacute mastoiditis in the right ear and initially showed increased icp with no csf protein elevation, but after 2 months of confinement, died of pneumococcus type iii meningitis.3 gardner explained that this may be due to thrombosis of the right jugular bulb which occurred with the onset of otitis; sterile subdural effusion occurred as a result of either thrombosis or external pachymeningitis.3 he further opined that the subdural effusion plus the venous congestion occasioned by the thrombosis of the right jugular bulb was responsible for the high icp and that the thrombophlebitis gradually spread from the right jugular bulb to most of the major intracranial sinuses and cerebral veins, with meningitis terminating the picture.3 similarly, a 12-year-old girl with 6-year history of otorrhea was diagnosed with otitic hydrocephalus and cerebellar abscess secondary to atticoantral ear disease,4 and the ct scan of another case of otitic hydrocephalus showed dilatation of the left lateral ventricle body.5 although rare, otitic hydrocephalus, meningitis, cerebellar abscess and ventricular dilatation may develop at the same time. our patient had csom, headache, papilledema, lateral sinus thrombosis (lst) on ct and perisinus abscess and cholesteatoma on mastoidectomy. secondary infection of the clot or thrombus, subdural effusion, and meningitis may have developed requiring drainage and ventriculostomy four days later when the patient’s condition deteriorated. serial ct scans showed no ring enhancement although fluid accumulation or possible abscess formation was noted 10 days after ventriculostomy. culture of the ear discharge grew proteus mirabilis creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery letters to the editor while samples of the brain abscess drained during ventriculostomy had no growth after 3 days. communicating hydrocephalus may develop at the outset and may become obstructive later especially when the condition is associated with meningitis or brain abscess. lateral sinus thrombosis brought about by chronic ear disease may have altered the hemodynamics of the central venous circulation which in turn compromised the csf environment. this was documented in the imaging studies that showed progression of dilatation of the right sigmoid, transverse and superior sagittal sinuses. weeks prior to admission when the patient was experiencing headache, alterations in icp and csf protein may have occurred and subsequently elevated when the condition worsened upon admission. since the veins and venous sinuses are in the subarachnoid space, inflammation may reach the csf and pleocytosis may develop.6 this hypothetical sequence of events should have been documented with serial csf determinations, angiography and autopsy. we postulate that otitic hydrocephalus may be considered as a clinical spectrum and a dynamic disease process evolving in a continuum. in the early phase, sigmoid sinus thrombophlebitis, increased icp, clear csf, and absent ventricular dilatation may be manifested which usually improve with antibiotics and vp shunt and are therefore reversible. these were the early observations2,3 which may be attributed to the short duration of ear infection, early detection and management. these may represent the initial clinical picture of the patient. however, if ear infection continues with no intervention, the late phase may unfold characterized by propagation of sigmoid sinus thrombosis, subdural effusion, meningitis, increase icp and csf protein, and ventricular dilatation with which our patient may be classified. these may represent the dire outcome of persistent chronic ear infection and lst; the latter fraught with the risk of complete sagittal sinus occlusion which may result in severe neurologic deficits and death.7 we took note of the contradictory issues in our case and if we are going to follow definitions to the letter, concede that the case may not qualify. but if we are going to consider the parameters as preludes or antecedent events and the late phase manifestations as possible consequences which may have transpired, then our diagnosis may not be that farfetched or remote. we hope that this reply explains our side. we agree with and fully respect the opinion given by the good doctor. thank you. claudette gloria t. plumo, md resident physician iii emmanuel tadeus s. cruz, md consultant department of otorhinolaryngology head and neck surgery quezon city general hospital seminary rd., bgy. bahay toro, quezon city 1106 philippines phone: (+632) 8863 0800 local 401 email: orl_hns_qcgh@yahoo.com.ph references 1. azarmina m, azarmina h. the six syndromes of the sixth cranial nerve. j ophthalmic vis res. 2013 apr;8(2):160-71. pubmed pmid: 23943691; pubmed central pmcid: pmc3740468. 2. symonds cp. otitic hydrocephalus: a report of three cases. br med j. 1932 jan 9;1(3705):53-4. doi: 10.1136/bmj.1.3705.53; pubmed pmid: 20776602; pubmed central pmcid: pmc2519971. 3. gardner wj. otitic sinus thrombosis causing intracranial hypertension. arch otolaryngol. 1939;30(2):253–268. doi:10.1001/archotol.1939.00650060273007. 4. viswanatha b. otitic hydrocephalus: a report of 2 cases. ear nose throat j. 2010 jul;89(7):e34-7. doi: 10.1177/014556131008900708; pubmed pmid: 20628978. 5. modak vb, chavan vr, borade vr, kotnis dp, jaiswal sj. intracranial complications of otitis media: in retrospect. indian j otolaryngol head neck surg. 2005 apr;57(2):1305. doi: 10.1007/bf02907667; pubmed pmid: 23120149; pubmed central pmcid: pmc3450981. 6. greenlee j. bacterial meningitis. in: schapira ah, byrne e, dimauro s, frackowiak r, johnson r, mizuno y, samuels m, silberstein s, wszolek z, editors. neurology and clinical neuroscience. mosby; 2007. p. 1236-1248. 7. symonds c. otitic hydrocephalus. neurology. 1956;6(10):681-685 [cited 2022 aug 30]. available from: https://doi.org/10.1212/wnl.6.10.681 pubmed pmid: 13369649. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 2 july– december 2017 president’s page as our different training institutions from north to south of the archipelago strive to push their research agenda to the forefront, it is only imperative for the philippine society of otolaryngology-head and neck surgery to provide the platform for their research output to be documented, published and shared with the rest of the scientific community. and towards this end, the philippine journal of otolaryngology-head and neck surgery has not only met the expectations of our dear fellows and trainees but has far exceeded them. congratulations to the contributing authors and institutions and kudos to the editorial staff headed by dr. jose florencio lapeña. with all the laudable achievements it has accomplished, pjo-hns needs all our support to see it through its continuous journey of improvement and development into an open access journal. as we bring 2017 to a close, on behalf of the board of trustees of the pso-hns, i wish you all the very best for the new year to come. melfred l. hernandez, md, mha president philippine society of otolaryngology-head and neck surgery 2 philippine journal of otolaryngology-head and neck surgery opening the pjo-hns to the country and to the world philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2020; 35 (1): 60-62 c philippine society of otolaryngology – head and neck surgery, inc. bilateral facial nerve (bell’s) palsy in a 24-year-old woman: a case report camille q. tolentino, md emmanuel tadeus s. cruz, md department of otolaryngology head and neck surgery manila central university – filemon d. tanchoco medical foundation hospital correspondence: dr. emmanuel tadeus s. cruz department of otoaryngology – head and neck surgery mcu fdtmf hospital edsa, caloocan city 1400 phone: (632) 8367 2031 local 1212 opd 1144 fax: (632) 8367 2249 email: orlhns_mcu@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represent honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political views or beliefs, and institutional affiliations that might lead to conflict of interest. presented at the philippine society of otolaryngology head and neck surgery interesting case contest (3rd place). april 8, 2017. plaza del norte hotel & convention center, ilocos norte. abstract objective: to report a case of acute bilateral facial nerve palsy in a 24-year-old woman and to present the differential diagnoses, pathophysiology, management and prognosis. methods: design: case study setting: tertiary private hospital patient: one (1) result: a 24-year-old woman with fever, joint pains, cough, chest pain, difficulty ambulating and progressive facial muscle weakness was diagnosed with rheumatic fever. bilateral facial nerve paralysis was noted, and electromyography-nerve conduction velocity (emg-ncv) testing with special facial nerve study revealed abnormal facial nerve and blink reflex studies while emg-ncv of the upper and lower limbs were normal. audiometry and mri of the brain and facial nerve were normal while schirmer’s test showed decreased tearing in both eyes. the rheumatic fever resolved within 5 days of antibiotics, while prednisone and physiotherapy resulted in improvement of facial paralysis from house brackmann v to house brackmann ii-iii over a period of 6 months. conclusion: idiopathic facial paralysis or bell’s palsy is the most common cause of acute unilateral facial paralysis while bilateral facial nerve paralysis is a rare condition. patients with facial palsy should undergo appropriate diagnostics to determine the underlying condition and to facilitate prompt management. keywords: facial paralysis, idiopathic; bell’s palsy facial paralysis is not often encountered in our outpatient clinic. individuals who develop facial palsy consult because of the unusual facial asymmetry and inability to move facial muscles. often regarded as an ominous sign in clinical practice, paralysis of the lower half of the face may indicate central problem (such as a brain tumor, cerebrovascular accident or stroke).1 unilateral hemifacial paralysis may be due to peripheral compression of the tympanic segment of the facial nerve in cases of chronic mastoiditis and presence of cholesteatoma.2 in addition, unilateral facial palsy may be iatrogenic (after mastoidectomy or parotidectomy) or in the absence of an etiology, termed bell’s palsy.3 creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery case reports idiopathic facial paralysis or bell’s palsy often involves only one side of the face and very seldom manifests bilaterally.1 this report aims to present a case of acute bilateral facial nerve palsy, its differential diagnoses, pathophysiology, management and prognosis. case report a 24-year-old woman consulted due to high grade fever, progressive joint pains, nonproductive cough, sore throat and rashes for 2 weeks. she had taken oral antibiotics and antiseptic gargles but developed chest pain, stiff neck and shoulders, difficulty ambulating and facial muscle weakness after 4 days. she would drool and had to manually support her lower lip to avoid spilling liquids whenever she drank. the patient was admitted and elevated aso titers and acute phase reactants satisfied the jones criteria for diagnosis of rheumatic fever. her past medical and social and personal history were non-contributory. the progression of facial muscle weakness prompted referral to ent and neurology. the general physical examination was unremarkable, as was examination of the ears, nose, oral cavity and oropharynx. she had bilateral facial nerve paralysis, house-brackmann v (incomplete eye closure, could not raise eyebrows, wrinkle nose, puff cheeks, or smile and frown). electromyography-nerve conduction velocity (emg-ncv) with facial nerve study revealed abnormal facial nerve and blink reflex consistent with acute bilateral facial mononeuropathy (bell’s palsy) while emg-ncv of the upper and lower limbs was normal with no evidence of focal or diffuse distal neuropathy. pure tone audiometry, tympanometry and magnetic resonance imaging (mri) of the brain and facial nerve were normal while schirmer’s test showed decreased tearing bilaterally. the patient was started on prednisone 60mg/day for 6 days to taper down over a month, ceftriaxone 2g/iv once daily for 3 days, shifted to cefuroxime 500mg tab twice daily for 1 week and aspirin 80 mg tab 1 tab every 8 hours. the fever, cough, rashes and joint and body pains resolved on the 5th hospital day. there was no further progression of facial paralysis, but she had no forehead motion, incomplete eye closure and only slight movement of the mouth. physical therapy and management of dry eyes were started, and she was discharged on the 9th hospital day with a final diagnosis of bilateral bell’s palsy and rheumatic fever, resolved. the patient continued home physiotherapy exercises once daily for the face and prednisone was tapered down to complete one month. she was seen at the outpatient department (opd) every month with marked improvement of facial paralysis from house brackmann v to house brackmann ii-iii observed over a span of 6 months. (figure 1 a, b) discussion bell’s palsy is a condition where the facial muscles are weakened or paralyzed, possibly due to trauma to the 7th cranial nerve, and is usually not permanent. the condition is named after sir charles bell, a scottish surgeon who studied the nerve and innervation of the facial muscles two centuries ago.2 also known as idiopathic facial paralysis, bell’s palsy is the most common cause of acute unilateral facial paralysis accounting for 70% of cases.3 annual estimated incidence ranges from 15 to 40 per 100,000.3 bilateral facial nerve paralysis, on the other hand, is a rare condition with less than 0.3% 2% of facial palsy cases, with an incidence of 1 per 5,000,000 population.4 the clinical history and manifestations may include waking up with sudden facial palsy, or symptoms such as dry eyes, or a tingling sensation around the lips prior to paralysis.5 the degree of paralysis usually peaks within several days but not longer than 2-3 weeks, and a prodrome may be apparent such as neck pain, or pain behind the ear prior to palsy.5 our patient developed flu like symptoms such as fever and joint pain before developing weakness and subsequent immobility of the facial muscles (although these symptoms are attributable to rheumatic fever). the bilateral facial palsy was so incapacitating that she could not move her lips and there was a need to support her lower lip to avoid spillage of liquids when drinking. since the facial nerve is lodged within a bony hard and unyielding cavity, it may be at risk for inflammation, infection, vascular or mechanical compromise.6 such a first-degree block of the facial nerve trunk is a temporary conductive block but axonal continuity is preserved, and the facial muscles cannot be moved voluntarily but a facial twitch can be elicited by transcutaneous electrical stimulation of the nerve distal to the lesion. 7 figure 1a & b. photos of forehead, eyelids, nose and mouth showing a. house-brackmann v (no forehead motion, incomplete eye closure, slight mouth motion) before; and b. house-brackmann ii (moderate to good forehead motion, complete eye closure with minimum effort, slightly asymmetric mouth motion) 6 months after treatment. (photos published without eye bars, with permission) a b philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 6362 philippine journal of otolaryngology-head and neck surgery case reports bell’s palsy is a clinical manifestation of a wide array of systemic medical conditions from infectious, neurologic, traumatic and neoplastic disorders. teller and murphy list the differential diagnosis of acquired bilateral peripheral facial palsy which includes: trauma (e.g. skull fractures, parotid and mastoid surgery), infection (e.g. infectious mononucleosis, hiv infection, lyme disease, guillain-barre syndrome, syphilis), metabolic disorders (e.g diabetes), neoplastic (e.g. leukemia), autoimmune (e.g. sarcoidosis), neurological (e.g. multiple sclerosis, parkinson’s disease) and idiopathic (bell’s palsy).4 lyme disease was responsible for 36% of the cases for facial diplegia. guillain-barre syndrome (5%), trauma (4%), sarcoidosis (0.9%) and aids (0.9%).8 differential diagnosis in this particular case of bilateral bell’s palsy may include guillain barre syndrome, rheumatic fever and influenza. to evaluate the integrity of the facial nerve, ancillary procedures may include the schirmer’s test. fisch pointed out that tearing often is reduced bilaterally in bell’s palsy, perhaps because of subclinical involvement of other cranial nerves. thus, both the symmetry of the response and its absolute magnitude are important; a total response (sum of the lengths of wetted filter paper for both eyes) of less than 25m is considered abnormal.9 the role of electromyography (emg-in the early phase of bell’s palsy is limited, because it does not permit a quantitative estimate of the extent of nerve degeneration.10 however, emg may be helpful as a confirmatory test for nerve decompression for bell’s palsy. if emg shows voluntarily active facial motor units despite loss of excitability of the nerve trunk, the prognosis for a good spontaneous recovery is excellent.10 blink reflex allows the integrity of the facial nerve to be monitored by stimulation of the supraorbital branch of the trigeminal nerve which elicits a reflex contraction (blink) of the orbicularis oculi muscle.7 emg-ncv with special facial nerve study done on the patient revealed abnormal facial nerve and blink reflex studies that showed evidence for an acute bilateral facial mononeuropathy (bell’s palsy) while emg-ncv study of the upper and lower limbs was normal with no evidence of focal nor diffuse distal neuropathy. acute bilateral facial neuropathy on emg-ncv showed that the patient’s facial nerve was affected and not fully functional. this is crucial because without this supporting evidence, the patient’s apathetic facie might be misconstrued as a form of malingering. an unremarkable mri study ruled out the possibility of tumor in the cerebellopontine angle and temporal bone that usually presents with unilateral hearing loss which when large enough may compress the facial nerve within the internal auditory meatus. the management of facial palsy includes physical therapy, corticosteroids and antiviral drugs. other modalities include biofeedback, laser, electrotherapy, massage and thermotherapy which are used to hasten recovery.11 the rationale for the use of corticosteroids in the acute phase of bell’s palsy is to reduce inflammation and edema of the facial nerve.10 the use of antiviral agents alongside prednisone remains controversial. a study by sullivan concluded that there was a significant improvement in trials that contained prednisolone, but no additional benefit was found from antiviral treatment.12 this is one reason why anti-viral agents are not routinely used in bell’s palsy in our ent service. about 71% of patients with bell’s palsy have recovery of motor function within 6 months without treatment. poor prognostic factors include: old age, hypertension, diabetes mellitus, impairment of taste and complete facial weakness. about one-third of patients may have incomplete recovery and residual effect including post-paralytic hemifacial spasm, co-contracting muscles, synkinesis, sweating while eating or during physical exertion.13 in our case, the facial palsy improved from hb vi to ii after 6 months of therapy. perhaps her young age and prompt intervention augured well for a relatively fair to good prognosis with continued therapy. in conclusion, idiopathic facial paralysis or bell’s palsy is the most common cause of acute unilateral facial paralysis while bilateral facial nerve paralysis is a rare condition. patients with facial palsy should undergo appropriate diagnostics to determine the underlying condition and to facilitate prompt management. references 1. rowlands s, hooper r, hughes r, burney p. the epidemiology and treatment of bell’s palsy in the uk. eur j neurol. 2002 jan: 9(1): 63-7. doi: 10.1046/j.1468-1331.2002.00343.x pubmed pmid: 11784378. 2. adel b, kawthar s, amine d, souha by, abdellatif b. idiopathic facial paralysis (bell’s palsy). int. j dent. sci research. 2014; 2(5a):1-4. doi:10.12691/ijdsr-2-5a-1. 3. green jd jr, shelton c, brackman de. iatrogenic facial nerve injury during otologic surgery. laryngoscope. 1994 aug; 104 (8 pt 1): 922-926. doi: 10.1288/00005537-199408000-00002. pubmed pmid: 8052074. 4. teller dc, murphy tp. bilateral facial paralysis: a case presentation and literature review. j otolaryngol. 1992 feb; 21(1):44-7. pubmed pmid: 1564749. 5. pothiawala s, lateef f. bilateral facial nerve palsy: a diagnostic dilemma. case rep emerg med. 2012; 2012:458371. doi: 10.1155/2012/458371. pubmed pmid: 23326715 pubmed central pmcid: pmc3542940. 6. sutherland s. the anatomy and physiology of nerve injury. muscle nerve. 1990 sep; 13(9): 77184. doi: 10.1002/mus.880130903. pubmed pmid: 2233864. 7. sunderland s. some anatomical and pathophysiological data relevant to facial nerve injury and repair. in fisch u, editor. facial nerve surgery. birmingham, al: aesculapius publishing. 1977, pp. 47-61. 8. adour kk, byl fm, hilsinger rl jr, kahn zm, sheldon mi. the true nature of bell’s palsy: analysis of 1000 consecutive patients. laryngoscope 1978 may;88(5):787-801. doi:10.1002/ lary.1978.88.5.787 pubmed pmid: 642672. 9. fisch u. prognostic value of electrical tests in acute facial paralysis. am j otol 1984 oct;5(6):4948. pubmed pmid: 6393772. 10. grogan pm, gronseth gs. practice parameter: steroids, acyclovir, and surgery for bell’s palsy (an evidence-based review): report of the quality standards subcommittee of the american academy of neurology.  neurology.  2001 apr 10;56(7):830–6. doi: 10.1212/wnl.56.7.830. pubmed pmid: 11294918. 11. greenberg mr, urquhart mc, eygnor jk, worrilow cc, gesell nc, porter bg, miller ac. i can’t move my face! a case of bilateral facial palsy. j am osteopath assoc. 2013 oct;113(10):788-790. doi: https://doi.org/10.7556/jaoa.2013.048. 12. sullivan fm, swan ir, donnan pt, morrison jm, smith bh, mckinstry b, et al. early treatment with prednisolone or acyclovir in bell’s palsy.  n engl j med.  2007 oct 18;357(16):1598–607. doi:10.1056/nejmoa072006 pubmed pmid:17942873. 13. carapetis jr, mcdonald m, wilson nj. acute rheumatic fever. lancet 2005 jul 9-15;366(9480):15568. doi: 10.1016/s0140-6736(05)66874-2 pubmed pmid: 16005340. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2022; 37 (2): 38-41 c philippine society of otolaryngology – head and neck surgery, inc. airway obstruction from intralaryngeal extension of thyroglossal duct cyst in an elderly man: a case report gerson s. contreras, md milabelle b. lingan, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. milabelle b. lingan department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center, san lazaro compound rizal avenue, sta. cruz, manila 1003 philippines phone: (+63) 949 995 1235 e-mail: mblingan@ust.edu.ph the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. this study was not funded or given financial support by any grant or agency presented at the philippine society of otolaryngology head and neck surgery interesting case contest (3rd place), may 28, 2022 via zoom. abstract objective: to report an unusual presentation of thyroglossal duct cyst causing airway obstruction in an elderly man. methods: design: case report setting: tertiary government training hospital patient: one results: a 71-year-old man with an anterior neck mass was brought to the emergency room due to progressive difficulty of breathing. a smooth, non-ulcerating right supraglottic mass obstructed the airway. following an emergency high tracheotomy, contrast computed tomography scan of the neck revealed a hypodense mass with peripheral rim enhancement in the right supraglottis and an extralaryngeal component. intra-operatively, a dumbbellshaped cystic mass with a tract connected to the hyoid bone led to a sistrunk procedure. final histopathology findings were consistent with thyroglossal duct cyst. conclusion: it is possible for an elderly patient with impending upper airway obstruction, dysphonia, and neck mass to still have a benign and congenital thyroglossal duct cyst with intralaryngeal extension. keywords: thyroglossal duct cyst; intralaryngeal extension; saccular cyst; airway obstruction thyroglossal duct cyst is the most common congenital non-odontogenic mass of the neck, accounting for 70% of developmental neck lesions.1,2 it commonly presents as a painless midline anterior neck mass, and can occur anywhere along the course of thyroid gland development.3 most cases (99%) are located in the midline and are below the hyoid (61% between the hyoid and thyroid gland, 13% suprasternal); 24% are suprahyoid and 2% are intralingual.4 even though it is anatomically closely related to the larynx, intralaryngeal extension of the cyst is rare, and may be due to massive enlargement over a long period of time and weakness of laryngeal structures.1,5 with extension to the larynx, there may be hoarseness, dysphagia, and laryngeal obstruction leading to airway compromise.1,4 we present one such case. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery case reports case report a 71-year-old man presented at our emergency room with a 5-day history of difficulty breathing, a prior 3-year history of hoarseness, and an anterior neck mass that had been present for 35 years, without any prior consults or medication taken. physical examination revealed a 4 x 4 x 3 cm firm, non-tender mass on the right anterior neck from the level of the hyoid bone superiorly to the thyroid cartilage inferiorly. videolaryngoscopy showed a right-sided smooth, non-ulcerating, non-fungating, supraglottic mass obliterating the vallecula, pyriform sinus, and displacing the aryepiglottic fold medially, consequently obstructing the airway. (figure 1) considering a submucosal malignant new growth of the larynx, an emergency tracheotomy was performed to immediately establish the airway. the procedure proved to be difficult yet successful, however it was a high tracheotomy, and its stoma was created at the 1st tracheal ring (the tracheostomy tube was later observed to have assumed an awkward position, with the fenestra outside the tracheal lumen and the distal tip against the posterior tracheal wall). nevertheless, the patient was relieved of dyspnea. contrast computed tomography (ct) scans revealed a well-defined, homogenous, hypodense, non-enhancing mass with peripheral rim enhancement in the right supraglottic area approximately measuring 4.7 x 4.5 x 4.8 cm (ap x t x cc) with an extralaryngeal component and confirmed the awkward position of the tracheostomy tube. (figure 2) ultrasound-guided fine needle aspiration yielded a greenish-brown turbid aspirate. cytopathologic findings showed fairly cellular smears consisting of abundant inflammatory cells made of neutrophils and lymphocytes and few red blood cells. a lateral saccular cyst with intralaryngeal and extralaryngeal components was the primary consideration at that time. a primary extralaryngeal pathology was also considered as a differential in this case based on the chronology of the symptoms, wherein the neck mass presented before the hoarseness and dyspnea. thyroid function tests revealed findings consistent with subclinical hyperthyroidism. a thyroglossal duct cyst with intralaryngeal extension was also considered. hence we planned an external approach with excision if it was a saccular cyst and a sistrunk procedure if it was a thyroglossal duct cyst, followed by suspension laryngoscopy to evaluate the larynx. intraoperatively, the mass had no connection to the laryngeal saccule and a plane separated the mass from laryngeal mucosa and cartilage. a tract connected the 4 x 6 cm dumbbell-shaped cystic mass to the midline posterior body of the hyoid bone (figure 3) and a sistrunk procedure was completed. the mass was removed without disrupting the endolaryngeal mucosa and sent for histopathology. the distal tip of the tracheostomy tube was in contact with the posterior tracheal wall. this caused fibrin eschar and granulation tissue formation over the area and needed to be removed. after removal of the mass, supraglottic edema developed and obstructed the airway,  and the tracheostomy figure 1. videolaryngoscopy showing a smooth, non-ulcerating, non-fungating, supraglottic mass, completely obliterating the pyriform sinus, aryepiglottic fold, and vallecula on the right, obstructing the airway; vocal folds cannot be visualized on both a. abduction and b. adduction. a b figure 2. computed tomography (ct) scans with contrast of the neck: a. axial view showing a welldefined, homogenous, hypodense, non-enhancing mass (asterisk), with peripheral rim enhancement in the right supraglottic area measuring 4.7 x 4.5 x 4.8 cm (ap x t x cc); b. axial view showing extralaryngeal component (x); c. sagittal cut showing the fenestra of tracheostomy tube outside the tracheal lumen (arrow); and d. coronal cut showing intralaryngeal (*) and extralaryngeal (x) components. a c b d tube was retained and only changed to a smaller size. while waiting for the final histopathology result, our patient was discharged with tracheostomy tube in place. figure 3. intraoperative findings: a. a tract connecting the 4 x 6 cm dumbbell-shaped cystic mass (m) to the midline posterior body of the hyoid bone (arrow); and b. plane separating the cystic mass from the laryngeal mucosa (asterisk) and thyroid cartilage (t ). a b philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery case reports surgical pathology reported the specimen as consistent with a thyroglossal duct cyst, lined with respiratory epithelium with scattered thyroid follicles and with no malignant cells. (figure 4) follow-up and consults were challenging to most patients during the pandemic; this same reason hindered the timely decannulation of our patient. he was eventually decannulated after supraglottic swelling subsided and suprastomal granulation was excised and remains asymptomatic on latest follow up 4 months after. discussion we reported an unusual presentation of a thyroglossal duct cyst in an elderly man causing airway obstruction and the challenges encountered throughout its clinical course from diagnosis, management, and followup, including issues with airway management. to the best of our knowledge, based on a search of herdin plus, the asean citation index (aci), the who western pacific region index medicus (wprim), directory of open access journals (doaj), medline (pubmed and pubmed central), and google scholar using the search terms “intralaryngeal extension,” [and] “laryngeal extension,” [or] “thyroglossal duct cyst,” we only found 24 previous cases of tgdc with intralaryngeal extension in the english language literature. this includes those already tabulated in previous articles,1,5,6 making ours the 25th such case.” a thyroglossal duct cyst was not initially considered at the time of presentation since our patient was elderly with an off-midline anterior neck mass (more on the right) with accompanying supraglottic mass, hoarseness, and dyspnea, and had a 75-pack-year smoking history. hence, a submucosal malignant neoplasm of the larynx was the initial consideration. laryngeal carcinoma commonly occurs in older patients, is more common in males, and has a high association with tobacco smoking and alcohol consumption. the most common presentations of laryngeal carcinoma are hoarseness, dyspnea, and neck mass if with nodal involvement or with extralaryngeal extension.7 it is not uncommon for a thyroglossal duct cyst with intralaryngeal extension to be confused for a neoplasm, because the intralaryngeal extension leads to signs and symptoms that are not usually thought of in regard to thyroglossal duct cyst.4 similarly, bando et al. initially diagnosed a laryngeal submucosal tumor based on patient age, 30-year smoking history, and a large submucosal mass in the left aryepiglottic fold, but considered a thyroglossal duct cyst after further examination.6 in a patient presenting in the emergency room with difficulty breathing, surgery to establish the airway should not be delayed. in this case, securing the airway was the immediate priority, and ct scan imaging was delayed. the patient was in respiratory distress, with a large neck mass and a short neck, which led to difficult tracheotomy. moreover, in view of a possible laryngeal malignancy given a supraglottic and neck mass in an elderly man with a 75-pack year tobacco smoking history, a high tracheotomy was done. high tracheotomy is rarely performed, and only in a dire emergency at the level of 1st or 2nd tracheal rings. it has a very high-risk for tracheal or subglottic stenosis specially if the cricoid cartilage has been damaged. however, it is preferred in patients with dyspnea, where laryngectomy is anticipated, since this leaves the healthy tracheal rings for formation of the tracheostoma after surgery.8 of the 24 reported cases of thyroglossal duct cyst with intralaryngeal extension, only six underwent tracheotomy and these were done at the time of surgical cyst removal, where difficult intubation was noted due to airway narrowing, or wherein post-operative airway edema was anticipated. none reported performing it in an emergency setting due to impending airway obstruction, and further diagnostics such as ct scans could still be obtained.1,6,9-12 in our case, the impending upper airway obstruction was addressed with tracheotomy before further diagnostics were performed. on ct scan, a thyroglossal duct cyst appears as low-density mass of 19 hounsfield units (hu) but can also present as a high-density mass up to 80 hu, especially if with increased protein content. peripheral rim enhancement and occasional septations can also be appreciated.2 even with the aid of a ct scan, diagnosis can still be challenging. thyroglossal duct cyst with intralaryngeal extension has a similar ct scan and videolaryngoscopy appearance to primary laryngeal lesions such as a lateral saccular cyst. saccular cysts result from occlusion of the saccular orifice leading to fluid collection in the laryngeal saccule. they appear as submucosal mass on videolaryngoscopy and may also have an extralaryngeal extension to the neck penetrating the thyrohyoid membrane.6 hence, a lateral saccular cyst also appears as a cystic mass with both intraand extralaryngeal components on ct scan. there are some ct scan features that can veer the diagnosis more towards a thyroglossal duct cyst. booth et al. demonstrated the claw sign, wherein the cystic mass interdigitates with the strap muscles along the inferior hyoid.13 bando et al. also differentiated it from a saccular cyst based on figure 4 . post-operative surgical pathology slides, hematoxylin and eosin stain interpreted as consistent with thyroglossal duct cyst: a. low power view (40 x) shows lining respiratory epithelium (arrow) with scattered thyroid follicles (asterisk) and with no malignant cells; and b. thyroid follicles (asterisk) seen on higher magnification (100 x). a b philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery case reports proximity to the hyoid bone and laryngeal ventricle; the cyst being closer to the hyoid than to the laryngeal ventricle favored a thyroglossal duct cyst as their diagnosis.6 however, these distinguishing features were not present in our case; no claw sign was observed, and the cystic mass was closely related to both the hyoid and laryngeal ventricle. extension of a thyroglossal duct cyst into the larynx may be due to several factors such as massive enlargement of the cyst over a long period of time and weakness over the laryngeal structures. this exerts pressure and subsequent erosion or herniation through the thyrohyoid membrane or the thyroid cartilage. intralaryngeal extension can also be due to malignant transformation of thyroid tissue within the cyst.1,5 the former usually presents as a dumbbell-shaped mass, where the cyst expands on both sides of the hyoid and pushes through an intact thyrohyoid membrane into the preepiglottic space, leading to its laryngeal symptoms such as dysphagia, hoarseness, and dyspnea.1,4 this dumbbell-shaped configuration was also seen in our patient, and intralaryngeal extension could be due to massive enlargement over a long period of time given the 35-year history of anterior neck mass. fine needle aspiration of the cystic mass is of limited help in diagnosis. while it can determine components of cystic fluid, such as thyroid follicles consistent with a thyroglossal duct cyst as demonstrated in the case of soliman et al.,4 in our case, the liquid aspirate only yielded inflammatory cells composed of neutrophils and lymphocytes with few red blood cells and with no other cellular elements, insufficient to distinguish the particular cystic mass. it is important to differentiate a primary laryngeal mass such as lateral saccular cyst with extralaryngeal component, from a neck mass such as a thyroglossal duct cyst with intralaryngeal component since they are managed differently. the latter is managed with a sistrunk procedure to avoid recurrence, as was done in most of the reported cases. one case by loh et al. was initially managed via endolaryngeal approach and eventually converted to sistrunk procedure because their initial diagnosis at that time was a saccular cyst.3 this emphasizes the importance of including thyroglossal duct cyst with intralaryngeal extension as one of the differential diagnoses in an elderly patient with both anterior neck mass and laryngeal mass. of the six reported cases where tracheotomy was done, none developed a tracheostomal granulation tissue and were all decannulated with good airway and voice. this may be because these cases were immediately decannulated on the 4th to 5th post-operative day.6,9-12 however, in our case, immediate decannulation was not done due to the long period of no follow-up brought about by the restrictions and limitations of the ongoing covid-19 pandemic. the development of suprastomal granulation tissue could be attributed to the disproportionate excision of the anterior cartilage or partial destruction of the cricoid cartilage and friction between the superior aspect of the tracheostomy tube or fenestra and the anterior airway wall due to the acknowledgements we would like to acknowledge dr. jose niño g. opulencia and dr. xytus majella tolentino-molina, our colleagues from the radiology and pathology department, respectively, for providing guidance and photo documentation of the radiographs and histopathologic slides. references 1. ng acw, yuen hw, huang xy. atypical thyroglossal duct cyst with intra-laryngeal and para-glottic extension. am j otolaryngol. 2019 jul-aug; 40(4):601-604. doi: 10.1016/j. amjoto.2019.04.007; pubmed pmid: 31047714. 2. reede dl, bergeron rt, som pm. ct of thyroglossal duct cysts. radiology. 1985 oct; 157(1):1215. doi: 10.1148/radiology.157.1.4034956; pubmed pmid: 4034956. 3. loh ws, chong sm, loh ks. intralaryngeal thyroglossal duct cyst: implications for the migratory pathway of the thyroglossal duct. ann otol rhinol laryngol. 2006 feb; 115(2):114-6. doi: 10.1177/000348940611500206; pubmed pmid: 16514793. 4. soliman am, lee jm. imaging case study of the month: thyroglossal duct cyst with intralaryngeal extension. ann otol rhinol laryngol. 2006 jul; 115(7):559-62. doi: 10.1177/000348940611500711l; pubmed pmid: 16900811. 5. bosco s, cohn je, evarts m, papajohn p, lesser r. thyroglossal duct cyst occupying posterior hyoid space with endolaryngeal extension presenting after neck trauma. ann otol rhinol laryngol. 2020 jun; 129(6):628-632. doi: 10.1177/0003489419901140; pubmed pmid: 31965811. 6. bando h, uchida m, matsumoto s, ushijima c, dejima k. endolaryngeal extension of thyroglossal duct cyst. auris nasus larynx. 2012 apr; 39(2):220-3. doi: 10.1016/j.anl.2011.04.008. pubmed pmid: 21621356. 7. fasunla aj, ogundoyin oa, onakoya pa, nwaorgu og. malignant tumors of the larynx: clinicopathologic profile and implication for late disease presentation. niger med j. 2016 sep-oct; 57(5):280-285. doi: 10.4103/0300-1652.190596; pubmed pmid: 27833247; pubmed central pmcid: pmc5036299. 8. hathiram bt, rai r, watve p, khattar vs. tracheostomy in head and neck cancers. int j otorhinolaryngol clin. 2010 jan-apr; 2(1):53-60. doi: 10.5005/jp-journals-10003-1017. 9. lübben b, alberty j, lang-roth r, seifert e, stoll w. thyroglossal duct cyst causing intralaryngeal obstruction. otolaryngol head neck surg. 2001 oct; 125(4):426-7. doi: 10.1067/ mhn.2001.117168; pubmed pmid: 11593190. 10. slotnick d, som pm, giebfried j, biller hf. thyroglossal duct cysts that mimic laryngeal masses. laryngoscope. 1987 jun; 97(6):742-5. doi: 10.1288/00005537-198706000-00020; pubmed pmid: 3586819. 11. mokhtari n, tabatabai a, abdi r. thyroglossal duct cyst presenting as endolaryngeal mass. med j islam repub iran. 1997; 11(3):251-254. available from: https://mjiri.iums.ac.ir/article-1-1102-en. pdf. 12. brown eg, albernaz ms, emery mt. thyroglossal duct cyst causing airway obstruction in an adult. ear nose throat j. 1996 aug; 75(8):530-2, 534. doi: 10.1177/014556139607500812; pubmed pmid: 8828277. 13. booth r, tilak am, mukherjee s, daniero j. thyroglossal duct cyst masquerading as a laryngocele. bmj case rep. 2019 mar 25;12(3):e228319. doi: 10.1136/bcr-2018-228319; pubmed pmid: 30914413; pubmed central pmcid: pmc6453297. 14. takayama t, kotani i, kurosawa t, yoshimura h.  post-tracheotomy intratracheal granulation tissue response to local injections of triamcinolone. journal of bronchology. 2001 jan; 8(1):29– 31. doi:10.1097/00128594-200101000-00008. awkward position of the tracheostomy tube.8 this was addressed in our patient by excision of suprastomal granulation tissue with intralesional injection of triamcinolone and subsequent decannulation. takayama et al. demonstrated the effectivity of triamcinolone in eliminating intratracheal granulation tissue in small amounts.14 although the clinical course of our patient  was  cluttered with several unharmonious events, our management ultimately addressed his needs. when confronted with a diagnostic dilemma (even with available diagnostics such as videolaryngoscopy and ct scan) or management challenges (whether to utilize external or endoscopic surgical approach), the temporal sequence of history of the present illness is helpful in making a sound diagnosis and proper management. in conclusion, our experience shows that it is possible for an elderly patient with impending upper airway obstruction, dysphonia, and neck mass to still have a benign and congenital thyroglossal duct cyst with intralaryngeal extension. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to describe the initial outcomes of endoscopic co2 laser posterior cordectomy and  partial arytenoidectomy among patients with bilateral vocal cord paralysis in our institution. methods: design: case series setting: tertiary national university hospital participants: 17 patients results: seventeen (17) patients who underwent transoral posterior cordectomy and partial arytenoidectomy using carbon dioxide laser were included in the study consisting of 14 females and 3 males. iatrogenic injury was the most common cause of bilateral vocal cord paralysis in this subset of patients. five patients who tolerated decannulation and another six who had no preoperative tracheostomy all reported subjective improvement in breathing. all of them were also observed to have resolution of stridor and increased respiratory comfort compared to their preoperative condition. the most common postoperative complication was granuloma formation at the medial arytenoidectomy site occurring only in 4 patients. none of the patients complained of aspiration episodes or dysphagia during the postoperative period. conclusion: our initial experience with transoral endoscopic posterior cordectomy and partial arytenoidectomy using carbon dioxide laser has good postoperative outcomes among patients with bilateral vocal cord paralysis. keywords: vocal cord paralysis; arytenoid; vocal cords; laser; carbon dioxide; tracheostomy; voice quality vocal cord paralysis is a condition where in patients may present with hoarseness and  lifethreatening dyspnea. the most common cause of which is iatrogenic injury comprising 26 to 59% of cases.1   tracheostomy is the standard of care that remains to be a highly effective management of bilateral vocal cord paralysis.3,4 initial outcomes of endoscopic co2 laser posterior cordectomy and partial arytenoidectomy among patients with bilateral vocal cord paralysis: a case series karen joyce s. velasco, md1 anna pamela c. dela cruz, md1 ryner jose d. carrillo, md, msc1,2 daryl anne d. madrid, md1 1department of otolaryngology head and neck surgery philippine general hospital university of the philippines manila 2department of anatomy college of medicine university of the philippines manila correspondence: dr. anna pamela c. dela cruz department of otolaryngology-head and neck surgery philippine general hospital university of the philippines manila taft avenue, manila 1000 philippines phone: (632) 8554 8467 email: pamelacdelacruz@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by the authors, and that each author believes that the manuscript represents honest work. disclosure: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2022; 37 (2): 30-33 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles the introduction of endoscopic laser surgery offered a less invasive alternative for patients suffering from  bilateral vocal cord paralysis, with less trauma, shorter hospital stay, and shorter time to  successful decannulation.   dennis and kashima recommended posterior cordectomy using endoscopic carbon dioxide  laser. the voice quality was better postoperatively since the anterior three quarters of the  fold are retained in their position.6 based on a search of herdin plus, the asean citation index (aci), global index medicus western pacific region index medicus (who gim-wprim), directory of open access journals (doaj), medline (pubmed and pubmed central) and google scholar using the following search terms “vocal cord paralysis”, “incidence”, “laser”, “arytenoidectomy”, “cordectomy”, “philippines”, “filipinos”, we found no local studies regarding the incidence of vocal cord paralysis  and only limited reports regarding its management and outcomes.5   this case series aims to describe the initial outcomes of using endoscopic carbon dioxide laser posterior cordectomy and  partial arytenoidectomy among patients with bilateral vocal cord paralysis in our institution. methods with exemption from full ethical review by the university of the philippines manila research ethics board, this case series performed a chart review of records of all patients who underwent endoscopic carbon dioxide (co2) laser posterior cordectomy with partial arytenoidectomy for bilateral vocal cord paralysis in our institution from 2014 to 2017. excluded were incomplete records (without demographic data, clinical history, physical examination findings, operative technique, postoperative course and follow up) and patients whose vocal cord paralysis resulted from laryngeal masses. bilateral vocal cord paralysis among these patients was confirmed preoperatively by indirect laryngoscopy using a rigid 90 degree scope or nasopharyngolaryngoscopy with a flexible scope. all surgical procedures were conducted uniformly by the same team. general anesthesia was commenced prior to conversion to a mallinckrodt laser compatible tube (shiley, covidien, ireland) for patients with prior tracheostomy. direct laryngoscopy was performed using a kleinsasser laryngoscope suspended using a laryngoscope support rod and chest holder (karl storz gmbh & co., tuttlingen germany). using a opmi vario s88 operating microscope (soma international, bloomfield, ct, usa) with a working range of 200-415 mm, adequate visualization of the laryngeal complex was ensured. sterile moist cottonoid strips were placed in the subglottic area to protect the trachea. posterior cordectomy with partial arytenoidectomy was performed on only one side using continuous mode of co2 laser (c-las articulated arm, a.r.c laser, germany) at 4-6 watts per charge. a tracheostomy tube was reinserted postoperatively for patients with prior tracheostomies. postoperative medications included intravenous dexamethasone 4 mg given every 8 hours for 3 doses, amoxicillin + clavulanic acid 500 mg every 8 hours for 7 days and oral proton pump inhibitors at 40 mg once a day for 2 weeks. patients with tracheostomy tubes were instructed to begin corking one day postoperatively until they were able to tolerate occlusion for more than 24 hours without dyspneic episodes and desaturation. patients who were successfully decannulated during the same admission were discharged after 24 hours of observation. follow up was scheduled after two weeks post-op and then one month after for all patients. hospital records of patients meeting the inclusion criteria were reviewed and the following data were obtained: age, preoperative diagnosis, etiology of bilateral vocal cord paralysis, duration of bilateral vocal cord paralysis prior to surgery, date of posterior cordectomy and partial arytenoidectomy procedure, date of decannulation (for those who tolerated corking), date of follow-up, postoperative complications, and need for revision surgery. the data obtained were tabulated using ms excel for mac version 16.62 (microsoft corp. redmond, wa, usa). discrete and continuous variables such as age and duration of bilateral vocal cord paralysis were summarized using means and ranges. results a total of 17 patients underwent endoscopic carbon dioxide (co2) laser posterior cordectomy with partial arytenoidectomy for bilateral vocal cord paralysis in our institution from 2014 to 2017. there were 14 females and 3 males with ages ranging from 29 to 71 years old and a mean age of 54.6 years. the presenting symptoms of these patients and reasons for consulting included dyspnea, stridor, hoarseness, and desire for decannulation. the duration of their symptoms ranged from 2 days to 72 months. the most common cause of bilateral vocal cord paralysis was surgical injury to the recurrent laryngeal nerve during thyroid surgery (8; 47%). other etiologies of vocal cord paralysis were thyroid malignancy (5; 29%), central/neurologic disease (1; 6%), neck trauma (1; 6%), squamous papilloma (1; 6%), and idiopathic (1; 6%). bilateral vocal cord paralysis was confirmed preoperatively by indirect laryngoscopy using a rigid 90 degree scope or nasopharyngolaryngoscopy with a flexible scope. eleven out of 17 patients had tracheostomies prior to the procedure while six patients had no prior tracheostomy. the follow up period ranged from 3 weeks to 24 months. of the 11 with tracheostomies preoperatively, five tolerated decannulation within an average of 14 days postoperatively. four patients (patients # 09, 11, 15, 16) were lost to follow up and their tolerance for decannulation philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles could not be determined. the remaining two patients with prior tracheostomies (patient #13 and #14) could not be decannulated due to underlying co-morbidities. the first patient (patient #14) who could not tolerate decannulation had bilateral vocal cord paralysis secondary to non-accidental strangulation injury. this patient was unable to tolerate corking of the tracheostomy tube especially when supine or during episodes of exertion, and was advised further diagnostic examinations to evaluate a possible central cause and imaging to assess the state of the laryngeal framework. another patient (patient #13) who could not tolerate decannulation had recurrent papillary thyroid carcinoma. diagnostic suspension laryngoscopy revealed a submucosal bulge in the supraglottic area from an anterior neck mass causing an eighty to 90% airway obstruction. the patient no longer desired further surgery and had an excellent response to radioiodine therapy.  the most common postoperative complication was granuloma formation at the medial arytenoidectomy site occurring only in 4 patients. granuloma formation was managed conservatively with proton pump inhibitors for 4 weeks with resolution. no recurrence of granuloma was observed thereafter.   only one patient developed postoperative edema at the arytenoidectomy site.  five patients who tolerated decannulation and another six who had no preoperative tracheostomy all reported subjective improvement in breathing. all of them were also observed to have resolution of stridor and increased respiratory comfort compared to their preoperative condition. none of the patients complained of aspiration episodes or dysphagia during the postoperative period. it was notable that among patients with no prior tracheostomy, none experienced any postoperative complications and all had an unremarkable postoperative course.  discussion our preliminary series showed satisfactory outcomes among 11 of 17 patients who underwent endoscopic co2 laser posterior cordectomy with partial arytenoidectomy for bvcp. decannulation was achieved for five of six patients who had prior tracheostomy, while all six patients who had no prior tracheostomy reported subjective improvement in respiratory and vocal function. bilateral vocal cord paralysis (bvcp) is most commonly caused by iatrogenic injury to the recurrent laryngeal nerve. performing transoral posterior cordectomy and partial arytenoidectomy among patients with bvcp has improved the respiratory comfort and allowed decannulation in five of the patients in this case series. only four out of the 17 patients developed postoperative granuloma formation which was conservatively managed. according to motta et al.,7 removal of the posterior third of the true and false vocal cord with arytenoidectomy provided adequate glottic opening while ensuring preservation of voice quality. it also preserved glottal sphincter function decreasing the risk of developing aspiration postoperatively.7 in our present series, the vocal cord defect created by the co2 laser remained wide postoperatively probably due to contraction of both ends. performing this procedure also had several advantages such as the simplicity of the concept, reliable and predictable outcomes, low risk for complications, and option for revision surgery postoperatively. management of patients with bilateral vocal cord paralysis is complex especially among those with blunt neck trauma or underlying structural or functional disorders of the laryngeal framework as seen in the case of the non-accidental strangulation injury included in our series. according to kunii et al.,9 post-hanging vocal cord paralysis may be brought about by laryngohyoid fractures but also by edema of the surrounding laryngeal framework. although rare, vocal cord paralysis from blunt neck trauma may be due to neuropraxia.10 imaging such as computed tomography and magnetic resonance scans may help characterize and evaluate the state of the cartilaginous and soft tissue of the laryngeal complex.10   stringent selection is important in order to achieve excellent postoperative outcomes in patients undergoing this procedure. not all patients presenting with bilateral vocal cord paralysis can be good candidates to undergo the said procedure as exemplified by the two patients in our series who were not decannulated postoperatively due to underlying conditions. patient 13 whose bvcp was from iatrogenic injury secondary to thyroid surgery was elderly. older age (>66 years old) was identified by jackowska et al. to be a factor that can make decannulation less likely after performing this procedure. aside from older age, presence of comorbidities such as diabetes and gerd, undergoing more than one surgery for thyroid disease, presence of subglottic stenosis due to a “high tracheostomy” are some of the factors that make patients less likely to tolerate decannulation or achieve respiratory comfort. hence, presence of the aforementioned conditions may serve as a guide for surgeons when choosing the procedure for patients with bvcp. our small series has several limitations. objective measurements of preoperative and postoperative respiratory, voice, and swallowing functions were not performed. tolerance of decannulation postoperatively was the proxy measure of improved respiratory function. because preoperative vocal quality was not measured, subjective reporting by patients was the basis for determining improved vocal outcome. future studies can determine postoperative vocal quality using the voice handicap index-30, maximum phonation time (mpt), and videostroboscopy values such as jitter and shimmer percentages. swallowing and presence of postoperative aspiration philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles can also be evaluated using fiberoptic endoscopic evaluation of swallowing (fees). respiratory function can be tested using flow volume spirometry. it is also necessary to emphasize the importance of diagnostic imaging especially for patients with complicated etiologies of bvcp.  these aforementioned objective tests may be performed in future prospective studies involving a larger sample of patients. meanwhile, our initial experience suggests that transoral endoscopic posterior cordectomy and partial arytenoidectomy using carbon dioxide laser has good postoperative outcomes with minimal complications. further studies which include objective measurements of respiratory effort and voice quality are needed to demonstrate the safety and efficacy of this procedure among patients with bilateral vocal cord paralysis. references 1. toutounchi sjs, eydi m, golzari se, ghaffari mr, parvizian n. vocal cord paralysis and its etiologies: a prospective study. j cardiovasc thorac res. 2014;6(1):47-50. doi: 10.5681/ jcvtr.2014.009; pubmed pmid: 24753832; pubmed central pmcid: pmc3992732. 2. ahmad s, muzamil a, lateef, m. a study of incidence and etiopathology of vocal cord paralysis. indian j otolaryngol head neck surg.  2002 oct; 54(4): 294–296. doi:  10.1007/bf02993746; pubmed pmid: 23119914; pubmed central pmcid: pmc3450463. 3. jackowska j, sjogren ev, bartochowska a, czerniejewska-wolska h, piersiala k, wierzbicka m. outcomes of co2 laser-assisted posterior cordectomy in bilateral vocal cord paralysis in 132 cases. lasers med sci. 2018 jul;33(5):1115-1121. doi:10.1007/s10103-018-2478-9; pubmed pmid: 29557514; pubmed central pmcid: pmc6004269. 4. dennis dp, kashima h. carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis. ann otol rhinol laryngol. 1989 dec;98(12 pt 1):930-4. doi:10.1177/000348948909801203; pubmed pmid: 2589760. 5. ng ey, lim w, martinez nv, lopez ms. microscopic endolaryngeal arytenoidectomy. philipp j otolaryngol head neck surg. 1989;9:9–13. [cited 2022 september 5] available from: https:// pjohns.pso-hns.org/index.php/pjohns/issue/view/91/39. 6. manolopoulos l, stavroulaki p, yiotakis j, segas j, adamopoulos g. co2 and ktp-532 laser cordectomy for bilateral vocal fold paralysis. j laryngol otol. 1999 jul;113(7):637-41 doi:10.1017/s002221510014472x; pubmed pmid: 10605560. 7. motta s, moscillo l, imperiali m, motta g. co2 laser treatment of bilateral vocal cord paralysis in adduction. orl j otorhinolaryngol relat spec. 2003 nov-dec;65(6):359-65. doi:10.1159/000076055; pubmed pmid: 14981330. 8. sapundzhiev n, lichtenberger g, eckel he, friedrich g, zenev i, toohill rj, et al. surgery of adult bilateral vocal fold paralysis in adduction: history and trends. eur arch otorhinolaryngol. 2008 dec; 265(12):1501-14. doi: 10.1007/s00405-008-0665-1; pubmed pmid: 18418622. 9. kunii m, ishida k, ojima m, sogabe t, shimono k, tasuke t, et al. bilateral vocal cord paralysis in a hanging survivor: a case report. acute med surg. 2020 jun;7(1):e519. doi: 10.1002/ams2.519; pubmed pmid: 32528709; pubmed central pmcid: pmc7280028. 10. latoo m, lateef m, nawaz i, ali i. bilateral recurrent laryngeal nerve palsy following blunt neck trauma. indian j otolaryngol head neck surg. 2007 sep;59(3):298-9. doi:  10.1007/s12070-0070087-1; pubmed pmid: 23120459; pubmed central pmcid: pmc3452116. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 7170 philippine journal of otolaryngology-head and neck surgery featured grand rounds a 50-year-old single filipino woman was referred to our clinic by the dermatology department due to multiple large nevi on the face. her history started 29 years prior to consult when a 0.5 cm by 0.5 cm nevus appeared on her right lower eyelid. excision of the mass and histopathology revealed basal cell carcinoma of the skin and she ceased followup visits. meanwhile, progressively enlarging nevi appeared over multiple sites of her face. some of the lesions developed ulceration and occasionally bled. finally, she consulted again at our institution due to disfiguring multiple large nevi, and was seen by dermatology and ophthalmology services and underwent excision biopsy revealing basal cell carcinoma. she was then referred to us for definitive surgical management. the patient was a non-smoker, non-alcoholic beverage drinker and work did not undergo any prolonged sun exposure. she recalled that her mother had a similar condition and expired due to complications of the disease. physical examination revealed many large nevi over multiple sites of the face, the largest over the left nasolabial area. (figure 1a) there were hyperpigmented nevi over the central forehead and left infraorbital area, and the patient’s left eye was closed due to scarring from the previous excision in the left medial canthal area. (figure 1b) an ulcerating lesion that occasionally bled, involved multiple subsites of the nose. (figure 1c) gorlin-goltz syndrome: multiple basal cell carcinoma, bifid rib, palmar and plantar pits in a 50-year-old woman correspondence: dr. samantha s. castañeda department of otorhinolaryngology-head and neck surgery rizal medical center pasig blvd., pasig city 1600 philippines phone: (02) 8865 8400 local 318 or 207 / (63) 917 801 7664 email: docsamcastaneda@yahoo.com orlhns_rmc@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented as an e-poster presentation in the 18th asean orlhns congress on august 2019. emilaine m. balatibat, md1 benedick b. borbe, md1 samantha s. castañeda, md1,2 1department of otolaryngology head and neck surgery rizal medical center 2ateneo school of medicine and public health philipp j otolaryngol head neck surg 2020; 35 (1): 71-73 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international a b c figure 1a. right lateral view of the face b. profile view of the face and c. left lateral view of the face showing multiple lesions described in the text. (photos published in full, with permission) philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 7372 philippine journal of otolaryngology-head and neck surgery featured grand rounds figure 4. multiple skin grafts to reconstruct the defects after wide excision of tumors. figure 5. two weeks post-operatively, graft failures were noted over the defects at the right zygomatic, infraauricular and paranasal areas, which were allowed to heal by secondary intention. (photos published in full, with permission) figure 6. one year post-operative follow-up photos show no recurrence of lesions (photos published in full, with permission) figure 2a. multiple pits in both palms (arrows); and b, multiple plantar pits (arrows). figure 3. chest x-ray, postero-anterior (pa) upright view, showing bifid left third rib (encircled). a b due to the recurrent multiple basal cell carcinoma on the face, we suspected a possible syndromic disease. complete systemic physical examination revealed multiple nevi over the chest and back as well as plantar and palmar pits. (figure 2a, b) chest radiography revealed an incidental finding of a bifid third rib on the left. (figure 3) with these findings, we diagnosed her condition as gorlin-goltz syndrome with multiple basal cell carcinoma on the face. our goal of treatment was complete excision of tumors with preservation of function and cosmesis. following the national comprehensive cancer network (nccn) guidelines1 surgical excision with frozen section for adequate margins was performed. (figure 4) reconstruction with multiple skin grafts was performed to cover the defects. however, graft failures were noted over multiple sites two weeks post-operatively. (figure 5) our patient continued to follow-up for a year but declined any offers of reconstructive surgery. she maintained a good disposition and was satisfied with her appearance despite a less than ideal aesthetic postoperative outcome. (figure 6) philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 7372 philippine journal of otolaryngology-head and neck surgery featured grand rounds discussion nevoid basal cell carcinoma or gorlin-goltz syndrome is a rare autosomal dominant syndrome with near complete penetrance and extreme variable expressivity.2,3 this was first described in depth by doctors robert gorlin and robert goltz in 1960. genetic mutation in ptch1 and sufu that are related with the hedgehog signalling pathway were identified in the pathogenesis of this disease.2 gorlingoltz syndrome commonly presents with dermatologic, odontogenic and neurologic findings and affected patients have developmental anomalies and predisposition to cancer, specifically basal cell carcinoma (bcc). the incidence of gorlin-goltz syndrome ranges from 1 in 50,000 to 1 in 560,0004 with only one published case reported in the philippines.5 to establish the diagnosis of gorlin-goltz syndrome, either one major and two minor criteria or two major criteria must be fulfilled.6,7 our patient presented with multiple bcc, bifid third left rib and palmar and plantar pits, fulfilling three major criteria. only 67% of patients diagnosed with gorlin-goltz syndrome present with basal cell carcinoma with an equal male to female ratio.8 the mean age of bcc presentation in gorlin-goltz syndrome is roughly 25 years old and the probability of developing increases with age.9 there are racial differences in the occurrence of bcc; higher in caucasians than in african-americans and asians.6,8 however, bcc in patients diagnosed with gorlin-goltz syndrome have the same histology and presentation as sporadic cases. palmar and plantar pits are among the common dermatologic findings in gorlin-goltz syndrome. these lesions are found in 45% to 87% of gorlin-goltz syndrome and the percentage rises with age.6 the presence of palmar and plantar pits in a child should prompt a complete physical evaluation due to its association with other diseases. a bifid or forked rib is a developmental abnormality in which the sternal end is cleaved in two. this may be asymptomatic and is oftentimes an incidental finding, and can be observed as an isolated defect or may be associated with other multisystem malformations. in the general population, it was reported to occur at 3 to 6.3 per 1,000.10 among the rib anomalies, bifid rib occurs in 28% of cases.11 in gorlingoltz syndrome, it occurs in 36.4% of cases.12 gorlin-goltz syndrome has a wide spectrum of presentations varying from livable symptoms until adulthood to detrimental complications even during childhood. since this is a genetic mutation, there is no cure for disease and treatment is symptomatic. in our case, there is higher chance of recurrence or new lesions that may require multiple surgical procedures in the future. other lesions associated with this syndrome may still appear and immediate consultation is advised to prevent complications. genetic counselling is highly advised since it has high inheritance. in summary, our experience taught us that a high index of suspicion for syndromic disease and a complete physical examination are especially important in such cases. the diagnosis and management are challenging, and should consider the biopsychosocial context of the patient. as long as full disclosure of the condition is made and all options are clearly communicated, the patient’s wishes should be respected. references 1. national comprehensive cancer network [cited 2019 jul 21]. available from: https://www.nccn. org/professionals/physician_gls/pdf/nmsc.pdf. 2. evans dg, sims dg and donai d. family implications of implications of neonatal gorlin’s sydrome. arch dis child. 1991 oct; 66(10 spec no): 1162-1163. doi: 10.1136/adc.66.10_spec_ no.1162; pubmed pmid: 1750770 pubmed central pmcid: pmc1590282. 3.  al-jarboua mn, al-husayni ah, al-mgran m, al-omar af. gorlin-goltz syndrome: a case report and literature review. cureus. 2019 jan 8; 11(1): e3849. doi:  10.7759/cureus.3849; pubmed pmid: 30891389 pubmed central pmcid: pmc6411325. 4. jawa ds, sircar k, somani r, grover n, jaidka s, singh s. gorlin-goltz syndrome. j oral maxillofac pathol. 2009 jul; 13(2): 89–92. doi:  10.4103/0973-029x.57677; pubmed pmid: 21887009 pubmed central pmcid: pmc3162868. 5. magubuhat dg, matsuo jm, de la cruz ra. basal cell carcinoma, odontogenic cysts, brain and skeletal abnormalities (gorlin goltz) syndrome in a 46-year-old woman; philipp j otolaryngol head neck surg. 2017; 32(2): 38-42. doi: https://doi.org/10.32412/pjohns.v32i2.77. 6. kimonis ve, goldstein am, pastakia b, yang ml, kase r, digiovanna jj, et al. clinical manifestations in 105 persons with nevoid basal cell carcinoma syndrome. am j med genet. 1997 mar 31; 69(3): 299-308. pubmed pmid: 9096761. 7. scott cb, bonne lp, scott rg. nevoid basal carcinoma syndrome (gorlin syndrome). head and neck path. doi 10.1007/s12105-016-0706-9. 8. pandeya n, olsen cm, whiteman dc. the incidence and multiplicity rates of keratinocyte cancers in australia. med j aust. 2017 oct; 207 (8): 339-343. doi: 10.5694/mja17.00284; pubmed pmid: 29020905. 9. jones ea, sajid mi, shenton a, evans dg. basal cell carcinomas in gorlin syndrome: a review of 202 patients. j skin cancer. 2011; 2011: 217378. doi: 10.1155/2011/217378; pubmed pmid: 21152126 pubmed central pmcid: pmc2998699. 10. etter le. osseous abnormalities in thoracic cage seen in forty thousand consecutive chest. am j roentgenol. 1944; 51: 359–363. 11. wattanasirichaigoon d , prasad c , schneider g , evans ja , korf br . rib defects in patterns of multiple malformations: a retrospective review and phenotypic analysis of 47 cases. am j med genet a. 2003 sep 15; 122a (1):63-69. doi: 10.1002/ajmg.a.20241; pubmed pmid: 12949975. 12. ahn sg, lim ys, kim dk, kim sg, lee sh, yoon jh. nevoid basal cell carcinoma syndrome: a retrospective analysis of 33 affected korean individuals. int j oral maxillofac surg. 2004 jul; 33(5): 458-462. doi:10.1016/j.ijom.2003.11.001; pubmed pmid:15183409. philippine journal of otolaryngology-head and neck surgery 67 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 under the microscope a 42-year-old filipino male with a 10-month history of progressive left nasal obstruction and rhinorrhea and a clinical impression of nasal polyposis underwent endoscopic sinus surgery with partial ethmoidectomy and polypectomy. we received several dark-brown, irregular, rubbery tissue fragments with an aggregate diameter of 3 cm. histopathologic examination shows sheets of spindly tumor cells beneath the respiratory epithelial lining. these spindle cells are closely packed and arranged in short fascicles and storiform clusters surrounding hyalinized large vessels or thin-walled submucosal blood vessels. (figures 1 and 2) there is no atypia or necrosis. immunohistochemical studies show strong immunoreactivity to muscle specific actin, and focal reactivity to s-100. (figure 3) stains for cd34, caldesmon, cytokeratin, and desmin, are negative. (figure 4) based on these features, we diagnosed the case as glomangiopericytoma. glomangiopericytoma is a rare tumor arising from the pericytes surrounding capillaries, and accounts for less than 0.5% of all sinonasal tumors.1 it has a very slight female preponderance, with a peak incidence during the seventh decade of life. the most common symptom is nasal obstruction, or epistaxis, with accompanying difficulty breathing, sinusitis and headache. a mass, or polyp is the most common clinical finding.2 glomangiopericytoma: the sinonasal mimic of soft tissue hemangiopericytoma correspondence: dr. jose m. carnate, jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st. ermita, manila 1000 philippines phone (632) 526 4450 telefax (632) 400 3638 email: jmcjpath@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2016; 31 (1): 67-68 c philippine society of otolaryngology – head and neck surgery, inc. emilio q. villanueva iii, md1 jose m. carnate, jr., md2 1department of laboratories, philippine general hospital university of the philippines manila 2department of pathology, college of medicine university of the philippines manila figure 1. cellular spindle cell tumor with branching thick blood vessels (hematoxylin-eosin, 100x magnification) (hematoxylin – eosin, 100x) creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 under the microscope 68 philippine journal of otolaryngology-head and neck surgery references 1. higashi k, nakaya k, watanabe m, ikeda r, suzuki t, oshima t, et al. glomangiopericytoma of the nasal cavity. auris nasus larynx. 2011 jun; 38(3):415–417. 2. thompson ldr, fanburg-smith jc, wenig bm. borderline and low malignant potential tumours of soft tissues. in: barnes, l., eveson, jw., reichart, p. and sidransky, d. world health organization classification of tumours. pathology and genetics of head and neck tumors. 2005; lyon: iarc press. p. 43. 3. dandekar m, mchugh jb. sinonasal glomangiopericytoma: case report with emphasis on the differential diagnosis. arch pathol lab med. 2010 oct; 134(10):1444–1449. hematoxylin–eosin staining shows a well-delineated but unencapsulated cellular tumor underneath the normal respiratory epithelium that effaces or surrounds adjacent normal structures.2 the tumor is composed of closely packed, uniform, oval to spindle-shaped cells, in short fascicles and in storiform, whorled or palisaded patterns. the cells surround numerous branching thin-walled, blood vessels, thus the morphologic resemblance to soft tissue hemangiopericytoma/ solitary fibrous tumor. however, in contrast to hemangiopericytoma, glomangiopericytoma shows diffuse reactivity to muscle actins, and non-reactivity to cd34, while hemangiopericytoma shows the reverse reactions. desmin and caldesmon are likewise non-reactive, distinguishing the tumor from leiomyomas or leiomyosarcomas of the upper aerodigestive tract. cytokeratin non-reactivity distinguishes it from spindle cell carcinoma. s100, although typically negative, can be focally and weakly positive in a small percentage of tumor.3 glomangiopericytoma is categorized as a borderline low malignancy tumor with an overall survival of >90% in 5 years but which tends to recur in up to 30% of cases. strict follow-up is thus required, especially if complete resection is not achieved.1 figure 2. closely packed spindle cells, in short fascicles surrounding a thin-walled blood vessel (hematoxylin-eosin, 400x magnification). (hematoxylin – eosin, 400x ) figure 3. tumor cells strongly positive for smooth muscle actin and focally positive for s100 (horse radish peroxidase method, 400x magnification). (horse radish peroxidase, 400x) figure 4. tumor cells negative for cd34, caldesmon, desmin, and cytokeratin. focal caldesmon positivity is seen in associated capillaries (horse radish peroxidase method,100x magnification). (horse radish peroxidase,100x) philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery president’s page we have different reasons for publishing research. i can imagine the resident begrudging that without it, training would have been for naught. then there are those rare individuals with whom the prospect of interesting research gives an inordinate sense of excitement. many a time we say, “i’ve seen a case just like that” or “we’ve been doing that for a very long time”. but if it is not written, who can say that it happened? why research and publish? knowledge for the love of knowing. basic research often pursues questions that may have no clear application yet. but there is always promise it will make sense in the future. these little bits of information have, in many instances, come together into a bigger “aha” moment later on. answer a question --understand how, what, when, why. every single day, we ask something that there is no clear answer to. be it in the course of seeing patients in the clinic, doing surgery or in moments of quiet introspection. each candid query has potential to be a developed into a valid and rational research question. share knowledge. the philippine clinical environment is unique. patient profiles, conditions and treatments may vary from those reported elsewhere. that new case unseen or rarely reported in literature will be lost to memory without publication. sharing it as published scientific literature ensures that the information will be preserved and may be of use to others in the future. intellectual and academic impetus. residents take heart. consultants in academic institutions also have this requirement. “publish or perish” is taken seriously in the academe. this push from teaching institutions hopefully results in amplified output to sustain both the professor’s needs and the medical community at large. there are certainly more reasons. which one is yours? why in the pjo-hns? we absorb information from all over the world and incorporate it into the daily grind of medical practice. but conditions by which philippine orl-hns thrives is rife with its own special set of questions, answers, creative solutions, insight and the occasional surprise revelation. we have as much to share to the orl-hns community as the world has shared with us. the pjo-hns, under the stewardship of dr. jose florencio lapeña, has achieved much in terms of ensuring that the researches it publishes gains international recognition with enhanced online accessibility. thus, what is published in pjo-hns will be searchable online and is linked within a system that allows ease of searching, citation and linking. once it is written, published and uploaded, the information shared will never be lost or relegated to mere anecdotes. there is much work to be done to further philippine orl-hns research. as leaders of our specialty, the pso-hns enjoins all fellows to foster that inquisitive spirit, search for answers and share this knowledge through the pjo-hns. may this volume inspire you to contribute to this effort. mabuhay ang pjo-hns! mabuhay ang pso-hns! agnes t. remulla, md president philippine society of otolaryngology-head and neck surgery why research and publish? philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery contents cover images editorial 4 liwanag sa dilim: days of darkness, night of light! lapeña jff review articles 6 effect of proton pump inhibitors on reflux symptom index (rsi) and reflux finding score (rfs) in patients with laryngopharyngeal reflux: a systematic review and meta-analysis soriano pau, llanes egdv, dela cruz apc, mendoza kml original articles 15 epidermal growth factor application versus observation on healing of acute tympanic membrane perforations: a randomized open label clinical trial atanacio amo, teodoro-estaris egt 20 radiologic evaluation of the anterior and posterior ethmoidal foramen and optic canal by paranasal sinus computed tomography scan among adult filipinos palacios mka, amable jpm, capio kt 23 endoscopic management of sinonasal vascular tumors without embolization: our experience with vessel ligation segovia vpk, jarin psr, sucgang grg 27 dysphonia in smokers of combustible cigarettes and e-cigarettes measured using the filipino voice handicap index dealino mas, dela cruz apc 33 translation and validation of the filipino version of the university of washington quality of life questionnaire (uw-qol) for patients with head and neck cancer dominguez jm, dominguez ejp case reports 38 fatal otitic hydrocephalus due to lateral sinus thrombosis: a case report plumo cgt, cruz ets 43 tied to the top: a case report on an isolated ankyloglossia superior tan mko, agullo eja surgical innovations and instrumentation 46 orbital roof and lateral wall reconstruction using split-thickness calvarial bone graft with titanium mesh complex for a spheno-orbital meningioma miura cp, amable jpm featured grand rounds 52 luc’s abscess: the zygomatic route of infection from cholesteatoma dominguez raa, artates amv from the viewbox 55 inner ear hemorrhage: a cause of sensorineural hearing loss in leukemia yang nw under the microscope 59 secretory carcinoma of the salivary glands uy tcf, mohammad isa ahm, carnate jm captoons 59 doknet’s world billones wu passages 62 jose f. abaño, md abaño jag 63 jacob s. matubis, md hernandez jg “stitches and burns” canon eos 5d mark ii by rene louie gutierrez, md coronal view of a 23-yearold male showing multiple complications of cholesteatoma by ramon a. dominguez, md “natural wonder-philippine banawe rice terraces” ipad mini 3 by rowena s. saplala digital nasal bone x-ray (ap) by justin ian a. jabson, md liwanag sa dilim: days of darkness, night of light! effect of proton pump inhibitors on reflux symptom index (rsi) and reflux finding score (rfs) in patients with laryngopharyngeal reflux: a systematic review and meta-analysis epidermal growth factor application versus observation on healing of acute tympanic membrane perforations: a randomized open label clinical trial radiologic evaluation of the anterior and posterior ethmoidal foramen and optic canal by paranasal sinus computed tomography scan among adult filipinos endoscopic management of sinonasal vascular tumors without embolization: our experience with vessel ligation dysphonia in smokers of combustible cigarettes and e-cigarettes measured using the filipino voice handicap index translation and validation of the filipino version of the university of washington quality of life questionnaire (uw-qol) for patients with head and neck cancer fatal otitic hydrocephalus due to lateral sinus thrombosis: a case report tied to the top: a case report on an isolated ankyloglossia superior orbital roof and lateral wall reconstruction using split-thickness calvarial bone graft with titanium mesh complex for a spheno-orbital meningioma luc’s abscess: the zygomatic route of infection from cholesteatoma inner ear hemorrhage: a cause of sensorineural hearing loss in leukemia secretory carcinoma of the salivary glands doknet’s world jose f. abaño, md jacob s. matubis, md “liwanag sa dilim” 11.5 x 16.5 in, mixed by hypte raymond v. aujero, md philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2018; 33 (2): 45-47 c philippine society of otolaryngology – head and neck surgery, inc. crab shell impaction in the larynx with aphonianayan m. parekh, ms (orl), frcsi (orl) prashant r. kashyap, mbbs, ms (ent) ripas hospital brunei darussalam correspondence: dr. nayan m. parekh consultant ent surgeon department of otolaryngology level iii, specialist building ripas hospital brunei darussalam ba1710 phone: +(673) 2232111 ext 5316 fax: +(673) 22221085 email: drnayan11@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. abstract objective: to report a case of crab shell impaction at the glottic level presenting only as aphonia and cough. methods: design: case report setting: tertiary government hospital patient: one results: a 36-year-old male, who presented in emergency with sudden aphonia after a meal, was found to have crab shell with leg spines impacted at the glottic level. due to its large size, ragged edges and the sharp spines stuck in the tissue, endoscopic removal needed a prior tracheostomy. all pieces were extracted, with no bleeding, laceration or tissue damage. the patient completely recovered with normal vocal folds and a normal voice at follow up. conclusion: our experience suggests that an impacted foreign body may warrant a tracheostomy to secure the airway prior to extraction and avoid any possible complications including laryngeal injury. keywords: foreign body, larynx, crab shell, loss of voice foreign bodies in the aerodigestive tract are among the most common ear, nose and throat (ent) emergencies worldwide and may pose major diagnostic and management challenges. they are more common in children, the intellectually challenged or mentally ill individuals.1,2 accidental ingestion or inhalation is the most common cause in older children and adults but the chance of accidental inhalation is rarer than that of ingestion as the physiologic sphincter function of the larynx efficiently protects the lower respiratory tract.1 most aspirated foreign bodies pass through the laryngeal inlet and lodge lower in the airway and laryngeal impaction is very rare2,3 occurring in 1% to 18% of all patients.4-7 when inhaled, large, sticky, thorny or irregularly-shaped foreign bodies may lodge in the larynx1,2 and become life threatening due to spasm or direct obstruction leading to airway compromise, posing a great management challenge. we report one such case. case report a 36-year-old man presented in accident and emergency at ripas hospital (the only tertiary care hospital in brunei darussalam) with sudden-onset loss of voice which coincided with eating lunch that included crab legs. he was anxious, sweating and coughing relentlessly on presentation but had no stridor or respiratory distress. he was afebrile with blood pressure of 160/110 mmhg (not a known hypertensive), oxygen saturation of 100% on air and normal neurological examination. the case was immediately referred to the ent surgeon on call. flexible laryngoscopy revealed a thin, bony, conical crab shell with jagged free projecting margins circumferentially stuck at the level of the glottic opening. the bony shell had a central opening through which the patient appeared to be breathing comfortably but was unable to phonate. (figure 1) creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery case reports figure 1. flexible laryngoscopy findings showing a crab shell impacted at the glottic opening. figure 2. crab shells fragments removed piecemeal from larynx. figure 3. close-up view of crab shell fragments with sharp spines which anchored into the undersurface of the vocal folds. the patient was immediately posted as an emergency case for removal of the foreign body by direct laryngoscopy under general intravenous anaesthesia with spontaneous breathing. what was thought to be a fairly straightforward removal of the conical crab shell seen on flexible laryngoscopy turned out to be difficult on direct laryngoscopy and subsequent microlaryngoscopy. the crab shell could not be dislodged despite several attempts as it was very firmly and almost circumferentially impacted in the larynx at the glottic level, and only a few pieces of the thin brittle bony shell came out with each attempt at removal. as the procedure prolonged beyond 30 minutes and with endotracheal intubation not possible, it became imperative to do a tracheostomy to maintain anaesthesia and facilitate a safe and smooth procedure. the shell could not be removed as a single piece or as intact as possible as it was firmly impacted and brittle and kept breaking into pieces with each attempt to grasp and remove it. it was therefore removed piecemeal ensuring all the pieces were removed under direct vision. (figure 2) there was no bleeding, laceration or tissue damage encountered. the most notable parts of the shell were the very sharp and curved crab leg spines – 3 in number. these spines had firmly anchored into the tissue on the under surface of the vocal folds making removal very difficult. (figure 3) these were almost the final parts to come out. the patient was transferred to the ward following the procedure with an unremarkable course to recovery. flexible laryngoscopy on the second day revealed mobile vocal folds with minimal edema. the tracheostoma was closely approximated with tight dressing while patient was decannulated on the third postoperative day and he was able to phonate well and normally with no respiratory distress. he was discharged on the fourth postoperative day and followed up after a week by which time the tracheostoma had completely closed. endoscopy then revealed bilaterally normal, mobile vocal folds with a normal voice. discussion commonly inhaled foreign bodies can be organic or non-organic. the commonest inhaled organic foreign bodies reported are peanuts, but others include fruit seeds, fish bones, chicken bones and mutton pieces.2 all these can cause immediate or delayed tissue reaction and edema to worsen the airway obstruction. non-organic and metallic items when aspirated may cause minimal or no tissue reaction. these include latex balloons plastic toys, pieces of dentures, stones, earrings, coins and safety pins. 2 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery case reports the inhaled foreign bodies settle in hypopharynx (5%), larynx (2-9%), trachea (12%), or bronchi (83%).3 reviewing other series reporting tracheobronchial foreign bodies – mainly in children – the reported incidence of impaction in the larynx varies in range from 1% to 18.75% in various studies.4-7 a foreign body rarely settles in the larynx due to its strong inherent protection and tends to enter the hypopharynx more commonly or passes down in the tracheobronchial tree.8 only those which are too large, sharp or irregular can get lodged at the glottic level.1,2 a patient with laryngeal foreign body can present with sudden dyspnea and stridor, sudden airway obstruction including cyanosis, bouts of cough, hoarseness or aphonia, throat pain or discomfort and dysphagia to odynophagia.2 the severity of clinical presentation will depend on site of impaction, suddenness and degree of obstruction, size, shape and type of foreign body – including organic or non-organic, age of the patient and possible laryngeal irritation or spasm.2 unusual foreign bodies in the larynx, causing no or minimal breathing issues and presenting mainly with voice changes of variable duration or throat discomfort have included a piece of sticker,2 coin,9 metallic clip of a crepe bandage,9 a leech,3 denture,10 denture fragment,1 a bone piece,8 sewing needle,11 bird bone,12 open safety pin,13 metallic screw,14 ballpen metal tip,14 and a paper pin.15 our case had a clear history of eating crab after which the complaints started, clearly pointing to a possible foreign body. this was easily confirmed by flexible laryngoscopy. in view of the clinical picture, an x-ray was not considered necessary. however, the irregular surface and strong sharp spines had deeply embedded the crab shell, impacting at the glottic level. a tracheostomy was really decided for at that stage for adequate ventilation of the patient and to avoid any possible laryngospasm and/or further airway compromise while manipulating the foreign body at the glottic level. only after the airway was fully secured and ventilation stabilised was the shell fully removed in pieces with utmost care to avoid any injury. in retrospect, any forceful attempt to remove the foreign body without a tracheostomy would have been largely unsuccessful due to the sharp spines impacted under the vocal fold level and would have led to variable degrees of laryngeal injury. our report demonstrates a serious and potential life threatening medical emergency caused by the crab shell impaction in the throat. apparently, while the patient was trying to suck in the pink soft meaty part of the claw, the shell must have detached as well and was accidentally sucked in. this is reminiscent of the pathophysiology of a previously-reported aspiration of embryonated duck shell while slurping the soup, and may explain the reported high incidence of pin aspiration among young islamic women who hold pins with their lips while arranging their headscarf, or of needle darts among young boys.16 we did not find any literature on crab shell in the airway. however, there are two relevant newspaper reports of a 2 cm size crab shell17 references 1. kothari s, vijay a. a rare glottic foreign body with unusual presentation. world articles in ear nose and throat. 2013 mar 15;6-1. [cited 2018 mar 8]. available from http://www.waent.org/ archives/2013/vol6-1/20130217-glottic-foreign-body/glottic-foreign-body-manuscript.htm. 2. kansara ah, shah hv, patel ma, manjunatharao sv. unusual case of laryngeal foreign body; indian j otolaryngolog head neck surg. 2007 apr 26;59(1):63-65. doi: 10.1007/s12070-0070019-0 pmcid: pmc3451719; pmid: 23120391. 3. ganguly sn, reddy ns, shrestha a, shah d, shakya n, acharya s. unusual case of laryngeal foreign body. j college med sci nepal. 2010 aug 24; 6(1):45-46. doi: http://dx.doi.org/10.3126/ jcmsn.v6i1.3601 [cited 2018 mar 8]. available from: https://www.nepjol.info/index.php/jcmsn/ article/view/3601/3100. 4. mcguirt wf, holmes kd, feehs r, browne jd. tracheobronchial foreign bodies.; laryngoscope. 1988 jun;98(6):615-618. doi: 10.1288/00005537-198806000-00007 pmid:3374237. 5. rothman bf, boeckman cr. foreign bodies in the larynx and tracheobronchial tree in children. a review of 225 cases. ann otol rhinol laryngol. 1980 sep-oct; 89(5): 434-436. doi: 10.1177/000348948008900512 pmid:7436247. 6. silva ab, muntz hr, clary r. utility of conventional radiography in the diagnosis and management of pediatric airway foreign bodies. ann otol rhinol laryngol. 1998 oct; 107(10): 834-838. doi: 10.1177/000348949810701004 pmid:9794611. 7. razi hadi a, said h, ahmad k. foreign bodies in the laryngotracheobronchial tree. med j malaysia. 1988 mar; 43(1):74-83. pmid:3244325. 8. veccham c, gouripeddi s. silent laryngeal foreign body. journal of evolution of medical and dental sciences. 2015 jun 18;4(49):8609-8611. doi: 10.14260/jemds/2015/1245; available from: https://jemds.com/latest-articles.php?at_id=8134. 9. hada ms, samdhani s, chadha v, harshvardhan rs, prakash m. laryngeal foreign bodies among adults. j bronchology interv pulmonol. 2015 apr; 22(2):145–147. doi: 10.1097/ lbr.0000000000000056 pmid:25887012. 10. jeing yd, bin md nasir am, gendeh bs. unusual glottic denture impaction: a case report. asian journal of oral and maxillofacial surgery; 2011 mar; 23(1):50-52. doi:10.1016/j. ajoms.2010.10.010. 11. chouhan m, yadav js, bakshi j. unusual presentation of foreign body in larynx. egyptian j ear nose throat allied sci. 2012 mar; 13(1):61-63. doi:10.1016/j.ejenta.2012.02.002 [cited 2018 mar 8]. available from: https://doi.org/10.1016/j.ejenta.2012.02.002. 12. ambu vk, narayanan p, ratnasingam v. neglected laryngeal foreign body. the journal of laryngology & otology. 2001 sep; 115(9): 740-742. doi:10.1258/0022215011908801 [cited 2018 mar 8]. available from: https://doi.org/10.1258/0022215011908801. 13. baliarsingh d, rath a, hota a, panigrahi r. open safety pin in larynx: a case report and review of literature. int j otolaryngol clin. 2017 jan-apr; 9(1): 21-24. doi:10.5005/jp-journals-10003-1255. 14. hada ms, chadda v, mishra p, gupta p, grover m. unusual metallic foreign bodies in the larynx: two case reports. indian j pediatr. 2012 aug; 79(8): 1100-1102. doi: 10.1007/s12098-011-0621-8 pmid: 22237635. 15. bir singh g, abrol r, dass a. an unusual foreign body in the larynx in an adult. otolaryngol head neck surg. 2005 oct; 133(4): 639. doi: 10.1016/j.otohns.2004.09.059 pmid:16213945. 16. lapena jf jr. embryonated duck (“balut”) eggshell aspiration in a one-year-old boy. singapore med j. 2009 may;50(5):e170-1. pmid:19495500. 17. varanasi a. doctors fish out crab shell from 55-year-old mumbai man’s throat. mid-day.com. 2014 may 14. [cited 2018 june 22]. available from: http://www.mid-day.com/articles/doctorsfish-out-crab-shell-from-55-year-old-mumbai-man-s-throat/15312153. 18. dna correspondent. eating crab leaves boisar woman shell-shocked. dna india. 2013 mar 29. [cited 2018 june 22]. available from: http://www.dnaindia.com/mumbai/report-eating-crableaves-boisar-woman-shell-shocked-1816722. and a pointed piece of crab shell18 impacted in the esophagus of a 55-year-old man and lady respectively, that were both successfully removed in hospitals in india. in conclusion, laryngeal foreign bodies are rare particularly in adults and their presentation with aphonia only and no respiratory distress is extremely rare. our case of crab shell impaction at the glottic inlet is one such rare foreign body presenting only with aphonia. our experience suggests that a compromised airway or strongly impacted foreign body may warrant a tracheostomy to secure the airway prior to foreign body extraction, and avoid any possible complications including laryngeal injury. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 philippine journal of otolaryngology-head and neck surgery 3 contents hubris, humility and healing low frequency ultrasound in chronic rhinosinusitis with nasal polyposis and recovery after endoscopic sinus surgery: a randomized controlled trial bleeding time using moringa oleifera (malunggay) leaf extract versus saline control in a rabbit epistaxis model: a randomized controlled trial traumatic perforation of the tympanic membrane: etiologies and risk factors for healing and intervention fibular dimensions for mandibular reconstruction among filipinos demographic profile and risk factors of patients with benign vocal fold lesions diagnosed through laryngeal videoendoscopy and stroboscopy laryngeal cancer neck node metastasis: patterns of spread diagnostic-to-treatment interval and disease progression among head and neck cancer patients undergoing surgery capillary hemangioma of the temporal bone proboscis lateralis with rhinosinusitis an impacted live fish in the oropharynx of an 8-year-old child tuberculosis of the thyroid optical myringotomy knife peripheral t-cell lymphoma presenting as an auricle mass intracranial complications of acute sinusitis on brain ct middle ear paraganglioma cover images editorial 4 hubris, humility and healing lapeña jf original articles 6 low frequency ultrasound in chronic rhinosinusitis with nasal polyposis and recovery after endoscopic sinus surgery: a randomized controlled trial de castro rb, cruz-daylo mab, jardin mla 14 bleeding time using moringa oleifera (malunggay) leaf extract versus saline control in a rabbit epistaxis model: a randomized controlled trial caballero plg, cachuela je 17 traumatic perforation of the tympanic membrane: etiologies and risk factors for healing and intervention sannigrahi r, ghosh d, saha j, basu sk 23 fibular dimensions for mandibular reconstruction among filipinos muñoz np, fernando af, castañeda ss 27 demographic profile and risk factors of patients with benign vocal fold lesions diagnosed through laryngeal videoendoscopy and stroboscopy chan tcp, fortuna mcs, enriquez ps 30 laryngeal cancer neck node metastasis: patterns of spread austria mjdg, roldan ra 33 diagnostic-to-treatment interval and disease progression among head and neck cancer patients undergoing surgery lapiña gf, castañeda ss case reports 37 capillary hemangioma of the temporal bone fernando jz, ricalde rr 41 proboscis lateralis with rhinosinusitis vera cruz lmn, vicente gm 44 an impacted live fish in the oropharynx of an 8-yearold child joson sn, almazan na, cruz mgy 47 tuberculosis of the thyroid fabito ef, tipayno-lubos mj, ayahao fd surgical innovations and instrumentation 51 optical myringotomy knife de leon ro, amable jpm featured grand rounds 55 peripheral t-cell lymphoma presenting as an auricle mass mendoza vmm, perez de tagle jrv, fernando af from the viewbox 57 intracranial complications of acute sinusitis on brain ct bickle ic under the microscope 59 middle ear paraganglioma carnate jm, te vg, encinas-latoy mam from “an impacted live fish in the oropharynx of an 8-yearold child: application of jennings retractor, and depression of the tongue with a gloved finger reveals more of the fish” by melanie grace y. cruz, md “mastoidectomy” by heidi jesse a. moya, md “t2-weighted mri image in the axial plane at the level of the left internal auditory canal showing a large cerebellopontine angle tumor with mass effect on the adjacent pons and left cerebellar hemisphere” by nathaniel w. yang, md “harvest” paintography canon 5d mark ii + eos 17-40mm f4 l photomanipulation: adobe photoshop cc by rene louie c. gutierrez, md “woman who is about to dance” 10” x 14” oil on canvas by camille sidonie a. espina, md philippine journal of otolaryngology-head and neck surgery 3 blood and foliage: coral red and jade green recommendations for social media use in hospitals and health care facilities effects of dexamethasone versus saline-impregnated nasal packing on the postoperative outcome of patients with chronic rhinosinusitis and nasal polyps after endoscopic sinus surgery: a randomized controlled trial arnica montana and blood loss, surgical field bleeding and operative time in endoscopic sinus surgery: a randomized-controlled trial quality of life after fess among patients with nasal polyps using the nose questionnaire translated in filipino (nose-ph) vocal fold paralysis with intraoperative recurrent laryngeal nerve identification versus non-identification of recurrent laryngeal nerve in total thyroidectomy: a retrospective cohort study clinical profile of patients with laryngotracheal stenosis in a tertiary government hospital an initial survey of septorhinoplasty in crooked nose deformities prevalence of nasopharyngeal carcinoma among patients with nasopharyngeal mass in a philippine tertiary training hospital congenital oval window aplasia: an unusual cause of conductive hearing loss in an adult recurrent epistaxis from a post-traumatic infraorbital artery pseudoaneurysm tumoral calcinosis in secondary hyperparathyroidism mandibular ameloblastoma with lung metastasis 10 years after resection naso-glabello-frontal advancement reconstruction for chondroid syringoma of the nasal tip cytopathologic herpes simplex virus features in laryngeal squamous cell carcinoma olfactory neuroblastoma glomangiopericytoma: the sinonasal mimic of soft tissue hemangiopericytoma philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 contents cover images editorial 4 blood and foliage: coral red and jade green lapeña jf commentary 6 recommendations for social media use in hospitals and health care facilities patdu, id original articles 10 effects of dexamethasone versus saline-impregnated nasal packing on the postoperative outcome of patients with chronic rhinosinusitis and nasal polyps after endoscopic sinus surgery: a randomized controlled trial promentilla sma, onofre rdc, campomanes bsa. 14 arnica montana and blood loss, surgical field bleeding and operative time in endoscopic sinus surgery: a randomizedcontrolled trial salinas mlt, bato cre 17 quality of life after fess among patients with nasal polyps using the nose questionnaire translated in filipino (nose-ph) macasaet mav, cruz ets 22 vocal fold paralysis with intraoperative recurrent laryngeal nerve identification versus non-identification of recurrent laryngeal nerve in total thyroidectomy: a retrospective cohort study formanez aj. 26 clinical profile of patients with laryngotracheal stenosis in a tertiary government hospital arriola acp, chua ah. 31 an initial survey of septorhinoplasty in crooked nose deformities villafuerte cv, dy aes, lapena jf 35 prevalence of nasopharyngeal carcinoma among patients with nasopharyngeal mass in a philippine tertiary training hospital lara hhr, monroy a case reports 39 congenital oval window aplasia: an unusual cause of conductive hearing loss in an adult chiong cm, mercado-evasco rt, chiong a, perez me, abes fl, chan al. 45 recurrent epistaxis from a post-traumatic infraorbital artery pseudoaneurysm pascual mvp, alonzo dm. 48 tumoral calcinosis in secondary hyperparathyroidism bautista rls, lopa rab, cabungcal aca, de la cruz apc, lo ten. 53 mandibular ameloblastoma with lung metastasis 10 years after resection siy rabo jj, carpella ab, guevara es, romualdez ja. surgical innovations and instrumentation 57 naso-glabello-frontal advancement reconstruction for chondroid syringoma of the nasal tip tangco iv, ayahao fd. featured grand rounds 61 cytopathologic herpes simplex virus features in laryngeal squamous cell carcinoma devilleres-mendoza d, chang jv. from the viewbox 65 olfactory neuroblastoma bickle ic under the microscope 67 glomangiopericytoma: the sinonasal mimic of soft tissue hemangiopericytoma villanueva eq, carnate jm. rood screen in the 14th-century gothic église saint-pierre-le-jeune, strasbourg, france. note the predominantly red and green colors, and elaborate paintings. by josé florencio f. lapeña, md “giving hope” by ricky l. ramirez, jr., md “practicals” by rene louie c. gutierrez, md “emergency room at 12 midnight” 11.5” x 16.5” acrylic on harboard by mariano b. caparas, md “what’s in a name? that which we call a rose by any other word would smell as sweet”. from romeo and juliet, shakespeare [cited 2016 jun 3. available from: https:// www.pinterest.com pn/74731675 041179561/ by elmo r. lago, md philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 7978 philippine journal of otolaryngology-head and neck surgery letters to the editor surviving covid-19 pneumonia at home: covid case #1906 dear editor, i was exposed to a covid-19 positive cardiologist last march 1. i had ent clinics until march 11, treating mostly patients with complaints of cough and fever (sinusitis and bronchitis). i felt that my facial mask, hooded magnifier lens, and gloves gave me enough protection. i was wrong. they were not sufficient. i had a temperature of 38°c on march 13 and went home immediately to self-isolate. by march 15, i was coughing unremittingly and persistently as if a feather was stuck in my throat. i had no phlegm. i had no running nose, nor respiratory difficulty. but my rib muscles ached continuously an intense, miserable pain not relieved by any position. i felt a severe point tenderness over both lower back ribs that even soft pillows could not diminish. i lacked sleep. i felt weaker as days went by. my taste was flat as i swallowed soups and arroz caldo but i still had my sense of smell. on march 16, i took clarithromycin 500 mg and n-acetylcysteine 600 mg, both twice daily to treat what i diagnosed as acute pharyngitis. two more days of severe coughing, fever and sore throat made me worry about covid-19. how come i was not getting better? in fact, i was getting bitter over this uncertainty of covid-19 and the treatment i had prescribed myself. i had been religiously taking probiotics to imbue me with immunity for infections like these.1 i believed that lactobacillus acidophilus, the friendly gut bacteria, stimulates the gut associated lymphoid tissue (galt) to produce antibodies against virus and bacteria shedding into small intestines and against bacteria abnormally multiplying in the large intestine.2 i was assured by the research of russian dr. elie metchnikoff on the potent lactobacillus in yogurt (which comprised almost 50% of the bulgarian diet and made them strong and healthy). dr. metchnikoff (who had won the 1908 nobel prize in physiology and medicine) honored bulgaria by naming his friendly bacteria lactobacillus bulgaricus.3,4 dr. metchnikoff was later honored as the “father of natural immunity.”5 then came the spanish flu of 1918-1919 that killed more than 2.5 million europeans, mostly italians and british.6 yet the number of those killed in bulgaria was as close to that in switzerland, which was the lowest. now, the covid-19 pandemic marched into 2020 killing 4,633 patients out of 82,918 covid+ in wuhan, china; 31,855 out of 219,183 covid+ in great britain; 30,560 out of 219,070 covid+ in italy; and 80,787 out of 1,367,638 covid+ in the usa. ninety-one died of covid out of 1,965 positive for covid-19 in bulgaria.7 i was confident that the lactobacillus acidophilus 20 billion colony forming units (cfu) were stimulating production of the igg and igm (from galt which produces 70% of the body’s immune globulins) needed to neutralize viruses or bacteria.8 the acidophilus produces vitamin b specially vit b129 which i believe made for my stronger body. i had prepared myself as i prepared my patients for the flu by consuming vit c and zinc. zinc stimulates the thymus to increase immune responses to viruses.10,11 i was fortified with 2 colostrum pills daily, preformed sources of igg and iga.12 i followed my regimen for acute rhinitis (though there was no nasal obstruction) which meant doing nasal saline washing or sprays thrice a day. i knew that the flu virus (or even the sars-cov2) hides early in the nose and sinuses and is able to produce toxins which inflame the whole body. worse for sars-cov2 because these drop into the tonsils and into the lungs. the nasal sprays were meant to reduce the virus numbers (viral load) in the nose and sinuses so there were less shedding. saline washes decongest the nose to improve breathing. the 60 seconds antiseptic mouthwash followed a regimen of brushing the teeth then the palate and the tonsils and to the base of the tongue. this was to extinguish any virus lurking to go down into the lungs or git. this regimen was routine at 3x a day. the fever dropped slowly. coughing diminished though the muscles constantly ached after 3 days of clarithromycin. i was determined to have the covid tests and a high resolution ct scan of the chest. on march 20 at the hospital er, i explained i was a patient requesting a cbc, a covid test, and a chest ct scan and that i will wait for my turn since the er was full (took me 3 hours). after the interview with the er physician, i was led to a seat one meter apart from others. elderly patients with cough all quizzically looked at me in my white doctor’s gown wondering if i was sick. i changed to the gown, mask, and gloves i was provided with when the nurse escorted me to cubicle one. first came the cbc. next were rt-pcr swabs of the nose and nasopharynx and of the throat. finally after the staff sterilized the ct scan room, my scan was completed in a few minutes. the chest scan showed ground glass appearance consistent with bilateral basal pneumonia. i was told that the pcr results would be ready within 7 days. i was advised urgently by my classmate, a pulmonary specialist from another hospital, for admission for oxygen inhalation and treatment. she went out of her way to look for a pulmonologist but none was available due to quarantine. she looked for an infectious disease specialist who was now in isolation. i requested her that since i was not in respiratory distress and because of my weakened state, i was worried about getting a hospital acquired infection and that i be committed to strict home isolation with treatment prescribed by her. she reluctantly acceded with the admonition that i proceed immediately back to hospital if respiratory difficulties occur. i started the oseltamivir (tamiflu) at 2x a day for 5 days and azithromycin once daily for 7 days plus a mucolytic nacetylcysteine 600 mg 2x a day. there was another dimension beyond my physical stress. i was in mental stress, the pervasive fear of not surviving this that engulfed me. knowing my close colleagues died from covid-19 pneumonia after a short battle in icu with intubation, i realized this certainty of philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 7978 philippine journal of otolaryngology-head and neck surgery letters to the editor death and that uncertainty of recovery. i asked for a lifeline from my up med ‘76 classmates. (the lifeline in the family was unconditionally given though from a distance). my pulmonologist classmate closely monitored my condition daily. some offered their listening ears to my echoing worries. most prayed to god with their unconditional love for me to recover. another classmate had extraordinary pranic sessions for my healing, my relaxation and my energy. i reflected on my dad’s advice that in a righteous fight (like against this pneumonia), “you use all means and all ways to win.” i started deep breathing into the nose and slowly out through the mouth knowing full well that the nitric oxide i absorbed through the roof of the nose dilated my coronaries for better heart function and my pulmonary arteries for better oxygen exchange. the deep breathing provided nitric oxide to the bronchus and bronchioles to dilate them for more airflow. moreover, i was taking in lots of calamansi juices (or lemon or oranges) for its citrulline which has been researched to prolong the effects of nitric oxide.13 these breathing sessions were the most important activities if i were to survive and were continuous morning, noon and evening. fortunately, i was isolated in 3rd floor music room with access to the roof deck garden and fresh air from laguna de bay (about 1.5 km from the house in taguig) and of course, lps of the beatles, aiza and sharon, and mozart. i did chest thumping or percussion as far as i could reach my back to loosen the phlegm in my lungs. this self ‘physical therapy’ was 3x a day. i started to spit scanty whitish, thick phlegm. i made sure that oseltamivir (tamiflu) was taken mornings and evenings and the azithromycin was taken at lunch so there were no drug interactions. the 2 colostrum tabs were swallowed on waking up. the probiotics were taken after breakfast and after dinner. the zinc was taken after lunch. soft stools were present but that was my git reacting to the medications. adding to the controversy was the new regimen us president donald trump was trumpeting on fox news and cnn. a hospitalist physician treating covid-19 pneumonias in san francisco was giving us the new protocols for chloroquine and azithromycin, with promising results. he was the classmate of my daughter in up med. i went to pharmacies in taguig and greenhills for chloroquine. it was not available. my pulmonologist classmate was firm; “no!” when i suggested the shift. “you will need confinement and an ecg because these combination drugs prolong qtc on electrocardiogram.” this meant chloroquine and azithromycin combination may initially precipitate bradycardia (lower heart rate) then ventricular tachycardia (heightened heart rate), and finally, cardiac arrest for senior patients (68 years old) like me with a history of hypertension. this discussion stopped all controversies in treatment. moreover, i was getting better. my temperature decreased to 37.8 °c. the muscle pain diminished. the severe point tenderness over the lower ribs persisted. i was deep-breathing which i could not hold for more than 10 seconds. that was not normal! i listened to my lungs for the crackling sounds of pneumonia with my stethoscope. the maze of gurgling and churning sounds from the stomach and intestines seemed to mask the sounds i was listening for. or was i in denial? i decided to go back to er on the 3rd day for a chest x ray. the objective was to see if my pneumonia was progressing. the chest x ray still showed basal pneumonia. i had mixed feelings-good that pneumonia did not progress to middle lung fields and --bad that pneumonia was festering. i completed the 5-day regimen of oseltamivir (tamiflu) and was continuing the 8th day of azithromycin and n-acetylcysteine when my covid test finally arrived through email-i was covid positive #1906 . by this time, i was recovering physically and mentally. i had no fever (37.2 °c average), no cough, no sore throat. breathing was full. i had my appetite back. my outlook was as optimistic as the blooming flowers i nurtured during this trial. this timing was fortunate because even with confirmed covid-19 positive, i knew i had beaten covid-19 pneumonia at home. isolation was completed 2 weeks from my recovery which necessitated another covid test and rapid test april 10, 2020. this test was still positive. a third pcr done on april 20 was negative for sarscov-2. the new doh protocol was to isolate up to may 5 which i have followed. i am practicing social distancing and wearing a mask. yours truly, jaime f. flor, md consultant otorhinolaryngologist – head and neck surgeon cardinal santos medical center greenhills, san juan city, philippines references 1. montrose dc, floch mh. probiotics used in human studies. j clin gastroenterol. 2005 jul:39(6):469-84. doi: 10.1097/01.mcg.0000165649.32371.71. pmid:15942432. 2. corthésy b, gaskins hr, mercenier a. cross-talk between probiotic bacteria and the host immune system. j nutr. 2007 mar;137(3 suppl 2):781s-90s. doi:10.1093/jn/137.3.781s. pmid:17311975. 3. link-amster h, rochat f, saudan ky, mignot o, aeschlimannn jm. modulation of a specific humoral immune response and changes in intestinal flora mediated through fermented milk intake. fems immunol med microbiol. 1994 nov;10(1):55-63. doi: 10.1111/j.1574-695x.1994. tb00011.x. pubmed pmid: 7874079. 4. trenev n. probiotics: nature’s internal healers. new york: avery (penguin putnam inc.); 1998. p. 1-17. 5. gordon s. elie metchnikoff: father of natural immunity. eur j immunol. 2008 dec;38(12):3257-64. doi: 10.1002/eji.200838855. pubmed pmid: 19039772. 6. o’connor s (editor). the science of epidemics: inside the fight against deadly diseases, from ebola to aids. 2014, new york: time books; 2014. pp. 46-59. 7. worldometer [website]. coronavirus: reported cases and deaths by country, territory, of conveyance. [cited 2020 may 10] available from: https://www.worldometers.info/ coronavirus/#countries 8. rutherfurd-markwick kj, gill hs. probiotics and immunomodulation. in: hughes da, darlington lg, bendich a, (editors). diet and human immune function. totowa, new jersey: humana press, 2004. pp. 327-344. 9. leblanc jg, laino je, juarez del valle m, vannini v, van sinderen d, taranto mp, et al. b-group vitamin production by lactic acid bacteriacurrent knowledge and potential applications. j applied microbiology. 2011 sep 20;111(6):1297-1309. doi: 10.1111/j.1365-2672.2011.05157.x. 10. bogden jd, oleske jm, munves em, lavenhar ma, bruening ks, kemp fw, et al.. zinc and immunocompetence in the elderly: baseline data on zinc nutriture and immunity in unsupplemented subjects. am j clin nutr. 1987 jul;46(1):101-109. doi:10.1093/ajcn/46.1.101. pmid:3604960. 11. klaus-helge i, rink l. zinc. in: hughes da, darlington lg, bendich a, (editors). diet and human immune function. totowa, new jersey: humana press; 2004. pp 241-259. 12. hurley wl, thiel pk. perspectives on immunoglobulins in colostrum and milk. nutrients 2011 apr;3(4):442-474. doi:  10.3390/nu3040442. pubmed pmid:  22254105; pubmed central pmcid: pmc3257684. 13. liuking yc, engelen mp, deutz ne. regulation of nitric oxide production in health and disease curr opin clin nutr metab care. 2010 jan;13(1):97-104.doi: 10.1097/mco.0b013e328332f99d. pubmed pmid: 19841582; pubmed central pmcid: pmc2953417. philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 letter to the editor “the laryngectomee guide” philippine edition dear editor, i am happy to announce that “ the laryngectomee guide” philippine edition is available now in paperback and ebook. the ebook is free. the translation from english to tagalog was supervised by professor alfredo pontejos jr. from the university of the philippines, philippine general hospital, manila. the guide provides practical information that can assist laryngectomees with medical, dental and psychological issues. it contains information about side effects of radiation and chemotherapy; methods of speaking; airway, stoma, and voice prosthesis care; eating and swallowing; medical, dental and psychological concerns; respiration; anesthesia; and travelling. the american academy of otolaryngology head and neck surgery made the english edition available for free download on their website: http://www.entnet.org/content/laryngectomee-guide the e-book of the philippine version of the guide is available free at: http://bit.ly/2ilzesc paperback copies of the guide are available at: http://bit.ly/39idwvc the guide is also available in 20 additional languages english, russian, turkish, greek, italian, bulgarian, romanian, bosnian, arabic, spanish (4 styles), portuguese, french, persian (farsi), korean, japanese, indonesian and traditional and simplified chinese: https://dribrook.blogspot.com/2018/08/the-laryngectomee-guide-is-available-in.html i hope that the guide would be helpful to laryngectomees and their medical providers in the philippines. yours truly, itzhak brook, md, msc professor of pediatrics georgetown university medical center washington dc, usa 4431 albemarle st. nw washington dc, usa 20016 usa email: ib6@georgetown.edu philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 6766 philippine journal of otolaryngology-head and neck surgery practice pearls structural rhinoplasty is a term use by rhinoplastic surgeons wherein the existing structures are reconstructed and strengthened for functional and aesthetic improvement of the nose. the function refers mainly to breathing by correcting septal deviation and enlarging the internal valves.1 the usual surgical method is open rhinoplasty approach and all anatomical structures are analyzed. the central septal cartilage is removed while the remaining dorsal and caudal strut are reconstructed for better breathing and tip support.2 the general concept is to alter the length and height of the existing dorsal and caudal strut by restructuring with the use of the central harvested cartilage. cartilages used for strengthening the struts are called structural grafts while cartilages used for tip reshaping and projection are called contour grafts.3 structural grafts commonly include the columellar strut graft, septal extension graft (seg), spreader graft or extended spreader graft (esg).1 the columellar strut and seg are used for lower cartilage and tip support. the spreader graft is used for strengthening the dorsal strut and enlarging the internal valve. the esg is a spreader graft that is extended beyond the anterior angle of the septum for support of lower cartilage and tip. among the structural grafts for lower cartilage tip support it is the septal extension graft (seg) that gives the best longevity.4 the seg is either placed side-to-side to the caudal strut or end-to-end supported by bilateral extended spreader graft (esg). (figures 1 & 2) sometimes, a combination of esg with seg is needed to correct weakness of the struts. (figure 3) contour grafts are usually the dorsal graft and tip grafts. (figure 4) because asian (specifically south east asian) noses are usually small, the harvested septum is often small and soft.3,4 occasionally the septum may look strong but upon harvest the dorsal and caudal struts weaken. additional cartilage grafts are usually needed either from the auricle or from the rib. auricular cartilage is too soft as support graft while the rib cartilage is strong because of its resemblance to septum in its histology. autologous rib rhinoplasty is not only tedious and invasive but also more expensive which most patients do not prefer. because of the paucity of septum, there are many substitute commercial materials in the market which can simulate the strength of septal cartilage as support graft. these can be homologous processed human rib cartilage, or alloplastic non-absorbable porous polyethylene. these materials are prone to long term complications e.g. warping, fracture, infection, resorption and extrusion.5,6 scientists and bioengineers recently developed polycaprolactone (pcl) which is a new synthetic absorbable porous material. it is marketed as a better material because not only it gives support but it also serves as a scaffold for tissue regeneration.7-9 techniques in the safe use of polycaprolactone in structural rhinoplasty eduardo c. yap, md1,2 1belo medical group 2department of ent metropolitan medical center correspondence: dr. eduardo c. yap unit 3, 28 times st., west triangle, quezon city 1104 philippines phone: (632) 8254 1111 email: edcyap88@gmail.com the author declares that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2020; 35 (1): 66-70 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 6766 philippine journal of otolaryngology-head and neck surgery practice pearls figure 4. schematic drawing of contour grafts namely dorsal graft for augmentation and tip grafts for projection. figure 5. polycaprolactone (pcl) mesh use in septoplasty and rhinoplasty. shown here is the more common 10 mm x 40 mm x 1 mm mesh. figure 2. schematic drawing of end-to-end seg supported by bilateral extended spreader grafts (esg), a figure-of-8 suture in the middle and conchal cartilage at the posterior angle of septum. bilateral esg end to end seg figure of 8 suture conchal cartilage figure 3. schematic drawing of side-to-side seg on the right and esg on the left of the dorsal strut. anterior angle asg seg posterior angle figure 1. schematic drawing of side-to-side septal extension graft (seg). also depicted here is the modification done to produce a new anterior angle of the septum for tip support and projection. the posterior angle of the septum is maintained. anterior angle dorsal graft tip grafts posterior angle seg figure 6. schematic drawing of pcl inside membranous septum. seen here is the coverage of pcl with cartilages held by pds 5-0 sutures. because of the elevated mucosa after covering with cartilages, the mucosa does not come in direct contact with pcl and erosion is minimized. avoid quilting transmucosal suturing to avoid points of entry for infection. pcl mucosa cartilage empty space not in direct contact w mucosa philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 6968 philippine journal of otolaryngology-head and neck surgery practice pearls polycaprolactone (pcl) is an absorbable material used in craniomaxillofacial surgery as a scaffold for defects.10 it is absorbed completely in 2 years. it is also a material used as threads in facial rejuvenation.11-13 recently pcl has been fashioned into mesh for use in septoplasty and rhinoplasty as implants and support.14,15 its use is mainly as a scaffold for tissue regeneration and support. it has been shown in studies that osteoblasts, chondroblasts and mesenchymal tissues grow into its pores.10, 15 it comes in various shapes and sizes. the ideal ones for use in nasal surgery are the 10 mm x 30-40 mm mesh plate with thickness variety of 0.8-1.2 mm. (figure 5) polycaprolactone is not used routinely; it is still best to use all autologous tissues. the indication of the use of pcl depends on the structure of the nose (mainly the septum). it is best for use in cases of small septum with inadequate septal material for correction of deviation. it is also best for use in cases of weak septum or weak dorsal/ caudal struts after septal harvest to correct any possibility of collapse. moreover, pcl is not advisable in severe contracted nose because forces of healing may lead to wound dehiscence, extrusion and infection. extrusion and infection may also happen while pcl is still not completely absorbed in 2 years. since pcl is noted to lose its strength but provide well as a template for tissue regeneration, it is recommended to cover the pcl with septal or conchal cartilages whenever possible for 2 reasons: firstly, for protection against mucosal erosion and secondly as cartilage regeneration template for future support. (figure 6). the decision to use pcl is made intraoperatively. the pcl mesh is fashioned into either an end-to-end seg or esg; both techniques of grafting are covered majority with cartilages. following is the algorithm showing the indications when to use pcl after open rhinoplasty approach and assessment of the strength of the septum: i nt ra o p e rat i ve septal strength assessmement strong septoplasty, harvest central cartilage septoplasty, harvest central cartilage weak strong dorsal and caudal struts weak dorsal strut pcl as unilateral esg. see figure 8 weak caudal strut pcl as caudal strut batten graft. see figure 9 harvested septum as extended caudal batten graft, pcl as end-to-end seg. see figure 10 weak dorsal and caudal struts pcl as esg, pcl as end-to-end seg. see figure 11 big septal harvest all autologous as esg and seg. see figure 1,2,3 small septal harvest harvested septum as esg, pcl as end to end seg. see figure 7 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 6968 philippine journal of otolaryngology-head and neck surgery practice pearls figure 8. unilateral pcl as esg in cases of weak dorsal strut. pcl size is approx. 5 mm (w) x 1.5-2.0 mm (length). the pcl has to be covered with a thin cartilage for protection especially in the membranous septum area. figure 9. pcl is used as a batten graft for weak or deviated caudal strut. the pcl size varies depending on deformity and has to be covered with cartilage for protection. figure 10. in cases of strong dorsal strut with a weak caudal strut the remaining septum can be used as extended caudal batten graft while the pcl is used as end-toend seg. the pcl has to be covered with conchal cartilages. figure 11. pcl is almost used entirely for the new dorsal and caudal strut. the esg can be unilateral or bilateral. the end-to-end seg mainly depends on the strength of the esg. the entire pcl should be covered with remaining harvested septal cartilages supplemented with conchal cartilages for protection, cartilage tissue in growth and future support. this technique may obviate the need of extracorporeal septoplasty; it may be applicable to severely deviated superior and caudal septum. figure 12. pcl as a floating columellar strut. although the pcl is between the medial crura, it is still recommended to cover it with conchal cartilage. figure 7. for strong dorsal and caudal struts with small septum harvest, harvested septum is used as extended spreader graft while pcl is used as end-to-end seg. the pcl has to be covered with conchal cartilages. harvested septum as esg pcl as end to end seg philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 7170 philippine journal of otolaryngology-head and neck surgery practice pearls there are times wherein minimal surgery is needed for tip projection. since asian noses have weak medial crura with heavy skin and soft tissue envelope, pcl can be used just as a columellar strut either floating or fixed to the posterior caudal septum. fixing to the posterior caudal septum functions similar to a seg too. however, these techniques may be unstable. (figures 12 & 13) figure 13. columellar strut (2 pieces of thin pcl mesh) fixed at posterior septum. this functions very similarly to seg however it may be unstable. the pcl should be covered with conchal cartilages all the way from the tip to the posterior septum area to prevent erosion of mucosa. polycaprolactone was commercially available locally in the latter part of 2018. from august 2018 to march 2020, i used pcl in 213 (40.7%) out of 523 cases of septoplasty for structural rhinoplasty for various indications. all outcomes were followed up through calls and/or texts and all results were good with all patients satisfied with their results as of this writing, except for two. one patient developed post-operative deviation of the seg after a week; the etiology was due to the improper choice of pcl strength. revision surgery was done with replacement by a thicker pcl. another patient developed infection after 4 months. revision surgery involved removal of pcl and placement of columellar strut for support. this initial experience with the use of pcl is promising but it is too early to conclude. long term follow-up should be done to see changes in structure when the pcl is totally absorbed. in summary, pcl is a strong absorbable tissue template mesh in septoplasty and rhinoplasty. it is gradually absorbed within 2 yrs. while it is in its early stage as a mesh graft, it gives strength. however, as it is slowly absorbed, it imbibes the surrounding tissue cells for regeneration for future strength. it is highly recommended to cover the pcl with cartilages to prevent erosion to surrounding mucosa. aside from protection of the pcl against erosion and extrusion, the cartilage also gives the future strength as chondrocytes grow into the pcl mesh. references 1. toriumi dm. structural approach to primary rhinoplasty. aesthet surg j. 2002 jan; 2(1): 72-84. doi: 10.1067/maj.2002.122071; pmid: 19331957. 2. whitaker eg, johnson cm jr. the evolution of open structure rhinoplasty. arch facial plast surg. 2003 jul-aug; 5(4):291-300. doi: 10.1001/archfaci.5.4.291; pmid: 12873866. 3. yap ec. principles of structural rhinoplasty in south east asian noses. phillip j otolaryngol head neck surg. 2014 jul-dec; 29(2): 41-44. doi: https://doi.org/10.32412/pjohns.v29i2.437. 4. won tb, jin jr, lee hj. nasal tip surgery in asians. otolaryngology-head and neck surgery. 2008 may: 102. 5. wee jh, mun sj, na ws, kim h, park jh, kim dk, et al. autologous vs irradiated homologous costal cartilage as graft material in rhinoplasty. jama facial plast surg. 2017 may 1;19(3):183188. doi: 10.1001/jamafacial.2016.1776; pmid: 28334327 pmcid: pmc5540002. 6. winkler aa, soler zm, leong pl, murphy a, wang td, cook ta. complications associated with alloplastic implants in rhinoplasty. arch facial plast surg. 2012 nov; 14(6):437-441. doi: 10.1001/ archfacial.2012.583; pmid: 22928175. 7. siddiqui n, asawa s, birru b, baadhe r, rao s. pcl-based composite scaffold matrices for tissue engineering applications. mol biotechnol. 2018 jul; 60 (7): 506-532. doi: 10.1007/s12033-0180084-5; pmid: 29761314. 8. malikmammadov e, tanir te, kiziltay a, hasirci v, hasirci n. pcl and pcl-based materials in biomedical applications. j biomater sci polym ed. 2018 may-jun; 29(7-9): 863-893. doi: 10.1080/09205063.2017.1394711; pmid: 29053081. 9. patricio t, gloria a, bartolo p. mechanical and biological behavior of pcl and pcl/pla scaffolds fore tissue engineering applications. chemical engineering transactions. 2013 jun 20; 32: 16451650. doi: 10.3303/cet1332275. 10. gaviria l, pearson jj, montelongo sa, guda t, ong jl. three-dimensional printing for craniomaxillofacial regeneration. j korean assoc oral maxillofac surg. 2017 oct; 43 (5): 288-298. doi: 10.5125/jkaoms.2017.43.5.288; pmid: 29142862 pmcid: pmc5685857. 11. lin sl. polycaprolactone facial volume restoration of a 46-year-old asian women: a case report. j cosmetic dermatol. 2018 jun; 17(3):328-332. doi: 10.1111/jocd.12482; pmid: 29314648. 12. rezaee khiabanloo s, jebreili r, aalipour e, eftekhari h, saljoughi, shahidi a. innovative techniques for thread lifting of face and neck. j cosmet dermatol. 2019 may 3. doi: 10.1111/ jocd.12969; pmid: 31050152. 13. de melo f, marijnissen-hofste j. investigation of physical properties of a polycaprolactone dermal filler when mixed with lidocaine and lidocaine/epinephrine. dermatol ther (heidelv). 2012 dec; 2(1):13. doi: 10.1007/s13555-012-0013-7; pmid: 23205335 pmcid: pmc3510390. 14. kim dh, yun ws, shim jh, park kh, choi d, park mi, et al. clinical application of 3-dimensional printing technology for patients with nasal septal deformities: a multicenter study. jama otolaryngol head nek surg. 2018 dec 1; 144 (12): 1145-1152. doi: 10.1001/jamaoto.2018.2054; pmid: 30326042 pmcid: pmc6583092. 15. park yj, cha jh, bang si, kim sy. clinical application of three-dimensional printed biomaterial polycaprolactone (pcl) in augmentation rhinoplasty. aesthetic plast surg. 2019 apr; 43(2): 437446. doi: 10.1007/s00266-018-1280-1; pmid: 30498936. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial the philippine journal of otolaryngology head and neck surgery (pjohns) is the official refereed journal of the philippine society of otolaryngology head and neck surgery (psohns). what does it mean for our journal to be refereed or peer reviewed? according to the world association of medical editors (wame),1 “a peer-reviewed biomedical journal is one that regularly obtains advice on individual manuscripts from reviewers who are not part of the journal’s editorial staff. peer review is intended to improve the accuracy, clarity and completeness of published manuscripts and to help editors decide which manuscripts to publish. peer review does not guarantee manuscript quality and does not reliably detect scientific misconduct.” who are peer reviewers? integral to the whole system, they are experts in their chosen field who are expected to provide an unbiased opinion on the quality, timeliness and relevance of a submitted manuscript.2 they are responsible to the editor and journal, their specialty and/or subspecialty, study participants and/or subjects, and authors, to “make sure rubbish does not get published.”2 as editors, we understand that peer review (also called refereeing) is not a perfect antidote to poor science and we need to carefully evaluate manuscripts themselves for quality and validity.3 prior to review, we carefully review submissions for suitability to our journal and ensure that all important elements of the manuscript are included, in accordance with our instructions to authors.4 manuscripts are subjected to a double blinded external peer-review process, guided by the “responsibilities and rights of peer reviewers” contained in the editorial policy statements approved by the council of science editors board of directors.5 for participants in the psohns research contests, this review process is facilitated by pre-judging of anonymized manuscripts by blinded judge-reviewers. manuscripts are further reviewed by editors and other experts in the field and may be proofread, contentand formedited and returned for revision. the revision process is often tedious, particularly when authors fail to adequately address the concerns, comments and corrections of editors and reviewers (or referees). in this regard, authors have much to learn from research protocol and medical writing workshops. it is also in the best interests of editors and their journals to improve peer review and ways to do so have been identified by systematic reviews.6,7 correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 554 8467 telefax: (632) 524 4455 email: lapenajf@upm.edu.ph , jflapena@up.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines peer review and the pjohns: principles, problems and promise philipp j otolaryngol head neck surg 2018; 33 (1): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial double-blind review (blinding both author and reviewer to each other’s identity and anonymizing manuscripts before review) supposedly reduces the likelihood of bias for or against authors based on name, affiliation or country of origin and is perceived as more fair.3,8 unless they are able to guess the identity of authors, reviewers only discover such identities if the manuscript is finally accepted and published.7,9 on the other hand, lack of transparency may be considered a limitation of double-blind review although the cultural-appropriateness of transparency may be argued in collective cultural contexts such as ours. to minimize bias and manage and assure the quality of the peer review process, we try to select peer reviewers who possess the appropriate expertise needed to review a manuscript thoroughly and identify and exclude peer reviewers with potential conflicts of interest.10 in cooperation with the psohns, we conduct 1-day introduction to basic medical writing workshops, and 2-day advanced workshops for peer reviewers every year as well as mini-workshops during our annual convention. unfortunately, it seems that those who would benefit most from our courses are not the ones who participate in them. very few consultants have attended either workshop, evinced by the quality of co-authorship of their own papers, or their reviews of other papers. there are many instances where senior colleagues perpetuate inappropriate research and writing practices, contradicting what would have been the correct work of their junior co-authors (the latter merely applying what they learned from our workshops). worse, some of these consultants references 1. world association of medical editors. definition of a peer-reviewed journal. oct 19, 2007. [cited 26 may 2018]. available from: http://www.wame.org/policy-statements#definition%20 pr. 2. peh wc, ng kh. role of the manuscript reviewer. singapore med j 2009 oct; 50(10): 931-933. pmid:19907880. 3. lapeña jf, winker m. peer review, manuscript decisions, and author correspondence. wame elearning program. world association of medical editors 2018. (forthcoming). 4. philippine journal of otolaryngology head and neck surgery. instructions to authors. [cited 26 may 2018]. available from: https://journal.pso-hns.org/instructions-to-authors/. 5. council of science editors. responsibilities and rights of peer reviewers. cse editorial policy statement. science editor 2002 nov-dec;25(6):187. [cited 26 may 2018] available from: https:// www.councilscienceeditors.org/wp-content/uploads/v25n6p187.pdf. 6. jefferson t, rudin m, brodney folse s, davidoff f. editorial peer review for improving the quality of reports of biomedical studies. cochrane database of systematic reviews 2007, issue 2. art. no.: mr000016. doi: 10.1002/14651858.mr000016.pub3. 7. bruce r, chauvin a, trinquart l, ravaud p, boutron i. impact of interventions to improve the quality of peer review of biomedical journals: a systematic review and meta-analysis. bmc med. 2016 jun;14(1):85. doi: 10.1186/s12916-016-0631-5 pmid: 27287500 pmcid: pmc4902984. 8. okike k, hug kt, kocher ms, leopold ss. single-blind vs double-blind peer review in the setting of author prestige. jama. 2016 sep;316(12):1315–1316. doi:10.1001/jama.2016.11014 pmid:27673310. 9. justice ac, cho mk, winker ma, berlin ja, rennie d, and the peer investigators. does masking author identity improve peer review quality? a randomized controlled trial. jama. 1998 jul;280(3):240-242. doi:10.1001/jama.280.3.240 pmid:9676668. 10. moher d, galipeau j, alam s, barbour v, bartolomeos k, baskin p, et al. core competencies for scientific editors of biomedical journals: consensus statement. bmc med. 2017 sep 11;15(1):167. doi: 10.1186/s12916-017-0927-0. pmid:28893269 pmcid: pmc5592713 [cited 26 may 2018] available from: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0927-0. 11. international committee of medical journal editors (icmje). recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals. [cited 26 may 2018] available from: http://www.icmje.org/icmje-recommendations.pdf. 12. cope council. ethical guidelines for peer reviewers. september 2017. [cited 26 may 2018] available from: https://publicationethics.org/files/ethical_guidelines_for_peer_reviewers_2. pdf. insist on their way (as research supervisors, co-authors or reviewers), undoing our corrections and misguiding residents in the process. things would be different if they opened themselves to acquiring the knowledge, skills, and attitudes of good referees, and contribute to the ongoing history of scholarship in our field. meanwhile, regardless of the recommendations they make, the ultimate decision and responsibility is the editor’s. we aim to publish original work of value to the intellectual community in the best possible form and to the highest possible standards and expect similar standards from our reviewers and authors. our journal follows the “recommendations for the conduct, reporting, editing and publication of scholarly work in medical journals” of the international committee of medical journal editors (icmje), and is proudly listed as such.11 honesty, originality and fair dealing on the part of authors, and fairness, objectivity and confidentiality on the part of editors and reviewers are among the critical values that enable us to achieve our aim. to this end, we also endorse and uphold the ethical guidelines for peer reviewers established by the committee on publication ethics (cope).12 we hope that our efforts are well worth the hardships and heartaches we endure with each manuscript we process. guided by our principles, we painstakingly search for solutions to current problems as the promise of a better tomorrow beckons. we invite you to partner with us as peer reviewers and participate in our future. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to compare the incidence of recurrent laryngeal nerve injury and hypocalcemia in patients who underwent thyroidectomy using a superior-inferior versus an inferior to superior approach in identifying the recurrent laryngeal nerve in a tertiary government hospital between january 2012 to december 2016. methods: design: retrospective cohort study setting: tertiary government hospital patients: records of 241 adult patients who underwent surgery for thyroid diseases in the department of otorhinolaryngology – head and neck surgery between january 2012 and december 2016 were evaluated. records of patients with postoperative hoarseness after total thyroidectomy or lobectomy with isthmusectomy and hypocalcemia after total thyroidectomy were reviewed, and operative techniques analyzed for the approaches to recurrent laryngeal nerve identification. results: records of 119 patients (aged 20-73; median 41-years-old) meeting inclusion and exclusion criteria were analyzed. of 57 thyroidectomies using a superior-inferior approach, 42 were bilateral, totaling 99; of 62 using an inferior-superior approach, 40 were bilateral, totaling 102. there was a higher incidence of post-operative complications among those who underwent inferior-superior dissection than those who underwent superior-inferior dissection. chi square test showed the former approach (versus the latter) had 4.86 times the relative risk (rr) of permanent rln injury (1.9%, 0.0475 to 5.5914, p=.3058), 1.62 times the rr of transient rln injury (5%, 0.3971 to 6.5889, p=.5021), 1.92 times the rr of permanent hypocalcemia (1.9%, 0.0.1806 to 21.2838, p=.5910), and 2.06 times the rr of transient hypocalcemia (17%, 0.9055 to 4.4333, p=.0738). however, there was no significant difference between the two approaches with regard to hoarseness (independent t test, t value 0.90; p = .367) or hypocalcemia (t=0.428; p= .796). conclusion: there is no significant difference in the incidence of recurrent laryngeal nerve injury and hypocalcemia in patients who underwent thyroidectomy using a superior-inferior versus an inferior to superior approach in identifying the recurrent laryngeal nerve. intraoperatively, recurrent laryngeal nerve paralysis and hypocalcemia in superior to inferior compared to inferior to superior dissection approaches in thyroidectomy randel d. yu, md department of otorhinolaryngology head and neck surgery armed forces of the philippines medical center correspondence: dr. randel d. yu department of otorhinolaryngology head and neck surgery armed forces of the philippines medical center 7th floor armed forces of the philippines medical center v. luna avenue, quezon city 0840 philippines phone: (632) 426 2701 local 6172 email: ent_afpmc@yahoo.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believe that the manuscript represents honest work. the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery analytical research contest, november 9, 2017. menarini office, bonifacio high street, taguig city. philipp j otolaryngol head neck surg 2018; 33 (2): 24-27 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles surgeons may shift from one approach to the other as needed, and we recommend that they be well versed in both approaches and fully knowledgeable of the various anatomical courses of the recurrent laryngeal nerve and locations of parathyroid gland. keywords: recurrent laryngeal nerve injuries, thyroid neoplasms, thyroidectomy, vocal cord paralysis, hypoparathyroidism, hypocalcemia thyroidectomy remains the main source of iatrogenic recurrent laryngeal nerve (rln) paralysis1 and the most common complication after total thyroidectomy is still hypocalcemia with varied reported incidences for both transient and permanent hypocalcemia.2 these injuries induce significant post-operative morbidities from hoarseness to more serious complications including aspiration and dyspnea which are potentially life threatening.3,4 the management of such complications warrant hospitalization, and preventing them may help avoid further physical, emotional, social, psychological and financial burdens for the patient. it is prudent for surgeons to identify the rln during thyroidectomy5 and different thyroidectomy dissection approaches have been advocated to facilitate this and prevent complications.2,6-14,17-18 these include lateral-medial,17 medial-lateral,18 superior-inferior,2,6-7,10-12 or inferior-superior dissection.2,6,8-9,14 some prefer a superior-inferior approach suggesting it may decrease the incidence of postoperative permanent and transient rln injury and hypoparathyroidism2,6 but evidence for this approach is limited. this study aims to compare the incidence of rln injuries and hypoparathyroidism in patients who underwent thyroidectomy using a superior-inferior approach versus those using an inferior-superior approach over 5 years in a single institution. methods with institutional ethics review board approval, this 5-year retrospective study of medical records of all adult patients who underwent thyroid surgery from january 2012 to december 2016 was conducted in the otorhinolaryngology–head and neck surgery department of a tertiary government hospital. there were a total of 241 adult patients who underwent thyroid surgery in our department from january 2012 to december 2016. records of patients with multinodular non-toxic goiter, nodular non-toxic goiter, colloid goiter, grave disease and well-differentiated thyroid malignancy who underwent lobectomy with isthmusectomy or total thyroidectomy were considered for inclusion in the study. of these, records of patients with post-operative hoarseness after total thyroidectomy or lobectomy with isthmusectomy and hypocalcemia after total thyroidectomy were retrieved for further analysis. records of patients with pre-operative vocal fold paralysis, intrathoracic goiters, re-operation or completion thyroidectomy, or with gross involvement of the rln by malignant tumor, as well those with incomplete data were excluded. pre-operative evaluations considered included thyroid ultrasound results, thyroid stimulating hormone (tsh) and free t4 values, fine needle aspiration biopsy results, documentation of vocal cord mobility by flexible or rigid laryngoendoscopy, and serum calcium determination. parathyroid hormone assays were not used to evaluate parathyroid hormone levels in our institution. operative techniques were scrutinized. all thyroidectomies were performed by third year and fourth year residents with rln identification utilizing superior-inferior or inferior-superior dissection approaches, as documented in the operative records. intraoperative tumor size was also recorded, as it may have been a confounding factor. the superior-inferior dissection involved identifying the rln as it enters the cricothyroid articulation, followed by superior pedicle ligation, while inferior-superior dissection involved identifying the rln as it coursed through the tracheoesophageal groove after inferior pedicle ligation. postoperative evaluations recorded in the charts included vocal cord function assessed by flexible nasopharyngolaryngoscopy or 70˚ rigid laryngoendoscopy in all patients on the first post-operative day, and serum calcium levels determined 24 hours after surgery with a reference range of 2.10 – 2.55 mmol/l. post-thyroidectomy hypocalcemia was defined as levels below 2.00 mmol/l. patients were followed-up after one month then at three-month intervals for the first post-operative year. vocal cord function and serum calcium levels were assessed using flexible nasopharyngolaryngoscopy or 70˚ rigid laryngoendoscopy and serum calcium determination was repeated. permanent vocal cord paralysis was diagnosed when vocal fold mobility did not return 6 months after surgery and permanent hypocalcemia was considered when it persisted beyond 1 year. data analysis data (age, gender, tumor size, diagnosis, temporary and permanent post-operative vocal cord paralysis and hypocalcemia, inferior-superior and inferior-superior approach) were tabulated by the author using microsoft excel 2013 version 15.0.5041.1000 (microsoft corporation, redmond, wa, usa) and analyzed by a statistician. the incidence of permanent and temporary rln injury and hypoparathyroidism were expressed in percentages of the total number of rln identification per dissection approach. inferential statistics included the chi-square philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles test to compare the superior-inferior and inferior-superior approaches with outcomes, independent t test to determine whether there was a significant difference between the two approaches, and pearson correlation coefficient to determine any relationship between tumor size and technique performed. ibm spss version 21.0 (ibm corporation, armonk, ny, usa) was used for statistical computations. results a total of 119 records of patients meeting inclusion and exclusion criteria were included. the age range was 20 to 73 years-old (median age 41-years-old). there were more females (85, 71%) than males (34, 29%) with a f:m ratio of 2.5:1. the thyroid tumor size range was 1 to 8cm for inferior to superior approach with a mean tumor size of 3.31cm and 1 to 6cm for superior to inferior approach with a mean tumor size of 3.16cm. there was no correlation between the size of the predominant mass and the approach of choice in rln identification (pearson r=-0.0576, n=119, p=.278). there were 57 thyroidectomies performed using a superior-inferior approach and 62 performed using an inferior-superior approach. among the 57 superior-inferior approaches, 42 involved total thyroidectomy and 15 underwent lobectomy with isthmusectomy for a total of 99 superior-inferior approaches. among the 62 inferior-superior approaches, 40 underwent total thyroidectomy and 22 had lobectomy with isthmusectomy for a total of 102 inferior-superior approaches. those who underwent inferior-superior approaches had a higher incidence of postoperative complications: temporary rln injury (5, 4.9%); permanent rln injury (2, 1.96%); transient hypocalcemia (17, 16.67%); and permanent hypocalcemia (2, 1.96%) compared to those who underwent superior-inferior approaches: temporary rln injury (3, 3.03%); permanent rln injury nil; transient hypocalcemia (8, 8.08%); and permanent hypocalcemia (1, 1.01%). (table 1) compared to the superior-inferior approach using chi square test with the confidence interval of 95%, the inferior to superior approach had 4.86 times the relative risk of permanent rln injury (1.9%, 0.0475 to 5.5914, p=.3058), 1.62 times the relative risk of transient rln injury (5%, 0.3971 to 6.5889, p=.5021), 1.92 times the relative risk of permanent hypocalcemia (1.9%, 0.0.1806 to 21.2838, p=.5910), and 2.06 times the relative risk of transient hypocalcemia (17%, 0.9055 to 4.4333, p=.0738). compared to the inferior-superior approach, the relative risks of the superior to inferior approach were 0.21 times for permanent rln injury (0%, 0.1771 to 20.8776, p=.3058), 0.62 times for temporary rln injury (3%, 0.1518 to 2.5179, p=0.5021), 0.52 times for permanent hypocalcemia (1%, 0.2193 to 1.0721, p=0.5856) and 0.48 times for transient hypocalcemia (8%, 0.0100 to 4.2378, p=0.0738). utilizing the independent t-test to determine whether there is significant difference between the two approaches, there was no significant difference in inferior-superior (m: 1.07; sd: 0.319) and with superior-inferior (m:1.29; sd: 0.462) with a t value of 0.905 and a p value of .367. despite the apparent trends, there was no significant difference between the two approaches with regard to hoarseness (independent t test, t value 0.90; p = .367). with regard to the hypocalcemia, there was also no significant difference between the two approaches (t=0.428; p= .796). discussion our findings suggest that both thyroid surgical approaches in identifying the rln and preserving the parathyroid glands are comparable in terms of complications of temporary and permanent rln injury and hypoparathyroidism. of the 2 approaches to identifying the recurrent laryngeal nerve during thyroidectomy mentioned in the literature, veyseller et al. state that “the first identifies the nerve where it penetrates the larynx, following superior pedicle ligation, and the other traces the nerve in the superior direction after locating it in the tracheoesophageal groove.”11 also cited by babu et al.,2 both studies claim the superiorinferior approach was safer compared to the inferior-superior approach and had less complications of recurrent laryngeal nerve injury and hypocalcemia.2,11 several others state that the superior-inferior thyroidectomy approach allows the surgeon to reach the region directly involving less dissection with lower rates of rln injury and hypocalcemia.2,6,13 in this regard, rimpl et al. demonstrated that postoperative hypocalcemia was caused by extensive thyroid resection and parathyroid gland manipulation.13 on the other hand, lai et al.8 agree with loré et al. that “identification of the rln is best achieved through an inferior approach in a space table 1. outcomes of rln paralysis and hypocalcemia (number, n and %) superiorinferior inferiorsuperior p valueoutcomes temporary rln injury permanent rln injury transient hypocalcemia permanent hypocalcemia (n=99) n (%) 3 (3.03) 0 (0.00) 8 (8.08) 1 (1.01) (n=102) n (%) 5 (4.9) 2 (1.96) 17 (16.67) 2 (1.96) .4984587 nan .032924 .5793469 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles acknowledgements my heartfelt thanks to our department chairman robert f. rosqueta md and training officer grace naomi g. bravo md for their unwavering support, encouragement, input, contributions and useful discussions and advice on technical matters and clinical assistance. i would also like to thank maribel develos md, mph, drph for her insights and comments as a technical reviewer and my statisticians ms. melanie dp. turingan and ms. valerie d. cabanes. references 1. sulica l. laryngeal paralysis. in: snow jr. jb, wackym pa, editors. ballenger’s otorhinolaryngology head and neck surgery 17th edition. connecticut: people’s medical publishing house; 2009. p.923-924. 2. babu kv, nareshkumar s. study on the effect of recurrent laryngeal nerve identification technique in thyroidectomy on recurrent laryngeal nerve paralysis and hypoparathyroidism. int j sci res. 2016 oct; 5(10): 469 – 473. 3. zakaria hm, al awad na, kreedes as, al-mulhim am, al-sharway ma, hadi ma, et al. recurrent laryngeal nerve injury in thyroid surgery. oman med j. 2011 jan; 26(1): 34–38. doi: 10.5001/ omj.2011.09; pmid: 22043377 pmcid: pmc3191623. 4. bergamaschi r, becouarn g, ronceray j, arnaud jp. morbidity of thyroid surgery. am j surg. 1998 jul; 176(1):71-75. pmid: 9683138. 5. formanez aj. vocal fold paralysis with intraoperative recurrent laryngeal nerve identification versus non-identification of recurrent laryngeal nerve in total thyroidectomy: a retrospective cohort study. philipp j otolaryngol head neck surg. 2016 jan-jun; 31(1): 22-25. 6. veyseller b, aksoy f, yildirim ys, karatas a, ozturan o. effect of recurrent laryngeal nerve identification technique in thyroidectomy on recurrent laryngeal nerve paralysis and hypoparathyroidism. arch otolaryngol head neck surg. 2011 sep; 137(9):897-900. doi: 10.1001/ archoto.2011.134; pmid: 21844405. 7. clark oh, caron nr. fine needle aspiration biopsy of the thyroid: thyroid lobectomy and subtotal and total thyroidectomy. in: fischer je, bland ki, callery m, clagett gp, jones db, logerfo fw, seeger jm (editors). mastery of surgery by fischer, 5th edition. philadelphia: lippincott williams and wilkins; 2007. p. 398-410. 8. lai sy, mandel sj, weber rs. management of thyroid neoplasms. in: flint pw, haughey bh, lund vj, niparko jk, richardson ma, robbins kt, et al, (editors). cummings otolaryngology head and neck surgery 6th edition. philadelphia: mosby-elsevier; 2015. p. 1919 – 1920; 1926. 9. freeman jl. open thyroidectomy. in: myers en, ferris rl, editors. master techniques in otolaryngology-head and neck surgery head and neck surgery: thyroid, parathyroid, salivary glands, paranasal sinuses and nasopharynx volume2. philadelphia: lippincott william and wilkins; 2014. p. 118-122. 10. mochloulis g, semour fk, stepehen j. thyroidectomy. in: mochloulis g, semour fk, stepehen j (editors). ent & head and neck surgery an operative guide. taylor and francis group; 2014 p. 92-95. 11. bruncardi fc, anderson dk, billiar tr, dunn dl, hunter jg, mathews jb, et al. thyroid, parathyroid and adrenals. in: bruncardi fc, anderson dk, billiar tr, dunn dl, hunter jg, mathews jb, et al (editors). schwartz’s principles of surgery 9th edition. the mcgraw-hill.; 2010. p. 1551-1554. 12. kasperbauer jl, mciver b. disease of the thyroid and parathyroid glands. in: snow jr. jb, wackym pa (editors). ballenger’s otorhinolaryngology head and neck surgery 17th edition. connecticut: people’s medical publishing house; 2009. p.1175; 1176. 13. rimpl i, wahl ra. surgery of nodular goiter: postoperative hypocalcemia in relation to extent of resection and manipulation of the parathyroid glands. langenbecks arch chir suppl kongressbd. 1998; 115:1063-1066. pmid: 9931791. 14. loré jr. jm, farrell m, castillo nb. endocrine surgery. in: loré jr. jm, medina je (editors). an atlas of head and neck surgery 4th ed. philadelphia: mosby-elsevier; 2005. p. 903-909. 15. huang sm. do we over treat post-thyroidectomy hypocalcemia? world j surg. 2012 jul; 36(7):1503-8. doi: 10.1007/s00268-012-1580-6; pmid: 22491818. 16. american speech-language-hearing association. [http://www.asha.org/default.aspx]. vocal cord paralysis; [updated 2017; cited 2017 aug 02]. available from: http://www.asha.org/public/ speech/disorders/vfparalysis/. 17. panieri e, fagan j. thyroidectomy: open access of otorhinolaryngology, head & neck operative surgery. university of cape town. [cited 2017 aug 02]. available from: https://vula.uct.ac.za/ access/content/group/ba5fb1bd-be95-48e5-81be-586fbaeba29d/thyroidectomy.pdf. 18. rush bf jr, swaminathan ap, patel r. a medial approach to thyroidectomy. am j surg. 1975 oct; 130(4):430-432. pmid: 1166936. 19. dy ae, lapeña jf. transient bilateral vocal fold paralysis after total thyroidectomy. kulak burun bogaz ihtis derg. 2016 nov-dec;26(6):356-9. doi: 10.5606/kbbihtisas.2016.43077 pmid:27983904. defined by lore and colleagues as the retrolaryngeal node triangle.”14 despite proper technique and identification of the recurrent laryngeal nerve and parathyroid gland, postoperative hoarseness and hypocalcemia can ensue. dy and lapeña reported a case of transient bilateral vocal fold paralysis after total thyroidectomy and asked whether branched recurrent laryngeal nerves may be a risk factor for transient and permanent vocal cord paresis after surgery.19 we set out to address the divergence between superior-inferior and inferior-superior approaches. however, our study cannot favor either approach as it showed no significant difference between both approaches in terms of postoperative hoarseness and hypocalcemia and the status quo remains. this study has several limitations. it was unable to account for variability among surgeons and surgical skills, mastery and experience for each surgical approach. tumor size was another possible confounding factor but it was not statistically significant. we recommend a larger population size and a prospective study design to address the limitations of a retrospective study and having a team of surgeons that is well versed in both approaches and mastery of various anatomical variations of the recurrent laryngeal nerve and location of the parathyroid glands and its blood supply. in conclusion, our study showed no significant difference between both thyroidectomy approaches in terms of postoperative hoarseness and hypocalcemia. surgeons may intraoperatively shift from one approach to the other as needed, and we recommend that surgeons should be well versed in both approaches and fully knowledgeable of the various anatomical courses of the recurrent laryngeal nerve and location of parathyroid glands and their blood supply. philippine journal of otolaryngology head and neck surgery vol. 32 no. 2 july– december 2017 philippine journal of otolaryngology head and neck surgery 3 contents millenials in medicine: tradition and disruption ehretia microphylla (tsaang gubat) versus loratadine as treatment for allergic rhinitis: a randomized controlled trial hungry bone syndrome (hbs) in patients operated for primary hyperparathyroidism (phpt): a six-year experience prevalence and reasons for non-follow-up of newborns with “refer” results on initial hearing screening thyroid gland invasion in laryngeal carcinoma risk factors for recurrent papillary thyroid carcinoma an initial overview of management and treatment outcomes for head and neck hemangiomas oral propranolol therapy for benign capillary hemangiomas in a series of adult and pediatric patients basal cell carcinoma, odontogenic cysts, brain and skeletal abnormalities (gorlin goltz syndrome) in a 46-year-old woman unilateral tonsilar hypertrophy in a 4-year-old girl with focal dermal hypoplasia (goltz syndrome) late-onset anterolateral thigh free flap failure in buccal carcinoma reconstruction supernumerary nostril in a 15-year-old girl a second branchial cleft cyst presenting as a dumbbell-shaped anterior neck mass unilateral horizontal semicircular canal malformation causing recurrent vertigo sinonasal tract meningioma total thyroidectomy from a patient’s perspective joseph anthony r. rivera, md (1980-2016) cover images editorial 4 millenials in medicine: tradition and disruption lapeña jf original articles 6 ehretia microphylla (tsaang gubat) versus loratadine as treatment for allergic rhinitis: a randomized controlled trial umali fac, chua ah 11 hungry bone syndrome (hbs) in patients operated for primary hyperparathyroidism (phpt): a six-year experience padilla-baraoidan rzm, capuli-isidro mj, cudal bib, embestro-pontillas aa 17 prevalence and reasons for non-follow-up of newborns with “refer” results on initial hearing screening ong kmc, cruz tlg, grullo per 22 thyroid gland invasion in laryngeal carcinoma vitamog mc, castaneda ss 25 risk factors for recurrent papillary thyroid carcinoma gloria jdl, pontejos aqy, grullo per 30 an initial overview of management and treatment outcomes for head and neck hemangiomas fernandez ru 34 oral propranolol therapy for benign capillary hemangiomas in a series of adult and pediatric patients dimaguila gac, samson es case reports 38 basal cell carcinoma, odontogenic cysts, brain and skeletal abnormalities (gorlin goltz syndrome) in a 46-year-old woman magbuhat dcd, matsuo jms, de la cruz rar 43 unilateral tonsilar hypertrophy in a 4-year-old girl with focal dermal hypoplasia (goltz syndrome) ong jel, barrientos cmag, cruz ets 47 late-onset anterolateral thigh free flap failure in buccal carcinoma reconstruction mendoza djc, nieves cs, castañeda ss 51 supernumerary nostril in a 15-year-old girl lluisma acp featured grand rounds 55 a second branchial cleft cyst presenting as a dumbbell-shaped anterior neck mass sunga abg, castañeda ss from the viewbox 58 unilateral horizontal semicircular canal malformation causing recurrent vertigo yang nw under the microscope 60 sinonasal tract meningioma rivera jp, carnate jm letter to the editor 62 total thyroidectomy from a patient’s perspective villafuerte cv passages 65 joseph anthony r. rivera, md (1980-2016) gelera je “contrast-enhanced cranial ct scans, sagittal views, showing calcification of falx cerebi and tentorium cerebelli” samsung galaxy s7 edge by diane clarice d. magbuhat, md “intraoperative picture, cervicofacial flap and stsg” samsung galaxy s7 edge by diane clarice d. magbuhat, md “tranquility” canon 5d mark ii + ef 70-200l by rene louie c. gutierrez, md “practical exams” canon 5d mark ii + ef 70-200l by rene louie c. gutierrez, md “microlaryngeal surgery” 20”x25” oil on canvass by mariano b. caparas, md philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2019; 34 (2): 32-34 c philippine society of otolaryngology – head and neck surgery, inc. facial paralysis in longitudinal versus oblique and otic-sparing versus non otic-sparing temporal bone fractures ruben j. chua jr. md rene c. lacanilao md department of otolaryngology head and neck surgery amang rodriquez memorial medical center correspondence: dr. rene c. lacanilao department of otolaryngology-head and neck surgery amang rodriguez memorial medical center sumulong highway, sto. nino, marikina 1800 philippines phone: (632) 8941 5854 email: armmc_orlhns@yahoo.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest. october 22, 2018, maynila ballroom, the manila hotel, manila. abstract objective: to compare the proportion of temporal bone fractures using traditional (longitudinal vs. transverse) and otic involvement (otic sparing vs. non-otic sparing) classification schemes and their relationship with the development of facial paralysis. methods: design: retrospective case series setting: tertiary government hospital participants: records of 49 patients diagnosed with temporal bone fracture in our institution from august 2016 to june 2018. results: a total of 41 records of patients with temporal bone fractures, 32 males, 9 females, aged 5 to 70 years old (mean 37.5 years old) were included. in terms of laterality, 23 (56%) involved the right and 17 (41%) the left side. traditionally classified, 32 (78%) were longitudinal and 9 (22%) were transverse. using newer classification based on otic involvement and non-otic involvement, 38 (93%) were otic-sparing and 3 (7%) were non otic-sparing. only 9 (22%) out of 41 total fracture patients developed facial paralysis, involving 7 of the 32 longitudinal fractures and 2 of the 9 transverse fractures, or 8 of the 38 otic-sparing and 1 out of 3 non otic-sparing fractures. conclusion: because of the small sample size, no conclusions regarding the proportion of temporal bone fractures using traditional (longitudinal vs. transverse) and otic involvement (otic sparing vs. non-otic sparing) classification schemes and their relationship with the development of facial paralysis can be drawn in this study. keywords: head injuries; head trauma; skull fracture; temporal bone fracture; motor vehicles; traffic accidents; facial paralysis temporal bone fractures have been traditionally classified according to the fracture plane described as longitudinal or transverse in relation to the petrous ridge. a more recent classification gaining popularity describes fractures in terms of whether they penetrate the bony labyrinth (i.e. the cochlea, vestibule or semi-circular canals) as otic-capsule violating; or not, classified as oticcapsule sparing.1 the change in classification scheme allows a focus on the functional sequelae creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles and complications of temporal bone fractures as opposed to merely describing the anatomic orientation of the fracture.2 for example, a study of 173 patients done in korea found otic capsule-sparing fractures in 188 temporal bones by high-resolution computed tomography (ct). of these, 128 (68%) were longitudinal, 23 (12%) were transverse and 37 (20%) were mixed. among the 188 fractures there were 17 cases of facial paralysis (9%). out of these 17, 10 were longitudinal (7.8 % of the 128 longitudinal fractures), 3 were transverse (13.0 % of the 23 transverse fractures) and 4 were mixed types (10.8 % of the 37).3 a recent retrospective review showed that the otic capsule–sparing versus otic capsule–disrupting classification scheme demonstrated statistically significant predictive ability of determining facial nerve paralysis when compared with the older classification scheme.3 this study sought to compare the proportion of temporal bone fractures using traditional (longitudinal vs. transverse) and otic involvement (otic sparing vs. non-otic sparing) classification schemes and their relationship with the development of facial paralysis. methods with institutional ethical review board approval (erb no. r-201805-00), this retrospective case series retrieved records of patients with temporal bone fractures seen in our institution from august 2016 to june 2018. potential cases were identified from admission, referral and emergency room logbooks and the daily in-patient census. included were records of those seen in or referred to the emergency room department and in-patient ward with a suggestive history and documented symptoms and signs (hemotympanum, bloody otorrhea, battle sign) of temporal bone fracture, and ct scan diagnoses of temporal bone fracture that had been made by a senior radiology resident. diagnoses of facial paralysis had been previously recorded in the charts by an ear, nose, throat (ent) resident physician who performed the physical examination, using the house-brackmann classification. the hospital picture archiving and communication system (pacs) was utilized to retrieve digital imaging and communications in medicine (dicom) images of ct scans that had been obtained using a hitachi eclos 8 ct scanner (hitachi medical systems europe ag, steinhausen, switzerland). retrieved dicom images were independently reviewed by a blinded senior radiology resident and only those diagnosed with temporal bone fractures were included in the final analysis. excluded were records of patients with previous facial paralysis or asymmetry, those whose ct scan images could not be retrieved on our pacs, and those with signs or symptoms of temporal bone fracture that were not confirmed by ct scan, or when no temporal bone fractures could be confirmed upon review by the senior radiology resident. data from patient records was tabulated using ms excel version 14.6.3 (microsoft corp., redmond, wa, usa) and variables were analyzed using descriptive statistics (frequencies and percentages). results out of a total of 49 patients identified, only 41 patients with temporal bone fractures were included in this series, aged 5 to 70 years old (mean age 37.5 years old). thirty two (78.05%) were male and 9 (21.96%) were female. of the 41 fractures, 32 (78.05%) were longitudinal, 9 (21.96%) were transverse, 38 (92.68%) were otic-sparing and 3 (7.32%) were non otic-sparing. based on laterality 23 (56.10%) occurred in the right side and 17 (41.46%) occurred in the left. figures 1 to 4 show representative ct scan images of longitudinal, transverse, otic-sparing and non oticsparing fractures. out of 32 longitudinal temporal bone fractures, 7 (21.88%) had facial paralysis. out of 9 transverse temporal bone fractures, 2 (22.22%) had facial paralysis. on the other hand, out of 38 otic-sparing temporal bone fractures, 8 (21.05%) had facial paralysis and out of 3 otic-disrupting bone fractures only 1 (33.33%) had facial paralysis. in other words, facial paralysis occurred on the average in 22% of all temporal bone fractures whether or not they were longitudinal fractures, transverse fractures, or otic-sparing fractures, while otic-disrupting fractures had a facial paralysis occurrence of 33%. figure 1. representative plain temporal bone ct scan, axial view, bone window at the level of the mastoid air cells showing a longitudinal fracture (arrow). figure 2. representative plain temporal bone ct scan, coronal view, bone window at the level of the mastoid air cells showing a transverse fracture (arrow). philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery original articles discussion our study found that the percentage of facial paralysis was on the average 22% regardless of the type of fracture. there was no significant difference in proportion of facial paralysis when classified according to the traditional or newer classification scheme for temporal bone fractures. although otic-disrupting fractures had a facial paralysis occurrence of 33%, it is hard to draw a conclusion on their occurrence and relationship to facial paralysis because of the small sample size. facial paralysis is a severely disfiguring complication of temporal bone fractures wherein 7% result in facial paralysis.2 facial nerve palsy occurs in 20% of longitudinal temporal bone fractures and 50% of transverse temporal bone fractures.4 a previous study found that the incidence of facial paralysis was 10%-20% in longitudinal fractures and 50% in transverse fractures.5 both longitudinal and oblique fractures run parallel to the long axis of the petrous ridge and together account for 75-80% of temporal bone fractures with the facial nerve involved in 20-25%.6 a study by proctor et al. demonstrated that 80% of temporal bone fractures were longitudinal and 20% were transverse.7 several studies shows that 50% of transverse fractures will present with facial nerve paralysis.8,9 although the results of this study mirrored the observation that the anatomical classification of temporal bone fractures into longitudinal and transverse types may be convenient but offer no clinical distinction in predicting the development of facial nerve paralysis, the limitations of our study need to be considered. references 1. bhindi a, carpineta l, al qassabi b, waissbluth s, ywakim r, manoukian jj, et al. hearing loss in pediatric temporal bone fractures: evaluating two radiographic classification systems as prognosticators . int j pediatr otorhinolaryngol. 2018 jun; 109: 158-163. doi: 10.1016/j. ijporl.2018.04.005; pmid: 29728172. 2. brodie h, wilkerson b. management of temporal bone fracture. in: flint pw, haughey bh, lund v, niparko jk, thomas robbins k, regan thomas j, et al. cumming’s otorhinolaryngologyhead and neck surgery. 6th edition. pa: elsevier saunders. 2015. pp. 2220-2232. 3. song sw, jun bc, kim h. clinical features and radiological evaluation of otic capsule sparing temporal bone fractures. j laryngol otol. 2017 mar; 131(3): 209–214. doi: 10.1017/ s0022215117000123; pmid: 28124635. 4. stewart mg. head, face, and neck trauma. 1st edition.. ny: thieme new york. 2005. pp. 170 – 172. 5. nadol jr., jb, mckenna mj. surgery of the ear and temporal bone. pa: lippincott williams and wilkins. 2005. pp. 442 – 447. 6. schubl sd, klein tr, robitsek rj, trepeta s, fretwell k, seidmann d, et al. temporal bone fracture: evaluation in the era of modern computed tomography. injury. 2016; 1893-7. doi: 10.1016/j.injury.2016.06.026; pmid: 27387791. 7. grewal ds, hathiram bt. facial nerve in temporal bone fractures: in: house w, (editor). atlas of surgery of the facial nerve. philadelphia: mcgraw-hill .2007. pp. 50-57. 8. dela cruz rr, tuazon r. motorcycle related cranio-maxillofacial injuries at a tertiary hospital in the philippines. philipp j otolaryngol head neck surg. 2016 jul-dec; 31(2): 27-30. doi: https://doi. org/10.32412/pjohns.231. 9. yalciner g, kutluhan a, bozdemir k, cetin h, tarlak b, bilgen as. temporal bone fractures: evaluation of 77 patients and a management algorithm . turkish journal of trauma & emergency surgery. 2012 sep; 18(5): 424-428. doi: 10.5505/tjtes.2012.98957; pmid: 23188604. figure 3. representative plain temporal bone ct scan, axial view, bone window at the level of the otic capsule showing an otic-sparing fracture (arrow). figure 4. representative plain temporal bone ct scan, axial view, bone window at the level of the otic capsule showing an otic-disrupting fracture (arrow). a primary limitation of this study is the small sample size, especially reflected in the otic-disrupting subset that is not large enough to compare the occurrence of facial nerve paralysis. future studies with larger samples may yield better results for analysis. in conclusion, because of the small sample size, this study can draw no conclusions regarding the proportion of temporal bone fractures using traditional (longitudinal vs. transverse) and otic involvement (otic sparing vs. non-otic sparing) classification schemes and their relationship with the development of facial paralysis. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery contents cover images editorial 4 open access: doaj and plan s, digitization and disruption lapeña jf original articles 7 nasopharyngeal tuberculosis in a philippine tertiary general hospital gomez mat, villarta rl, caro rm, manasan cvc, carnate jm 11 salivary ph and taste sensitivity among geriatric and non-geriatric patients in a tertiary hospital: a cross-sectional study crisostomo mv, ureta cv 16 timing of tracheostomy, weaning from mechanical ventilation and duration of hospitalization among a sample of pediatric patients ferrolino jba, lapeña jff, carrillo rjd 20 timing of tracheostomy and outcomes in adults with moderate and severe tetanus: a cross-sectional study espinosa wz, vinco vv 24 association of ultrasonographic findings and thyroid malignancy: a cross-sectional study trinchera cs, cruz ets 29 maxillofacial gunshot and blast injuries seen in a tertiary military hospital garimbao jfp 32 facial paralysis in longitudinal versus oblique and otic-sparing versus non otic-sparing temporal bone fractures chua rj, lacanilao rc case reports 35 kikuchi-fujimoto disease in a filipino boy: a case report escalderon jrdj, monroy aa 39 congenital muscular torticollis: a case report villanueva lmb 42 emergent reconstruction of laryngeal penetrating neck injury: a case report pecolera rs, onofre rdc 47 autologous fat transfer to improve aesthetic appearance in facial asymmetry from parry-romberg syndrome: a case report sison mnk, cruz ets, fernandez mar featured grand rounds 52 left hemifacial lymphatic malformation in a nine-year-old boy cambe smm, rabo jis, navarro-locsin cgs under the microscope 55 traumatic ulcerative granuloma with stromal eosinophilia inoferio ksa, agbay rlm, carnate jm from “under the microscope” mandibulectomy specimen phone huawei y611 720x1280 resolution by jennifer tan-go, md “digital lateral nasal bone x-ray” of foreign body toy battery in the nose by justin ian a. jabson, md “surhano” acrylic on canvas 24x36 by angelito r. lepalam 2017 “philippine banaue rice terraces” setting: photo apple ipad mini 3 model no. mgj22pp/a software version: 12.4.2 by rowena c. saplala “alpha rooster” crayola markers on cardboard 8x6 by anna carlissa a. aujero, md open access: doaj and plan s, digitization and disruption nasopharyngeal tuberculosis in a philippine tertiary general hospital  salivary ph and taste sensitivity among geriatric and non-geriatric patients in a tertiary hospital:  a cross-sectional study timing of tracheostomy, weaning from mechanical ventilation and duration of hospitalization among a sample of pediatric patients timing of tracheostomy and outcomes in adults with moderate and severe tetanus: a cross-sectional study association of ultrasonographic findings and thyroid malignancy: a cross-sectional study maxillofacial gunshot and blast injuries seen in a tertiary military hospital facial paralysis in longitudinal versus oblique and otic-sparing versus non otic-sparing temporal bone fractures  kikuchi-fujimoto disease in a filipino boy: a case report congenital muscular torticollis: a case report emergent reconstruction of laryngeal penetrating neck injury: a case report autologous fat transfer to improve aesthetic appearance in facial asymmetry from parry-romberg syndrome: a case report left hemifacial lymphatic malformation in a nine-year-old boy traumatic ulcerative granuloma with stromal eosinophilia philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 case reports philipp j otolaryngol head neck surg 2020; 35 (2): 44-47 c philippine society of otolaryngology – head and neck surgery, inc. endoscopic management of a large tornwaldt cyst: a case report wenrol z. espinosa, md michael joseph c. david, md department of otolaryngology-head and neck surgery corazon locsin montelibano memorial regional hospital correspondence: dr. michael joseph c. david department of otolaryngologyhead and neck surgery corazon locsin montelibano memorial medical center lacson st., bacolod city 6100 philippines phone: +63 34 708 4575 email: enthns_clmmrh@yahoo.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery poster session on surgical innovation and instrumentation. december 7, 2019. batanes 1 and 2 function rooms, edsa shangri la hotel, mandaluyong city and at the 6th asian society of head and neck oncology poster exhibition. march 27-30, 2019. seoul, korea. abstract objective: to report successful marsupialization of a large tornwaldt cyst using combined transnasal and transoral endoscopic surgery in a 7-year-old girl who presented with nasal obstruction. methods: design: case report setting: tertiary government training hospital patient: one result: a 7-year-old girl presented with an 11-month history of recurrent yellowish nasal discharge gradually associated with nasal obstruction. examination revealed a large, well encapsulated, broad-based cystic mass in the nasopharynx immediately adjacent to the posterior choanae, continuing posterior to the soft palate (pushing the uvula anteriorly) and extending inferiorly to the epiglottic area. computerized tomography (ct) demonstrated a well-circumscribed, midline hypodense mass with fluid attenuation obstructing the nasopharyngeal area extending inferiorly to the oropharyngeal area. endoscopic marsupialization via transnasal and transoral approach was successful, and a respiratory epithelium-lined cyst consistent with a tornwaldt cyst was confirmed by histopathologic examination conclusion: combined transnasal and transoral endoscopic marsupialization is possible a for a large symptomatic tornwaldt cyst in a pediatric patient with relatively smaller and complex nasal cavities. keywords: tornwald cyst, thornwaldt cyst, nasopharyngeal cyst, endoscopic marsupialization tornwaldt cysts are uncommon congenital cysts of the nasopharynx, usually located in the region of the pharyngeal bursa.1 although most are asymptomatic throughout life, large tornwaldt cysts may cause nasal obstruction, foreign body sensation, halitosis, post nasal discharge, headache and otitis media secondary to eustachian tube dysfunction.2,3 a search of creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 case reports herdin and this journal (philipp j otolaryngol head neck surg) yielded no local case reports on tornwaldt cysts and the management of symptomatic cases. we document the case of a large tornwaldt cyst in a 7-year-old girl who presented with chronic purulent nasal discharge and nasal obstruction, and our experience in marsupializing it using combined transnasal and transoral endoscopy. case report a 7-year-old girl presented with an 11-month history of recurrent yellowish nasal discharge gradually associated with nasal obstruction. she was brought on several occasions to a pediatrician, and had been diagnosed and treated as a case of chronic sinusitis and allergic rhinitis. antihistamines and antibiotics offered no relief. there were no other symptoms such as fever, ear fullness, hearing loss, otorrhea, dysphagia nor odynophagia noted. anterior rhinoscopy revealed boggy turbinates with moderate yellowish nasal discharge. nasal endoscopy using a 0-degree rigid endoscope revealed a large, well encapsulated, cystic mass in the nasopharynx immediately adjacent to the posterior choanae. oropharyngeal examination confirmed continuation of the broadbased cystic mass posterior to the soft palate pushing the uvula anteriorly, extending inferiorly to the epiglottic area. a facial ct scan demonstrated a 4.8 x 2.4 x 1.8 cm wellcircumscribed, midline, hypodense mass with fluid attenuation in the nasopharyngeal area significantly obstructing the nasopharyngeal endotracheal anesthesia using a south-preformed right angle endotracheal (rae) tube for better view of the oral cavity. guided by a 0° rigid nasal endoscope, a transnasal punch of the cyst wall using blakesley forceps was initially done, and brownish fluid was observed to come out. this confirmed the clinical impression that it was a nasopharyngeal cyst and was unlikely containing cerebrospinal fliud. further aspiration resulted in marked decrease in cyst size. marsupialization of the nasopharyngeal portion of the cyst wall was performed transnasally and oropharyngeal remnants of the cyst were accessed transorally using 0° and 30° rigid nasal endoscopes. (figure 2) a powered straight and curve blade straightshot m4 microdebrider® (medtronic xomed® jacksonville, fl usa) allowed complete marsupialization down to the base of the cyst. there was minimal bleeding noted, but anterior and posterior nasal packing were applied in anticipation of postoperative bleeding. intraoperative intravenous tranexamic acid and dexamethasone were given and continued postoperatively for a day, along with oral ibuprofen and intravenous nalbuphine for pain control. the procedure lasted 1 hour and 30 minutes. nasal packing was removed the next day, and she was subsequently discharged on regular weekly follow-up visits for 1 month. there was resolution of the yellowish nasal discharge, and good mucosal healing was observed during her serial follow-up visits. final histopathology revealed a respiratory epitheliumlined cyst. in conjunction with the clinical and radiologic findings, the diagnosis of a tornwaldt cyst was made. figure 1. ct scan images, a. axial; b. sagittal; and c. coronal showing a 4.8 x 2.4 x 1.8 cm well-circumscribed, midline hypodense mass with fluid attenuation. a b c lumen, extending inferiorly to the oropharyngeal area. partial opacities (from nasal secretions) were noted in the nasal cavity and paranasal sinuses. no bony wall erosion, nasal septum deviation nor intracranial communication was demonstrated. the primary impression was a large tornwaldt cyst. (figure 1) she underwent endoscopic cyst marsupialization via a combined transnasal and transoral approach to the nasopharynx under general discussion a tornwaldt (also known as thornwaldt) cyst is an embryologic remnant of the pharynx-to-notochord contact located at the midline posterosuperior portion of the nasopharynx. it is classified as a congenital cyst of the nasopharynx, along with the rathke pouch cyst and dermoid cyst.2,3 the said area, otherwise known as a pharyngeal bursa, is a sac-like depression at the posterior portion of the nasopharyngeal philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 case reports wall that develops during sixth to tenth week of gestation, when the notochord transiently comes in contact with the superior portion of the pharyngeal mucosa.2 persistence of this communication forms an ingrowth of pharyngeal respiratory epithelium, which form the tornwaldt bursa, and once the orifice is partially or totally obstructed as result of infection or after adenoidectomy, a fluid-filled potential space called a tornwaldt cyst is formed.4-6 this nasopharyngeal cyst was first observed in 1840 by mayer in autopsy specimens7 and eventually recognized in 1885 by gustoff ludwig tornwaldt as a pathologic entity.8 in 1912, huber postulated that a pharyngeal bursa may form in the nasopharynx where the notochord has retained its communication with the pharyngeal epithelium.9 this uncommon congenital cyst was found by moody et al. to have a prevalence rate from 1.4 to 3.3% in autopsies, and from 0.2 to 5% in magnetic resonance imaging (mri) studies.10 they also found that most tornwaldt cysts are small, with an average volume of 0.66cm3 and 0.58cm3 on ct and mri, respectively.10 the cyst found in our patient was large, measuring 4.8 x 2.4 x 1.8 cm, or having a volume of 20.74 cm3. tornwaldt cysts can be classified as crusting or cystic. the crusting type can spontaneously rupture and drain into the nasopharynx, but the cystic variety does not drain because its means of drainage is completely obstructed.11 a tornwaldt cyst may cause tornwaldt disease if it is infected or inflamed, and causes eustachian tube dysfunction, otitis media, halitosis, pharyngitis and occipital headache.11 our patient qualifies as having tornwald disease due to the persistent yellow nasal discharge that did not adequately respond to antibiotics. figure 2. endoscopic views of: a, b. tornwaldt cyst (tc) through both nasal cavities; c. tc through the oropharynx; d. transnasal biopsy of the cyst wall; e. aspiration of the cyst; f. marsupialization using a microdebrider; g. marsupialized cyst base through the nasal cavity; and h. through the oral cavity. a e b f c g d h mri is optimal for investigating soft tissue masses such as nasopharyngeal cysts. jyotimar et al. recommended mri as the preoperative imaging of choice owing to the high signal created by the high cystic protein concentration and blood products.12 facial ct scan with contrast was requested for the patient due to its cost effectiveness, and for the information it provides to rule out bony defects of the skullbase and the cervical spine, with which the cyst was intimately related. a 5-year retrospective study by el-anwar et al. of 11 patients undergoing transnasal endoscopic approach to tornwaldt cysts using a microdebrider noted significant improvement in headache and nasal obstruction.13 complete wound healing was noted within 6 weeks and no reoperation was documented.13 there was no cyst recurrence, with resolution of symptoms (particularly ear related symptoms secondary to eustachian tube dysfunction) and normal tympanometry.13 however, the majority of their patients were adults with relatively larger nasal cavities and smaller thornwaldt cysts (range 5-20mm) compared to our case. in our patient, the tornwaldt cyst was relatively large, obstructing the nasopharyngeal airway and nasal mucociliary clearance and resulting in chronic rhinosinusitis and difficulty in breathing through the nose. these immediately resolved after the surgery. the use of combined approaches provided optimal visualization of and access to the nasopharynx. prudence and caution dictate that an initial cyst aspiration or small punch be done to confirm that the cyst contents are indeed not cerebrospinal fluid, prior to proceeding with marsupialization. powered philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 case reports references 1. weissman jl. thornwaldt cysts. am j otolaryngol. 1992 nov 01;13(6):381-5. doi: 10.1016/01960709(92)90080-d; pubmed pmid: 1443394. 2. kulsange kl, nagle s, jagade m, gupta p, pandhare m, parelkar k et al. thornwaldt cyst: case report. international journal of otolaryngology and head & neck surgery. 2016 sep 30; 5(2016): 203-7. doi: 10.4236/ijohns.2016.55032. 3. conley lm, phillips cd. imaging of the central skull base. radiol clin north am. 2017 jan; 55(1): 53-67. doi: 10.1016/j.rcl.2016.08.007; pubmed pmid: 27890188. 4. magliulo g, fusconi m, d’amico r, vincentis md. tornwaldt’s cyst and magnetic resonance imaging. ann otol rhinol laryngol 2001; 110(9):895-896. doi: 10.1177/000348940111000916; pubmed pmid: 11558769. 5. kawok p, hawke m, jahn af, mehtha m. tornwaldt’s cyst: clinical and radiological aspects. j otolaryngol 1987; 16: 104-107. pubmed pmid: 3599152. 6. shank ec, burgess lpa, geyer ca. tornwaldt’s cyst: case report with magnetic resonance imaging. otolaryngol head neck surg. 1990; 102: 169-173. doi: 10.1177/019459989010200213; pubmed pmid: 2113242. 7. mayer afc1. bursa seu cystis tubae eustachianae bei eingen saugcthieren. neue notizen aus dem gebiete der nature und heilk unde von froe iep. 1840 ;14:1.[german] 8. tornwaldt gl. uberdi e bedeutung der bursa pharygea furdieerkennung und behandlung gewisser nasen rauchenraum . krankheiten.weisbaden: j.e bergmann; 1885.[german] 9. huber gc. on the relation of the chorda dorsalis to the anlage of the pharyngeal bursa or median pharyngeal recess. anat rec. 1912 oct; 6:373-4 04. doi: 10.1002/ar.1090061002. 10. moody mw, chi dh, mason jc, phillips cd, gross cw, schlosser rj. tornwaldt’s cyst: incidence and a case report. ear nose throat j. 2007 jan; 86(1): 45-7: 52. pubmed pmid: 17315835. 11. miyahara h, matsunaga t. tornwaldt ‘s disease. acta otolaryng suppl 1994;517 :369. doi: 10.3109/00016489409124336; pubmed pmid: 7856446. 12. jyotirmay h, kumar sa, preetam p, manjunath d, bijiraj vv. recent trends in the management of thornwaldts cyst: a case report. j clin diagn res. 2014 aug 20; 8(8): 3-4. doi: 10.7860/ jcdr/2014/8086.4695; pubmed pmid: 25302225; pubmed central pmcid: pmc4190747. 13. el-anwar mw, amer hs, elnashar i, askar sm, ahmed af. 5 years follow up after transnasal endoscopic surgery of thornwaldt’s cyst with powered instrumentation. auris nasus larynx. 2015 feb; 42(1): 29–33. doi: 10.1016/j.anl.2014.08.016; pubmed pmid: 25240946. instrumentation such as the microdebrider® allowed for precise excision of delicate cyst walls, less traumatic intranasal instrument manipulation, and visualization due to the suction feature. this case exemplifies the need for otolaryngologic referral and evaluation of cases of chronic rhinosinusitis that do not improve with maximal medical management. because nasopharyngeal lesions such as these are uncommon and impossible to visualize without specialized diagnostic procedures and equipment, these may go undetected as a source of chronic ear, nose, and throat conditions. to the best of our knowledge, this is the first locally-reported case of a tornwaldt cyst, based on our literature search of herdin and this journal. these cysts may not be rare, but the large size of the cyst in this case is uncommon, and our experience in the management of this case is worth documenting. in conclusion, our experience suggests that a combined transnasal and transoral endoscopic marsupialization is a safe and effective solution for a large symptomatic tornwaldt cyst in a pediatric patient with relatively smaller and complex nasal cavities. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 7574 philippine journal of otolaryngology-head and neck surgery from the viewbox philipp j otolaryngol head neck surg 2020; 35 (1): 74-75 c philippine society of otolaryngology – head and neck surgery, inc. eye movement autophony: a unique presenting symptom of semicircular canal dehiscence syndrome nathaniel w. yang, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila department of otolaryngology head and neck surgery feu-nrmf institute of medicine correspondence: dr. nathaniel w. yang department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 8526 4360 fax: (632) 8525 5444 email: nathaniel.w.yang@gmail.com the author declared that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. a 31-year-old woman presented with the very unusual symptom of being able to hear the movement of her eyeballs in her left ear: “i can hear my eyeballs move!” she initially described hearing a recurrent “swishing” sound that would occur intermittently. she eventually realized that its occurrence coincided with eyeball movement. in the eight months’ duration of her symptom, she had been unable to obtain a diagnosis from physicians whom she consulted and had even been referred for psychiatric evaluation and treatment. an otolaryngologist whom she consulted had a standard pure tone audiometric examination done, and this showed normal hearing acuity in both ears. a magnetic resonance imaging (mri) of the inner ear and brain likewise showed no abnormalities. due to the peculiarity of the patient’s complaint, the otolaryngologist consulted with a neurotologist who suspected the presence of a semicircular canal dehiscence. a computerized tomographic imaging study of the temporal bone confirmed the presence of a left superior semicircular canal dehiscence syndrome. (figures 1 & 2) creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. coronal ct image at the level of the anterior (ampullated) limb of the superior semicircular canal shows the absence of bone that normally caps the left superior semicircular canal (white solid arrow) and separates it from the intracranial contents of the middle cranial fossa. figure 2. reformatted ct images in the pöschl projection, which is an oblique coronal image along the long axis of the superior semicircular canal allows visualization of this canal as a complete ring. the dehiscent left superior semicircular canal is clearly demonstrated (white solid arrow). philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 7574 philippine journal of otolaryngology-head and neck surgery from the viewbox first described by minor et al. in 1998, superior semicircular canal dehiscence syndrome is a neurotologic condition that characteristically presents as vertigo, oscillopsia, and/or disequilibrium induced by sound or changes in middle ear or intracranial pressure.1 subsequent clinical studies described the presence of audiologic symptoms, the most prominent of which were conductive hearing loss and autophony with or without vestibular manifestations.2 patients described an increased sensitivity to internally generated bone-conducted sounds, such as the heartbeat, chewing, footsteps hitting the ground and eye movements. it is of particular interest that the ability to hear one’s own eye movements, a condition known as eye movement autophony, currently appears to have been described as a symptom only in patients with semicircular canal dehiscence syndrome.3 anecdotally, although the author of this report has diagnosed quite a number of patients with semicircular canal dehiscence syndrome manifesting primarily with vestibular symptoms, this particular case is the only one that presented with eye movement autophony as the primary and only symptom. although the patient was not physically incapacitated by vertigo or chronic disequilibrium, she was significantly bothered by the unrelenting nature of her particular symptom. she subsequently underwent a transmastoid plugging of the superior semicircular canal which completely relieved her of the symptom. references 1. minor lb, solomon d, zinreich js, zee ds. soundand/or pressure-induced vertigo due to bone dehiscence of the superior semicircular canal. arch otolaryngol head neck surg. 1998 mar; 124(3): 249–58. doi: 10.1001/archotol.124.3.249; pmid: 9525507. 2. zhou g, gopen q, poe ds. clinical and diagnostic characterization of canal dehiscence syndrome: a great otologic mimicker. otol neurotol. 2007 oct; 28(7): 920–6. pmid: 17955609. 3. bhutta mf. eye movement autophony in superior semicircular canal dehiscence syndrome may be caused by trans-dural transmission of extraocular muscle contraction. int j audiol, 2015 jan; 54(1): 61-2. doi: 10.3109/14992027.2014.963711; pmid: 25328030. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 contents cover images editorial 4 covid-19 and climate change: signing up for our impossible dream lapeña jff special announcement 6 global health community calls for climate action ahead of cop26 to avert “biggest health threat facing humanity” original articles 8 pre-operative temporal bone ct scan readings and intraoperative findings during mastoidectomy toral db, laganao crd 13 endoscopic type i tympanoplasty in 70 patients with chronic otitis media: a preliminary report singh b, pal p, osahan hs, sood as 18 determination of ambient noise levels in the medical and surgical intensive care units and adult ward of the makati medical center chan-zamora jp, cedeño jrr, guzman pb, bigalbal jl 22 cerebro-spinal fluid leak in skull base reconstruction using hadad bassagasteguy flap after endoscopic endonasal transsphenoidal surgery: a case series formalejo jp, amable jp 25 nasolabial flap reconstruction for orofacial defects: a case series diaz rz, cabungcal ac 30 application of open-source 3d planning software in virtual reconstruction of complex maxillofacial defects caro dj, pamintuan fg case reports 36 approach to a sewing needle in the parapharyngeal space: a case report bettadahalli v, bhargava r, kumar s 40 single stage transoral cordectomy and medialization thyroplasty in early glottic squamous cell carcinoma: a case report regalado -go jaf, flores tj, santiago ae surgical innovations and instrumentation 44 aerosol and droplet particles contained by inexpensive barrier tent during mastoidectomy: a covid-19 innovation mangubat ad, labra pjp 49 addressing difficulty in communication while wearing a respirator mask during the covid-19 pandemic by using a laryngophone kongsun ching lvc, liu plaa featured grand rounds 52 pyoderma gangrenosum initially presenting as an ulceration of the ear lobule dulnuan hg, garcia cv, tirona-remulla a from the viewbox 55 post-traumatic malleo-incudal complex dislocation yang nw under the microscope 57 acantholytic squamous cell carcinoma maganito sc, carnate jm captoons 59 doknet’s world billones wu passages 60 joselito b. buluran, md lacanilao rc 61 ibarra r. crisostomo, md bautista ra 62 eusebio e. llamas, md martinez nv 63 robie v. zantua, md zantua act “or surgery” canon eos5dmk2 by rene louie c. gutierrez, md, mha histopathologic slide showing dyschohesive keratinocytes with glassy eosinophilic cytoplasm and distinct intercellular bridges in a case of acantholytic squamous cell carcinoma (h and e, 400x) by jose m. carnate, jr., md “peace, hope and love” watercolor on paper, 18”x12” by victoria c. sarmiento., md “light streaks” canon eos 350dc.2004 by rene louie c. gutierrez, md, mha post-operative ct after complex maxillary reconstruction using 3d planning by dann joel c. caro, md covid-19 and climate change: signing up for our impossible dream global health community calls for climate action ahead of cop26 to avert “biggest health threat facing humanity” pre-operative temporal bone ct scan readings and intraoperative findings during mastoidectomy endoscopic type i tympanoplasty in 70 patients with chronic otitis media: a preliminary report determination of ambient noise levels in the medical and surgical intensive care units and adult ward of the makati medical center cerebro-spinal fluid leak in skull base reconstruction using hadad bassagasteguy flap after endoscopic endonasal transsphenoidal surgery: a case series nasolabial flap reconstruction for orofacial defects: a case series application of open-source 3d planning software in virtual reconstruction of complex maxillofacial defects approach to a sewing needle in the parapharyngeal space: a case report single stage transoral cordectomy and medialization thyroplasty in early glottic squamous cell carcinoma: a case report aerosol and droplet particles contained by inexpensive barrier tent during mastoidectomy: a covid19 innovation addressing difficulty in communication while wearing a respirator mask during the covid-19 pandemic by using a laryngophone pyoderma gangrenosum initially presenting as an ulceration of the ear lobule post-traumatic malleo-incudal complex dislocation acantholytic squamous cell carcinoma doknet’s world joselito b. buluran, md ibarra r. crisostomo, md eusebio e. llamas, md robie v. zantua, md philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to describe the incidence, pattern and severity of maxillofacial trauma among patients who sustained gunshot and blast injuries of the maxillofacial region in a tertiary military hospital. methods: design: retrospective case series setting: tertiary military general hospital participantss: all patients admitted under the otorhinolaryngology service with gunshot and blast injuries to the face results: a total of 108 patients were admitted due to gunshot and blast injuries to the face from january 2010 to december 2015. most sustained gunshot injuries (73, 67.6%) compared to blast injuries (35, 32.4%). of 108 patients, 71 had maxillofacial fractures (65.7%) while the remaining 37 only had soft tissue injuries (34.3%). majority of those with maxillofacial fractures had single bone involvement (52, 72.2%); the rest had two or more bones affected (19, 27.8%) the most common bone injured was the mandible (77.5%), followed by the maxilla (35.2%), zygoma (12.7%), and others (frontal, nasal, and temporal bones) at 5.6%. conclusion: gunshot injuries had a higher incidence than blast injuries among military personnel with projectile injuries to the face seen during the study period. there were more fractures and combinations of fractured bones affected in gunshot injuries, although the breakdown of soft tissue injuries was similar among those with gunshot and blast injuries. however, the relation of injury patterns and severity to gunshot or blast etiology, or to other factors such as protective gear cannot be established in this present study. keywords: gunshot injuries; blast injuries; maxillofacial; projectile gunshot and blast injuries are commonly seen in a military hospital and patients come from different areas of the country where insurgency and terrorism are rampant. these patients are managed by multidisciplinary trauma teams including head and neck surgery, trauma surgery, neurosurgery and ophthalmology.1 injuries to the maxillofacial area pose a great problem maxillofacial gunshot and blast injuries seen in a tertiary military hospital julius france p. garimbao, md department of otorhinolaryngology head and neck surgery armed forces of the philippines medical center quezon city, philippines correspondence: dr. julius france p. garimbao department of otorhinolaryngology head and neck surgery armed forces of the philippines medical center 7th floor, armed forces of the philippines medical center v. luna avenue, quezon city 0840 philippines phone: (632) 8426 2701 local 6172 email: juliusgarimbao85@gmail.com the author declared that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2019; 34 (2): 29-31 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles because of close proximity to vital structures.1 they depend on the speed and energy of the projectile and the damage is often very difficult to repair.1,2 institutional data on maxillofacial injuries is important for patient care, as well as for preparation of plans and programs such as procurement of supplies and implants necessary for the management of these conditions. however, to the best of our knowledge there is only one previous relevant study in our institution and it described mandibular fractures only.3 this study aims to describe the incidence, pattern, and severity of facial trauma among patients who sustained gunshot and blast injuries to the maxillofacial region in a tertiary military hospital. this study also aims to identify the facial bones commonly involved with these types of injuries. methods with ethics review board approval, this retrospective case series reviewed records of all patients admitted to the otorhinolaryngologyhead and neck surgery (orl-hns) ward of the armed forces of the philippines medical center in quezon city from january 1, 2010 to december 31, 2015 who sustained gunshot and blast injuries to the maxillofacial area. data regarding sex, age, mechanism of injury (blast/ gunshot), and location and number of fractured bones of the face were gathered from hospital in-patient and radiographic examination records. the data was hand-searched, extracted and tabulated using microsoft excel for mac 2019 version 16.3 (19101301), (microsoft corp., redmond, wa, usa). descriptive statistics were used to describe categorical data. results a total of 108 patients were admitted to the orl-hns ward due to gunshot and blast injuries to the face during the study period from 2010 to 2015. all of the patients in this study were males. ages ranged from 21 to 56 years old (median age 32 years old). most (50) were aged 21 to 30 years old, followed by 41 patients aged 31 to 40 years old. only 14 and 3 patients were aged 41 to 50 and 51 to 60 years old, respectively. out of 108 patients, most sustained gunshot injuries (73 or 67.6%) compared to blast injuries (35 or 32.4%). most of the patients (71 or 65.7%) had fractures in the maxillofacial area while the remaining 37 (34.3%) only had soft tissue injuries. of the 71 with fractures, most (54 or 76.1%) were among those with gunshot injuries than those with blast injuries (17 or 23.9%), although the breakdown of soft tissue injuries was similar among those with gunshot injuries (19 or 51.4%) and blast injuries (18 or 48.6%). majority of patients with maxillofacial fractures had single bone involvement (52 or 72.2%) compared to multiple bone involvement (19 or 27.8%). of the 52 with single bone involvement, 36 (69.2%) were among those with gunshot injuries while 16 (30.8%) were among those with blast injuries. among the 19 with multiple bone involvement, 18 (94.7%) involved those with gunshot injuries while only one (5.3%) involved blast injury. of the 71 fractures, the most common bone fractured was the mandible (55 or 77.5%), followed by the maxilla (25 or 35.2%), zygoma (9 or 12.7%), and frontal, nasal or temporal bones, (4 or 5.6%). the majority of fractures were from gunshot injuries: 40 of the 55 mandibular fractures, 23 of the 25 maxillary fractures, all of the nine zygomatic fractures, and three of the four frontal/nasal/temporal bone fractures. discussion in our military hospital, wounded personnel come in daily with gunshot and blast injuries. among them are patients with injuries in the maxillofacial region. the management of maxillofacial gunshot and blast injuries is multifaceted because it involves the facial skeleton, orbit, cranium, airway and resulting deformities are usually disfiguring.4 all of the patients in this study were males. similar to the previous study in our institution on mandibular fractures, the predominant age group in our study was 21 to 30 years old which could reflect the fact that this age group makes up the fighting force of our soldiers engaged in actual combat.3 out of 108 patients, there were only 35 patients (32.4%) who sustained blast injuries to the face compared to 73 patients (67.6%) who had gunshot injuries in the same area. one explanation may be that blast injuries due to land mines and grenades are more commonly seen in the extremities especially in the lower limbs.5 gunshot injuries compared to blast or shrapnel injuries are expected to have more extensive damage due to their high velocity resulting in greater energy transfer to soft tissues and bones.4-6 this may explain why the breakdown of soft tissue injuries was similar among those with gunshot injuries and blast injuries while there were more fractures with the former than the latter. as expected from other studies, in almost all the facial bones included in our study, gunshots were still the leading cause of injury with higher risk of resulting fracture.5 furthermore, both single and multiple-bone fractures were more common in gunshot than blast injuries. high-velocity projectiles are more likely to cause unstable fracture configurations with butterfly fragments and large amounts of comminution.7 this might explain the higher occurrence of both multiple and single-bone involvement (such as comminuted mandibular fractures) in gunshot injuries in our study. on the other hand, in blast injuries the blast wave loses velocity and magnitude philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles before decaying into an acoustic wave.8,9 this might explain less fractures to the maxillofacial region from blast injuries in our study. similar to our findings, previous studies about penetrating and blunt injuries to the maxillofacial region also showed that mandible is the most frequent facial bone fractured in these types of injuries.4,10 on the other hand, we found that fractures in the nasal, frontal and temporal bone were less common compared to the other facial bones. one possible reason for this may be that the area is mostly covered by protective gear. another explanation may be the proximity of these bones to the brain, such that patients with injuries in this area may have been referred to neurosurgery and not included in this study. this is a limitation of our study and also extends to patients with primary injuries to the extremities being admitted under the orthopedic service. our only including patients admitted in the orl-hns ward also excluded patients in other wards who may have had concomitant maxillofacial injuries and future studies should account for these. another limitation of our study is the unavailability of data on the number of deaths from these type of injuries to account for the mortality rate among such patients. in conclusion, gunshot injuries had a higher incidence than blast injuries among military personnel with projectile injuries to the face seen during the study period. there were more fractures and combinations of fractured bones affected in gunshot injuries although the breakdown of soft tissue injuries was similar among those with gunshot and blast injuries. despite possible initial trends and patterns, the relation of injury patterns and severity to gunshot or blast etiology or to other factors such as protective gear, cannot be established in this present study. acknowledgements the author wishes to thank dr. ma. sheila p. jardiolin who provided general support, trisha kay p. lumio for data collection and technical support and dr. grace naomi g. bravo and dr. kirby p. jaramilla for data encoding and assistance with manuscript revisions. references 1. tholpady ss, de moss p, murage kp, havlik rj, flores rl. (2014). epidemiology, demographics, and outcomes of craniomaxillofacial gunshot wounds in a level i trauma center. j craniomaxillofac surg. 2014 jul; 42(5): 403-411. doi: 10.1016/j.jcms.2013.06.004; pmid: 23932740. 2. karaca ma, kartal nd, erbil b, oztuk e, kunt mm, sahin tt, et al. evaluation of gunshot wounds in the emergency department. ulus travma acil cerrahi derg. 2015 jul; 21(4): 248-55. doi:10.5505/ tjtes.2015.64495; pmid: 26374410. 3. galvan gb. evaluation of mandibular fractures in a tertiary military hospital: a 10-year retrospective study. philipp j otolaryngol head neck surg. 2011 jan-jun; 26(1): 16-20. doi: https://doi.org/10.32412/pjohns.v26i1.595. 4. norris o, mehra p, salama a. maxillofacial gunshot injuries at an urban level i trauma center—10-year analysis. j oral maxillofac surg. 2015 aug; 73(8): 1532-1539. doi:10.1016/j. joms.2015.03.019; pmid: 25865718. 5. rozen n, dudkiewicz i. wound ballistics and tissue damage. in: lerner a, soudry m, editors. armed conflict injuries to the extremities: a treatment manual. berlin-heidelberg: springerverglag; 2011. p. 21-33. doi:10.1007/978-3-642-16155-1. 6. stewart mg. principles of ballistics and penetrating trauma. in: stewart mg, editor. head, face, and neck trauma: comprehensive management. new york: thieme; 2005. p. 188 – 191. 7. bartlett cs, helfet dl, hausman mr, strauss e. ballistics and gunshot wounds: effects on musculoskeletal tissues. j am acad orthop surg 2000 jan-feb;8(1):21–36. pmid: 10666650.  8. cullis ig. blast waves and how they interact with structures. j r army med corps. 2001 feb;147(1):16–26. doi:10.1136/jramc-147-01-02 pmid:11307674. 9. hull jb, cooper gj. pattern and mechanism of traumatic amputation by explosive blast. j trauma. 1996 mar;40(3 suppl):s198–205. doi:10.1097/00005373-199603001-00044 pmid:8606410. 10. motamedi mh, mortazavi sh, behnia s, yaghmaei m, khodayari a, akhlaghi f, et al. maxillofacial reconstruction of ballistic injuries. in: motamedi mh, editor. a textbook of advanced oral and maxillofacial surgery. london: intechopen. 2013. p. 531-557. doi:10.5772/53119. 48 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports philipp j otolaryngol head neck surg 2016; 31 (1): 48-52 c philippine society of otolaryngology – head and neck surgery, inc. tumoral calcinosis in secondary hyperparathyroidism reinzi luz s. bautista, md ramon antonio b. lopa, md arsenio claro a. cabungcal, md anna pamela c. dela cruz, md tom edward n. lo, m.d. department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: dr. arsenio claro a. cabungcal department of otorhinolaryngology philippine general hospital ward 10 university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 5548 400 local 2152 email: acabungcal@upm.edu.ph the authors declare that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest presented at the philippine society of otolaryngology-head and neck surgery clinical case report contest (2nd place), menarini office, 4/f w bldg. 11th ave. cor. 28th st. bonifacio high st. bgc taguig, june 2, 2015. abstract objective: to report a case of tumoral calcinosis from secondary hyperparathyroidism and to describe its surgical management. methods: design: case report setting: tertiary public university hospital patient: one results: a 34-year-old woman presented with progressively-enlarging bilateral upper extremity masses. diagnostic tests revealed hyperfunctioning parathyroid glands. the patient underwent subtotal parathyroidectomy, right thyroid lobectomy with isthmusectomy, and transcervical thymectomy. follow-up revealed marked decrease in parathyroid hormone, and progressive resolution of the tumoral calcinosis. conclusion: subtotal parathyroidectomy and transcervical thymectomy have a role in the management of tumoral calcinosis, and in this case led to excellent post-operative results. the rare presentation of secondary hyperparathyroidism and intervention in this patient may have potential lessons for future management of similar cases. keywords: tumoral calcinosis, parathyroid, parathyroidectomy, thymectomy tumoral calcinosis is a rare condition involving periarticular soft tissue calcium deposition that may arise secondary to chronic renal insufficiency.1 we describe a case of tumoral calcinosis involving both shoulders and the right elbow of a woman who was being treated for chronic kidney disease due to chronic glomerulonephritis. case report a 34-year-old woman with a seven-year history of weakness, occasional nausea and decreasing urine output was eventually diagnosed with chronic kidney disease stage v2 due to chronic glomerulonephritis. she had twice-weekly hemodialysis and was maintained on carvedilol, amlodipine, iron and calcium supplementation, and erythropoietin. during the course of treatment she developed firm nontender masses on both shoulders and her right elbow. (figure 1, 2) initial intact parathyroid hormone (pth) was elevated at 1791pg/ ml, and both calcium and phosphorus levels were elevated at 2.68 mmol/l and 2.94 mmol/l, respectively. calcium supplementation was discontinued and sevelamer was started. a neck ultrasonogram revealed bilateral solid hyperechoic foci posterior to the thyroid gland, suggestive of parathyroid pathology. a tc-99m sestamibi scan showed evidence of hyperfunctioning creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international 49 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports parathyroid tissue in the superior left thyroid bed. she was diagnosed with tumoral calcinosis secondary to chronic kidney disease. the masses progressed in size despite medical management, and she was referred to the otorhinolaryngology – head and neck surgery service for surgical treatment. physical examination findings were confirmed radiographically. (figure 3, 4, 5) bilateral parathyroid exploration, subtotal parathyroidectomy, right thyroid lobectomy with isthmusectomy, transcervical thymectomy and incision biopsy of the elbow mass were done in june 2014. (figure 6) bilateral superior and inferior parathyroid glands were identified, the right superior measuring 2.8x2x2.1 cm (enlarged), left superior 2.6x1.6x0.7 cm (enlarged), right inferior 1x1x1 cm, and left inferior 1.2x1x1 cm. (figure 7) the specimens were consistent with parathyroid tissue on frozen section. a subtotal or 3 ½ parathyroidectomy was then performed, preserving ½ of the left inferior parathyroid gland. a right thyroid lobectomy with isthmusectomy was performed following figure 1. frontal view of the patient showing shoulder masses (published with permission): a) pre-operative, b) seven weeks post-operative, c) two months post-operative, d) eight months post-operative. figure 2. right elbow mass: a) pre-operative, b) seven weeks post-operative, c) two months post-operative, d) eight months post-operative. figure 3. radiograph (shoulder ap view) of right shoulder mass: a) seven weeks post-operative, b) two months post-operative, c) eight months post-operative. 50 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports mass, obtained 1x1cm of soft translucent whitish tissue. final histopathologic results showed parathyroid hyperplasia for the left superior and right superior parathyroid glands, and normal parathyroid tissue in the left inferior and right inferior tissue. (figure 8) no diagnostic abnormality was noted in the dissected right thyroid lobe. thymic remnants and four reactive lymph nodes were detected in the sample obtained from transcervical thymectomy, with no note of ectopic parathyroid tissue. the right elbow mass yielded fibrovascular connective tissue with calcifications, consistent with tumoral calcinosis. (figure 9) post-operative calcium levels decreased to 1.7 mmol/l (from 2.69 mmol/l) and phosphorus levels to 2.03 mmol/l (from 2.94 mmol/l). rapid intact parathyroid hormone (pth) was not available at our institution and thus an intraoperative pth was not obtained. however, pth levels dropped from a pre-operative 1791pg/ml to 14.27pg/ml post-operatively. the patient developed hypocalcemic symptoms and healthcare-associated pneumonia, both of which were managed and resolved during her hospital stay. she was discharged on the 19th postoperative day with a serum calcium level of 2.04 mmol/l. the patient was maintained on oral calcium supplementation, and regular once to twice-weekly dialysis sessions. on follow-up, significant decrease in the size of her shoulder and elbow masses was noted, with her right shoulder mass being clinically undetectable four months post-operatively. (figure 1, 2) at the eighth post-operative month, she reported near-total resolution of the masses. post-operative radiography showed marked decrease in calcinosis for her elbows and shoulders. (figure 3,4,5) calcium levels have since normalized and she is currently awaiting a kidney transplant, which is the definitive management for her chronic kidney disease. discussion tumoral calcinosis (tc) is a rare benign condition characterized by deposition of large hydroxyapatite or calcium phosphate crystals in periarticular soft tissue, usually around large joints.1 it usually manifests the detection of a thyroid nodule measuring 0.6x0.5x0.5cm. partial transcervical thymectomy by the thoracocardiovascular surgery service excised the left and right thymic horns with blunt dissection of intrathoracic thymic tissues beyond the innominate vein, obtaining a sample measuring 4.4x2.5x1.5 cm. incision biopsy of the right elbow figure 4. radiograph (shoulder ap view) of left shoulder mass: a) seven weeks post-operative, b) two months post-operative, c) eight months post-operative. figure 5. radiograph (lateral view) of right elbow mass: a) seven weeks post-operative, b) two months post-operative. figure 6. parathyroid exploration, right superior gland (arrow pointing to gland). philippine journal of otolaryngology-head and neck surgery 51 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports as a palpable asymptomatic tumor-like mass, with calcification limited to the soft tissues and not extending to erode underlying bony surfaces. the mechanism of calcinosis remains unknown; however, a pathogenesis-based classification of tumoral calcinosis describes three subtypes: 1) primary normophosphatemic, 2) primary hyperphosphatemic, and 3) secondary.3 secondary tumoral calcinosis occurs in patients who have a concurrent disease capable of causing soft tissue calcification-in this case, associated with the chronic kidney disease causing secondary hyperparathyroidism (shpt). renal insufficiency leads to reduced synthesis of 1,25dihydroxy-vitamin d and decreased phosphate excretion resulting in hypocalcemia and hyperphospatemia. consequently, parathyroid hormone (pth) secretion increases resulting in parathyroid cell hyperplasia.4 the prevalence of periarticular calcinosis in chronic kidney disease patients is very small at 0.5-1.2%.5 the lesions have also mostly been described as varying in size from 2-10mm.6 this patient’s tumoral calcinosis was much larger than commonly reported, with masses measuring 15x12x8cm at the largest, which led to mass-effect limitation of extremity mobility and problems with cosmesis. primary conservative therapy for tc includes dialysis to address the underlying renal insufficiency, calcium supplementation, dietary phosphorus restriction and calcium-free phosphate binding agents, which possibly induce rapid mobilization of the bound calcium in the calcified mass.7 however, our patient did not respond to initial medical management, despite good compliance and regular follow-up. uremic calcinosis has been noted to occur more commonly in patients on hemodialysis for more than three years.6 our patient did present with the masses three years into dialysis, and thus failure of medical management was already a strong consideration. observational studies have estimated that up to 2.5% of patients on dialysis are eventually referred for parathyroidectomy each year.8 figure 7. intraoperative specimens, showing enlarged parathyroid glands. figure 8. parathyroid tissue, hematoxylin – eosin, low magnification (10x), showing hyperplasia. (hematoxylin – eosin, 10x) figure 9. histopathologic slide of incision biopsy of right elbow mass, hematoxylin – eosin, left, low power (10x) and right, high power (40x), showing calcifications within the connective tissue matrix (arrows). (hematoxylin – eosin, 10x) (hematoxylin – eosin, 40x) philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports 52 philippine journal of otolaryngology-head and neck surgery references 1. mohamed s, jong-hun j, weon-yoo k. tumo ral calcinosis of the foot with unusual presen tation in an 11-year-old boy: a case report and review of literature. j postgrad med. 2007 oct; 53(4): 247-9. 2. international society of nephrology. kdigo 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. kidney int suppl. 2012; (3)1: 5-6. 3. smack dp, norton sa, fitzpatrick je. proposal for a pathogenesis-based classification of tumoral calcinosis. int j dermatol. 1996 apr; 35(4):265-71. 4. goodman wg. medical management of secondary hyperparathyroidism in chronic renal failure. nephrol dial transplant. 2003 jun; (18 suppl 3): iii2-iii8. 5. franco m, van elslande l, passeron c, verdier jf, barrillon d, cassuto-viguier e, pettelot g, bracco j. tumoral calcinosis in hemodialysis patients: a review of three cases. rev rhum engl ed. 1997 jan; 64(1):59 – 62. 6. huang y, chen cy, yang cm, yao ms, chan wp. tumoral calcinosis-like metastatic calcifications in a patient on renal dialysis. clin imaging. 2006 jan-feb; 30(1):66-68. 7. van straten a, hoogeveen e, khan s, de scheperr a. unusual presentation of tumoral calcinosis in chronic renal failure: a case report. eur j radiol. 2005; 53: 81-85. 8. decker pa, cohen ep, doffek km, ashley ba, bienemann me, zhu yr, et al. subtotal parathyroidectomy in renal failure: still needed after all these years. world j surg. 2001 jun; 25(6): 708-12. 9. darr a, sritharan n, pellitteri p, sofferman r, randolph g. management of parathyroid disorders. in: flint pw, haughey bh, lund vj, niparko jk, richardson ma, robbins kt, thomas jr. cummings otolaryngology head and neck surgery. 6th ed. philadelphia: mosby elsevier; 2015. p. 1929-1955. 10. mockel g, buttgereit f, labs k, perka c. tumoral calcinosis revisited: pathophysiology and treatment. rheumatol int. 2005 jan; 25(1): 55-9. 11. hiramatsu r, ubara y, hayami n, yamanouchi m, hasegawa e, sumida k, et al. occurrence of new bone-like tissue formation in uremic tumoral calcinosis. bone. 2013 feb; 52(2): 684–688. 12. thakur a, hines oj, thakur v, gordon he. tumoral calcinosis regression after subtotal parathyroidectomy: a case presentation and review of the literature. surgery. 1999 jul; 126(1): 95-98. 13. akerstrom g, malmaeus j, berstrom r. surgical anatomy of human parathyroid glands. surgery. 1984 jan; 95(1):14–21. 14. caron nr, sturgeon c, clark oh. persistent and recurrent hyperparathyroidism. curr treat options oncol. 2004 aug; 5(4): 335-45. 15. de la rosa a, jimeno j, membrilla e, sancho j, pereira ja, sitges-serra a. usefulness of preoperative tc-mibi parathyroid scintigraphy in secondary hyperparathyroidism. langenbecks arch surg. 2008 jan; 393(1):21-24. 16. ritter he, milas m. bilateral parathyroid exploration for hyperparathyroidism. op tech otolaryngol. 2009; 20: 44-53. 17. welch k, mchenry cr. the role of transcervical thymectomy in patients with hyperparathyroidism. am j surg. 2012 mar; 203(3):292-5. 18. schneider r, bartsch dk, schlosser k. relevance of bilateral cervical thymectomy in patients with renal hyperparathyroidism: analysis of 161 patients undergoing reoperative parathyroidectomy. world j surg. 2013 sep; 37(9):2155-61. the parathyroid glands help in maintaining calcium homeostasis by responding to changes in serum ionized calcium concentrations, and secrete pth in response to a fall in serum calcium.9 parathyroidectomy has been recommended in patients who have persistent hyperparathyroidism. complete regression of tc, as well as correction of hypercalcemia, have been observed in patients who underwent subtotal parathyroidectomy.10-12 a major concern for the surgical management of the patient was achieving successful dissection of the parathyroid tissue involved. secondary hyperparathyroidism has been known to persist or recur because of failure to locate supernumerary glands, which can be expected in 13% of patients with shpt.13 repeat parathyroid exploration is associated with more complications compared to initial explorations,14 and the most cost-effective and safest management of persistent or recurrent hyperparathyroidism is to avoid reoperation by performing a complete initial surgery. localization studies such as ultrasound and sestamibi scanning are recommended, both of which the patient had pre-operatively. however, even sestamibi scanning may detect only between 35-65% of hyperplastic glands and identifies ectopic glands in around 5-10% of cases.15 thus, a significant factor in successful surgery lies in the intraoperative localization of parathyroid glands, as well as dissecting the most common ectopic sites. ectopic parathyroid tissue has been noted most commonly within the thymus, as a consequence of the extensive embryologic migration of the inferior parathyroid glands.16 routine thymectomy has not yet been established as a gold standard accompanying parathyroidectomy, but studies have shown promising results for the procedure. intrathymic parathyroid tissue has been found in 33% of patients with hyperparathyroidism who underwent transcervical thymectomy, including supernumerary glands in 11%.17 intrathymic parathyroid tissue has also been found in 28.4% of patients who underwent re-operative parathyroidectomy due to persistent shpt.18 transcervical thymectomy involves removing one or both cervical tongues of the thymus, with an estimated 30-40% of thymic tissue removed. post-operative hypocalcemia has been reported in 51% of patients compared to 25% in those undergoing parathyroidectomy alone. other precautions for thymectomy include limiting bleeding and risk of injury to the recurrent laryngeal nerves. however, the transcervical approach still results in a high yield of parathyroid tissue in a relatively non-invasive way, compared to routine thymectomy that necessitates a sternotomy. this approach was deemed ideal for the patient, who preferred a minimally invasive surgery that would also lessen her chances of needing a subsequent operation to locate missed parathyroid tissue. intrathyroidal parathyroid tissue has also been found in up to 10% of patients with ectopic parathyroid glands , 18 and right thyroid lobectomy and isthmusectomy was performed after detection of a right thyroid nodule intraoperatively. the decision to perform a lobectomy at that point was also to lessen the need for re-operation, should the nodule have turned out to be pathologic. post-operative issues encountered included transient hypocalcemia, which was managed with intravenous calcium infusion, and development of healthcare-associated pneumonia which was attributed to the prolonged hospital stay. however, these issues were resolved and the patient is still on regular follow-up with otorhinolaryngology – head and neck surgery, endocrinology, orthopedic, and neprhology services. since the operation, eight months post-operatively, she has had remarkable progress to complete resolution of her tumoral calcinosis, with both clinical and radiographic evidence. tumoral calcinosis may present as a rare and devastating complication of renal insufficiency leading to secondary hyperparathyroidism. despite good medical management, this disease can progress and necessitate surgical management. this case affirms that subtotal parathyroidectomy and transcervical thymectomy have a role in the management of tumoral calcinosis, and may lead to excellent post-operative results. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 case reports philippine journal of otolaryngology-head and neck surgery 37 philipp j otolaryngol head neck surg 2017; 32 (1): 37-40 c philippine society of otolaryngology – head and neck surgery, inc. capillary hemangioma of the temporal bonejose z. fernando iii, mdrosario r. ricalde, md department of otorhinolaryngology head and neck surgery quirino memorial medical center correspondence: dr. rosario r. ricalde department of otorhinolaryngology head and neck surgery quirino memorial medical center katipunan road ext., project 4, quezon city 1108 philippines phone: (632) 421 2250 local 117 email: quirino_orlhns@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery, interesting case contest. june 2, 2015. menarini office, 4/f w building, bgc taguig city. abstract objectives: to discuss a rare case of temporal bone capillary hemangioma and its diagnosis and management. methods: design: case report setting: tertiary government hospital patient: one results: a 44-year-old woman with a history of on-and-off right ear discharge, tinnitus and decreased hearing, and a pinkish, smooth-surfaced, non-friable, non-pulsating mass occluding the right external auditory canal, was initially treated for chronic suppurative otitis media with aural polyp. a punch biopsy due to persistence of disease despite medical treatment revealed capillary hemangioma. she underwent canal wall down mastoidectomy with obliteration to completely resect the tumor. conclusion: capillary hemangiomas of the temporal bone are benign lesions that may lead to complications such as bone erosion, hearing loss, recurrent infection and bleeding if left untreated. surgery remains the ideal treatment and recurrence is rare and the prognosis is good if resection is complete. keywords: hemangioma, capillary hemangioma, temporal bone, middle ear hemangiomas in the head and neck are common accounting for more than 60 percent of all hemangiomas.1 they are vascular anomalies commonly seen in children and young adults that usually grow intermittently throughout the first year of life, go through a quiescent period then spontaneously involute by 5 or 6 years old.1 they are exceptionally reported in the middle ear.1 when located in the temporal bone they are commonly seen in adults such as in this case. this case was initially treated as a case of chronic supportive otitis media with aural polyp, a protracted treatment period that may have led to progression of the disease and complications. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 ba c case reports 38 philippine journal of otolaryngology-head and neck surgery the majority of intraosseous hemangiomas arising from the skull base are cavernous and only few are capillary.2 capillary hemangiomas arise predominantly in the area of the geniculate ganglion and the internal auditory canal.2, 3 according to singh et al., only 18 cases have been reported in english literature, with 8 cases confined to the middle ear and 9 cases confined to the external auditory canal, plus a case with involvement of the mastoid, middle ear and external ear canal.4 the patient was initially diagnosed as chronic suppurative otitis media with aural polyp until biopsy and subsequent surgery discredited the initial diagnosis with an impression of capillary hemangioma. we present a similar case. case report a 44-year-old woman presented with a history of on-and-off right ear discharge of 8 years duration. she also noted tinnitus and decreased hearing after 3 years and reported right aural bleeding and postauricular swelling and discharge. no facial asymmetry was observed. she was treated for chronic suppurative otitis media with aural polyp without relief. the patient was seen 8 years after the onset of symptoms. on examination, a pinkish, smooth-surfaced, non-friable, non-pulsating mass occluded the right external auditory canal. a draining postauricular sinus was surrounded by a hypertrophic scar. (figure 1) temporal bone computed tomography showed a heterogenous mass with enhancement in the right external ear canal with canal erosions extending to the right temporo-mandibular joint and space behind the right parotid gland. (figure 2) pure tone audiometry revealed conductive hearing loss on the right. a punch biopsy revealed capillary hemangioma. mild bleeding was observed during the biopsy, easily controlled by packing. the patient underwent canal wall down mastoidectomy with mastoid obliteration using abdominal fat and temporalis muscle and blind sac closure. intra-operatively, a friable mass surrounded by granulation tissue occupied the epitympanum, middle ear cavity and external auditory canal eroding the mallues, incus and stapes suprastructure. the stapes foot plate was fixed. (figure 3) histopathology showed proliferation of well-circumscribed mature formed dilated capillaries without anastomoses and cellular atypia consistent with capillary hemangioma. (figure 4) discussion hemangiomas are benign vascular tumors that can be classified as capillary or cavernous. the former consist of closely arranged capillary-like channels while the latter are composed of cavernous vascular spaces.4 capillary hemangiomas typically occur in the skin, figure 1. a. right ear showing mass extruding out of the right external ear canal b. closer view of right external ear canal with mass c. hypertrophic scar in the right postauricular area. subcutaneous tissues, lips, liver and spleen or kidneys.1 cavernous hemangiomas often appear in the skin, mucosal surfaces and internal organs.1 histologically, capillary hemangiomas consist of closely arranged capillary like channels.1 this case of capillary hemangioma showed proliferation of well-circumscribed mature formed dilated capillaries. the symptoms encountered by patients with hemangiomas of the ear include hearing loss, pulsating tinnitus, aural bleeding, facial nerve dysfunction, ear pain and recurrent ear infection and ear discharge.2-5 our patient also experienced on-and-off ear discharge, hearing loss and non-pulsatile tinnitus without facial nerve dysfunction. the types of hearing loss of patients with hemangioma of the ear can be conductive or mixed;4,6-8 our patient had conductive hearing loss. a diagnostic ct-scan of the temporal bone is important to localize the lesion and to determine bony erosion and involvement of the ossicular chain.7,9 hemangiomas are enhancing soft tissue masses philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 philippine journal of otolaryngology-head and neck surgery 39 case reports figure 3. intra-operative view of capillary hemangioma occupying the middle ear and external auditory canal (arrow). figure 2. temporal bone ct scan a. axial section bone window, showing soft tissue density inside the external auditory canal and middle ear cavity with bone erosion of the anterior and posterior canal wall of the right ear. b. axial section with contrast showing the same mass on the right ear which is heterogeneously enhancing c. coronal section, bone window, showing erosion of the ossicles of the right ear. anterior inferior posterior superior c a b philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 case reports 40 philippine journal of otolaryngology-head and neck surgery references 1. martines f, bentivegna d, maira e, marasa s, ferrara s. cavernous haemangioma of the external auditory canal: clinical case and review of the literature. acta otorhinolaryngol ital. 2012 feb; 32(1):54-57. pmid: 22500069; pmcid: pmc3324958. 2. yang g, li c, chen x, liu y, han d, gao x, et al. large capillary hemangioma of the temporal bone with a dural tail sign: a case report. oncol lett. 2014 jul; 8(1):183-186. doi: 10.3892/ ol.2014.2143; pmid: 24959241; pmcid: pmc4063632. 3. fierek o, laskawi r, kunze e. large intraosseous hemangioma of the temporal bone in a child. ann otol rhinol laryngol. 2004 may; 113(5):394-8. doi: 10.1177/000348940411300510; pmid: 15174768. 4. singh rk, bhandary s, tiwary a,karki s. capillary hemangioma of tympanic cleft. online j health allied sci. 2008; 7(4):8. [cited 2014 jul 28]. available from: http://www.ojhas.org/issue28/20084-8.htm. 5. hartwein jh, raschke dt. hemangioma of the middle ear. laryngol rhinol otol (stuttg). 1987 may; 66(5):280-2. pmid: 3613779. 6. pistorio v, de stefano a, petrucci ag, achilli v. capillary haemangioma of the middle ear: a rare lesion difficult to evaluate. acta otorhinolaryngol ital. 2011 apr; 31(2):109-112. pmid: 22064794; pmcid: pmc3203740. 7. alvarez-buyllablanco m, vazquez barro jc, lopez amado m, santiago freijanes mp, martinez vidal j. capillary hemangioma of middle ear a case report. acta otorrinolaringol esp. 2011 janfeb; 62 (1):74-76. doi: 10.1016/j.otorri.2010.02.001; pmid: 20347430 8. nouri h, harkani a, eloualiidrissi m, rochdi y, aderdour l, oussehal a, raji a, et al. capillary hemangioma of the middle ear: one case report and review of the literature. case rep otolaryngol.2012; 2012:305172. doi: 10.1155/2012/305172; pmid: 22953107; pmcid: pmc3420627. 9. neto jfl, miura ms, saleh c, de andrade m, assmann m. hemangioma as mass of external ear canal. intl arch otorhinolaryngol. 2007; 11(4): 498-500. 10. yasar h, ozkul h, somay a. a rare vascular tumor of the external auditory canal: the capillary hemangioma. kulak burun bogaz ihtis derg. 2009 jul-aug; 19 (4):212-5. pmid: 19860637. as seen in the contrast ct-scan of our patient.4 some cases reported in literature had no bony erosion or involvement of ossicular chain because they were either limited to the external auditory canal or early intervention was done.1-10 our patient had erosion of both the posterior and anterior auditory ear canal walls and all ossicles. on magnetic resonance imaging (mri), t1 weighted images show a lesion of moderate intensity and t2 weighted images show high intensity while the tumor is clearly enhanced.6 angiography can be helpful in identifying feeding vessels for embolization prior to surgery.1,6 hemangioma has been described as a vascular blush on arteriography.8 our patient did not undergo pre-operative embolization due to financial constraints. however, we only sustained a total 900 ml blood loss out of an allowable blood loss of 1,095 ml. the surgical approach for capillary hemangioma of the ear depends on the involved area and extent. the procedure can be done transcanal if there is only external ear involvement or transmastoid with middle ear involvement.1,4,8-10 in our patient, a transmastoid approach was done for both middle ear and external auditory canal involvement. compared to other cases where middle ear structures like the ossicles were not involved,1-10 our patient had erosion of the ossicles with ossification of the stapes footplate. this may have been caused by overlapping infection from manipulation and disease progression. our case may suggest that such hemangiomas can become extensive and present with complications if no intervention is made. since there was a post-auricular sinus and a large mastoid cavity with multiple small bleeders from the bone bed despite aggressive hemostasis after excision of the hemangioma, surrounding granulation and fibrosis, we decided to completely obliterate the mastoid with abdominal fat and temporalis muscle and perform blind sac closure of the external auditory canal. the stapes footplate was also fixed, so hearing rehabilitation surgery as a second stage procedure would most likely not result in better hearing. post-operatively, she was offered the use of a bone anchored hearing aid (baha) or a bone conducting hearing aid to address the conductive hearing loss on the right side. the prognosis of capillary hemangioma is good and recurrence is rare after complete resection.1,4,6-8 however, it is associated with a high recurrence rate of 43.5 % if resection is incomplete.2 capillary hemangiomas of the middle ear are benign lesions of the temporal bone. however, left untreated, they may lead to disease progression and complications such as bone erosion, hearing loss, recurrent infection and bleeding. surgery remains the ideal treatment, and prognosis is good, and the chance of recurrence is rare for complete resection. figure 4. histopathologic low-power view (10x), hematoxylin-eosin stain, showing proliferation of well-circumscribed mature formed dilated capillaries (arrow pointing at a mature formed dilated capillary). (hematoxylin – eosin , 10x)(hematoxylin – eosin , 10x) philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to describe the clinical profiles, interventions and surgical outcomes of patients with advanced (grade iii and iv) laryngotracheal stenosis prospectively seen over a 2-year period. methods: design: prospective case series setting: tertiary provincial government hospital participants: five (5) patients with advanced laryngotracheal stenosis confirmed by laryngoscopy and/or tracheoscopy. results: five (5) patients (4 males, 1 female), aged 23 to 31years (mean 27 years old) diagnosed with advanced laryngotracheal stenosis between june 2016 to june 2018 were included in this series. four resulted from prolonged intubation (14 60 days) while one had a prolonged tracheotomy (13 years). presentations of stenosis included dyspnea on extubation attempt (n=3), failure to extubate (n=1) and failure to decannulate tracheotomy (n=1). stenosis length was 3 cm in two and 1.5 cm in three. of the five (5) patients, three had grade iv stenosis while two had grade iii stenosis based on the cotton-myer classification system. two of those with grade iv stenosis and both patients with grade iii stenosis had undergone prolonged intubation. the stenosis involved the subglottis in three and combined subglottic and tracheal stenosis in two. prolonged intubation was present in all three with subglottic stenosis and in one of the two with combined subglottic and tracheal stenosis. two patients underwent open surgical approaches while three underwent endoscopic dilatation procedures. four patients were successfully decannulated while one is still on tracheostomy. none of them had post-operative complications. conclusion: advanced laryngotracheal stenosis is a challenging entity that results from heterogenous causes. categorizing stenosis and measuring stenosis length may help in treatment planning and predicting surgical outcome. keywords: laryngotracheal stenosis; laryngotracheal reconstruction; tracheal resection anastomosis; subglottic stenosis; tracheal stenosis laryngotracheal stenosis (lts) is a life-threatening, fixed, extrathoracic restriction in pulmonary ventilation1 involving a partial or complete cicatricial narrowing of the endolarynx, subglottis or trachea.2 various etiologies include intubation, trauma, infection and local tumors.3 a refractory disease with high morbidity, injury is initiated by ischemic necrosis of advanced laryngotracheal stenosis patients in a tertiary provincial government hospital: a prospective case series jules verne m. villanueva, md ronaldo g. soriano, md department of otorhinolaryngology head and neck surgery dr. paulino j. garcia memorial research and medical center correspondence: dr. ronaldo g. soriano department of otorhinolaryngology head and neck surgery dr. paulino j. garcia memorial research and medical center mabini st., quezon district, cabanatuan city nueva ecija 3100 philippines phone: (044) 463-8888 email: ronsorianomd@gmail.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest (2nd place). october 22, 2018, maynila ballroom, the manila hotel, manila. philipp j otolaryngol head neck surg 2019; 34 (1): 30-33 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles the mucosa leading to ulceration of cartilage, inflammation with granulation and fibrous contraction.4 it poses a great management challenge to otolaryngologists due to the complexity of the region, including delicate structures such as the vocal cords and recurrent laryngeal nerves that coordinate the functions of respiration, deglutition and phonation.5 laryngotracheal stenosis can be graded based on the percentage of luminal narrowing according to the cotton-myer classification ranging from grade i (0 – 50%) to grade iv (complete obstruction).3 there is no standard approach to the management of advanced lts that includes various modalities from endoscopic dilatations of the stenotic area to open surgical resection of the diseased segment with end-to-end anastomosis.1 moreover, because lts is not a homogenous clinical entity, understanding the mechanism of injury and comorbidities is critical to treatment. although a previous local study described the clinical profile of patients with lts, it focused on “causal factors, presentation, endotracheal tube (et ) intubation (history, indication, et tube size, duration, frequency of re-intubation, interval from latest extubation until stenosis diagnosis) and grading and location of stenosis.”4 furthermore, the study was conducted in the highly-urbanized national capital region, a context quite different from ours. to the best of our knowledge, no previous study has been published describing treatment outcomes for lts in a setting similar to our locality. thus, our study aims to describe the clinical profiles, interventions and surgical outcomes of patients prospectively diagnosed with advanced (grade iii and iv) laryngotracheal stenosis over a 2-year period in our tertiary provincial hospital. methods with institutional review board approval, this prospective case series sought to enroll patients of all age groups diagnosed with advanced (grade iii and iv) lts at the dr. paulino j. garcia memorial research and medical center in cabanatuan city, nueva ecija between june 2016 and june 2018. after obtaining written informed consent, a thorough history was obtained and physical examination with clinical evaluation including laryngoscopy for airway assessment and vocal cord mobility was carried out by the author for all the patients in the study. a noncontrast and contrast-enhanced computed tomographic (ct) scan of the neck was performed. the diagnosis of lts was further confirmed by endoscopic evaluation of the larynx and trachea under general anesthesia to assess the site and grade of stenosis based on the cottonmyer grading classification (see below). the age, sex, probable cause of stenosis, presentation of stenosis, history of endotracheal tube (et) intubation (including the et tube size and total duration of intubation) and stenosis morphology (site and grade of stenosis) were recorded by pen and paper using a data collection sheet. for this study, grade i or grade ii stenosis was classified as early lts whereas grade iii or grade iv stenosis was classified as advanced stenosis. patients with laryngeal malignancy and early laryngotracheal stenosis were excluded. treatment options for lts included endoscopic dilatation of stenosis and open surgical resection of the stenotic segment with end-to-end anastomosis. all candidates for surgical management were tracheotomised prior to the procedure and initial laryngotracheoscopy was carried out under general anesthesia. patients with stenosis 2 cm or more below the stenotic segment were offered open surgical reconstruction while those with less than 2 cm stenosis were offered endoscopic dilatation. following surgical interventions, initial review was scheduled one-week post-surgery to assess healing and to evaluate for any post-operative complications. following this, patients were generally reviewed once in 2-4 weeks in case of endoscopic intervention and after 8-12 weeks in case of open surgery. successful surgical intervention was defined as decannulation of tracheostomy and restoration of the laryngo-tracheal lumen with nasal breathing. another follow-up was scheduled 6 months post-decannulation to evaluate for re-stenosis. interventions and results were tabulated using the previouslydescribed data collection sheet and simple descriptive statistics were used to analyze the data. results a total of five patients (four males, one female) were evaluated for laryngotracheal stenosis from june 2016 to june 2018 and all of them were included in this study. all five patients were adults with ages ranging from 23 to 31 years old (mean age of 27 years old. four had lts following prolonged intubation (14 – 160 days) while one had prolonged tracheotomy (13 years). the indications for et intubation were altered sensorium secondary to strangulation injury, vehicular accident and snake bite envenomation and caustic substance ingestion (insecticide). the patient with outright tracheotomy had a clothesline injury. presentations included dyspnea on extubation attempt in three, failure to extubate in one and failure to decannulate tracheotomy in another. all intubated patients had et tubes compatible with their ideal size for age. the length of stenosis was 3 cm in two patients and 1.5 cm in three. of the five patients, three had grade iv stenosis while the two had grade iii stenosis. two each of the intubated patients had grade iii and iv stenosis respectively. based on the site of stenosis, three were subglottic and two were combined subglottic and tracheal. all three subglottic stenoses involved intubated patients while one of the two combined subglottic and tracheal stenosis patients was intubated. table 1 shows the probable causes and presentations of stenosis, total duration of intubation (days) and length, grade and location of stenosis in these 5 patients. two patients underwent open surgical approaches while three underwent endoscopic dilatation procedures. the first two cases with philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles a stenosis length of 3 cm, grade iv stenosis and a combined subglottic and tracheal stenosis underwent open (external) surgical approaches. all three cases that underwent endoscopic approaches had a stenosis length of 1.5 cm with two having grade iii stenosis and one having grade iv stenosis. four patients were successfully decannulated while one is still on tracheostomy. none of the patients had post-operative complications such as bleeding, surgical site infection or difficulty of breathing. however, the patient still on tracheostomy underwent a second endoscopic dilatation procedure and is yet to be evaluated for decannulation. discussion laryngotracheal stenosis (lts) remains a challenging condition for otolaryngologist – head and surgeons. the airway is compromised by submucosal fibrosis and scar contraction that result from healing by secondary intention involving the larynx, trachea or both.4 it is seen more commonly in the age group of 26-34 years.1 consistent with the literature, the mean age in our study was 27 years with male predilection. in our study, stenosis was seen in three patients following et intubation. laryngotracheal stenosis is one of the most frequent sequelae of prolonged nasal/orotracheal intubation and tracheotomy. approximately 10% of intubated patients develop laryngotracheal stenosis3 with a 0-2% incidence of subglottic stenosis6 and 6-21% incidence of tracheal stenosis.7 the incidence of tracheal stenosis following tracheotomy ranges from 0.6-21%.7 the endotracheal tube causes erosion and mucosal necrosis just within hours.4 the aptness of et tube size was not a factor in causing stenosis since the ideal et tube size for age was used in the study. however, pressure from the tube can cause full thickness injury that can expose cartilage predisposing to perichondritis with subsequent scarring and necrosis.4 the duration of et intubation in our study ranged from 14 to 60 days before converting to tracheostomy. in adults, orotracheal intubation for more than 96 hours has been associated with permanent damage.4 in fact, stenosis was seen in 2% of patients who were intubated between 3-5 days while it increased to 5% when intubation reached 6-10 days.7 there is no safe time limit before considering tracheostomy in an intubated patient. however, longer intubation periods correlated with broader and deeper ulcers, injury in the subglottis and posterior glottis.11 in our study, the length of stenosis assessed intraoperatively significantly correlated with the data obtained from neck ct and direct laryngoscopy with tracheoscopy. the sensitivity and specificity of both ct and tracheobronchoscopy in the detection of subglottic stenosis has been reported to be 100%.2 it has also been reported that the detection rate for tracheal stenotic lesions was 94% by ct and 88% by rigid bronchoscopy.2 a preoperative assessment of the length of stenosis was accurate in 87% of the stenotic segments detected by ct and in 73% of the segments detected by bronchoscopy.8 the severity (degree of narrowing) is graded by the cotton-myer classification system, based on the percentage of obstruction -grade i (from 0 to 50%) grade ii (51-70%), grade iii (71-99%) and grade iv (no detectable lumen).9 two of our patients had grade iv stenosis while three had grade iii stenosis. previous studies have shown that lowgrade stenosis and a stenosis inferior to 50% of total tracheal extension table 1. clinical profile of laryngotracheal stenosis patients from june 2016 to june 2018. age sex probable cause of stenosis presentation of stenosis total duration of intubation (days) length of stenosis (cm) stenosis grade stenosis location 29 23 31 25 28 m m m f m clothesline injury intubation due to altered sensorium secondary to strangulation injury intubation due to snake bite envenomation intubation due to altered sensorium secondary to vehicular accident intubation due to caustic substance ingestion (insecticide) failure to decannulate tracheotomy dyspnea on extubation attempt failure to extubate dyspnea on extubation attempt dyspnea on extubation attempt 21 converted to tracheostomy 60 converted to tracheostomy 14 converted to tracheostomy 19 converted to tracheostomy 3 3 1.5 1.5 1.5 iv iv iv iii iii subglottis + trachea subglottis + trachea subglottis subglottis subglottis philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles references 1. gelbard a, francis do, sandulache vc, simmons jc, donovan dt, ongkasuwan j. causes and consequences of adult laryngotracheal stenosis. laryngoscope. 2015 may; 125(5): 1137-43. doi: 10.1002/lary.24956; pmid: 25290987 pmcid: pmc4562418. 2. ramdev s, ghosh p, mukhopadhyaya s. radiological evaluation of chronic laryngotracheal stenosis. indian j otolaryngol head neck surg.2005 apr; 57(2): 108-109. doi: 10.1007/ bf02907661; pmid: 23120143 pmcid: pmc3450972. 3. janssen lm. laryngotracheal stenosis and reconstruction. [internet]. erasmus university rotterdam; 2010. [cited 2018 jul 16]. available from: http://hdl.handle.net/1765/19828. 4. arriola ac, chua a. clinical profile of patients with laryngotracheal stenosis in a tertiary government hospital. philipp j otolaryngol head neck surg. 2016; 31 (1): 26-30. doi: 10.32412/ pjohns.v31i1.309. 5. marulli g, rizzardi g, bartolotti l, loy m, breda c, hamad am, et al. single-staged laryngotracheal resection and reconstruction for benign strictures in adults. interact cardiovasc thorac surg. 2008 apr; 7(2): 227-230. doi: 10.1510/icvts.2007.168054; pmid: 18216046. 6. tantinikorn w, sinrachtanant c, assanasen p. how to overcome laryngotracheal stenosis. j med assoc thai. 2004 jul; 87(7): 800-9. pmid: 15521236. 7. gallo a, pagliuca g, greco a, martellucci s, mascelli a, fusconi m, et al. larygotracheal stenosis treated with multiple surgeries: experience, results and prognostic factors in 70 patients. acta otorhinolaryngol ital. 2012 jun; 32(3): 182-8. pmid: 22767984 pmcid: pmc3385058. 8. morshed k, trojanowska a, szymanski m, trojanowski p, szymanska a, smolen a, drop a. evaluation of tracheal stenosis: comparison between computed tomography virtual tracheobronchoscopy with multiplanar reformatting, flexible tracheofiberoscopy and intraoperative findings. eur arch otorhinolaryngol. 2011 apr; 268(4): 591-7. doi: 10.1007/s00405010-1380-2; pmid: 20848120 pmcid: pmc3052474. 9. myer cm 3rd, o’connor dm, cotton rt. proposed grading system for subglottic stenosis based on endotracheal tube sizes. ann otol rhinol laryngol. 1994 apr; 103 (4 pt 1):319-23. doi: 10.1177/000348949410300410; pmid: 8154776. 10. zalzal gh, cotton rt. glottic and subglottic stenosis. in flint pw, haughey bh, lund vj, niparko jk, robbins kt, thomas jr, et al (editors). cummings otolaryngology head and neck surgery. 6th ed. vol. iii. 2015. philadelphia, pa: elsevier saunders. pp. 3158-3182 11. divatia jv, bhowmick k. complications of endotracheal intubation and other airway management procedures. indian j anesth. 2005; 49 (4): 308-318. seem to have better prognosis.7 we could neither observe this nor infer anything because our study excluded grade i and ii stenoses. surgical repair of lts involves two basic modalities: 1) external (laryngotracheoplasty, laryngotracheal resection with end-to-end anastomosis); and 2) endoscopic (laryngeal microsurgery, laser-assisted excision, traditional dilatation and endoscopic stent insertion).3,7 in our series, the external and endoscopic approaches used were laryngotracheal resection with anastamosis and traditional dilatation without stent, respectively. stenosis length is one of the factors that determines treatment option. in patients who required multiple dilatation procedures and with stenosis length of at least 2 cm, a consideration for open surgical approach was offered. two of our patients with a stenosis length of 3cm underwent external approaches while three with stenosis lengths of 1.5 cm underwent endoscopic approaches. the ultimate outcome in open treatment of lts is removal of the stenotic segment with laryngotracheal reconstruction establishing a normal nasal breathing pattern without periods of pulmonary distress and prevention of re-stenosis.5 if the tracheostomy is not successfully removed within 3 interventions (whether endoscopic or open approach), the odds of decannulating the patient decrease significantly, and additional surgeries may not be beneficial especially in older patients and in those with higher grade stenosis.7 in our series, only one of our five patients underwent repeat endoscopic dilatation and has not yet been decannulated as of this writing. limitations of this study are many. the small sample size and lack of comparators, as well as our exclusion of patients with grade i and ii stenosis seriously impair our ability to obtain a comprehensive picture of lts in our locality. in terms of procedure, our study failed to perform laryngotracheoscopy prior to converting to tracheostomy and did not record the number of re-intubations. it would be helpful if future studies would address these shortcomings. in conclusion, our findings confirm that advanced laryngotracheal stenosis is a challenging entity that results from heterogenous causes. categorizing stenosis and measuring stenosis length may help in treatment planning and predicting surgical outcome. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 6362 philippine journal of otolaryngology-head and neck surgery featured grand rounds keywords: ophthalmic artery; vasospasm; iatrogenic; endoscopic sinus surgery; blindness endoscopic sinus surgery (ess) is a generally benign, minimally invasive procedure used for management of paranasal sinus diseases, although complications may occur due to proximity of vital structures such as the brain, orbit and great vessels.1 the overall ess major complication rate is 0.5-1%, of which orbital injury accounts for 0.09% due to direct trauma.2 we report a case of unilateral delayed sudden visual loss without orbital trauma observed intraoperatively or on postoperative imaging studies, following a seemingly routine endoscopic sinus surgery for chronic rhinosinusitis. case report an 18-year-old lad with no significant medical history underwent ess for bilateral chronic rhinosinusitis with nasal polyposis. (figure 1 a-d) the surgery and recovery from anesthesia were uneventful. on the 12th hour post-operatively, the patient noted blurring of vision on the left. ophthalmologic examination revealed hyperemic conjunctiva (figure 2a) with visual acuity of counting fingers at 1 foot while fundoscopy showed retinal hemorrhages. extraocular eye movements (eom) and intraocular pressure (iop) were normal (12mmhg). with an assessment of pre-retinal hemorrhages, 500 mg tranexamic acid was intravenously infused, and a paranasal sinus (pns) computed tomography (ct) scan and orbital magnetic resonance imaging (mri) were requested. a few hours later, he complained of left eye pain with increasing intensity and further deterioration of vision. repeat visual acuity testing showed light perception. there was now a constricted pupil, non-reactive pupillary light reflex, periorbital swelling and progression of conjunctival chemosis. (figure 2b) the iop of the left eye had increased to 30mmhg then progressed to 40mmhg with development of total visual loss and a lateral gaze limitation. with an impression of choroidal hemorrhage and retrobulbar hemorrhage, a lateral canthotomy relieved the eye pain. the contrast pns ct scan with orbital cuts showed that the lamina papyracea was intact with no definite hemorrhagic collections in the intraconal or extraconal spaces of both orbits. (figure 3a, b) a small hyper density along the lateral inferior margin of the left globe at the intraconal region with slight thickening of the anterior periorbital region represented the lateral canthotomy. the pns mri / magnetic resonance angiography (mra) with orbital cuts showed retinal detachment and periorbital edema in the left eye. (figure 4) a b-scan ocular ultrasonogram showed retinal detachment and vitreous opacities. the diagnosis was ocular ischemic syndrome secondary to ophthalmic artery vasospasm, and the patient was given sublingual nitroglycerine and intravenous dexamethasone 8mg every 12 hours for 24 hours, with improvement of periorbital swelling. he was discharged after 12 days with no resolution of the unilateral visual loss. delayed sudden blindness from unilateral ophthalmic artery vasospasm following endoscopic sinus surgery? correspondence: dr. january e. gelera department of otolaryngology – head and neck surgery amang rodriguez memorial medical center sumulong highway, bgy. sto. niño, marikina city 1800 philippines phone: +63 915 490 4673 email: januarygelera@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at pso-hns 1st virtual interesting case contest. july 22, 2020 and at the virtual inter hospital grand rounds 2020 “nightmares in ent surgeries” virtual pso-hns halloween party october 30, 2020. ruben j. chua jr., md joyce anne f. regalado, md january e. gelera, md department of otolaryngology – head and neck surgery amang rodriguez memorial medical center philipp j otolaryngol head neck surg 2021; 36 (1): 62-64 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 6362 philippine journal of otolaryngology-head and neck surgery featured grand rounds which are both easily recognizable intraoperatively and postoperatively.3 the sequelae of such injuries are dependent on which part of the eye is involved. eye muscle involvement results in diplopia while optic nerve involvement leads to visual loss.4 orbital hematoma presents with rapid unilateral orbital swelling and is easily treated with lateral canthotomy, and rapid recognition of the cause and appropriate management is vital given the disastrous outcome of permanent and irreversible visual loss.3 iatrogenic orbital injury is associated with the extent of ess. a study of 50,734 patients in japan showed that the occurrence of total orbital injury was high in patients who had undergone ethmoidectomy, maxillary antrostomy with frontal sinusotomy (<0.2%) compared to zero orbital injuries if only maxillary antrostomy was done.2 our patient underwent uncinectomy, partial turbinectomy for the concha bullosa, and antrostomy. the surgeon clearly identified the medial orbital floor, and no further surgery was done beyond the area. this is why orbital injury was highly unlikely in relation to the extent of ess performed in this case. this was corroborated by the post-operative pns ct scan, which showed an intact lamina papyracea and no demonstrable periorbital emphysema or retrobulbar hematoma, ruling out direct trauma to the eye. this led the authors to look for other causes of perioperative visual loss especially because this was a probable case of delayed sudden blindness. perioperative visual loss (povl) following a non-ocular surgery has a reported incidence of around 0.056 to 1.3%.5 the highest povl rates are associated with cardiac and spine surgery, with an incidence rate of 0.09% and 0.2%, respectively.6 although the pathophysiology of povl is still unknown, proposed mechanisms include increased intraocular pressure, ophthalmic vein congestion, emboli, or direct pressure to the globe, which causes ischemia or vasospasm.5 the etiology of povl can be classified into ischemic optic neuropathy (ion) and retinal vascular occlusion, such as central retinal artery occlusion (crao) and branch retinal artery occlusion (brao).5 these were all considered in our case. acute retinal ischemia produces permanent visual dysfunction due to the central retinal artery or a retinal artery branch blockage, which figure 3. post-operative ct scans showing intact lamina papyracea (solid arrows); a. coronal view; b. axial view. no hemorrhagic collection is seen in intraconal and extraconal spaces (dashed arrows). a b figure 2. a. chemosis of left eye; b. progression of chemosis (post-canthotomy) a b figure 1. pre-operative ct scans: a, b. axial views; c, d. coronal views. a c b d figure 4. mri, axial view showing retinal detachment (solid arrow). discussion orbital injury resulting in visual loss is a rare but devastating complication of ess. the incidence ranges from 0.07-0.09% with iatrogenic injury as the most common cause.2 such orbital injury can be attributed to orbital muscle or optic nerve injury and orbital hematoma philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 6564 philippine journal of otolaryngology-head and neck surgery featured grand rounds causes retinal hypoperfusion.5 this leads to rapid and progressive cellular damage then vision loss.7 central retinal artery occlusion following ess has been cited in the literature and usually presents with sudden painless monocular vision loss.8 visual acuity may vary from loss of light perception to counting fingers but iop and eom are normal.7,8 our patient initially had normal iop and eom, but when the iop rapidly increased to 40mmhg and eom limitations were also noted, a lateral canthotomy was performed. fundoscopy is the gold standard in the diagnosis of crao, with intravenous fluorescein angiography (fa) and/or electroretinography as confirmatory tests.7 fundoscopic findings in patients with crao show a diffusely pale retina with a cherry-red central spot7 but these were not evident in our patient. fluorescein angiography and succeeding fundoscopic examination was not possible because of severe anterior chamber reaction blocking the view to the lens and posterior pole. since we did not have any evidence of which vessel was most likely affected, the authors conjectured that it might have been the ophthalmic artery as the main blood supply of the eye. could it have been a thromboembolic event or vasospastic event leading to ischemia of the eye, with reperfusion injury5 taking place when the obstruction or vasospasm resolved? occurrence of ophthalmic artery vasospasm has been reported, and although extremely rare is particularly important to recognize and treat accordingly as permanent, irreversible vision loss is usually seen in 60–90 minutes.3 another pertinent finding in our patient was retinal detachment. this event was associated with clinical findings related to increased orbital compartment pressure such as proptosis, limitations of eoms, chemosis, and retinal loss. these were all seen in our patient as well as on mri. retinal detachment (rd) has been found to be associated with ocular artery vasospasm in animal studies.5 one plausible theory that the resistance or obstruction of the venous outflow from the eye can lead to rd may be attributed to ophthalmic artery vasospasm. obstruction to the venous outflow can rupture fine pupillary and retinal capillaries which may result in significant hemorrhage spreading to the subretinal space, followed by retinal hypoperfusion, eventually leading to retinal detachment.5 this mechanism may explain the events in this case, resulting in blindness. however, due to unavailability of optical coherence tomography (oct), we failed to gather additional information that could have explained what happened to his eye vessels. it could have been a good diagnostic tool that would have aided in the diagnosis of the case.5 a follow-up indocyanine green or fluorescence angiography was not possible because of severe anterior chamber reaction blocking the view to the lens and posterior pole. as for treatment, prompt administration of vasodilating sublingual nitroglycerine has prevented a patient with presumed ophthalmic artery vasospasm from suffering permanent visual loss.3 in our case, nitroglycerine sublingual tablet and intravenous dexamethasone were given 24 hours post-operatively, which improved the symptoms of references 1. seredyka-burduck m, burduk pw, weirzchowska m, kaunzy b, malukiewicz g. ophthalmic complications of endoscopic sinus surgery. braz j otorhinolaryngol. 2017 may-jun;83(3):318-323. doi: 10.1016/j.bjorl.2016.04.006. pubmed pmid: 27233691. 2. suzuki s, yasunaga h, matsui h, fushimi k, kondo k, yamasoba t. complication rates after functional endoscopic sinus surgery: analysis of 50,734 japanese patients. laryngoscope. 2015 aug;125(8):1785-91. doi: 10.1002/lary.25334; pubmed pmid: 25946047. 3. byrd s, hussaini as, antisdel j.  acute vision loss following endoscopic sinus surgery. case rep otolaryngol. 2017;2017:4935123. doi: 10.1155/2017/4935123; pubmed pmid: 28286685; pubmed central pmcid: pmc5327765. 4. haller d, gosepath j, mann wj, the management of acute visual loss after sinus surgery— two cases of rhinogenic optic neuropathy. rhinology. 2006 sep; 44(3):216-8. pubmed pmid: 17020071. 5. roth s. perioperative visual loss: what do we know, what can we do? br j anaesth. 2009 dec;103 suppl 1(suppl 1):i31-40. doi: 10.1093/bja/aep295; pubmed pmid: 20007988; pubmed central pmcid: pmc2791856. 6. kuhn f, morris r, mester v. choroidal detachment and expulsive choroidal hemorrhage. ophthalmol clin north am. 2001;14(4):639-650. doi: 10.1016/s0896-1549(05)70263-7. pubmed pmid: 11787743. 7. muprhy l, carroll g. acture bilateral retinal artery occlusion causing blindness in a 25-year-old patient. am j emerg med. 2018 jun; 36(6):1124.e3-1124.e4. doi: 10.1016/j.ajem.2018.03.013. epub 2018 mar 6. pubmed pmid: 29534917. 8. kim ke, ahn sj, woo sj, kim n, hwang jm. central retinal artery occlusion caused by fat embolism following endoscopic sinus surgery. j neuroophthalmol. 2013 jun;33(2):149-50. doi: 10.1097/wno.0b013e31828657d6. pubmed pmid: 23571187. 9. kuan ec, tajudeen ba, bhandarkar nd, st john ma, palmer jn, adappa nd. is topical epinephrine safe for hemostasis in endoscopic sinus surgery? laryngoscope. 2019 jan;129(1):13. doi: 10.1002/lary.27238. epub 2018 may 14. pubmed pmid: 29756219. 10. korkmaz h, yao wc, korkmaz m, bleier bs. safety and efficacy of concentrated topical epinephrine use in endoscopic endonasal surgery. int forum allergy rhinol. 2015 dec;5(12):111823. doi: 10.1002/alr.21590. epub 2015 jul 8. pubmed pmid: 26152362. 11. gunaratne da, barham hp, christensen jm, bhatia dd, stamm ac, harvey rj. topical concentrated epinephrine (1:1000) does not cause acute cardiovascular changes during endoscopic sinus surgery. int forum allergy rhinol. 2016 feb;6(2):135-9. doi: 10.1002/alr.21642. epub 2015 sep 18. pubmed pmid: 26383187. orbital swelling but not the patient’s vision. finally, could the use of the topical nasal vasoconstrictor 1:1000 epinephrine during ess cause ophthalmic artery vasospasm? numerous studies have been published on the safety and usefulness of epinephrine in ess.9-11 ophthalmic artery spasm is only highly probable in surgeries extending into the skull base wherein the ethmoidal arteries and the optic nerves can be compromised.2 in our case, topical epinephrine was bilaterally instilled to optimize the endoscopic field, yet only the left eye was affected. direct trauma to the optic nerve or orbital hemorrhage are the most common causes of acute blindness after ess. in their absence however, the rare possibility of non-iatrogenic delayed sudden perioperative blindness must also be considered. the series of events in our case may plausibly be attributed to ophthalmic artery vasospasm which could have caused permanent blindness. the evidence about its possible mechanisms (such as irregularities in vascular endothelial muscle activity) is still inconclusive and may be conjectural but acknowledging that such conditions have the risk of happening may aid otolaryngologists and ophthalmologists in their early detection and prompt initiation of appropriate management can lead to saving a post-ess patient’s vision. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to present the demographic profile, etiology and treatment outcome of patients presenting with epistaxis in our local setting. methods: design: retrospective study setting: tertiary private university hospital participants: records of 188 patients who presented with epistaxis at the emergency room as well as in-patient admissions and referrals due to epistaxis from january 2017 to december 2017 were reviewed. results: there were a total of 188 patients who presented with epistaxis with a male to female ratio of 2:1. peak incidence was noted in young children aged 0-10 years old and again rising in adults above 60 years of age. the most common cause of epistaxis was noted to be trauma (56, 29.79%) followed by hypertension (41, 21.81%) and mucositis at (38, 20.21%). conservative management were done in majority of the cases (187, 99.47%) with an overall success rate of 95.19% (178 out of 188). conclusion: one of the most common emergencies that people may encounter in their lifetime is epistaxis. understanding the demographic profile, etiology, intervention and treatment outcome of patients with epistaxis is essential for the establishment of cost-effective treatment guidelines, protocols and preventive strategies. health education remains to be a key in reducing morbidity and mortality resulting from epistaxis. keywords: epistaxis; etiology, demographics, treatment, treatment outcome epistaxis is reported to be one of the most common otorhinolaryngological emergencies worldwide and is frequently encountered in general practice as well. it is estimated to occur in 60% of persons during their lifetime with approximately 6% requiring medical attention.1,2 epistaxis may present in various ways; as an acute emergency, a chronic problem of recurrent bleeding or as a symptom of a systemic disorder. it is commonly divided into anterior or posterior depending on the site of origin. anterior epistaxis accounts for more than 80% of cases and arises from damage to the kiesselbach’s plexus along the anterior nasal septum.2 epistaxis in this area clinical profile of filipino patients with epistaxis in a university hospital therese monique d.g. gutierrez, md francisco jesus v. lerma, jr., md department of otorhinolaryngology head and neck surgery university of santo tomas hospital correspondence: dr. francisco jesus v. lerma, jr. department of otorhinolaryngology head and neck surgery university of santo tomas hospital españa blvd., manila 1015 philippines phone: (632) 731 3001 loc. 2411 email: ust_enthns@yahoo.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest. october 22, 2018, maynila ballroom, the manila hotel, manila. philipp j otolaryngol head neck surg 2019; 34 (1): 26-29 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles is usually self-limiting and easier to control. posterior epistaxis which includes damage to the woodruff ’s plexus are less common occurring in 10% of patients and may be more challenging to control.3 no matter the type or severity of the epistaxis the correct management is always essential. although epistaxis has been dealt with for centuries, its management remains a challenge for both the public and many health professionals. a survey done among clinical staff at the emergency department of a national teaching hospital showed that only 38.1% of the respondents demonstrated the correct site for manual compression of the nose.4 indeed, management of epistaxis causes great anxiety not only to patients and their relatives but to health care workers and physicians as well. several studies on the causes, treatment, and outcome of patients with epistaxis have been done worldwide however, there is a paucity of local data available. a literature search of medline, herdin and google scholar using the keywords “epistaxis” and “philippines” yielded studies among the pediatric population only. there were no local studies available that examine the clinical profile of patients with epistaxis across all age groups. this study aims to determine the demographic profile, etiology and treatment outcome of patients presenting with epistaxis across all ages in our local setting. specifically, it seeks to identify the most common age range and gender distribution, the most common underlying cause of epistaxis in our setting and the success and failure rate of surgical and non-surgical interventions for epistaxis. methods with institutional review board approval, a retrospective review of records of all patients who presented with epistaxis during a period of one year from january to december 2017 was carried out. this included cases of epistaxis seen at the emergency room of the clinical and private division, as well as both admissions and in-patient referrals from all services severe enough to warrant urgent consult. excluded were those patients presenting with epistaxis at the out-patient department since majority of patients seen at the opd were inactive cases. patient anonymity was protected in the collection of data. confidential patient data was known only to the authors and each patient was assigned a reference number for identification known only to the investigator. demographics such as age and gender, as well as the etiology/cause of bleeding were collected and tabulated. the treatment rendered was also noted for each of the cases. treatment outcome was assessed based on the criteria by basheer, et al.5 which included the following: successful treatment was defined as no readmission or consult at the emergency room within 24 hours of discharge or no recurrence of epistaxis for 24 hours following nasal packing removal. failure of treatment was defined as readmission or consult at the emergency room within 24 hours of hospital discharge or persistent epistaxis after nasal packing for 24-48 hours. data collected were analyzed with descriptive statistics using microsoft excel for mac 2016 version 16.12. (microsoft corp., redmond, ca, usa). the age, gender, etiology, treatment rendered and treatment outcome were collected and tabulated. the actual number of cases for each was divided by the total population and multiplied by 100 to obtain percentages. results a total of 188 records of patients who presented with epistaxis from january 2017 – december 2017 were included in this study. there were a total of 125 males (66.5%) and 63 females (33.5%) with a male to female ratio of 2:1. ages ranged from 9 months to 82 years old with a peak incidence in young children aged 0-10 years old and again in adults above 60 years of age. one hundred forty six (146) patients (77.7%) presented at the emergency room department while 42 patients (22.3%) were in-patient admissions and referrals. overall, the most common cause of epistaxis was noted to be trauma (56, 29.79%). trauma included cases of epistaxis due to direct or blunt injury from sports, vehicular accidents, mauling and fall. this was followed by hypertension (41, 21.81%) and mucositis (38, 20.21%). other causes included digital manipulation (32, 17.02%), other systemic illnesses (7, 3.72%), intranasal mass or tumor (5, 2.66%), blood dyscrasia including anticoagulant use (4, 2.13%), secondary to dengue fever (4, 2.13%) and iatrogenic injury (1, 0.53%). for children 10 years and below, the most common cause was digital manipulation (13, 36.11%) followed by trauma (11, 30.55%). trauma remained to be the most common etiology for epistaxis among patients aged 11-50 years old. for both the middle and old age population (51-60 and 61above), hypertension was the most common etiology. (table 1) table 1. causes of epistaxis according to age group age range trauma hypertension digital manipulation other systemic causes mass/ tumor dengue fever iatrogenic blood dyscrasia mucositis 0-10 11-20 21-30 31-40 41-50 51-60 61 above 11 10 12 9 7 4 3 0 0 3 1 6 8 23 13 8 1 3 2 3 2 2 1 1 0 2 0 1 0 1 0 0 1 3 0 0 0 0 0 0 1 3 1 1 1 0 1 0 0 0 0 0 1 0 0 0 9 3 10 7 3 3 3 philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles non-surgical measures were the main intervention in majority of the cases (187, 99.47%). conservative measures such as manual digital compression, application of ice packs and topical vasoconstrictors as well as control of hypertension provided relief in the majority (177, 94.15%) of patients. anterior nasal packing were warranted in 3.19% (6 out of 188) of patients while 2.13% (4 out of 188) of patients required posterior nasal packing. only 1 out of 188 patients (0.53%) required surgical intervention with cauterization of bleeders. the overall success rate for non-surgical treatment was 95.19% (178 out of 188 patients). out of 177 patients treated conservatively with manual digital compression, application of ice packs, topical vasoconstrictors and control of hypertension, 169 (95.48%) had no recurrence of epistaxis within 24 hours while only 8 patients (4.52%) were considered failure of treatment. all patients who underwent anterior nasal packing were treated successfully while 75% of patients (3 out of 4 patients) who had posterior nasal packing were also successfully treated. surgical management on the other hand also had a 100% success rate. (table 2) among those above 60 years of age. the increased incidence in the pediatric age population in our setting may be due to the fact that they are more prone to digital manipulation or nose picking, and are also often victims of trauma such as minor falls. a rise in the old age group was also seen and may be attributed to factors such as hypertension and poor blood pressure control. most of the underlying causes of epistaxis are preventable. our study showed that trauma was the most common cause closely followed by hypertension and mucositis. the high incidence of traumatic epistaxis across all age groups warrants emphasis on the importance of rhinologic assessment among all trauma patients. hypertension was noted to be the second most common cause of epistaxis overall in our setting, present in 21.81% of cases, and also the most common cause among the middle age (51-60 years) and older age group (61 years above). epistaxis in the elderly have a diverse etiology with hypertension as the most common etiological factor as seen in other studies as well.8 this may explain its increased incidence among patients more than 60 years of age, and emphasizes the importance of proper compliance with antihypertensive medications as well as the need for regular check-ups and blood pressure monitoring. initial assessment of a patient presenting with epistaxis should focus on the general status of the patient vital signs and cardiopulmonary stability. once these are established, a more thorough history and physical examination may proceed.3 the treatment of epistaxis is based on the site and degree of bleeding. treatment modalities are divided into two groups: conservative or non-surgical and surgical approaches.1 non-surgical approaches have been reported to stop the bleeding in the majority of the cases which was likewise evident in our study with a 95.19% success rate. surgical treatment is reserved for ongoing hemorrhage that fails conservative interventions. in our study, the diagnosis of epistaxis was based on a thorough clinical history and complete physical examination with special emphasis on the nose and oral cavity to identify the origin and site of bleeding. all patients were initially treated conservatively and surgical intervention was considered only when conservative management failed to control the epistaxis. conservative management was utilized in a stepwise fashion. patient positioning with the head bent forward was ensured to avoid swallowing of blood and subsequent nausea and vomiting. manual digital compression over the nasal ala was initially done and is recommended as well in studies as the first step in controlling simple anterior nose bleeding in all stable patients.1 application of ice compress over the forehead and nape area, together with the use of a locally applied vasoconstrictor in the form of oxymetazoline 0.025% nasal drops (3-5 drops per nostril) for children table 2. treatment outcomes of non-surgical and surgical intervention treatment modality no. of patients no. of patients succesfully treated success rate (%) failure rate (%) non-surgical manual compression, ice pack +topical vasoconstrictor anterior nasal packing posterior nasal packing surgical endoscopic cauterization arterial ligation 187 177 6 4 1 1 0 178 169 6 3 1 1 0 95.19 95.48 100 75 100 100 0 4.81 4.52 0 15 0 0 0 discussion epistaxis, defined as an acute hemorrhage from the nostril, nasal cavity or nasopharynx is considered the most common otorhinolaryngologic emergency affecting up to 60% of the population in their lifetime with up to 6% warranting medical attention.1,2 in this retrospective review of records, epistaxis was noted to be more common in men with a male to female ratio of 1.98:1. globally, there is a male preponderance in epistaxis as shown in different studies as well.6,7 in our study, peak incidence of epistaxis was noted among the pediatric age group less than 10 years of age and it was again observed philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles references 1. diamond l. managing epistaxis. jaapa. 2014 nov; 27(11):35-39. doi: 10.1097/01. jaa.0™000455643.58683.26; pmid: 25303882. 2. melinte v, musteata o, sarafoleanu c. epistaxis management – our point of view and literature review. romanian journal of rhinology. 2017 oct-dec; 7 (28): 207-2013. doi: 10.1515/rjr-20170022. 3. andreeff, r. epistaxis. jaapa. 2016 jan; 29(1):46-47. doi: 10.1097/01.jaa.0000473373.47749.5f; pmid: 26704654. 4. mugwe p, kamau kj, nyambaka ok. knowledge, attitude and practice in first aid management of epistaxis by accident and emergency clinical staff at kenyatta national hospital. east cent afrc jsurg. 2014 mar-apr; 19(1): 17-21. 5. basheer nk, jaya c, sabir vt. epistaxis: etiological profile and treatment outcome in a teaching hospital in south india. int j otorhinolaryngol head neck surg. 2017 oct; 3(4): 878-84. doi: http:// dx.doi.org/10.18203/issn.2454-5929.ijohns20174099. 6. varshney s, saxena rk. epistaxis: a retrospective clinical study. indian j otolaryngol head neck surg. 2005 apr; 57(2): 125-129. doi: 10.1007/bf02907666; pmcid: pmc3450961; pmid: 23120148. 7. gilyoma j, chalya pl. etiological profile and treatment outcome of epistaxis at a tertiary care hospital in northwestern tanzania: a prospective review of 104 cases. bmc ear nose throat disord. 2011 sep 5; 11:8. doi: 10.1186/1472-6815-11-8; pmid: 21892930 pmcid: pmc3175172. 8. sharma k, kumar s, islam t, krishnatreya m. a retrospective study on etiology and management of epistaxis in elderly patients. arch med health sci. 2015; 3(2): 234-8. doi: 10.4103/23214848.171911. 9. traboulsi h, alam e, hadi u. changing trends in the management of epistaxis. int j otolaryngol. 2015; 2015: 263987. doi: 10.1155/2015/263987; pmid: 26351457 pmcid: pmc4553192. 10. pallin dj, chng ym, mckay mp, emond ja, pelletier aj, camargo ca jr. epidemiology of epistaxis in us emergency departments, 1992 to 2001. ann emerg med. 2005 jul; 46(1): 77-81. doi: 10.1016/j.annemergmed.2004.12.014; pmid: 15988431. 11. beck r, sorge m, schneider a, dietz a. current approaches to epistaxis treatment in primary and secondary care. dtsch arztebl int. 2018 jan 8; 115(1-02): 12–22. doi: 10.3238/arztebl.2018.0012; pmid: 29345234 pmcid: pmc5778404. 12. morgan dj, kellerman r. epistaxis: evaluation and treatment. prim care. 2014 mar; 41(1):63–73. doi: 10.1016/j.pop.2013.10.007; pmid: 24439881. and 0.05% nasal spray (2 sprays per nostril) for adults (provided that blood pressure was controlled) to aid in the cessation of bleeding was then done. this method provided relief of epistaxis in 95.48% (169 out of 177 patients) of cases with no recurrence noted in 24 hours. in resource-poor areas where facilities and specialists are limited, this finding suggests that majority of epistaxis presenting at the emergency department may be controlled with proper first aid measures. this may serve as a guide in educating health care workers and patients as well when faced in a situation with epistaxis. anterior nasal packing was used in 3.19% (6 out of 187 patients) of our cases with a good outcome. contrary to other studies which state that anterior nasal packing was the most frequent modality of treatment,7 nasal packing may be uncomfortable and may be responsible for a plethora of complications. other studies show that the failure rate of nasal packing has been reported to be up to 52%, and the rate of re-bleeding increased to 70% in patients with known bleeding disorders.9 the insertion of the nasal packing itself may be traumatic and can further induce bleeding in areas different from the primary site. hence, anterior nasal packing is reserved for cases when manual compression failed to control the bleeding. given the limited number of patients that underwent nasal packing in this study, a significant correlation between the type of nasal packing used and treatment outcome could not be derived. posterior nasal packing was done in only 2.13% (4 out of 188) cases. out of the 4 patients who underwent this intervention, only 1 needed surgical management through endoscopic cauterization of bleeders. indeed, monopolar cauterization under endoscopic guidance for control of posterior epistaxis may offer a safe and effective management for refractory nasal bleeding. electrocautery has a reported efficacy of 90%.2 when done inside the operating room under general anesthesia, patient safety and comfort is ensured and this can be easily performed by a trained physician. arterial ligation is necessary only in intractable cases of epistaxis when all measures fail. in our study, no surgical ligation of vessels was required. there was also no mortality recorded in this series. one of the most common emergencies that people may encounter in their lifetime is epistaxis. fortunately, most of the underlying causes of epistaxis are preventable. in our setting, trauma remains the most common etiology, closely followed by hypertension and mucositis. non-surgical treatment remains the first line management in controlling epistaxis in our setting. conservative measures such as proper head positioning, manual digital compression, application of ice compress and use of topical vasoconstrictors alone are sufficient in controlling a majority of cases with a success rate of 95.48%. it is safe, cost-effective and efficient in arresting the bleeding. understanding the causes, treatment and outcome of these patients is essential for the establishment of preventive strategies and treatment guidelines and protocols. in resource poor communities where facilities and specialists are limited, training of health care workers and proper health education on the first aid measures on epistaxis may be helpful and life-saving. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2019; 34 (2): 42-46 c philippine society of otolaryngology – head and neck surgery, inc. emergent reconstruction of laryngeal penetrating neck injury: a case report ruthlyn s. pecolera, md rubiliza dc. onofre telan, md department of otorhinolaryngology head and neck surgery east avenue medical center correspondence: dr. rubiliza dc. onofre telan department of otorhinolaryngology head and neck surgery 6th floor, east avenue medical center east avenue, diliman, quezon city 1100 philippines phone: (632) 8928 0611 local 324 fax: (632) 3435 6988 email: rubiliza.onofre8211@gmail.com the authors declared that this represents original material, that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the interdepartmental interesting case report contest, department of urology, east avenue medical center. october 3, 2017. conference room, east avenue medical center, quezon city. presented at the philippine society of otolaryngologyhead and neck surgery poster session contest on surgical innovation & instrumentation. october 24, 2018. millenium foyer, the manila hotel. manila. presented as a poster at frontiers in laryngology. inaugural congress of the asia pacific laryngology association. november 1 to 3, 2019. the academia, singapore. abstract objective: this paper aims to describe an unconventional surgical procedure performed in a case of penetrating neck injury involving the larynx. methods: design: case report setting: tertiary government hospital patient: one results: a 38-year-old man sustained a hacking laceration to the anterior neck that extended into the hypopharyngeal area transecting the thyroid cartilage. after pre-emptive tracheostomy, the patient was referred to otorhinolaryngology – head and neck surgery due to the extensive hypopharyngeal injury. neck exploration performed to control bleeders confirmed a schaeferfuhrman classification group 3 penetrating neck injury. anastomotic reconstruction of the hypopharynx, transected thyroid cartilage and strap muscles was attempted using absorbable sutures with post-operative re-establishment of structural continuity and documentation of full bilateral vocal fold mobility. the patient was about to be discharged home with a tracheotomy and nasogastric tube when he suddenly deteriorated and expired on the eighth post-operative day. conclusion: our technique might be utilized in cases where urgent reconstruction of laryngeal structures is considered despite serious damage to the laryngeal skeleton and may provide a temporary surgical option for similar cases in an emergent setting. however, we cannot recommend it as a routine standard on the basis of one case. keywords: larynx; penetrating neck injury; vocal cord; reconstruction; neck exploration creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery case reports the neck contains many important vital structures that are potentially life threatening when severed, so penetrating neck trauma can cause significant morbidity and mortality.1-3 zone ii of the neck is a defined anatomic region extending from the cricoid to the angle of the mandible that has been observed to have the most number of neck injuries.4 its anatomic contents (e.g. major blood vessels) make zone ii injuries challenging to manage and explore with open surgical approaches and prompt diagnosis and timely intervention can be crucial in such cases.5 we present one such case. case report a 38-year-old man was brought to the emergency room with a deep open wound on his anterior neck after being hacked with a “bolo” (jungle machete). the patient was awake with no signs of respiratory distress and minimal bleeding. he was immediately brought to the operating room where pre-emptive tracheostomy was performed by a general surgeon who referred the patient intraoperatively to otorhinolaryngology – head and neck surgery. wound exploration revealed an approximately 10 cm long, smooth-edged diagonal laceration over the anterior neck. its depth extended to the anterior border of the carotid artery on the right severing some fibers of the infrahyoid muscles on the left. (figure 1) it was approximately at the level of the upper half of the thyroid cartilage, 1 cm from glottic area. (figure 2a-c) the cut transected the thyroid cartilage and detached the epiglottis from the posterior surface attachment at the petiole. it also reached the hypopharyngeal area up to the anterior border of the prevertebral mucosa above the esophageal inlet in close proximity to the major blood vessels. ligation of smaller bleeders was performed with no significant carotid or major venous injuries identified. figure 1. anterior neck wound exposing the anterior border of the carotid artery (right) and infrahyoid muscles (left). the petiole of the epiglottis also seen in the picture (dashed circle). note the upper half of the thyroid cartilage (solid arrow) and notch of the thyroid cartilage (dashed arrow). figure 2. a horizontal cut along the thyroid cartilage exposing the vocal cords. noted intact and fully mobile vocal cords. the white arrows show the position of the vocal cords a. fully abducted; b. intermediate position; and c. fully adducted. a b c philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery case reports discussion in this case, we were presented with an anterior neck injury through a hacking wound that extended into the hypopharyngeal area, transecting the thyroid cartilage. considering the extent of the patient’s injury, it was important to have a well-planned management from figure 3. intraoperative photo after reconstruction of the thyroid cartilage using absorbable sutures via simple interrupted suturing. note the thyroid cartilage (solid arrow). reconstruction of the severed structures involved simple closure of the hypopharyngeal area using vicryl 4.0 rb-1 simple interrupted sutures, anastomosis of the divided thyroid cartilage using vicryl 4.0 rb-1 simple interrupted sutures, and repair of damaged strap muscles using vicryl 3.0 rb-1 sutures. (figure 3) a schematic diagram of the surgical procedure is presented in figures 4a-c. the tracheostomy tube was maintained post-operatively and a nasogastric tube was inserted. no intraoperative problems or immediate post-operative complications were encountered. standard post-operative wound and tracheostomy care were performed. one day after surgery, flexible laryngoscopy to evaluate the status of the vocal cords was deferred because the patient exhibited behavioral changes. he was irritated and combative with episodes of flat affect. a toxicology five-panel drug test revealed no evidence of prohibited substance use. a psychiatry referral was suggested but not made by the main service. on the 5th post-operative day, laryngoscopy revealed a patent airway with fully mobile vocal cords but noticeable swelling and edema of the arytenoids and mucoid secretions. (figure 6) the patient was maintained on nasogastric tube feeding and anti-inflammatory steroid medications were given. on the 8th post-operative day, the patient remained stable and was counselled to maintain nasogastric and tracheostomy tube for two weeks. he was preparing to be discharged home when he suddenly had changes in sensorium and became hypotensive and bradycardic. resuscitation was initiated but the patient expired. the cause of death remains unknown because the relatives did not consent to an autopsy. figure 4. a diagram of the surgical technique. a. approximation of the line of injury (dashed line); b. approximation of the cut at the level of the upper half of the thyroid cartilage, 1 cm above the glottic area (solid vertical line); c. closure of the hypopharyngeal area and anastomosis of the divided thyroid cartilage via simple interrupted suturing (interrupted lines). illustrations by ruthlyn s. pecolera md. a b c philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery case reports assessment to treatment to attain maximum recovery.5 the structural complexity of the neck makes it one of the anatomically complicated parts of the human body that can sustain multiorgan injuries from extra-laryngeal or penetrating traumas.6 this patient’s neck injury was classified using the 5-group schaefer-furhman classification.7 first developed in 1982 by schaefer et al., and later amended by fuhrman et al. in 1990 to describe the four groups and add the 5th group, the schaefer-furhman classification is the most widely used classification of laryngeal trauma severity.7 group i covers all minor laryngeal edema or lacerations without any detectable fractures. group ii covers all demonstrable severe edema, hematomas minor mucosa discontinuity without any cartilage exposed, or absence of displaced fractures. group iii involves massive edema, extensive mucosal lacerations, exposed cartilages and or displaced fractures; any presence of vocal cord immobility. group iv includes cases with destabilized laryngeal framework, noticeable disruption of the anterior commissure, presence of more than 1 unstable displaced fracture, and/or presence of severe mucosal injuries. those with complete laryngotracheal separation fall under group v.3-7 our patient had massive edema of the anterior neck area and large mucosal lacerations exposing the thyroid cartilage without displaced fractures or vocal cord immobility making him fall under group iii. in the united states, approximately 1 in 137, 000 cases of laryngeal trauma are attributed to external causes.8 to the best of our knowledge, there are no local studies or statistics on blunt and penetrating neck figure 5. postoperative endoscopy revealed a patent airway with mobile vocal cords and noticeable swelling and edema of the arytenoids. injuries. examination and initial management of laryngeal trauma should be part of primary and secondary surveys according to advanced trauma life support guidelines.9 airway support and securing viable blood supply should be the immediate concern. there are numerous algorithms recommended for the management of laryngeal injuries depending on its severity.5,7,10 management ranges from medical treatment (e.g. antibiotics, steroids, and anti-reflux agents) for mild cases to surgical treatments including endoscopy, stent and plate application for more severe injuries.6,7,11 disparity of management can be observed within each class hence the management must be modified.12 in addition, none of the existing classifications describes the prognosis although recommended management is indicated per grouping described by schaefer and fuhrman.3,5,6 there is disagreement over the optimal timing of repair for severe cases requiring surgical intervention.3,5,13 jewett et al. in 1999 proposed the time for initiation of laryngeal repair is within 12 hours post injury and should not be delayed after 24 hours.5,8 thevasagayam and pracy in 2005 recommended varied timing for initiation of treatment depending on severity according to schaefer-fuhrman classification: 24 to 48 hours observation for group i; open exploration within 24 hours for groups 3, 4 and 5.7 even deferral of intervention may result in granulation tissue proliferation and more problematically, laryngeal stenosis.5,8 on the other hand, liao et al. in their 2014 study involving 48 patients with external laryngeal trauma, found that the long term outcome of laryngeal function was related to initial injury status and not affected by surgical timing.6 furthermore, they reported that definitive surgical treatment can be delayed until the patient is ready for the procedure.6 the main indications for open laryngeal repair are displaced, unstable laryngeal fracture, cricotracheal separation, detachment of anterior commissure or extensive mucosal disruption as suggested based on the schaefer-fuhrman classification.5-7 endoscopy should be performed for further evaluation of other endolaryngeal injuries, mucosal loss should be addressed if noticed and further cartilage repair and stent application should also be considered.5,7,11 on the other hand, based on the laryngeal trauma management protocol,14 cases that belong to the group 3 classification should undergo open reduction and internal fixation of fractures with or without endoscopic repair. the need for endolaryngeal stenting in the presence of massive mucosal injury is also recommended11 but controversies attributed to their usage concerns the type of material to be used as stent and its duration of use11 as well as its association with granulation tissue formation and mucosal ischemia.7 the problem arises if the resources needed (e.g. stents) are not readily available. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery case reports references 1. luqman z, khan ma, nazir z. penetrating pharyngeal injuries in children: trivial trauma leading to devastating complications. pediatr surg int. 2005 jun; 21(6):432-5. doi: 10.1007/s00383-0051447-0; pmid: 15891890. 2. demetriades d, velmahos gg, asensio ja. cervical pharyngoesophageal and laryngotracheal injuries. world j surg. 2001 aug; 25(8):1044-8. doi: 10.1007/s00268-001-0057-9;  pmid: 11571970. 3. kim jp, cho sj, son hy, park jj, woo sh. analysis of clinical feature and management of laryngeal fracture: recent 22 case review. yonsei med j. 2012;53(5):992-998. doi: 10.3349/ ymj.2012.53.5.992; pmid: 22869483 pmcid: pmc3423852. 4. kim jp, park jj, won sj, woo sh. penetrating carotid artery injuries treated by an urgent endovascular stent technique: report of two cases. chonnam med j. 2011 aug; 47(2):134-7. doi: 10.4068/cmj.2011.47.2.134; pmid: 22111076. pmcid: pmc3214866. 5. omakobia e, micallef a. approach to the patient with external laryngeal trauma: the schaefer classification. otolaryngol sunnyvale. 2016;6 (2):230. doi:10.4172/2162-119x.1000230. 6. liao ch, huang jf, chen sw, fu cy, lee la, ouyang ch, et al. impact of deferred surgical intervention on the outcome of external laryngeal trauma. ann thorac surg. 2014;98:477-83. doi: 10.1016/j.athorasur.2014.04.079; pmid: 24961838. 7. thevasagayam ms, pracy p. laryngeal trauma: a systematic approach to management. trauma. 2005;7:87-94. doi: 10.1191/146040860ta3360a. 8. jewett bs, shockley ww, rutledge r. external laryngeal trauma analysis of 392 patients. arch otolaryngol head neck surg. 1999;125:877-880. doi: 10.1001/archotol.125.8.877; pmid: 10448735. 9. the committee on traumaamerican college of surgeons. chapter 1: initial assessment and management. in: merrick c, executive editor. atlsadvance trauma life support. student course manual. 10th edition. chicago: american college of surgeons; 2018. p. 2-21. 10. sniezek jc, thomas rw. chapter 8: laryngeal trauma. in: holt gr, editor. resident manual of trauma to the face, head and neck. 1st edition. virginia: american academy of otolaryngologyhead and neck surgery foundation; 2012. p. 117-187. 11. attifi h, elfarouki a, nadour k, hmidi m, touihem n, elboukharu a, et al. diagnosis and management of laryngeal fracture: a case report. int j otorhinolaryngol head neck surg. 2017 oct;3(4):1095-1098. doi: 10.18203/issn.2454-5929.ijohns20174098. 12. randall dr, rudmik lr, ball cg, bosch jd. external laryngotracheal trauma: incidence, airway control, and outcomes in a large canadian center. laryngoscope. 2014 apr; 124(4): e123-133. doi: 10.1002/lary.24432; pmid: 24122903. 13. kaya kh, koc ak, uzut m, altintas a, yegin y, sayin i, et al. timely management of penetrating neck trauma: report of three cases. j emerg trauma shock. 2013 oct-dec;6(4):289-292. doi: 10.4103/0974-2700.120382; pmid: 24339665 pmcid: pmc3841539. 14. sandhu gs, nouraei sr. chapter 67: laryngeal and esophageal trauma. in: flint pw, haughey bh, lund vj, niparko jk, robbins kt, thomas jr, lesperance mm, editors. cummings otolaryngology head and neck surgery. 6th edition. philadelphia: elsevier saunders; 2015. p. 970-981. in this case, the immediate technique performed entailed hypopharyngeal repair by simple interrupted suturing using absorbable sutures. the technique was relatively easy to perform with fairly good post-repair laryngeal function. although the vocal cords were edematous post-operatively, they were fully mobile and could fully coaptate. in conclusion, our technique might be utilized in cases where urgent reconstruction of laryngeal structures is considered despite serious damage to the laryngeal skeleton, and may provide a temporary surgical option for similar cases in an emergent setting. the following conditions should be noted: the wound was <10 centimeters long and had smooth edges; there was no involvement of major blood vessels; and the upper half of the thyroid cartilage was transected without involvement of the glottic area. however, even with these conditions, we cannot recommend our technique as a routine standard on the basis of one case. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery meta-analysis abstract objective: the primary objective of this meta-analysis is to compare locoregional recurrence, vocal cord paralysis and permanent hypoparathyroidism in patients with thyroid papillary carcinoma without neck node metastases, after total thyroidectomy with and without prophylactic central neck dissection. methods: two independent reviewers performed a detailed literature search of medline (pubmed), herdin and cochrane library electronic databases to assess research studies until 2018 for inclusion. the primary endpoints of locoregional recurrence, permanent hypoparathyroidism and vocal cord paralysis were included in the assessment. design: meta-analysis of retrospective cohort studies setting: university hospitals and tertiary referral centers participants: patients with node-negative papillary thyroid cancer who underwent either total thyroidectomy alone or total thyroidectomy with prophylactic central neck dissection (either unilateral or bilateral). results: this meta-analysis showed that there is a significantly increased risk for locoregional recurrence in the total thyroidectomy alone group (1.96% tt with pcnd vs 2.60% tt, rr=0.62, 95% cl=0.40-0.95, p=.03), permanent hypoparathyroidism in the total thyroidectomy with prophylactic central neck dissection group (5.72% tt with pcnd vs 3.34% tt, rr=2.19, 95% cl=1.62-2.98, p=.00001) and no significant difference for vocal cord paralysis between the 2 groups (rr=1.56, 95% cl=0.86-2.84, p=.14). conclusion: this meta-analysis revealed that performing pcnd in patients with node-negative ptc increases the risk of morbidity for hypoparathyroidism but not for vocal cord paralysis. more importantly, the incidence of recurrence is decreased in the pcnd group which may have implications on the overall survival of patients. the benefit of performing pcnd may outweigh the risk but the role of prophylactic cnd in the treatment of patients with ptc with clinically negative lymph nodes is still debatable in terms of overall survival. keywords: thyroidectomy, complications; neck dissection; papillary thyroid carcinoma; lymph node dissection; recurrence; vocal cord paralysis; hypoparathyroidism morbidity outcomes of prophylactic central neck dissection with total thyroidectomy versus total thyroidectomy alone in patients with node-negative papillary thyroid cancer: a meta-analysis of observational studies christen-zen i. sison, md adrian f. fernando, md therese monique d.g. gutierrez, md department of otorhinolaryngology head & neck surgery university of santo tomas hospital correspondence: dr. christen-zen i. sison department of otorhinolaryngology head and neck surgery university of santo tomas hospital españa blvd., sampaloc, manila 1015 philippines phone: (632) 731 3001 loc. 2411 email: sison.christen@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of oncologists, inc. research paper contest (2nd place). september 22, 2018. makati diamond residences. makati city. presented at the philippine society of otolaryngology-head and neck surgery, analytical research contest (1st place). october 23, 2018. roma salon, the manila hotel. manila. philipp j otolaryngol head neck surg 2019; 34 (1): 6-13 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery meta-analysis among the thyroid malignancies, papillary thyroid carcinoma (ptc) is the most common type accounting for about 80 90% of all thyroid cancers worldwide.1-4 the consensus on the appropriate treatment of patients with papillary thyroid cancer has undergone paradigm shifts over the years yet there are still points of controversy.3-6 currently, the most widely debated subject in the management of ptc is whether a prophylactic central neck dissection (pcnd) should be done in patients who are clinically node-negative.5 elective or prophylactic central neck dissection (pcnd) has been proposed in the treatment of ptc without clinical and ultrasound evidence of lymph node metastasis in the neck (cn0).7 a central neck dissection (cnd) consists of removal of all lymph nodes and fibrofatty tissue between the common carotid arteries laterally from the hyoid bone superiorly to the innominate artery inferiorly.8 the rationale of this procedure is to remove clinically non-detectable pathologic lymph nodes to reduce the rate of recurrent disease and the morbidity associated with re-operation.9 on the other hand, some studies report that there is no oncologic benefit, as no difference has been shown in preablation radioiodine uptake in the neck whether or not pcnd was performed.8 although most management guidelines agree in performing cnd routinely for patients with clinically evident nodal disease, the role of prophylactic central neck dissection remains controversial in patients who are clinically node-negative. the american thyroid association management guidelines recommend pcnd in clinically node-negative (cn0) ptc patients especially in those with a tumor size larger than 4 cm or those with extrathyroidal extension.8 at the same time, a european consensus statement on pcnd endorsed by the european thyroid association in 2006 stated that there is no evidence that pcnd improves recurrence or mortality rates, but it does allow an accurate staging of the disease that may guide subsequent treatment and follow-up.8 proponents of pcnd also support its routine use as it has the advantage of increasing accuracy in tnm staging of pathologic lymph nodes.8,10 on the other hand, those against the routine use of pcnd claim that the clinical impact of occult micrometastases has yet to be demonstrated and it may lead to an overstaging of disease without clear evidence of reduction in recurrence or added benefit to survival. it was also found that the overall complication rate was significantly higher in patients treated with total thyroidectomy and pcnd compared to total thyroidectomy alone.4 the commonly reported complications included vocal cord paralysis or recurrent laryngeal nerve injury and hypothyroidism, with a noted higher risk of permanent hypoparathyroidism if bilateral neck dissection was done.11-13 interestingly, the overall recurrence rate and survival rate did not significantly differ between the two groups in these studies.11-14 from the results of these studies, it seems evident that the incidence of morbidity is clearly and consistently proportional to the extent of surgery. this result is not unexpected however, since more extensive dissection in the central neck during surgery may interfere with the blood supply to the parathyroid glands, particularly the inferior parathyroid glands.8 despite these complications, those that favor pcnd argue that it reduces the need for reoperation in central recurrence, which can exhibit more aggressive behavior and may lead to greater morbidity. the primary objective of this meta-analysis is to provide evidence of prophylactic central neck dissection in the management of papillary carcinoma of the thyroid without clinically apparent neck node metatases, specifically to compare rates of oncologic control and morbidities after total thyroidectomy with and without prophylactic neck dissection in patients with thyroid papillary carcinoma. methods protocol and registration this meta-analysis was carried out according to the preferred reporting items for systematic reviews and meta-analysis (prisma) guidelines. a protocol for this meta-analysis has been registered on prospero (http://www.crd.york.ac.uk/prospero) under the registration number crd42019125369. eligibility criteria for all the studies, the population included patients with papillary thyroid carcinoma without lymph node metastasis (n0 neck). the intervention would be total thyroidectomy combined with central neck dissection and the comparator is total thyroidectomy alone, with locoregional recurrence and morbidities as vocal cord paralysis and hypoparathyroidism. the inclusion criteria of eligible studies were: (1) retrospective cohort design to ensure homogeneity, (2) studies with more than 10 patients, (3) patients with ptc and no lymph node metastasis preoperatively, (4) studies having pcnd + tt group and tt alone group; and (5) available data about recurrence and incidence rate of complications with a follow up period of at least 2 years. exclusion criteria were as follows: (1) cnd alone (2) thyroidectomy alone (3) lobectomy (4) pcnd combined with lateral neck dissections/ other procedures (5) video-assisted or robotic techniques (6) revision operations, and (7) endoscopic procedures. information sources and search strategy two independent authors searched medline (pubmed), herdin and the cochrane library electronic databases journal articles published in the english language from 2010 until 2018. the following keywords were used in all fields as search strategy: (1) philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery meta-analysis papillary thyroid carcinoma or papillary thyroid cancer or thyroid papillary cancer, (2) central neck dissection or central compartment neck dissection or central compartment lymph node dissection or central compartment node dissection; and (3) 1 and 2. the references of previous meta-analysis were also backtracked and assessed for eligibility. to ensure homogeneity in the scope of the studies, the limits used were any studies that included lateral neck, modified radical, hemithryoidectomy, or lobectomy in any of the titles, abstracts or keywords. study selection and data collection process the abstracts were initially assessed for eligibility based on the specified criteria followed by a full-text analysis of the screened studies to resolve any uncertainty or conflict. a data form was used to extract all data we would evaluate. the following data on study characteristics were collected: first authorship, the publication year, the type of study, follow-up period, the number of patients in pcnd + tt group and tt alone group, the number of patients having recurrence and the number of patients having surgical-related complications. primary endpoints of the study included the rate of morbidity including permanent laryngeal nerve (rln) injury, permanent hypoparathyroidism and locoregional recurrence. recurrent laryngeal nerve injury was defined as a postoperative impairment of the motility of one or both vocal cords postoperatively. permanent hypoparathyroidism was defined as persistent postoperative hypocalcemia 6 months after surgery requiring calcium and vitamin d supplementation. locoregional recurrence was defined as either the cytological evidence of disease in the central or in the lateral compartment of the neck or the evidence of disease on follow-up ultrasound. dichotomous variables were presented as relative risks with 95% confidence intervals. risk of bias in individual studies the quality of the cohort studies were assessed using the newcastleottawa quality assessment scale.15 the quality was assessed based on representativeness, selection of non-exposed cohort, ascertainment of exposure, demonstration that outcome was not present at the start of the study, comparability of cohorts, assessment of outcome, follow-up period and adequacy of follow-up. the funnel plot method was also used to evaluate publication bias. summary measures and synthesis of results statistical analysis was performed using review manager (revman) 5.3 software (cochrane collaboration, london, u.k.). fixed effects models were used for the analyses. heterogeneity across studies was assessed by χ2 test and quantified with i2 statistically with a p<0.1 and an i2>50% was considered a significant difference. a pooled risk ratio (rr) with 95% confidence interval (cl) by the fixed effects model was used to estimate arms in studies included in this meta-analysis. in all tests, p value smaller than .05 was considered statistically significant. results the flow chart of literature filtration is presented in figure 1. a total of 780 publications were obtained from the initial search including 773 from pubmed, 1 from herdin and 6 from cochrane library electronic databases. excluding the duplicates, unrelated topics, studies having no control group or tt alone group and studies combining other procedures, 35 full-text articles were assessed for eligibility. finally, 8 retrospective studies with comparison between pcnd + tt and tt alone were deemed eligible and included in this meta-analysis. the basic characteristics of included studies are shown in table 1. there were 8 retrospective cohort studies included which were published recently from 2010 until 2017. among these hospital-based studies, a total of 13,429 cases were identified in this analysis, including 9,634 cases in the pcnd+tt group and 3,795 cases in the tt alone group. three of these included studies set the subgroup analysis and divided the pcnd into unilateral pcnd and bilateral pcnd. for this meta-analysis, the data has been combined for unilateral and bilateral cnd since most of the studies had pooled the data together in both figure 1. flowchart of literature search philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery meta-analysis groups and were not specified. the scale distribution (0-10 stars) for the study quality ranged from 6 to 8 stars based on the newcastle-ottawa quality assessment scale.15 all the included studies demonstrated a relatively high quality as shown in tables 2 and 3. risk of bias assessment is summarized in table 4. since the included studies shown in table 4 are retrospective and observational in design, evaluations of allocation concealment, blinding of participants and personnel, and blinding of outcome assessments are absent. thus, the studies were judged to have a high risk of selection, information and confounding biases. the post-operative morbidity outcomes of permanent vocal cord paralysis, permanent hypoparathyroidism and locoregional recurrence between the two groups are shown as forest plots of the risk difference in figures 2 to 4. risk of publication bias for each study is shown in table 4. the overall rate of vocal cord paralysis is 1.44% (44/3050), permanent hypoparathyroidism is 4.48% (183/4083) and locoregional recurrence is 2.3% (86/8376). there was no significant difference in the incidence of permanent vocal cord paralysis between the tt alone group and the tt + pcnd group (rr=1.56, 95% cl=0.86-2.84, p =.14, fig 2a). there was no significant heterogeneity between studies (i2=0% and p=.55). the funnel plot method confirmed no significant publication bias. (figure 2b) permanent hypoparathyroidism was reported in all studies with no significant heterogeneity between studies with i2=14% and p=.32. the rate of permanent hypoparathyroidism in the pcnd+tt group was significantly higher than that in tt alone group (5.72% vs 3.34%, rr=2.19, 95% cl=1.62-2.98, p =.00001. (figure 3a). a publication bias table 1. characteristics of included studies * pcnd = prophylactic central neck dissection, tt = total thyroidectomy table 2. newcastle-ottawa scale for cohort studies 1a study can be awarded a maximum of one star for each numbered item within the selection and outcome category, and a maximum of two stars can be given for comparability. for the selection category, a star is awarded if the exposed cohort is representative; if the unexposed cohort is drawn from the same community as the exposed cohort; if exposure was ascertained by secure record and if it was demonstrated that the outcome of interest was not present at the start of the study. for comparability, one star is awarded if the study controls for the most important factor and another star can be awarded if the study controls for any additional factor. for outcome, a star is awarded if the assessment of the outcome is an independent blind assessment or by record linkage; if there was a long enough follow-up for the outcomes to occur; and if there was complete follow-up. table 3. detailed assessment using the newcastle-ottawa scale for cohort studies philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery meta-analysis table 4. risk of bias assessment summary key: + = low risk of bias, = high risk of bias, ? = unclear risk of bias was shown in one study but was not present in the rest of the studies. (figure 3b) the overall locoregional recurrence was reported in all studies. there was no significant heterogeneity between studies with i2=6% and p=.38. the rate of locoregional recurrence was statistically significantly lower in the pcnd+tt group compared to the tt alone group (1.96% vs 2.60%, rr=0.62, 95% cl=0.40-0.95, p=.03). (figure 4a) the funnel plot method confirmed no significant publication bias. (figure 4b) discussion this meta-analysis found an increased risk for permanent hypoparathyroidism when central neck dissection was performed in addition to total thyroidectomy but no significant risk for vocal cord paralysis. there was also an increased risk for locoregional recurrence with total thyroidectomy was done alone. this meta-analysis is significant in guiding the current surgical management since it may elucidate on the role of pcnd for important risk outcomes including vocal cord paralysis, post-operative hypoparathyroidism and locoregional recurrence. in addition to total thyroidectomy surgery, the recent evidence has grown to include the procedure of central neck dissection due to the increasing incidence of lymph node metastases in level vi nodes estimated to occur between 20 90% of cases.5,15 in these cases, regional lymph node metastasis may be present at the time of diagnosis based on the preoperative ultrasound. however, imaging only reveals metastatic involvement of the central neck in only 50% of cases with pathologic lymph nodes found on definitive pathology.18 macroscopically positive nodal disease is present in 10 to 30% of patients and the incidence of the subclinical disease is reported in 40 to 70% of patients.8 for ptc, the pattern of metastases usually spreads to the lymph nodes from central nodes, lateral nodes to the mediastinal nodes consecutively, and occurs more commonly in the ipsilateral central node of the primary tumor.11 because of this pattern, there are some studies that propose unilateral central neck dissection as an alternative approach to bilateral central neck dissection to decrease the risk of postoperative complications.11,13 however, the evidence to favor this approach over the other is still inconclusive. overall, there is limited evidence to support the commonly held belief that prophylactic cnd is beneficial in the treatment of node-negative ptc. this meta-analysis was conducted to provide updated information on this ongoing debate. to our knowledge, the latest meta-analyses by zhao et al. included only studies published from 2006 until 2016.15 different from previous metaanalyses and systematic reviews, we strictly included only retrospective cohort designs and excluded studies in which lobectomy, or lateral neck dissection was combined with pcnd. this would provide more standardized results on the effect of pcnd on morbidity. however, analysis of preoperative staging, tumor size, presence of micrometastases which are important in comparing the 2 groups to assess homogeneity was not performed. this may lead to overor underestimation of risk ratios. an important issue of controversy is that the clinical impact of subclinical central lymph node metastasis is yet to be demonstrated. preoperatively, it is standard practice to obtain an ultrasonographic examination to evaluate the central and lateral compartments of the neck for abnormal lymph nodes. sonographic features raising suspicion for metastatic lymph nodes include: a diameter greater than 1 cm; loss of the normal fatty hilum; an irregular rounded contour; heterogeneous echogenicity; microcalcifications; hypervascularity; and cystic areas.8 however, it is important to point out that preoperative imaging is not always reliable in detailing lymph node involvement. lymph node metastasis is a known significant predictor of overall survival, especially in older patients. zhang et al. further demonstrates an advantage of pcnd in removing subclinical metastases and thus improving the recurrence rate and avoiding reoperation in their patients.16 the retrospective study results of giordano et al. on 610 patients show a similar rate of neck recurrence in all groups regardless of whether they underwent total thyroidectomy alone or total thyroidectomy with either ipsilateral or bilateral central neck dissection.12 this finding suggests that lymph node micrometastasis seems not to affect the clinical outcome of patients with ptc.12 moreover, patients with ptc developing locoregional recurrence or distant metastasis can be treated effectively in most cases. this is similar to the results of kim et al., the largest study on pcnd to date, that found that pcnd did not significantly decrease the risk of locoregional recurrence in cn0 ptc patients, even though philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery meta-analysis figure 2a. forest plot for permanent vocal cord paralysis events showing no significant difference between the pcnd + tt versus tt alone groups. figure 2b. funnel plot analysis depicting publication bias for the studies comparing permanent vocal cord paralysis events figure 3a. forest plot showing a higher incidence for permanent hypoparathyroidism events in the pcnd + tt group versus tt alone group. figure 3b. funnel plot analysis depicting publication bias for the studies comparing permanent hypoparathyroidism events figure 4a. forest plot showing a higher incidence for locoregional recurrence events in the tt alone group versus pcnd + tt group. figure 4b. funnel plot analysis depicting publication bias for the studies comparing locoregional recurrence events significantly higher numbers and doses of rai were administered in the pcnd group.13 although the previous study by moo et al. revealed a higher recurrence rate for patients undergoing total thyroidectomy alone, this was not found to be statistically significant.14 overall, the meta-analysis by mchenry and stulberg concludes that the potential benefit of pcnd may be precise lymph node staging to help determine the need for radioiodine ablation although the effectiveness is still questionable due to the lack of high-level evidence.8 an important complication addressed in this meta-analyses is the risk of permanent hypoparathyroidism which is significantly higher in the tt + pcnd group. this increased risk is to be expected as cnd involves more surgical handling of the tissues which may contain the parathyroid glands. accidental parathyroidectomy is a common event (15–35%) in this circumstance since identification and appropriate in situ preservation of the parathyroid glands particularly the inferior pair may be difficult.3,17 there was no significant increased risk of permanent hypoparathyroidism in the study by hartl et al. and so et al.18-19 this finding is in contrast to the meta-analyses conducted by chisholm et al. wherein there was an increased risk for transient hypoparathyroidism in the pcnd group but not for permanent hypoparathyroidism.20 almost every comparative study included in this meta-analyses reported a higher incidence of postoperative hypocalcemia after prophylactic cnd.6,18,21-23 conversely, the rate of permanent hypoparathyroidism significantly increased when bilateral but not ipsilateral, cnd was done.6 vocal cord paralysis or recurrent laryngeal nerve injury is another philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery meta-analysis complication common in thyroid surgery. similar to the previous metaanalysis, most of these studies revealed no significant differences in the rates of temporary or permanent nerve injury in patients undergoing prophylactic cnd compared to patients undergoing total thyroidectomy alone.6,8,12,14-17,25-27 giordano et al. also found no significant differences in recurrent laryngeal nerve injury for tt alone patients compared to those with combined ipsilateral or bilateral pcnd.25 the study by kim et al. was the only other study that showed a significantly increased rate of temporary vocal cord palsy in pcnd patients however these results may be skewed since the pre-operative and post-operative laryngoscopic examination was not performed in all patients.13 the results of this meta-analyses are in agreement with the majority of the published studies. in most retrospective studies, central lymph node metastasis has been shown to be associated with an increased risk of locoregional recurrence but not with overall survival.3,17 in analyzing the most recent series, a similar recurrence rate was reported in patients who have undergone total thyroidectomy alone compared to those with an additional pcnd operation.28-29 the large-scale study by kim et al. reports significantly higher numbers and doses of rai administered in the pcnd group, which implies that microscopically detected metastasis in ptc has little chance of evolving into clinically and prognostically significant disease.13 calo et al. also report similar locoregional nodal recurrence rates in patients who underwent tt alone or combined with either ipsilateral or bilateral cnd.5 it has been postulated that locoregional infiltration and multifocality were associated with a risk of recurrence.4,5,8 in addition to these factors, chang et al. also report that male sex, tumor size ≥ 0.5 cm, extrathyroidal extension, were associated with a significantly increased risk of recurrence.30 on the other hand, tartaglia et al. showed that even microcarcinomas <5 mm may be associated with metastatic disease as shown by their recurrence rate of 4.8% in 63 patients despite the cnd and the post-operative radioactive iodine treatment.17 the results of this study are in agreement with the most recent reviews wherein there is a significantly increased risk for locoregional recurrence in the tt alone group compared to the tt + pcnd group. however, the rate of recurrence does not equate with an effect on the survival rate. 11,13,15 the most recent american thyroid association (ata) guidelines stated that prophylactic cnd could be considered in high-risk patients with advanced primary tumors and should be performed by experienced surgeons to avoid definitive complications.6,21,28 to date, there is still no standardized system that determines those patients who can benefit from prophylactic cnd. many of the studies do not favor routine cnd. in the philippine setting, the latest clinical practice guidelines for the management of well-differentiated thyroid cancer state that prophylactic central node dissection is not recommended because it does not improve overall and disease-free survival.31 furthermore, most of the studies recommend that the treatment should be tailored to the type of patient: for example, patients older than 45 years have larger tumors, with a greater propensity for regional metastasis and poorer response to radioiodine therapy.11,21 on the other hand, tartaglia et al. reveal that only extra-capsular extension may be   considered a predictor of relapse based on their data.17 thus, it is prudent to consider a prophylactic cnd in the higher risk cohort for these patients. these include males >45 years of age and large tumor size, provided the surgeon has the appropriate level of expertise.17 however, this procedure cannot be done routinely since the results of this systematic review show that pcnd in combination with total thyroidectomy is associated with a higher risk of causing permanent hypoparathyroidism after surgery. although the locoregional recurrence rate has been shown to be lower in this group, the survival rate and overall benefit is still not fully established. our study has several limitations. one is the inherent selection bias in a nonrandomized and non-blinded retrospective cohort design. there are only a few rct study designs on pcnd in the current literature, limiting its inclusion in the meta-analysis. secondly, subgroup analysis was not done comparing unilateral and bilateral pcnd since it was combined in some studies or not specified. third, the follow-up period is also variable between the studies, which may also affect the reporting of recurrence in the cohorts. fourth, there is a considerable difference in the number of patients for the pcnd+tt group and tt alone group for some studies which may also lead to measurement bias. thus, the authors recommend the inclusion of high-quality rcts when feasible to further determine the impact of pcnd on patient outcomes. although therapeutic cnd is an important adjunct to total thyroidectomy for the treatment of ptc, the benefit of prophylactic cnd remains to be established. furthermore, it is also important to take into account the risk of morbidity related to the procedure. similar to the trend seen in most studies, there is a significant increase in the risk for permanent hypoparathyroidism but not for vocal cord paralysis. locoregional recurrence has been shown to be lower in the pcnd group. the results of this meta-analysis show that the benefit of performing pcnd may outweigh the risk but the role of prophylactic cnd in the treatment of patients with ptc with clinically negative lymph nodes is still debatable in terms of overall survival. thus, we conclude that more studies are warranted in order to establish a critical review of indications for the routine use of prophylactic cnd with total thyroidectomy. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery meta-analysis references 1. sadowski bm, snyder sk, lairmore tc. routine bilateral central lymph node clearance for papillary thyroid cancer.surgery. 2009 oct; 146(4): 696 – 705.  doi: 10.1016/j.surg.2009.06.046; pmid: 19789029. 2. costa s, giugliano g, santoro l, ywata de carvalho a, massaro ma, gibelli b, et al. role of prophylactic central neck dissection in cn0 papillary thyroid cancer.  acta otorhinolaryngol ital. 2009 apr; 29(2): 61-69. pmid: 20111614 pmcid: pmc2808683. 3. lee dy, oh kh, cho jg, kwon sy, woo js, baek sk, et al. the benefits and risks of prophylactic central neck dissection for papillary thyroid carcinoma: prospective cohort study. int j endocrinol. 2015; 2015: 571480, doi: 10.1155/2015/571480; pmid: 26246805 pmcid: pmc4515503. 4. calo pg, pisano g, medas f, marcialis j, gordini l, erdas e, et al. total thyroidectomy without prophylactic central neck dissection in clinically node-negative papillary thyroid cancer: is it an adequate treatment? world j surg oncol. 2014 may 20; 12:152. doi: 10.1186/1477-7819-12-152; pmid: 24885654 pmcid: pmc4032348. 5. calo pg, lombardi cp, podda f, sessa l, santini l, conzo g. role of prophylactic central neck dissection in clinically node-negative differentiated thyroid cancer: assessment of the risk of regional recurrence.  updates surg. 2017 jun; 69(2): 241-248. doi 10.1007/s13304-017-0438-8; pmid: 28409443. 6. caliskan m, park jh, jeong js, lee cr, park sk, kang sw, et al. role of prophylactic ipsilateral central compartment lymph node dissection in papillary thyroid microcarcinoma. endocr j. 2012 ; 59 (4) : 305-311. pmid: 22240889. 7. sitges-serra a, lorente l, mateu g, sancho j. central neck dissection: a step forward in the treatment of papillary thyroid cancer.  eur j endocrinol. 2015 dec; 173(6): r199-206.  doi: 10.1530/eje-15-0481; pmid: 26088823. 8. mchenry cr, stulberg jj. prophylactic central compartment neck dissection for papillary thyroid cancer.  surg clin north am. 2014 jun; 94(3): 529-540. doi: 10.1016/j.suc.2014.02.003; pmid: 24857575. 9. conso g, tartaglia e, avenia n, calo pg, bellis a, esposito k, et al. role of prophylactic central compartment lymph node dissection in clinically n0 differentiated thyroid cancer patients: analysis of risk factors and review of modern trends. world j surg oncol. 2016 may 17; 14:149. doi 10.1186/s12957-016-0879-4; pmid: 27185169 pmcid: pmc4869299. 10. mamelle e, borget i, leboullex s, mirghani h, suarez c, pellitteri pk, et al. impact of prophylactic central neck dissection on oncologic outcomes of papillary thyroid carcinoma: a review.  eur arch otorhinolaryngol. 2015 jul; 272(7): 1577-1586. doi:10.1007/s00405-014-3104-5.  pmid: 25022716 pmcid: pmc4986511. 11. dobrinja c, troian m, cipolat mis t, rebez g, bernardi s, fabris b, et al. rationality in prophylactic central neck dissection in clinically node-negative (cn0) papillary thyroid carcinoma: is there anything more to say? a decade experience in a single-center. int j surg. 2017 may; 41 suppl 1: s40-47. doi: 10.1016/j.ijsu.2017.01.113; pmid: 28506412. 12. giordano d, frasoldati a, gabrielli e, pernice c, zini m, castelluci a, et al. long-term outcomes of central neck dissection for cn0 papillary thyroid carcinoma. am j otolaryngol. 2017 sep-oct; 38(5): 576-581. doi: 10.1016/j.amjoto.2017.06.004. pmid: 28599790. 13. kim sk, woo jw, lee jh, park i, choe jh, kim jh, et al. prophylactic central neck dissection may not be necessary in papillary thyroid carcinoma: analysis of 11,569 cases from a single institution.  j am coll surg. 2016 may; 222(5): 853-64. doi: 10.1016/j.jamcollsurg.2016.02.001; pmid: 27113516. 14. moo ta, mcgill j, allendorf j, lee j, fahey t 3rd, zarnegar r. impact of prophylactic central neck lymph node dissection on early recurrence in papillary thyroid carcinoma.  world j surg.  2010 jun; 34(6): 1187-1191. doi: 10.1007/s00268-010-0418-3; pmid: 20130868. 15. zhao wj, luo h, zhou ym, dai wy, zhu jq. evaluating the effectiveness of prophylactic central neck dissection with total thyroidectomy for cn0 papillary thyroid carcinoma: an update metaanalysis. eur j surg oncol. 2017 nov; 43(11): 1989-2000. doi: 10.1016/j.ejso.2017.07.008. pmid: 28807633. 16. zhang l, liu z, liu y, gao w, zheng c. the clinical prognosis of patients with cn0 papillary thyroid microcarcinoma by central neck dissection. world j surg oncol. 2015 apr 7; 13: 138. doi 10.1186/s12957-015-0553-2. pmid: 25889385 pmcid: pmc4443599. 17. tartaglia f, blasi s, giulani a, sgueglia m, tromba l, carbotta s, et al. central neck dissection in papillary thyroid carcinoma: results of a retrospective study. int j surg. 2014; 12 suppl 1: s57-62. doi: 10.1016/j.ijsu.2014.05.053; pmid: 24862662. 18. hartl dm, mamelle e, borget i, leboulleux s, mirghani h, schlumberger m. influence of prophylactic neck dissection on rate of retreatment for papillary thyroid carcinoma.  world j surg. 2013 aug; 37(8): 1951 – 1958. doi: 10.1007/s00268-013-2089-3; pmid: 23677562. 19. so yk, seo my, son yi. prophylactic central lymph node dissection for clinically node-negative papillary thyroid microcarcinoma: influence on serum thyroglobulin level, recurrence rate, and postoperative complications.  surgery.  2012 feb; 151(2): 192-198. doi: 10.1016/j. surg.2011.02.004; pmid: 21497873. 20. chisholm ej, kulinskaya e, tolley ns. systematic review and meta-analysis of the adverse effects of thyroidectomy combined with central neck dissection as compared with thyroidectomy alone. laryngoscope. 2009 jun; 119(6): 1135-1139. doi: 10.1002/lary.20236; pmid: 19358241. 21. aydin ou, soylu l, ozbas s, ilgan s, bilezikci b, gursoy a, et al. the risk of hypoparathyroidism after central compartment lymph node dissection in the surgical treatment of pt1, n0 thyroid papillary carcinoma. eur rev med pharmacol sci. 2016 may; 20(9): 1781-1787. pmid: 27212170. 22. calo` pg, conzo g, raffaelli m, medas f, gambardella c, de crea c, et al. total thyroidectomy alone versus ipsilateral versus bilateral prophylactic central neck dissection in clinically nodenegative differentiated thyroid carcinoma. a retrospective multicenter study.  eur j surg oncol. 2017 jan; 43(1):126–132.  doi: 10.1016/j.ejso.2016.09.017; pmid: 27780677. 23. shindo m, stern a. total thyroidectomy with and without selective central compartment dissection: a comparison of complication rates.  arch otolaryngol head neck surg.  2010 jun; 136(6): 584-587. doi: 10.1001/archoto.2010.79; pmid: 20566909. 24. barczynski m, konturek a, stopa m, nowak w. prophylactic central neck dissection for papillary thyroid cancer. br j surg.2013 feb; 100(3): 410-418. doi: 10.1002/bjs.8985; pmid: 23188784. 25. giordano d, valcavi r, thompson gb, pedroni c, renna l, gradoni p, et al. complications of central neck dissection in patients with papillary thyroid carcinoma: results of a study on 1087 patients and review of literature.  thyroid.  2012 sep; 22(9): 911 – 917. doi: 10.1089/ thy.2012.0011; pmid: 22827494.  26. perrino m, vannucchi g, vicentini l, cantoni g, dazzi d, colombo c, et al. outcome predictors and impact of central node dissection and radiometabolic treatments in papillary thyroid cancers < or = 2cm. endocr relat cancer. 2009 mar; 16(1): 201-210. doi: 10.1677/erc-08-0119; pmid: 19106146.  27. raffaelli m, de crea c, sessa l, giustacchini p, revelli l, bellantone c et al.  prospective evaluation of total thyroidectomy versus ipsilateral versus bilateral central neck dissection in patients with clinically node-negative papillary thyroid carcinoma. surgery. 2012 dec; 152(6): 957 – 964. doi: 10.1016/j.surg.2012.08.053; pmid: 23158170. 28. bozec a, dassonville o, chamorey e, poissonnet g, sudaka a, peyrottes i, et al. clinical impact of cervical lymph node involvement and central neck dissection in patients with papillary thyroid carcinoma: a retrospective analysis of 368 cases.  eur arch otorhinolaryngol. 2011 aug; 268(8): 1205-1212. doi: 10.1007/s00405-011-1639-2; pmid: 21607578. 29. chan ac, lang bh, wong kp. the pros and cons of routine central compartment neck dissection for clinically nodal negative (cn0) papillary thyroid cancer.  gland surg.  2013 nov; 2(4): 186195. doi: 10.3978/j.issn.2227-684x.2013.10.10; pmid: 25083482 pmcid: pmc4115750. 30. chang yw, kim hs, kim hy, lee jb, bae jw, son gs. should central lymph node dissection be considered for all papillary thyroid microcarcinoma? asian j surg. 2016 oct; 39(4): 197-201. doi: 10.1016/j.asjsur.2015.02.006; pmid: 25913730. 31. tabangay-lim im, fajardo at, matic me, de dios ap, lopez fl, de los santos nc, et al. updates on certain aspects of the evidence-based clinical practice guidelines on thyroid nodules (focused on the diagnosis and management of well-differentiated thyroid cancer). philippine journal of surgical specialties 2013 jan-mar; 68(1): 1-20. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 6362 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2020; 35 (1): 63-65 c philippine society of otolaryngology – head and neck surgery, inc. thyroglossal duct carcinoma with concurrent papillary thyroid carcinoma: a case report anna claudine f. lahoz, md1 precious eunice r. grullo, md, mph 1 ryner jose c. carrillo, md, msc1,2 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2department of anatomy college of medicine university of the philippines manila correspondence: dr. ryner jose c. carrillo department of otorhinolaryngology philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8400 local 2152 email address: rynercarrillo@gmail.com the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. reprints will not be available from the author. presented at the 2nd congress of the asia-pacific society of thyroid surgery. november 1-3, 2017 in okinawa, japan. abstract objective: to report a case of thyroglossal duct carcinoma with concurrent papillary thyroid carcinoma methods: design: case report setting: tertiary national university hospital patient: one results: a 46-year-old woman was diagnosed with thyroglossal duct carcinoma after undergoing a sistrunk procedure. due to presence of thyroid nodules, the patient underwent second stage thyroidectomy with central neck dissection which revealed papillary thyroid carcinoma. conclusion: thyroglossal duct carcinomas are rare entities and there is no current consensus regarding their management. difficulties arise in the diagnosis of these tumors as they present similarly to benign thyroglossal duct cysts. most cases are diagnosed postoperatively. proper preoperative assessment including head and neck examination, biopsy, and radiologic imaging is necessary to recognize patients who could benefit from more aggressive management. keywords: thyroglossal carcinoma; thyroglossal duct cyst; papillary thyroid carcinoma thyroglossal duct cysts are the most common developmental anomalies of the thyroid gland. they stem from the persistence of the tract of the migrating thyroid gland as it descends from its origin in the foramen cecum to its adult position inferior to the cricoid cartilage.1 the thyroglossal duct cyst may contain remnants of thyroid tissue from which thyroid malignancies may arise. thyroglossal duct carcinomas are rare malignancies accounting for 1% of all cases of thyroglossal duct tumors and may occur concurrently with thyroid malignancies.2 we present a case of papillary thyroid carcinoma in a thyroglossal duct cyst with a concurrent thyroid papillary carcinoma. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 6564 philippine journal of otolaryngology-head and neck surgery case reports case report a 46-year-old woman presented with a three-year history of slowly growing anterior neck mass with no associated hypothyroid or hyperthyroid symptoms. there was no family history of carcinoma and the patient had no exposure to radiation. on physical examination, there was a 7 x 6 x 5.9 cm firm anterior neck mass located in the midline which moved with tongue protrusion. (figure 1) a neck ultrasonogram revealed a cystic mass in the anterior neck consistent with a thyroglossal duct cyst and normal thyroid glands. fine needle aspiration biopsy revealed benign cyst contents and the patient underwent a sistrunk procedure. intraoperatively, there was note of a 6 x 5 x 4 cm cyst with solid areas adherent to the strap muscles (figure 2) and an enlarged pre-laryngeal node. (figure 3) final histopathology results revealed classical variant papillary thyroid carcinoma, 4.2 cm in greatest tumor dimension, with extension to adjacent soft tissues. the enlarged pre-laryngeal node was positive for tumor. on repeat neck ultrasonography done after the sistrunk procedure, two cystic nodules were noted in the right thyroid lobe. the patient underwent a second stage total thyroidectomy with central neck dissection. intraoperatively, the right thyroid lobe measured 4 x 3 x 2 cm with multiple nodules palpable in the lobe. the left thyroid lobe measured 4 x 2 x 1 cm with no masses noted within the lobe. (figure 4) there were no visible or palpable enlarged central lymph nodes. final histopathologic examination of the thyroidectomy specimen revealed multifocal classical variant papillary carcinoma of the right thyroid lobe and multinodular colloid goiter of the left thyroid lobe and isthmus. level 6 lymph nodes were negative for tumor. the patient was scheduled to undergo radioactive iodine therapy but was lost to follow up. discussion the thyroid gland initially arises as a mass from a depression at the foramen cecum during the 5th week of development. the thyroid gland migrates inferiorly and reaches its final adult position at the level below the cricoid cartilage during the 7th week of development.1 the most common developmental anomalies of the thyroid gland are thyroglossal duct cysts which occur in 7% of the adult population. a thyroglossal duct cyst may develop if the tract of the descending thyroid fails to degenerate. the cyst may contain remnants of thyroid tissue from which malignancies may arise.3 thyroglossal duct carcinomas are rare entities with an incidence of <1% of all cases of thyroglossal duct cyst.2 concurrent thyroglossal duct carcinomas and thyroid carcinomas have been reported to occur at a rate between 0 – 25%.4 however, the true incidence is difficult to ascertain as not all patients undergo thyroidectomy. the most figure 1. preoperative picture of the patient showing a midline anterior neck mass figure 2. thyroglossal duct cyst seen intraoperatively figure 3. arrow pointing to an enlarged pre-laryngeal node seen intraoperatively figure 4. resected thyroid gland philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 6564 philippine journal of otolaryngology-head and neck surgery case reports common histologic type of carcinoma found in thyroglossal duct cysts are papillary carcinomas but other types of carcinoma, such as mixed papillary-follicular, squamous cell, anaplastic, and hurthle cell have been reported.5 there are no reported cases of medullary carcinomas found in thyroglossal duct cysts as medullary carcinomas arise from the parafollicular cells which have a different embryologic origin from the thyroid.6 this supports the theory that thyroglossal duct carcinomas arise de novo from the cyst itself. two theories accounting for the origin of thyroglossal duct carcinomas are development of the carcinoma from thyroid tissue in the cyst and metastasis from a primary cancer in the thyroid gland.7 fine needle aspiration biopsy and neck ultrasound are standard diagnostic tests used for preoperative evaluation of midline neck masses. however, fine needle aspiration biopsy is often inaccurate when diagnosing thyroglossal duct carcinomas.8 yang et al. reported a true positive rate of 53% and false negative rate of 47% for diagnosing thyroglossal duct carcinomas using fine needle aspiration biopsy. ultrasound guided aspiration biopsy can improve accuracy of results.9 on ultrasonography, presence of a central solid component, calcifications, irregular borders, and thickened cyst walls are suggestive for carcinoma. however, they may be indistinguishable from benign tgdcs.5 thyroglossal duct carcinomas are usually diagnosed postoperatively upon histopathologic examination of the operative specimen. frozen section examination of the specimen should be considered when malignancy is a consideration. danilovic et al. recommended use of frozen section to diagnose papillary carcinoma due to poor sensitivity of fnab. in their study, frozen section correctly diagnosed all cases of thyroglossal duct carcinomas based on suspicious findings on ultrasound.10 there is no current standard for treatment of thyroglossal duct carcinomas. sistrunk procedure is usually done for thyroglossal duct carcinomas with some studies supporting its use as sufficient for treatment. the cure rate for papillary thyroglossal duct carcinomas has been reported at 95% when treated with sistrunk procedure alone. addition of total thyroidectomy with lymph node dissection increases the cure rate to 100%.11 some studies suggest performing a total thyroidectomy owing to the incidence of concurrent thyroid carcinoma with thyroglossal duct carcinomas.12 this highlights the importance of adequate preoperative evaluation for the patients. radioactive iodine therapy has also been advised for patients with thyroglossal duct carcinomas however there is still no consensus for its use.13 recent studies have proposed a risk stratification system to screen for high risk patients. more aggressive treatment is recommended if the patient has any of the following features: (1) age greater than 45 years, references 1. chen ey, sie kcy. developmental anatomy. in: flint pw, haughey bh, lund v, niparko jk, robbins kt, thomas jr, lesperance mm (editors). cummings otolaryngology sixth edition. philadelphia, pa: elsevier saunders; 2015. p.2821-2830. 2. patel sg, escrig m, shaha ar, singh b, shah jp. management of a well-differentiated thyroid carcinoma presenting within a thyroglossal duct cyst. j surg oncol.  2002 mar;79(3):134-9; discussion 140-1. doi: 10.1002/jso.10059; pmid: 11870661. 3. nugent a, el-deiry m. differential diagnosis of neck masses. in: flint pw, haughey bh, lund v, niparko jk, robbins kt, thomas jr, lesperance mm (editors). cummings otolaryngology sixth edition. philadelphia, pa: elsevier saunders; 2015. p.2821-2830. 4. tew s, reeve ts, poole ag, delbridge l. papillary thyroid carcinoma arising in thyroglossal duct cysts: incidence and management. aust n z j surg. 1995 oct; 65(10):717-8. doi: 10.1111/j.14452197. 1995. tb00543.x; pmid: 7487710. 5. kermani w, belcadhi m, abdelkefi m, bouzouita k. papillary carcinoma arising in a thyroglossal duct cyst: case report and discussion of management modalities. eur arch otorhinolaryngol. 2008 feb; 265(2): 233-6. doi: 10.1007/s00405-007-0405-y; pmid: 17668227. 6. kandogan t, erkan n, vardar e. papillary carcinoma arising in a thyroglossal duct cyst with associated microcarcinoma of the thyroid and without cervical lymph node metastasis: a case report. j med case rep. 2008 feb 8; 2:42. doi: 10.1186/1752-1947-2-42; pmid: 18257934 pmcid: pmc2262906. 7. rossi ed, martini m, straccia p, cocomazzi a, pennacchia i, revelli l, et al. thyroglossal duct cyst cancer most likely arises from a thyroid gland remnant. virchows arch. 2014 jul; 465(1): 67-72. doi: 10.1007/s00428-014-1583-9; pmid: 24777145. 8. aculate nr, jones hb, bansal a, ho mw. papillary carcinoma within a thyroglossal duct cyst: significance of a central solid component on ultrasound imaging. br j oral maxillofac surg. 2014 mar; 52(3): 277-8. doi: 10.1016/j.bjoms.2013.10.003; pmid: 24210780. 9. yang yj, haghir s, wanamaker jr, powers cn. diagnosis of papillary carcinoma in a thyroglossal duct cyst by fine needle aspiration biopsy. arch pathol lab med. 2000 jan; 124(1): 139-142. doi: 10.1043/0003-9985(2000)124<0139:dopcia>2.0.co;2; pmid: 10629147. 10. danilovic dl, marui s, lima eu, luiz av, brescia md, moyses ra, et al. papillary carcinoma in thyroglossal duct cyst: role of fine needle aspiration and frozen section biopsy to guide surgical approach. endocrine 2014 may; 46 (1):160-3. doi: 10.1007/s12020-014-0173-6; pmid: 24493029 11. choi ym, kim ty, song de, hong sj, jang ek, jeon mj, et al. papillary thyroid carcinoma arising from a thyroglossal duct cyst: a single institution experience. endocrine j. 2013; 60 (5):665-670. doi: 10.1507/endocrj.ej12-0366; pmid: 23318645. 12. gebbia v, di gregorio c, attard m. thyroglossal duct cyst carcinoma with concurrent thyroid carcinoma: a case report. j med case reports. 2008 apr 29; 2:132. doi: 10.1186/1752-1947-2132; pmid: 18445281 pmcid: pmc2387158. 13. sobri fb, ramli m, sari un, umar m, mudrick dk. papillary carcinoma occurence in a thyroglossal duct cyst with synchronous papillary thyroid carcinoma without cervical lymph node metastasis: two-cases report. case rep surg.  2015; 2015:872054. doi: 10.1155/2015/872054; pmid: 25785223 pmcid: pmc4345054. (2) history of radiation exposure, (3) thyroid mass seen on imaging studies, (4) cervical lymphadenopathies evident clinically or on imaging studies, (5) tumor size greater than 1.5 cm in diameter, and (6) cyst wall invasion and positive margins on histopathologic examination.5 in conclusion, thyroglossal duct carcinomas are rare entities and there is no current consensus regarding its management. difficulties arise in the diagnosis of these tumors as they present similarly to benign thyroglossal duct cysts. most cases are diagnosed postoperatively. proper preoperative assessment including proper head and neck examination, biopsy, and radiologic imaging is necessary to recognize patients who could benefit from more aggressive management. philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 2 july – december 2018 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery contents a dozen years, a dozen roses efficacy of clarithromycin versus methylprednisolone in the treatment of non-eosinophilic and eosinophilic nasal polyposis: a randomized controlled trial simulation platform for myringotomy with ventilation tube insertion in adult ears prevalence of supraorbital ethmoid air cells among filipinos recurrent laryngeal nerve paralysis and hypocalcemia in superior to inferior compared to inferior to superior dissection approaches in thyroidectomy pathologic laryngoscopic findings, number of years in teaching, and related factors among secondary public-school teachers in bacolod city, negros occidental tracheal diameter estimates using age-related formula versus radiographic findings: which approximates the actual tracheostomy tube in pediatric patients? lethal midline granuloma in a 15-year-old girl: a diagnostic dilemma tuberculosis of the temporomandibular region crab shell impaction in the larynx with aphonia phonetovox: a novel device for alaryngeal speech can modified laryngosternopexy (laryngoclaviculopexy) project the larynx anteriorly? cleft beyond the lip and palate: a bilateral tessier cleft pulsatile tinnitus due to a sigmoid sinus diverticulum and/or dehiscence respiratory epithelial adenomatoid hamartoma armando t. chiong, sr. (1930 2018) carlos p. dumlao (1950 2018) cover images editorial 4 a dozen years, a dozen roses lapeña jf original articles 6 efficacy of clarithromycin versus methylprednisolone in the treatment of non-eosinophilic and eosinophilic nasal polyposis: a randomized controlled trial gammad jc, chua ah, templonuevo-flores cs 14 simulation platform for myringotomy with ventilation tube insertion in adult ears chan al, carrillo rjd, ong kc 21 prevalence of supraorbital ethmoid air cells among filipinos carlos alc, gelera je 24 recurrent laryngeal nerve paralysis and hypocalcemia in superior to inferior compared to inferior to superior dissection approaches in thyroidectomy yu rd 28 pathologic laryngoscopic findings, number of years in teaching, and related factors among secondary public-school teachers in bacolod city, negros occidental mundo np, vinco vv 32 tracheal diameter estimates using age-related formula versus radiographic findings: which approximates the actual tracheostomy tube in pediatric patients? de guzman ics case reports 37 lethal midline granuloma in a 15-year-old girl: a diagnostic dilemma gonzales ica 41 tuberculosis of the temporomandibular region santos jm, reala et 45 crab shell impaction in the larynx with aphonia parekh nm, kashyap pr surgical innovation and instrumentation 48 phonetovox: a novel device for alaryngeal speech econ me, soriano rg 53 can modified laryngosternopexy (laryngoclaviculopexy) project the larynx anteriorly? carrillo rjc, lapeña jf featured grand rounds 56 cleft beyond the lip and palate: a bilateral tessier cleft canta lab from the viewbox 60 pulsatile tinnitus due to a sigmoid sinus diverticulum and/or dehiscence yang nw under the microscope 62 respiratory epithelial adenomatoid hamartoma carnate jm, abelardo ad passages 64 armando t. chiong, sr. (1930 2018) jamir jc 65 carlos p. dumlao (1950 2018) pontejos aqy “digital x-ray of foreign body in the nose” by justin ian a. jabson, md “teamwork” canon 5d ii + 17-40mm l by rene louie c. gutierrez, md “nudi” in el nido palawan by anna carlissa a. aujero, md “wanda the beaglea” 9x12 acrylic on hardboard by anna carlissa a. aujero, md from “simulation platform for myringotomy with ventilation tube insertion in adult ears” by kimberly c. ong, md philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation philipp j otolaryngol head neck surg 2022; 37 (2): 46-49 c philippine society of otolaryngology – head and neck surgery, inc. a makeshift blue light filter for endoscopic identification of traumatic cerebrospinal fluid leak using fluorescein bianca denise e. edora, md ryan u. chua, md patrick joseph l. estolano, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. ryan u. chua department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal ave., sta. cruz, manila 1003 philippines phone: (632) 8711 9491 local 320 e-mail: ryanuychua.md@gmail.com the authors declare that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. verbal consent was obtained from the patient for publication of this case report and accompanying images. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. abstract objective: to describe a makeshift blue light filter for endoscopic visualization of a traumatic cerebrospinal fluid leak repair using intrathecal fluorescein and its application in one patient. methods: study design: surgical instrumentation setting: tertiary government training hospital patient: one results: intra-operative endoscopic identification of fistulae sites was achieved using intrathecal injection of fluorescein that fluoresced using our makeshift blue light filter in a 43-year-old man who presented with a 3-month history of rhinorrhea due to skull base fractures along with multiple facial and upper extremity fractures he sustained after a fall from a standing height of 6 feet. he underwent transnasal endoscopic repair of cerebrospinal fluid fistulae in the planum sphenoidale, clivus and sellar floor. post-operatively, there was complete resolution of rhinorrhea with no complications noted. conclusion: our makeshift blue light filter made from readily available materials may be useful for endoscopic identification of csf leaks using fluorescein in a lowto middle-income country setting like ours. keywords: rhinorrhea; csf leak; cerebrospinal fluid fistula; basilar skull fracture; posterior cranial fossa; post-traumatic cerebrospinal fluid leakage; blue light filter, endoscopic csf leak repair, clivus cerebrospinal fluid leak is classified into traumatic or spontaneous (non-traumatic) based on etiology.1 traumatic skull fractures typically result in dura and arachnoid tears which lead to cerebrospinal fluid (csf) leaking into the nasal cavity, paranasal sinuses, and middle ear and approximately 80% of csf leaks are caused by head injuries with craniofacial fractures.2 accidental head trauma carries a 32% overall risk of developing meningitis, significantly higher than iatrogenic trauma and spontaneous leaks at 22% and 10%, respectively.3 – 5 therefore, appropriate creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation investigation and timing of the surgical repair are crucial and depend on the identification of csf leaks. several localization techniques for csf leaks can be utilized including computed tomography scan with or without cisternography, magnetic resonance imaging with or without cisternography, and tracer studies with intrathecal fluorescein being the preferred technique. 1 intrathecal fluorescein can be used off-label for localization of multiple csf leak sources, but a blue light filter is still needed for visualization.6 in areas where a blue light filter is not available, a makeshift blue light filter can be devised using low-cost materials. to the best of our knowledge, based on a search of herdin plus, the asean citation index (aci), the western pacific region index medicus (wprim), the directory of open access journals (doaj), medline (pubmed and pubmed central), and google scholar using the search terms “blue light,” “blue light filter,” “csf leak blue light filter,” and “csf leak repair ,” we did not find any innovation of a makeshift blue filter for endonasal csf fluorescein visualization. since commercially available blue light filters are costly and pre-made for specific endoscopes and light sources, we sought to develop a makeshift blue light filter that can be both economical and effective especially in developing countries like ours. we describe our makeshift blue light filter for endoscopic visualization of a traumatic cerebrospinal fluid leak repair using intrathecal fluorescein, and its application in one patient. methods we used a commercially available acetate face shield (philippine blue cross biotech corporation, philippines), one violet permanent marker, fine-tipped, super color marker (sc-f, pilot, japan), one blue permanent marker (blue permanent marker, fine-tipped, super color marker (scf), pilot, japan) a 10-centavo coin (bsp coin series, 1995 issue, bangko sentral ng pilipinas, philippines), and a 3-0, 45cm length, black braided silk suture with sh-1, 22mm ½ circle, taper needle (perma-hand c003d, ethicon, usa) to mimic the filtering effect. (figure 1a) since the port diameter of our portable light source (5-watt es201 compact led light source, firefly global, usa) was 1.1 cm, a 10-centavo coin which measured 1.3 cm to produce a round shape was used to fit the light source port with slight overcorrection of measurement for a snug fit. to construct a blue light filter, three 1.3-cm circles were traced around the coin on the acetate, shaded entirely with single-layered horizontal parallel strokes using the permanent markers, and cut out. (figure 1b, c) to produce the effect of the blue light filter, sets of two circles shaded blue and one circle shaded violet were made. for each set, a violet circle was placed in between two blue circles and they were sutured together for easy removal from the light source. (figure 1d, e) results with approval from the jrrmmc institutional review board (jrrmmc irb 2021-161) and informed consent, we utilized our makeshift blue light filter in a 43-year-old man who presented with a 3-month history of rhinorrhea due to skull base fractures along with multiple facial and upper extremity fractures he sustained after a fall from a standing height of 6 feet while picking an avocado from the tree. he lost consciousness for one hour and had epistaxis. clear, watery nasal discharge was observed on the 6th day of admission in a local hospital. plain cranial computed tomography scans revealed intracranial hematoma and multiple craniofacial fractures and he was transferred to our institution. there was no significant improvement with or response to medical management of the suspected csf leak for one month, and the patient was referred to us for surgical repair of the traumatic csf leak. nasal endoscopy revealed no lesions in both nasal cavities and no actively draining fluid even on valsalva maneuver. a halo test was negative since the watery nasal discharge was not mixed with blood while a positive reservoir sign was observed. computed tomography cisternography with supplemental contrast-enhanced ct scans of the head revealed post-traumatic csf fistulae secondary to sphenoid sinus and sellar floor fractures, multiple craniofacial fractures, pneumocephalus, and resolving right inferior frontal lobe abscess. the patient underwent transnasal endoscopic repair of the planum sphenoidale, clivus, and sellar floor using tensor fascia lata, abdominal fat graft, and nasoseptal flap. before general anesthesia induction, the awake patient was positioned preoperatively in left lateral decubitus for sterile insertion of a lumbar catheter. (figure 2a) around 10 ml of cerebrospinal fluid (csf) was slowly withdrawn and mixed with 0.1 ml of sterile 10% fluorescein sodium (contacare ophthalmics and diagnostics, india) and then reinjected slowly over a period of several minutes while monitoring for any adverse reaction. (figure 2b) in order to visualize the fluorescein injection into the csf and properly identify the location of the csf fistulae, the makeshift blue light filter that was made preoperatively for our portable light source was utilized intraoperatively. (figure 1f) three hours post-injection, fluorescein fully fluoresced using the blue light filter, allowing identification and differentiation between csf and nasal secretions. (figure 3) the patient was repositioned with the head slightly elevated at 15 degrees. bilateral sphenoidotomy with preservation of turbinates were performed prior to flap elevation. a left-sided nasoseptal flap was harvested prior to opening the sphenoid sinus. to fully visualize the sphenoid sinus and skull base, the rostrum was drilled down and the middle and superior turbinates on the right were lateralized as well. at this point, the sphenoid intersinus septum and sphenoid mucosa were visualized alongside yellowphilippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation colored soft tissue and a bulge on the mucosa containing fluorescein. (figure 4a)  on correlation with the preoperative ct scan, the mass appeared isodense with brain tissue and it seemed to protrude from a skull base defect on the planum sphenoidale. (figure 4b, c, d) the makeshift blue light filter was used to evaluate the yellowish soft tissue and check if it was surrounded by or stained with fluorescein. the soft tissue did not fluoresce compared to the other tissues that had csf with fluorescein. (figure 5a, b) posterior to the herniated soft tissue there was also csf leakage which was identified using the makeshift blue light filter. (figure 5c, d) the neurosurgery service confirmed the suspicion that it was a herniated pituitary gland. the remnants of sphenoid sinus mucosa were further removed by drilling the intersinus septum and bony separation of the onodi cell from the sphenoid. the mucosa surrounding the sellar floor defect was also removed. a total of 3 differently located defects that were irregularly shaped were identified, and three layers of repair were used—abdominal fat graft, tensor fascia lata graft, and nasoseptal flap. abdominal fat graft plugs were primarily placed into the sellar floor defect. prior to placement of succeeding layers of repair, the makeshift blue light filter was used to check for other unaddressed areas of csf leak. there was no detected fluorescence signifying that all areas were repaired. (figure 5e, f) one fascia lata graft was used as inlay then another fascia lata graft and nasoseptal flap as onlay layers of repair. additional abdominal fat graft was placed anterior to the nasoseptal flap to serve as additional support. hemostasis was achieved, and an intranasal foley catheter balloon (7 cc of sterile water) was inflated anterior to the layers of repair and an intranasal bioresorbable pack (netcell pva nasal pack, hydroxylated polyvinyl acetate, network medical products, united kingkdom) was placed inferior to the balloon as additional support. there was no post-operative rhinorrhea, bleeding or changes in vision. there was no csf leakage after removal of the intranasal foley catheter and bioresorbable nasal pack on day 7 and the patient was discharged. he remained well with no csf leaks on one week and four weekly follow ups when nasal endoscopy showed crust formation around the anterior abdominal fat graft. discussion we successfully fabricated a makeshift blue light filter and applied it in our patient with csf leak. the makeshift filter aided in localization of the csf leak and evaluation of post-repair csf leakage. we discovered intraoperatively that around 2 minutes is the ideal time to maximize its light frequency blocking effect and form. beyond this would lead to discoloration and deformation of the acetate filter. fluorescein sodium is a dye that that emits light of wavelength 520-530 nm or green-yellow, and fluoresces when excited by light with figure 1. preparation of the makeshift blue light filter: a. materials include commercially available face shield, two permanent markers (blue and violet), 10-centavo coin, silk suture (or any suture of your preference); b. and c. tracing a circular shape using the 10-centavo coin and permanent marker; d. arranging the shaded circular acetate pieces with the violet shaded circle in between two blue circles; e. suturing the 3 pieces together; and f. positioning the makeshift blue light filter within the light source port. a d b e c f figure 2. intrathecal injection of 10% fluorescein: a. left lateral decubitus positioning of patient for insertion of lumbar catheter; b. withdrawn csf was mixed with 0.1 ml of sterile 10% fluorescein sodium and then reinjected into the patient over a period of several minutes. a b figure 3. intraoperative visualization: a. clear watery nasal discharge from right sphenoid sinus ostium (asterisk); b. white light; and c. blue light, showing egress of csf admixed with fluorescein three hours post-injection. s, superior; i, inferior. a b c wavelength of 465 – 490 nm, represented by the blue spectrum.7 in order to create a blue light filter to visualize the fluorescence, a blue-pass filter and a green-yellow-pass barrier filter must be used to separate the image of the fluorescein from background illumination.8 by definition, filters are designed to have absorption characteristics that block light at undesired frequencies and allow light in its passband to pass through.6 the use of blue light filter contributes to better visualization of csf leak sites.9 fluorescein can be injected intrathecally by mixing 0.1ml of 10% fluorescein with 10ml of the patient’s csf injected over a period of 10 minutes and the dye is allowed to circulate for approximately 1-3 hours.3 in our case, the fluorescence was detected 3 hours post-injection using our makeshift blue light filter. guided by these principles in visualizing fluorescein, we were able to fabricate a makeshift blue light filter that philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 2 july – december 2022 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation mimics the role of commercially available, blue light filter systems that are made for specific endoscopes or light sources. our choice of material was a limitation of this study. since the commercially available face shield was made of acetate, it could only tolerate a maximum of 2 minutes before the acetate circles softened and became non-functional. future studies may explore the use of a more heat-resistant type of plastic and application in more cases. meanwhile, based on our single-patient experience, our makeshift blue light filter made from readily available materials may be useful for endoscopic identification of csf leaks using fluorescein in a lowto middle-income country setting like ours. references 1. bohnen a, louie ce, domingo ra, de biase g, donaldson am, olomu ou, boahene k, quinoneshinojosa a. management of cerebrospinal fluid leaks. in: quinones-hinojosa a, editor. schmidek and sweet: operative neurosurgical techniques, 7th edition. philadelphia: saunders; 2022. p. 1024-1036. 2. ali zs, ma ts, yan ch, adappa nd, palmer jn, grady ns. traumatic cerebrospinal fluid fistulas. in: winn h, editor. youmans and winn neurological surgery, 7th ed. philadelphia: elsevier; 2017. p. 2980-2987. 3. ziu m, savage jg, jimenez df. diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures. neurosurg focus. 2012 jun; 32(6):e3. doi: 10.3171/2012.4.focus1244; pubmed pmid: 22655692. 4. jefferson a, reilly g. fractures of the floor of the anterior cranial fossa. the selection of patients for dural repair. br j surg. 1972 aug; 59(8):585-92. doi:  10.1002/bjs.1800590802; pubmed pmid: 5069195. 5. daudia a, biswas d, jones ns. risk of meningitis with cerebrospinal fluid rhinorrhea. ann otol rhinol laryngol. 2007 dec; 116(12):902-5. doi:  10.1177/000348940711601206; pubmed pmid: 18217509. 6. felisati g, bianchi a, lozza p, portaleone s. italian multicenter study on intrathecal fluorescein for craniosinusal fistulae. acta otorhinolaryngol ital. 2008 aug 28(4): 159-163. 7. nagaya t, nakamura y, choyke p, kobayashi h. current and new fluorescent probes for fluorescence-guided surgery. in: hoffman rm, bouvet m, editors. strategies for curative fluorescence-guided surgery of cancer, new york: elsevier; 2020. p. 75-114. 8. wolfe r. fluorescein angiography basic science and engineering. ophthalmology. 1986 dec; 93(12):1617-20. doi: 10.1016/s0161-6420(86)33521-8; pubmed pmid: 3808620. 9. ramalingam n, nair np, saxena sk, hegde js. role of blue-green light filter in detecting a spontaneous cerebrospinal fluid rhinorrhea in an unusual site. clin rhinol an int j. 2018 may; 11(2 and 3):52-54. doi: 10.5005/jp-journals-10013-1344. figure 4. visualization of the sphenoid intersinus septum and mucosa: a. right side (r) of the intersinus septum (asterisk) shows yellow-colored unstained soft tissue; left (l) bulge on the mucosa contains fluorescein, correlating with encircled areas in b. sagittal, c. coronal, and d. axial ct scan views. s, superior. a c b d figure 5. comparative images a. without, and b. with makeshift blue light filter to evaluate the herniated soft tissue demonstrates no fluorescence; c. sellar floor defect under white light and d. under blue light showing fluorescence; e. abdominal fat plug grafts under white light and f. under blue light showing no fluorescence. asterisk, sphenoid intersinus septum; x, herniated soft tissue; y, abdominal fat graft; s, superior; i, inferior. a c e b d f philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles abstract objective: to determine the relationship of the surgeon handedness and operative site laterality on operative duration and hearing improvement in otologic surgery, and to further explore whether this relationship may be related to surgeon experience. methods: design: retrospective cohort setting: tertiary private teaching hospital participants: seventy-three (73) patients aged 18 to 65 years old who underwent primary ear surgery under general anesthesia between january 2016 and december 2019 were retrospectively divided into two groups: 39 contralateral and 34 ipsilateral. the operative durations and hearing improvements were compared using independent t-tests, with consideration of surgeon experience in years further stratifying patients. results: there was no significant difference in operative duration, t(71) = 1.14, p = .26, between the contralateral (m = 281.95 minutes, sd = 71.82) and ipsilateral (m = 261.15, sd = 79.26) groups. this same pattern was more pronounced among surgeons with 10+ years of experience although there was also no significant difference in operative time, t(33) = 1.31, p = .19 for both ipsilateral and contralateral surgeries there was no statistically significant difference, t(36) = -0.72, p = .47, in overall mean hearing gain among patients in the contralateral (m = +2.22 db, sd = 10.54) and ipsilateral (m = +5.12 db, sd = 14.26) groups. although the difference was also not statistically significant, t(16) = -1.94, p = .07 for contralateral (m = 0.00, sd = 5.43) and ipsilateral (m = +7.95 db, sd = 11.52) procedures performed by surgeons with experience of 10 years or more, a mean hearing gain of +7 db in the ipsilateral group compared to 0 db in the contralateral group was notable. conclusion: this study did not prove that regardless of surgeon experience, right-handed surgeons operating on the right ear and left-handed surgeons operating on the left ear have better ear surgery outcomes of operative duration and hearing improvement compared to righthanded surgeons operating on the left ear and left-handed surgeons operating on the right ear. future studies on larger samples with more complete data may yet demonstrate this effect. keywords: handedness; laterality; otologic surgical procedure; hearing; operative times. the relationship of surgeon handedness and experience on operative duration and hearing improvement in ipsilateral and contralateral otologic surgeries gillian t. barzaga, md department of otorhinolaryngology head and neck surgery de la salle university medical center correspondence: dr. gillian t. barzaga department of otorhinolaryngology head and neck surgery de la salle university medical center de la salle health sciences institute gov. d. mangubat avenue, dasmariñas cavite 4114 philippines phone: (632) 916 207 6401 e-mail address: gtbarzaga@dlshsi.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by the author, and the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationship, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. philipp j otolaryngol head neck surg 2020; 35 (2): 17-21 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles most people all over the world are right-handed (90%);1 and this is reflected among surgeons, where left-handed individuals represent only 9-10%.2 surgeon handedness may be related to optimal surgical performance, and their inherent dominant hand may contribute to this performance depending on the laterality of the surgical field. very few studies on orthopedics,3,4 breast surgery,5 and microlaryngeal surgery6 document the relationship of handedness and laterality of operative site with positive outcomes. a study of a right-handed orthopedic surgeon operating on knees of different literalities found that the odds of having a poor outcome were higher when operating on the contralateral side.3 another study found that surgeons performing total hip replacements were able to increase the angulation of the joint socket more easily when operating ipsilateral to their dominant hand, restoring the hip nearer to its normal anatomic position.4 breast surgeons have no significant differences in terms of complication when operating on either breast, but it was found that less experienced surgeons had significantly more complications than experienced ones.5 to the best of my knowledge, there are no published reports so far on the effect of surgeon handedness on otologic surgery. do right-handed surgeons operating on the right ear and lefthanded surgeons operating on the left ear have an advantage in ear surgery outcomes such as operative duration and hearing improvement compared to right-handed surgeons operating on the left ear and lefthanded surgeons operating on the right ear of the patient? would surgeon experience contribute to the effect of such surgeon-patient positioning? hypothesizing that operative duration should be shorter and hearing gain will be better when operative ears are ipsilateral to the surgeon’s dominant hand, and that these outcomes may be further improved with surgeon experience greater than ten years, this research aims to determine the difference in the operative duration and hearing improvement between patients whose surgical site was ipsilateral the surgeon’s dominant hand compared to those whose surgical site was contralateral the surgeon’s dominant hand, and to further explore whether this relationship may be related to surgeon experience. methods this retrospective cohort study reviewed records of patients aged 18-65 years who underwent primary ear surgery under general anesthesia in a tertiary private teaching hospital between january 1, 2016 and december 31, 2019. the study was approved by the de la salle health sciences institute independent ethics committee [dlshsiiec(2019)-52-02-a]. informed consent was waived by the board. the list of otologic surgeries performed on adult patients was generated from the departmental census, and records of operations were retrieved from the hospital medical records section. the following variables were extracted: age, sex, otologic procedure performed and post-operative diagnosis, laterality, start and end times of operation, and intraoperative ossicular findings. audiograms were retrieved from the institutional hearing center when they were not found in individual clinical records. the name of the surgeon was listed, and their dominant hand and experience in years (<10 or 10 or more) were confirmed and tabulated by the author. records of patients with incomplete demographic and operative data were excluded. records with incomplete audiograms were only excluded from hearing gain outcome computations. the primary outcome was operative duration measured in minutes, while the secondary outcome was hearing gain, measured by the preoperative and post-operative air-bone gap difference. the two groups were additionally compared with regard to surgeon experience. the patients were classified into two groups: contralateral, c (righthanded surgeons operating on the left ear; left-handed surgeons operating on the right ear) and ipsilateral, i (right-handed surgeons operating on the right ear; left-handed surgeons operating on the left ear). operative duration was measured in minutes. hearing gain was computed from the difference between preand post-operative airbone gaps in pure-tone audiograms. the groups were further stratified based on surgeon experience in years (< 10 vs. 10 or more). the mean time duration of ear surgeries (regardless of handedness and laterality) in the institution for the year 2018 was 282 minutes, with procedures operated ipsilateral to the dominant hand of the surgeon lasting 230 minutes while those on the contralateral side lasting 290 minutes. assuming these means with a standard deviation of 89 minutes, a power of 80% and a 5% level of significance, the sample size calculated was 35 per group, or a total of 70 subjects using the formula: the data was collated and analyzed by the investigator in ms excel for mac v.16.33 (2019, microsoft corp., redmond, wa). descriptive measures (mean, standard deviation) were used and inferential statistics included a two-sample t-test assuming equal variances with a 95% confidence level and a level of significance of 0.05 to compare the mean difference of patients in the two groups that were considered as independent samples. philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles results a total of 105 records of patients who underwent ear surgery in our institution between january 1, 2016 and december 31, 2019 were examined for eligibility. after applying inclusion and exclusion criteria, records of 73 patients were included in the study for operative time outcome. mean age was 38 years (18 to 65 years old). there were 39 patients in the contralateral (c) group and 34 in the ipsilateral (i) group with a male-to-female ratio of 15:24 and 14:20, respectively. table 1 shows the diagnoses of the patients sorted by group. out of the 73 patients included in the study, only 38 had complete pre-operative and post-operative audiograms: 22 in the contralateral (c) group, 16 in the ipsilateral (i) group. distribution according to hearing level is shown in figure 1 for the c group, and figure 2 for the i group. diagnoses ipsilateralcontralateral chronic otitis media cholesteatoma facial nerve dehiscence facial paralysis labyrinthine fistula mastoiditis intracranial extension no complications congenital cholesteatoma tympanic membrane perforation secondary to chemical burn grand total 34 17 0 2 1 1 1 12 0 0 34 37 14 1 2 1 0 0 19 1 1 39 table 1. demographics of disease and complications figure 1. preand post-operative world health organization (who) hearing level classifications of patients in the contralateral group: superior solid bars, pre-operative; inferior stippled bars, postoperative. figure 2. preand post-operative world health organization (who) hearing level classifications of patients in the ipsilateral group: superior solid bars, pre-operative; inferior stippled bars, postoperative. figure 1 shows the preand post-operative hearing level classifications of the patients in the contralateral (c) group. among the 22 patients, the majority had pre-operative mild (8) hearing loss, followed by profound (5), moderate (4) and severe (1) hearing loss, and normal hearing levels, (4). post-operatively, most patients had moderate hearing loss (8), followed by profound (5), mild (4), severe (3), and normal (2) hearing levels. figure 2 shows the preand post-operative hearing level classifications of the patients in the ipsilateral (i) group. among the 16 patients, the majority pre-operatively had moderate hearing loss (6), followed by severe (5), profound (3), mild (1) hearing loss, and normal hearing (1). post-operatively, most patients had profound (4), severe (4), and mild (4), followed by moderate (2) hearing loss, and normal hearing (2). figure 3 shows the otologic procedures performed. for both contralateral (c) and ipsilateral (i) surgeries respectively, the majority (c=17; i=14) were canal wall down mastoidectomies with tympanoplasties (cwd+t), followed by intact canal wall mastoidectomies with tympanoplasties (icw+t, c=11; i=11), radical mastoidectomies (rm, c=5; i=5) and tympanoplasties (t, c=6; i=5). table 2 lists the intraoperative ossicular status of the patients. out of 73 patient records, 63 reported the status of the ossicles: 35 from the contralateral group, 28 from the ipsilateral group. most patients had intact ossicular chains (c=15; i=10) followed by those with partially eroded malleus and incus but intact stapes (c=5; i=5), those with absent ossicles (c=4; i=2), those with partially eroded malleus but intact incus and stapes (c=3; i=3) and solely absent incus (c=3; i=3), those with solely present stapes (c=2; i=2), then those with absent philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles a total of 38 patients were included in the computations for hearing gain. of these, 22 patients were in the contralateral (c) group and 16 were in the ipsilateral (i) group. there was no statistically significant difference, t(36) = -0.72, p = .47, in overall mean hearing gain among patients in the contralateral (m = +2.22 db, sd = 10.54) and ipsilateral (m = +5.12 db, sd = 14.26) groups. those procedures operated on by surgeons with less than 10 years of experience, the contralateral (m = +4.06db, sd = 13.41) and ipsilateral (m = +2.29 db, sd = 16.88) hearing gains did not differ significantly, t(18) = 0.26, p = .79. although the difference was also not statistically significant, t(16) = -1.94, p = .07 for contralateral (m = 0.00, sd = 5.43) and ipsilateral (m = +7.95 db, sd = 11.52) procedures performed by surgeons with experience of 10 years or more a mean hearing gain of +7 db in the ipsilateral group compared to 0 db in the contralateral group was notable, as it was closer to the 10 db preand post-operative air-bone gap difference cut-off for significant hearing improvement. discussion this study found no significant difference in operative duration or hearing improvement among patients whose surgical site was ipsilateral the surgeon’s dominant hand compared to those whose surgical site was contralateral the surgeon’s dominant hand, even when surgeon experience was taken into consideration. however, the shorter overall operative duration of 20 minutes in the ipsilateral group, increasing to 37 minutes among surgeons with 10 or more years of experience cannot be overlooked. although there was also no significant difference between surgeon handedness and surgical site laterality in terms of hearing gain, the ipsilateral group operated on by surgeons with 10 or more years of experience attained hearing gains better by 7db. because of these, my hypothesis that operative duration should be shorter and hearing gain will be better when operative ears are ipsilateral to the surgeon’s dominant hand, and that these outcomes may be further improved with surgeon experience greater than ten years, cannot just be dismissed outright. although they are not statistically significant, these findings are clinically important to the surgeon, because they can help gauge success rates and estimate duration of operations. they may also be relevant to the patient because shorter operative times would mean less exposure to anesthetics and other intraoperative medications. hearing gain is considered significant if the pre-operative and post-operative air-bone gap difference is 10 db or higher.7 since the ipsilateral group came closer to this value, there may yet be a potential advantage associated with operating on the ear ipsilateral to the surgeon’s dominant hand. the findings of this study echo those of previous studies in other surgical fields operating on paired body parts. a right-handed surgeon figure 3. otologic procedures performed: t, tympanoplasty; rm, radical mastoidectomy; icw+t, intact canal wall mastoidectomy with tympanoplasty; cwd+t, canal wall down mastoidectomy with tympanoplasty: superior stippled bars, ipsilateral; inferior solid bars, contralateral. malleus, partially eroded incus but intact stapes (c=1; i=1), absent incus but partially eroded malleus and stapes (c=1; i=1), and partially eroded malleus and incus but intact stapes (c=1; i=1). there was no significant time difference in operative duration, t(71) = 1.14, p = .26 between the 39 patients in the contralateral group (m = 281.95 minutes, sd = 71.82) compared to the 34 patients in the ipsilateral group (m = 261.15, sd = 79.26), even if the ipsilateral group had a shorter operative duration by 20 minutes. there was also no significant difference in operative time, t(36) = 0.09, p = .93 for surgeon experience of less than 10 years for both the contralateral (m = 265.59 minutes, sd = 87.63) and ipsilateral (m = 263.24 minutes, sd = 65.28) groups. there was also no significant difference in operative time, t(33) = 1.31, p = .19 for surgeon experience of 10 or more years, although the ipsilateral group had a shorter operative duration by 34 minutes. ossicular status † ipsilateralcontralateral m+i+s+ mpi+s+ m+i-s+ mpips+ m-ips+ m-i-s+ mpi-sp mpipsm-i-sgrand total 10 3 3 5 1 2 1 1 2 28 15 3 3 5 1 2 1 1 4 35 table 2. ossicular chain status of the patients †m, malleus; i, incus; s, stapes; +, present; -, absent; p, eroded philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles operating on the left side of the patient had higher odds of having a poor outcome than when operating on the right,3 favoring procedures done on the side ipsilateral to the surgeon’s dominant hand. there was also evidence that operating ipsilateral to the surgeon’s dominant hand resulted in a better surgical outcome.4 the additional impact of surgeon experience seems to attenuate the effects of surgeon handedness and laterality of the surgical site alone.5 although statistically insignificant, this may be suggested by our findings of shorter durations and higher hearing gains among contralateral and ipsilateral groups for procedures performed by more experienced surgeons. a more extensive series or perhaps a future randomized controlled trial may shed more light on this issue. perhaps the reason for the advantage of operating on the ear ipsilateral the surgeon’s dominant hand may relate to the ergonomically easier access and maneuvering of instruments in the ipsilateral middle ear and mastoid. in contrast, operating on the side contralateral to the surgeon’s dominant hand may require hyper-adducting their wrist to manipulate and dissect the middle ear, especially in the attic and the sinodural angle. a future simulation study may demonstrate whether this is so. this was a retrospective cohort study wherein records of patients were reviewed. causation of phenomena such as change in operative duration and improvement in post-operative hearing, cannot be determined although association may be. an important limitation of the study is that our obtained sample size, while adequate per computed sample size, was not consistent for both outcomes. half of the patients lacked records of post-operative audiograms for various reasons (the surgeons did not request them, the patients did not have the audiogram done, or the patients did not return for follow-up after the procedure). this affects our results and conclusions for this outcome. the otologic procedures varied, and perhaps to have a more consistent determination of association, one type of surgical procedure should be included (e.g., tympanoplasty only or type 3 mastoidectomy with tympanoplasty only). also, a surgeon’s experience on otologic surgery varies widely since few perform the same type of surgery with the same frequency despite the number of years of being a boardcertified otolaryngologist. future studies could stratify surgeons by the number of tympanomastoidectomies done per year as to better gauge their skill or experience. another limitation is that complications were not recorded in the study, and this is an important variable to consider when measuring the surgical outcome of operative duration in future research. to the best of my knowledge, this is the first study to examine how surgeon handedness, surgeon experience, and surgical site laterality may impact ear surgery outcomes. although a measure of efficiency may have been approximated by the number of minutes per procedure, efficacy cannot be adequately measured because of the numerous study limitations. in conclusion, this study did not prove that regardless of surgeon experience, right-handed surgeons operating on the right ear and left-handed surgeons operating on the left ear have better ear surgery outcomes of operative duration and hearing improvement compared to right-handed surgeons operating on the left ear and lefthanded surgeons operating on the right ear of the patient. however, future studies on larger samples with more complete data may yet demonstrate this effect. acknowledgements i would like to thank my adviser dr. jose acuin, for overall supervision of my research and dr. patrick pardo for providing feedback on my manuscript; our department chairman dr. ramon ramos iii, for general support in this endeavor; and ms. loida aquino and mr. brian jay feranil for assistance in data collection. references 1. mcmanus ic. the history and geography of human handedness. in: sommer, iris ec and rene s kahn. language lateralization and psychosis. cambridge: cambridge university press, 2009. p. 37-57. doi: https://doi.org/10.1017/cbo9780511576744.004. 2. zaghloul m, saguib j, al-mazrou a, saguib n. a qualitative assessment of the impact of handedness among left-handed surgeons in saudi arabia. laterality. 2018 jan;23(1):39-50. doi: 10.1080/1357650x.2017.1309049; pubmed pmid: 28363266. 3. mehta s, lotke pa. impact of surgeon handedness and laterality on outcomes of total knee arthroplasties: should right-handed surgeons do only right tkas? am journal orthop. 2007 oct;36(10):530-3. pubmed pmid: 18033564. 4. pennington n, redmond a, stewart t, stone m. the impact of surgeon handedness in total hip replacement. ann r coll surg engl. 2014 sep; 96(6): 437–441. doi: 10.1308/003588414x1394618 4902488; pubmed pmid: 25198975; pubmed central pmcid: pmc4474195. 5. luvisa k,  fan kl,  black ck, wirth p, won lee d,  del corral g,  et al. does surgeon handedness or experience predict immediate complications after mastectomy? a critical examination of outcomes in a single health system. the breast journal. 2019 aug; 26(10) 1-8. doi: 10.1111/ tbj.13487. 6. naunheim mr, le a, dedmon mm, franco ra, anderson j, song pc. the effect of handedness and laterality in a microlaryngeal surgery simulator. am j otolaryngol. 2017 jul-aug; 38(4):472474. doi: 10.1016/j.amjoto.2017.04.009; pubmed pmid: 28449823. 7. gupta s, parmod k, sehgal s, gupta n. review of parameters used to assess hearing improvement in tympanoplasty. iosr-jdms. 2016 feb; 15(2 ver x): 122-128. doi: 10.9790/085315210122128. president’s page greetings to all! i am pleased to extend my sincere congratulations to the editors, reviewers, authors, co-authors and the rest of the hardworking and dedicated staff of the philippine journal of otolaryngology – head & neck surgery. as you all know my term is almost over and it was a very fruitful year. it will be more so since the pjohns will soon join the celebration of the pso-hns 60th jubilee year on its next edition and i am sure the editorial staff is already well at work to prepare an issue worth keeping and remembering. we always hope for pjohns to continue its goal in documenting medical and surgical researches and clinical practices which have initiated the progress and development of orl-hns in the philippines in significant ways. the articles and abstracts of the journal appropriately document the research papers basically done by our residents every year and we do hope that our consultants can still find time to help their residents to gain new knowledge, and give extensive efforts to author an article worth publishing in this journal that are at par with foreign counterparts. in our field of specialization, there is always the need to develop new concepts and strategies to keep abreast with the continuous challenges. through the years, the pso-hns has developed steady progress in the field of otorhinolaryngology. ending this message will not be complete without mentioning and giving recognition to the editorial board under the leadership of dr. jose florencio lapena, jr., as well as to the authors who contributed to this particular issue. the philippine society of otolaryngology-head and neck surgery is grateful to be associated with the pjohns. may this partnership continue and strengthen over the next 60 years! armando m. chiong, jr., md president philippine society of otolaryngology-head and neck surgery 2 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 pjo-hns… a steady progress philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 25 abstract objective: to describe the extended transpalatine approach (etpa) with transection of the ipsilateral greater palatine artery and extension of the ipsilateral retromolar incision and its corresponding surgical outcomes and present it as an option in the excision of juvenile angiofibroma (ja). methods: design: descriptive case series setting: tertiary public university hospital subjects: 13 ja cases undergoing etpa results: records of ja in a tertiary hospital from 2007 – 2013 were reviewed. out of 35 ja patients, 13 underwent excision via extended transpalatine approach. preoperative work-up included ct scan with contrast with or without preoperative embolization. in all patients, the wide field allowed easy tumor excision and facilitated inspection and hemostasis. there was only one recurrence in our series compared to 1 each for 4 endoscopic and 18 transmaxillary approaches. not one of the patients developed a fistula or hypernasal speech. all patients had minimal palatal scarring, symmetric alveolar growth and palatal function. conclusion: the etpa is a robust technique. it provides good exposure of ja with minimal preoperative requirements and postoperative complications. keywords: juvenile angiofibroma, juvenile nasopharyngeal angiofibroma, transpalatine approach juvenile angiofibroma (ja) is a highly vascular, locally invasive benign tumor of the nasopharynx developing among adolescent males. patients usually present with recurrent epistaxis and a nasopharyngeal tumor.1 management is excision of tumor from its origin and extensions in the nasal cavity, nasopharynx, sinuses and pterygomaxillary fissure into the infratemporal fossa. a bloody surgical field and narrow working area is a typical scenario during treatment. pre-operative embolization of feeding vessels lessen intra-operative bleeding while blunt dissection decreases the chance of leaving tumor behind. the growth pattern of ja is peculiar since it has a tendency to insinuate into crevices and cavities, resulting in multiple lobulations that may be left unexcised during surgery. the tumor originates in the posterior nasal cavity rather than in the nasopharynx itself. the specific site of origin is the posterior lateral and superior nasal cavity at the point where the sphenoidal process of the palatine bone meets the horizontal ala of the vomer and the root of the pterygoid process extended transpalatine approach for excision of juvenile angiofibroma josefino g. hernandez, md1 arsenio a. cabungcal, md1 ryner jose d. carrillo, md, msc1,2 1department of otorhinolaryngology college of medicine philippine general hospital university of the philippines-manila 2department of anatomy college of medicine, university of the philippines-manila correspondence: dr. ryner jose d. carrillo department of otorhinolaryngology ward 10 philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 554 8467 email: ryner_c@yahoo.com reprints will not be available from the authors. the authors declare that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest philipp j otolaryngol head neck surg 2015; 30 (2): 25-29 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 26 philippine journal of otolaryngology-head and neck surgery original articles of the sphenoid bone.2 this can extend anteriorly along the nasal cavity with the tumor pushing the septum to the opposite side, posteriorly into the nasopharynx, upwards to the sphenoid sinus, the area of the vidian canal and laterally into the pterygomaxillary fossa and infratemporal fossa producing a dumbbell type of tumor. the origin of the tumor which is embedded in bone is in an area that is more difficult to release.2 anterior approaches to ja surgery include the endonasal, lateral rhinotomy, sublabial, midfacial degloving for soft tissue exposure and medial maxillectomy or le-fort i osteotomies for bony exposure. for large to extensive tumors, a transfacial approach is applied with varying degrees of exposure, resecting the bony sinonasal anatomy while leaving the palate bone intact. endonasal approaches have been done to utilize the nostril as a natural access to the tumor using endoscopes.3, 4, 5 the type of approach used depends on tumor classification or staging, surgeon experience and institutional preference. the inferior transpalatine approach allows wide tumor exposure through the oral cavity with direct access to the nasal cavity, nasopharynx, sinuses and pterygomaxillary fissure with minimal disturbance to soft tissues and the bony anterior face. this can be combined with endoscopes or microscopes if additional visualization and documentation is desired. the transpalatine technique, as described in lore’s an atlas of head and neck surgery,3 used to be the common approach to this tumor. however, it was observed that lateral extent of exposure was limited by the need to preserve the greater palatine foramen and palatine arteries. a modification of the procedure is the extended transpalatine approach (etpa) where routine transection of the ipsilateral greater palatine artery and extension of the ipsilateral retromolar incision are done. the objective of this case series is to describe the extended transpalatine approach (etpa) and its corresponding surgical outcomes and present it as an option in the excision of juvenile nasopharyngeal angiofibroma (ja). methods a retrospective review of records was conducted on all cases of ja operated on at the department of otorhinolaryngology, university of the philippines philippine general hospital from 2007 to 2013. compliance with strict confidentiality of patient information was ensured; and approval from unit institutional / ethical review board was obtained. diagnosis was based on findings of a fleshy nasal and nasopharyngeal mass, epistaxis, an enhancing tumor on ct-scan involving the ipsilateral vidian canal, and final histopathology. all ja cases that underwent etpa were evaluated. adequacy of exposure and complications of oro-nasal fistula and speech problems were determined. etpa technique in each patient, general anesthesia was induced and the endotracheal tube was retracted from the operative site using the grooved tongue blade of a dingman mouth-gag. lidocaine 2% with epinephrine 1:100,000 was infiltrated locally, and an inverted ‘u’ palatal mucosal incision was made, extending posterior to the ipsilateral third molar toward the anterior tonsillar pillar. the ipsilateral greater palatine artery was routinely transected and ligated, and the palatal incision extended posteriorly towards the tonsillar pillar to ensure adequate exposure. to prevent the possible development of an oro-nasal fistula, the mucosa was incised lateral to and beyond the projected palatal bone excision. this ensured that palatal soft tissue would rest on remaining bone during repair. using kerrison rongeours and/or a drill with cutting burrs, palatal bone was removed as anteriorly and laterally as possible without reaching the anterior or lateral mucosal incision line. careful blunt dissection using a freer periosteal elevator and fingers was performed to ensure that pseudopod-like extensions into crevices and fissures were not left behind. bleeders were controlled using cautery. hemostatic material (gelfoam®, surgicel®) was placed in areas with great possibility of bleeding. packing was done using gauze impregnated with antibiotic ointment, nasal tampons or balloon nasal packs. layered closure was done using polyglactin 4-0 with round needle. the nasal and nasopharyngeal mucosa, muscles of the soft palate and palatal mucosa were sutured with care. a pre-fabricated palatal obturator was positioned to allow immediated post-operative oral feeding with soft diet, or a thin hammock dressing was sutured in place. extubation was delayed one day post-operatively to protect the airway in case of immediate post-operative bleeding. nasal packs were removed from 3 to 7 days post – surgery. a representative case is illustrated. (figures 1 to 6) figure 1. transpalatine approach: incision markings along the alveolar or palatine bone. dots approximate location of the greater palatine arteries. note planned incision extension posterior to the third molar, towards the tonsillar pillar on the patient’s left (arrow). philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 27 results from 2007-2013, 35 cases diagnosed with juvenile angiofibroma underwent excision at our institution. two were not initially diagnosed as having ja; one had no history of recurrent epistaxis while the other had a left unilateral nasal and nasopharyngeal mass with no destruction of the vidian canal. both cases underwent biopsy that produced significant hemorrhage upon biting the nasal mass necessitating tight nasal packing. histopathologic diagnosis for both cases was juvenile nasopharyngeal angiofibroma. all the 35 cases diagnosed with juvenile angiofibroma underwent ct-scan of the nasopharynx. the surgical approach for 18 patients was transmaxillary (11 hemifacial degloving, 7 lateral rhinotomy). four of these were endoscopically assisted. there were four other cases that underwent excision purely via endoscopic approach; all of them underwent pre-operative embolization. figure 2. palatal incision extended to the ipsilateral tonsillar pillar. ipsilateral greater palatine artery has been ligated and the palatal flap raised down to the periosteum and reflected inferiorly. the hard palate is being excised, leaving portions to support palatal flap during repair. figure 4. surgical bed inspection and hemostasis before hemostatic material and antibioticimpregnated gauze are packed in place. figure 5. layered closure of palatal flap. figure 6. application of pre-fabricated palatal obturator or hammock splint. note antibioticimpregnated gauze strip extending from ipsilateral nostril. figure 3. exposed tumor (arrow) bluntly dissected using a finger and elevators. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 28 philippine journal of otolaryngology-head and neck surgery original articles thirteen out of 35 ja cases underwent etpa. the mean age was 15 (11-18) years-old. radkowski5 stages ia, ib, iia, iib, iic yielded 4, 3, 4, 1 and 1 case(s) respectively. (table 1) there were no stage iiia and iiib cases or skull base erosion. three had pre-operative embolization. one had an infratemporal extension and underwent a combined extended transpalatine and trans-maxillary approach. of the 12 cases using a purely extended transpalatine approach, the surgeons found the approach very effective with a big part of the tumor visible to the surgeon at the start of excision. there was no need for an endoscope and both hands could be used for dissection. finger-dissection or dissection using a periosteal elevator allowed adequate blunt dissection. inspection of the bed and the site of origin of the tumor to assess possible residuals was also facilitated. any bleeder was readily visualized and controlled. in all patients, the operative site was easily packed with surgicel® or gelfoam® and antibiotic-impregnated gauze strips, and the palatal obturators or thin hammock dressings were positioned on the palate after closure of the palatal mucosa incision. delayed extubation, 24 hours after the procedure, was uneventful in all cases. packing was usually removed beginning on the third day and completely removed from 5 to 7 days. of the 13 cases, not one developed oro-nasal or oro-nasopharyngeal fistula post-operatively. there were also no cases of hypernasality of speech. to the best of our knowledge, there was only one case of recurrence in our series, and this was in the area of the vidian canal. follow-up for all cases ranged from 2 months to 7 years. the representative case with 7 years follow up is illustrated. (figure 7-10) table 1. thirteen cases of ja who underwent etpa age stagea embolization recurrenceapproach 1 2 3 4 5 6 7 8 9 10 11 12 13 15 15 15 15 18 13 18 17 11 17 16 14 11 iia ia ib ia ia ia iia ib iia ib iic iia iib yes yes none none none none none none none yes none none none none none none none none none none none none none none yes none etpa etpa etpa etpa etpa etpa etpa etpa etpa etpa etpa combined with transmaxillary etpa etpa a-radkowski staging for ja figure 7. two weeks post surgery figure 8. one month post surgery figure 9. seven years post-surgery showing minimal scarring of the palate and symmetrical alveolar growth philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 29 references 1. batsakis jg. tumors of the head and neck; clinical and pathological considerations. 2nd ed. baltimore:williams and wilkins; 1979. pp. 296-300. 2. nicolai p, castelnuovo p. benign tumors of the sinonasal tract. in: flint p, haughey b, lund v, niparko j, robbins t, thomas r, lesperance m, editors. cummings otolaryngology head and neck surgery. 6th ed. canada: saunders; 2015. pp. 744-746. 3. lore jm, medina je. an atlas of head & neck surgery. 4th ed. philadelphia: elsevier saunders; 2005. (1) pp 288-293. 4. silver ce, rubin js. atlas of head and neck surgery. 2nd ed. new york: churchill livingstone; 1999. pp. 156-161. 5. nicolai p, schreiber a, villaret ab. juvenile angiofibroma: evolution of management. int j pediatr. 2012; 2012: 412545. doi:10.1155/2012/412545. 6. gaillard al, anastacio vm, piatto vb, maniglia jv, molina fd. a seven-year experience with patients with juvenile nasopharyngeal angiofibroma. braz j otorhinolaryngol. 2010 mar-apr; 76(2):245-250. 7. pippal sk, khare m, yashveer b. a study on reliability and safety of transpalatine approach for nasopharyngeal angiofibroma: a case series. world articles in ear, nose and throat. 2011 may 2; 4(1).[cited 2015 aug 25]. available from:http://www.waent.org/archives/2011/vol41/20110415-angiofibroma/angiofibroma.htm discussion juvenile angiofibroma excision has always been considered difficult because of its bloody nature and anatomic location. a common cause of residual or recurrent disease is incomplete exposure of and access to tumor stalk or extensions during surgery. preoperative angiography with embolization allows less intraoperative bleeding with the objective of better surgical site exposure and less blood loss.6 however, not all patients can afford the cost of pre-operative embolization of feeding vessels supplying the tumor, which are mainly branches of the internal maxillary artery. moreover, while preoperative embolization allows a less bloody surgical field, it is not always available and is associated with tumor residual.2, 5,7 in the absence of preoperative embolization, the transpalatine approach to ja has provided good results with minimal morbidity and mortality.7 the etpa, a modification of the transpalatine approach,3 allows direct access to tumor with a wide surgical exposure. as a primary approach, it does not violate the soft tissue and bony face. the components allowing wide exposure both for visualization and dissection are: 1. a wider entry site, i.e., the oral cavity (compared to the nasal or transmaxillary route); and 2. wide and direct tumor access with an inferiorly-reflected palatal flap, transection of the ipsilateral greater palatine artery plus extended incision of the soft palate behind the ipsilateral molar and removal of a big part of the bony palate. (figure 3, 4) the approach may be likened to a wider funnel providing access to the nasal cavity, nasopharynx and pterygomaxillary fossa. blunt dissection of the tumor lessens the amount of bleeding in the operative field. sharp dissection will cut tumor tissue and expose the sinusoids which will allow blood to flood the operative site. the excised tumor is figure 10. seven years post-surgery showing symmetrical alveolar growth and palatal elevation inspected for any raw or unsmooth areas which may suggest a portion left behind. after tumor removal, bleeding areas may suggest residual disease and must be bluntly dissected to determine whether part of the tumor has been left behind. with a bigger field to work in, bleeders are more easily visualized, accessed and controlled. to the best of our knowledge, there was only one recurrence in our series, in the area of the vidian canal. this is comparable to recurrence rates among the other 22 cases managed with other approaches, as there was 1 recurrence among the 4 endoscopic approaches, and 1 recurrence in the transmaxillary approach. a limitation of our study is the great variation in our follow-up period ranging from 2 months to 7 years. in our setting, many patients only follow up when they experience intolerable symptoms such as recurrent, persistent epistaxis. another limitation is that postoperative ct or mri imaging was not routinely performed on our patients due to cost considerations, as repeat imaging is usually requested only for recurrence of symptoms. to our knowledge, not one of the 13 cases of ja who underwent etpa developed oroantral fistula or nasal resonance problems. having a bony bed at the incision site may provide support and serve as a scaffold during healing, such that even minor dehiscence is not expected to result in fistula formation. hypernasality of speech was not observed for any of the 13 cases that we know of. the use of a palatal obturator has allowed patients to ingest a liquid diet immediately postoperatively without need for a nasogastric tube. delayed extubation also prevented the need for a tracheotomy. an extended transpalatine approach with transection of the ipsilateral greater palatine artery seems to provide good exposure of ja and the operative site. this approach allows the surgeon to more effectively handle most cases of juvenile nasopharyngeal angiofibroma confined to the nasal cavity, nasopharynx, paranasal sinuses and limited pterygomaxillary fossa. cases with infratemporal fossa extension may need a modified approach. the robustness of the etpa allows it to be very versatile as a primary approach or in combination with other techniques in managing ja. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 7170 philippine journal of otolaryngology-head and neck surgery passages elvira geluz ilano-colmenar, md (1930 – 2021) manuel tomas i. colmenar, md ent-hns department in 1987. she worked very hard to establish an accredited residency training program, all while serving as a beacon and guide to our residents and staff. influenced by her service, my brother loy and i followed in her footsteps, pursuing our own careers in dentistry and medicine later on. she was also a source of inspiration to several of her nieces who later became established physicians in their own fields of specialty, as well as two of her grandchildren who are also pursuing dentistry and medicine. mom was known for her 30-minute cold knife tonsillectomies, but one thing she would always emphasize was the importance of patient safety over speed. a natural peacemaker, she also served in the hospital ethics committee, where she mediated in settling cases between warring physicians, hospital staff, and patients. this value of hers would also be evident in our clan, as we would always approach her first during times of family crisis. after retirement, she continued her practice at home, mostly for free, until she could no longer do so. while it broke our hearts to see her go, my mom lived a beautiful and fulfilling life. she will always be remembered as a steadfast doctor, an inspiring mentor, a doting wife, mother, and grandmother, and one of the strongest and most generous women we will ever have the pleasure of knowing. may she rest in peace in the hands of our lord. a fighter through and through, my mother elvie passed away at the age of 90 in st. luke’s, quezon city due to cancer. during her last days in the hospital, with nurses and attendings rushing back and forth her room with various equipment, she would often marvel at how medicine has advanced since her younger years. “iba na talaga ngayon…”, she would say, followed by a pained chuckle and a faraway look in her eyes. while times have certainly changed and continue to do so, this did not hinder my mom from being the best doctor she could be. born in imus, cavite, elvie was the youngest daughter in a family of eight children. her father passed when she was just a toddler, so they were raised single-handedly by her mother since then. she was known as ‘tia elvie’ to her nieces and nephews, whom she nurtured and cared for dearly. she finished medicine at the university of santo tomas in 1954, and beauty and brains that she was, was also a candidate for miss medicine in that year. she then pursued her residency in otolaryngology at king’s county hospital, brooklyn new york in 1960. she married the love of her life, manolo colmenar in 1964. dr. colmenar established her practice in st. luke’s, where she joined the staff of the eent department at cathedral heights, quezon city and was subsequently appointed the first chairperson of our very own philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 contents cover images editorial 4 seasons and times, reasons and rhymes: di niyo ba naririnig? lapeña jff original articles 6 effectiveness of levodropropizine on post-operative sore throat after endotracheal intubation for head and neck surgery: a double-blind randomized controlled trial ducto im, cachuela je 11 efficacy of carragelose® nasal spray impregnated versus mupirocin ointment impregnated nasal packs on mucosal healing after endoscopic sinus surgery: a double-blind, non-randomized, right-left side comparison lo jbb, cruz ets 17 the relationship of surgeon handedness and experience on operative duration and hearing improvement in ipsilateral and contralateral otologic surgeries barzaga gt 22 assessment of nasal airflow and pain, safety and cost of an improvised nasal airway (nasogastric) tube after endoscopic sinus surgery rojo jgc, ramos rzh 27 prevalence of diabetes mellitus and clinicodemographic profiles of patients with head and neck infections in a philippine tertiary government hospital santos jm 32 head and neck symptoms as predictors of outcome in tetanus patients carlos-hiceta ac, carrillo rjd, lapeña jff 37 a linguistic validation study on the filipino dizziness handicap inventory agustin sn, ureta cv, almazan na case reports 41 blindness from fungal rhinosinusitis of the paranasal sinuses: a case report de jesus drt, estolano pjl 44 endoscopic management of a large tornwaldt cyst: a case report espinosa wz, david mjc 48 a case report of maxillary calcifying epithelial odontogenic tumor in a teenage girl magno jpm, hernandez jg, del mundo daa practice pearls 51 on the importance of proper window and level settings in temporal bone ct imaging yang nw featured grand rounds 55 reconstruction of a large nasal alar squamous cell carcinoma defect using a superiorly-based nasolabial flap cordero jcb under the microscope 59 odontogenic keratocyst carnate jm letter to the editor 61 “the laryngectomee guide” philippine edition brook i “axial ct of the temporal bone on a bone window setting (ww 4000, wl 1000); black dot, head of malleus; black star, central bony island of lateral semicircular canal.” by nathaniel w. yang, md fb_img_1528793889969 by anna carliassa p. arriola, md “warped” orl-hns in the frontline insta 360+ iphone xs by rene louie c. gutierrez, md, mha “pandemic” orl-hns in the frontline canon 5d mark 2 ef 24-70mm by rene louie c. gutierrez, md, mha “mystical garden” watercolor and pen 9x12 inches by teresa paz g. pascual, md seasons and times, reasons and rhymes: di niyo ba naririnig? effectiveness of levodropropizine on post-operative sore throat after endotracheal intubation for head and neck surgery: a double-blind randomized controlled trial efficacy of carragelose® nasal spray impregnated versus mupirocin ointment impregnated nasal packs on mucosal healing after endoscopic sinus surgery: a double-blind, non-randomized, right-left side comparison the relationship of surgeon handedness and experience on operative duration and hearing improvement in ipsilateral and contralateral otologic surgeries assessment of nasal airflow and pain, safety and cost of an improvised nasal airway (nasogastric) tube after endoscopic sinus surgery prevalence of diabetes mellitus and clinicodemographic profiles of patients with head and neck infections in a philippine tertiary government hospital head and neck symptoms as predictors of outcome in tetanus patients a linguistic validation study on the filipino dizziness handicap inventory blindness from fungal rhinosinusitis of the paranasal sinuses: a case report endoscopic management of a large tornwaldt cyst: a case report a case report of maxillary calcifying epithelial odontogenic tumor in a teenage girl on the importance of proper window and level settings in temporal bone ct imaging reconstruction of a large nasal alar squamous cell carcinoma defect using a superiorlybased nasolabial flap odontogenic keratocyst “the laryngectomee guide” philippine edition philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 editorial 4 philippine journal of otolaryngology-head and neck surgery the journal impact factor is defined as “the average number of times (citable) articles from the journal published in the past two years have been cited in the jcr ( journal citation report) year.”1 an impact factor of 1.5 means that on average, articles published 1-2 years ago have been cited one and a half times in journals included in the web of science. the impact factor has been used, misused and abused to rank journals within a discipline (and by inference, rank authors who are published in these journals), to evaluate the scholarly worth of a journal (and by extension, the worth of articles published in it), to decide institutional journal subscriptions, and to guide authors in choosing where to aim to submit articles to. but as has been eloquently pointed out by amit joshi2 the impact factor of a journal is not the same as its impact, or the impact of individual journal articles: a high impact factor journal may have zero impact in a remote pacific island, just as a low impact (or no impact factor journal) may have very high impact in the country where it is read. more importantly, an article may achieve awesome impact, even if it is published in a low (or no) impact factor journal. “to achieve real impact, and not just impact factor,” the “manila declaration on the availability and use of health research information in and for lowand middle-income countries in the asia pacific region” was launched at the 2015 convention of the asia pacific association of medical journal editors (apame 2015) held in manila from 24 to 26 august 2015 in conjunction with the cohred global forum on research and innovation for health (forum 2015). it is concurrently published by journals linked to apame and listed in the index medicus of the south east asia region (imsear) and the western pacific region index medicus (wprim), and is published as a special announcement in this issue.3 it is also available online at http://www.wpro.who.int/entity/apame/publications/en/ at http://www.hifa2015.org/wp-content/uploads/manila_declaration_2015_final_august_242.pdf and at http://www.equator-network.org/2015/08/28/the-manila-declaration/ the apame 2015 convention in manila was a meaningful and a memorable experience for the 500 editors, reviewers, authors, researchers, clinicians, scientists, students, librarians and publishers who joined us from all over the philippines and around the world. our participation in the new leaders for health pre-forum at the philippine international convention center on correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 554 8467 telefax: (632) 524 4455 email: lapenajf@upm.edu.ph reprints will not be available from the author. the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr., ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines impact, not just impact factor: responding to the manila declaration on the availability and use of health research information philipp j otolaryngol head neck surg 2015; 30 (2): 4-5 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery 5 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 editorial august 22, our general assembly and joint meeting with the western pacific region index medicus and index medicus of the south east asia regions at the who western pacific region office on august 24, the conjoint sessions with the cohred global forum on research and innovation for health at the picc from august 24-27 (broadcast on cnn philippines), the apame 2015 convention at the sofitel philippine plaza hotel on august 25-26 (culminating in a hifa tweetchat), and 8th national medical writing workshop and 1st writeshop for young researchers at the sofitel philippine plaza hotel from august 27-28, comprised scientific sessions, workshops, discussions, special events and socials that were exemplary and inspiring. through the manila declaration launched at the apame 2015, we committed “ourselves and our journals to publishing innovative and solution-focused research in all healthcare and related fields … particularly health research applicable to lowand middleincome countries;” and committed “ourselves and our publishers to disseminating scientific, healthcare and medical knowledge fairly and impartially by developing and using … indices … databases … and open data systems.”3 thus the response of the philipp j otolaryngol head neck surg “to explore new paradigms, trends and innovations, especially with regard the social media… and “to consider the transition to a full open access model and adopting creative commons licenses.”4 with this issue, we begin that transition, by aligning our journal with the requirements for indexing in the directory of open access journals (doaj), “an online directory that indexes and provides access to high quality, open access, peer-reviewed journals.”5 an important part of this transition involves replacing the copyright transfer the philippine society of otolaryngology head and neck surgery requires of all authors published in our journal, with a creative commons attribution-noncommercial-noderivatives 4.0 international (cc bync-nd 4.0) or related license.6 we are also activating our facebook, twitter, and linkedin pages, and encourage published authors, reviewers, editors and readers to “like,” “tweet,” and comment on our published material and the discussions, blogs and microblogs that will arise from these. to this end, we will initiate the practice of posting “laymanized abstracts” of published scientific material on our social media sites, by requesting authors of articles accepted for publication to submit such abstracts. references 1. web of science, thompson reuters help page. journal citation reports: journal impact factor. [cited 12 november 2015] available at http://admin-apps.webofknowledge.com/jcr/help/h_ impfact.htm 2. joshi a. impact versus impact factor. lecture delivered at the asia pacific association of medical journal editors 2015 convention, 26 august 2015. [cited 12 november 2015] available at at https://mdpie.com/all-proceedings/500-apame-proceedings/apame-20150824-convention/ apame-2015-convention-session-e/2128-impact-vs-impact-factor-among-apame-journals 3. asia pacific association of medical journal editors. “manila declaration on the availability and use of health research information in and for lowand middle-income countries in the asia pacific region.” (special announcement) philipp j otolaryngol head neck surg. 2015 jul – dec; 30(2):6-7. also available at http://www.wpro.who.int/entity/apame/publications/en/ 4. lapeña jf. “advancing access to health information and publication: shifting paradigms, trends and innovations.” philipp j otolaryngol head neck surg. 2015 jan – jun; 30(1):4-5. 5. directory of open access journals. [cited 7 november 2015] available at https://doaj.org 6. creative commons attribution-noncommercial-noderivatives 4.0 international (cc by-nc-nd 4.0) license. [cited 7 november 2015] available at http://creativecommons.org/licenses/by-ncnd/4.0/ 7. heraclitus of ephesus. [cited 7 november 2015] available from http://www.optionality.net/ heraclitus/ meanwhile, we urgently need to improve our competencies in research, medical writing, and peer review – and this applies to young residents and senior consultants alike. while the quantity of manuscripts submitted to the journal has increased exponentially, the quality of these manuscripts leave much to be desired, as evinced by our tedious and thankless review and editing process. it is ironic that we are invited to speak on and conduct post-graduate courses and workshops in research, medical writing, peer review and editing by many other societies, colleges, academies, institutions, organizations and ministries around the country and abroad, but hardly within our very own philippine society of otolaryngology head and neck surgery. be that as it may, our fellows, diplomates and residents need regular medical writing and review workshops in order to improve the quality and impact of our journal articles, and consequently improve the impact of our journal. to this end, we all need to leave our comfort zones and welcome change. pace heraclitus, “no man steps in the same river twice, for it’s not the same river and he’s not the same man,” because “παντα ρει (panta rei)—all is change.”7 these transitions will not come easily, nor will they happen overnight. but they are imperative if we are to uphold our commitment “to achieve real impact, and not just impact factor, as we advance free and open access to health information and publication that improves global health-related quality of life.”3 philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 president’s page as we approach the last quarter of the year, it is time that fellows of the philippine society of otolaryngology-head and neck surgery (psohns) receive this report from the president and the board of trustees. following the successful staging of the midyear congress at edsa shangrila and distribution of the coffeetable book-another chronicle of our rich history-we also witnessed the launching of the advocacy campaign “change is in the air” led by philippine academy of rhinology (par) chair dr. tony chua with drs. mari enecilla and joel romuladez that even saw print in the newspapers. despite the challenges, the support we received from our pharmaceutical friends was tremendous and the avowed fund support for advocacy from the proceeds of that congress amounting to a little over p2 million will certainly go a long way for our future campaigns. our new home and headquarters at 27 manga road, quezon city was finally inaugurated last july 8. legal ownership with the title of the property under the name of psohns has been effected as has been approved by the general assembly with the funds related to our transfer and total expenses for minor renovation and transfer and other taxes amounting to an expenditure of almost p29 million. the tax-exempt certificate filed from our medical plaza ortigas business address will be transferred to quezon city with the application for a change in business address. there have already been activities, meetings and functions held at our new headquarters. as approved by the board, we have invited the philippine board of otolaryngology head and neck surgery (pbohns) to hold their meetings there and also hold office in one of the rooms. we expect full transfer by the time this tax-exempt certificate and occupancy permit have been obtained. the work on becoming a recognized specialty by the philippine medical association (pma) is still a work in progress but the task is in hand more than ever with about 5000 more votes during the last congress and hopefully the final turnover of these votes before the next pma convention in may 2017 will make the campaign a success. i urge all the fellows and chapters to continue to rally their colleagues and use the proxy forms available at the secretariat. we have written the pma to inform us of the number of votes still needed. it is on record that our society in fact submitted the most number of proxy votes for this campaign during the last pma convention. let us all work even harder to make this a reality by may 2017. the professional regulations commission (prc) and philippine regulatory board of medicine (prbom) required us last may to develop and submit an outcomes based education (obe) curriculum. we submitted the required curriculum to the prbom led by dr. miguel noche in cooperation and close collaboration with the pbohns led by dr. rodolfo nonato through the commendable hard work of drs. agnes t. remulla, elmo lago and ed alfanta as well as other committed fellows from the different subspecialties and institutions. welcome changes to the required list and number of procedures for resident trainees as a result of the formulation of this new curriculum were approved. our core values of professionalism, service with excellence, outstanding education and research, honor and integrity, nationalism and solidarity stood as pillars that guided the whole process of crafting this obe. it will now be incumbent upon the institutions to tweak their instructional designs and particular curricula to conform to or even surpass the common minimum standards. we will bring to the table this curriculum and standards when we talk with our association of south east asian nations (asean) counterparts in the move to asean harmonization and integration. the next midyear congress will be held in laoag city under the leadership of dr. jose orosa iii. the next annual congress will be jointly held with the 10th international symposium on recent advances in rhinosinusitis and nasal polyposis from november 29december 2, 2017 with par and dr. gil vicente as prime mover. the philippines will also host the 10th otorhinolaryngology international academic conference (orliac) on march 1-3, 2018 with myself as co-chair. the theme will be “east meets west: the future of orlhns” with prof. jan veldman and prof. lokman saim helping organize this with world renowned orl clinician-researchers willing to share their expertise on issues relevant to our country and the region. we hope this will inspire our young ent diplomates and fellows to embark on academic and innovative strategies in the interest of achieving better care in orlhns. the 60th annual congress at marriott grand ballroom from december 1-3, 2016 will culminate the celebration of our diamond jubilee year. the psohns will host the 6th pan asia academy of facial plastic and reconstructive surgery in this joint congress. we are excited at this year’s theme: restoring form and function and the record number of speakers for the congress with its interesting scientific and social programme will be astounding. as we close the year more projects are forthcoming such as the updated clinical practice guidelines (sleep surgery has been disseminated with otitis media and sinusitis to follow). on its 35th year, the philippine journal of otolaryngology head and neck surgery’s continued moves toward open access will make our research work more accessible and available to scientific circles worldwide. we have recognized the loyalty and service of our personnel mia, sharon, melissa and kiko by a windfall increase in salaries and benefits that have long been overdue. we are now in the process of digitizing our records along with other housekeeping functions that we have embarked on this year. we also foresee a constitutional amendment to accommodate an expanded membership programme to be attuned with the mandate and direction of the philippine medical association to be as inclusive as possible. the kind approval of the fellows in the general assembly meeting is prayed for considering the fact that our scientific calendar and a lot of psohns activities have been geared towards preparing the resident trainees, diplomates and non-diplomates and board eligibles to be dedicated fellows of psohns in the future, imbued with the core values we so cherish. see you all soon and mabuhay! charlotte martinez chiong, md, phd president philippine society of otolaryngology-head and neck surgery 2 philippine journal of otolaryngology-head and neck surgery a chronicle of change: the core values we cherish philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 7170 philippine journal of otolaryngology-head and neck surgery passages ruben g. henson jr., md (1935-2020) ruben d. henson iii, md most of his patients were the wives of military officers and personnel from clark air force base during the 70’s and 80’s. he also practiced in st. luke’s medical center, quezon city. passion for teaching also led him to be a professor of otolaryngology at the university of the east ramon magsaysay memorial medical hospital and angeles university foundation. i remember one of his students in uerm told me that his lectures also included life lessons, how to enjoy your practice and how to be a wellrounded doctor. he inspired a lot of students and residents who trained under him. growing up as the child of a doctor, my siblings and i were enthralled by his life as a medical man. he was well-respected in the community not just in medicine but also in government service. his passion to serve brought him into politics and he once served as a provincial board member of the province of pampanga during the cory aquino administration. he was also very active in the rotary club both locally and internationally. he was a people person and everyone knew him. he had that certain charisma that lights up the room. as a family, we were known to be a tennis team. everybody played including my mom and my brothers. he also enjoyed playing golf with my mom-and don’t even ask who was the better player! family dinner was usually spent in debates about medical and surgical cases with my mother as the referee. he really took care of his patients. he always reminded us to give the best service to our patients because they travelled from faraway places just to see you. he never gave up even on challenging cases. i was always in awe when i saw him do local anesthesia on patients undergoing tonsillectomy and caldwell luc procedures after my residency. he always advocated using local anesthesia on almost all his surgical procedures. seeing patients with him in the clinic has taught me a lot but it was also interesting and challenging because we sometimes debated on treatments in front of a patient. i enjoyed travelling with him during conferences and courses abroad. he liked to update himself by observing in fess, temporal bone and oculoplasty courses. these were our bonding moments as father and son and also with my brother raoul who is an ophthalmologistoculoplastic surgeon. one thing i miss most about him is when we used to do surgery together. when my brother and i encounter difficult or challenging cases he was always there to provide advice on how to go about it. i am indeed lucky to have a father with the same passion and vocation. i hope i can continue the legacy with my children. i hope my father remains to be an inspiration to his former students and residents. a true gentleman to his family, profession and the community he served. my father was a true blue “promdi” from angeles city, pampanga. a son of a humble businessman who grew up with 3 siblings. a happy-go-lucky teenager who sometimes got into trouble with the usual traps of growing up and never really cared about his future. with the carefree attitude growing up, he was given an ultimatum by my grandfather. “son, if you won’t study and don’t get serious with your life, you will be a bum or a beggar on the street.” having an epiphany, he started getting inspiration from an uncle who was an eent doctor -observing in his clinic during summer and that started the fire that built his career of becoming a doctor. he graduated from the university of santo tomas faculty of medicine in manila in 1959 then flew to the united states and had seven years of specialization -first at the elmhurst hospital, new york city where he became chief resident in otolaryngology. not content with his training in ent he decided to take a second specialty in ophthalmology, with a three-year residency in toronto east general hospital in canada. he could have stayed in north america to practice but opted to return to his hometown and serve his fellow kapampangans, establishing clinica henson eye, ear, nose and throat center in angeles city. he always liked to tell stories about his residency training days in the us. they did a lot of stapedectomy cases during those times and after every procedure the surgeon whispered in the ear of the patient and asked, “who is the president of the united states” and the patient should answer “john f. kennedy.” a memorable situation was while he was doing a tonsillectomy, the nurse said out loud that jfk had been just been assassinated. the most memorable memento he brought home after his training was a zeiss operating microscope. his mentors told him he should buy one and bring it home to better diagnose and manage ent cases especially otologic procedures. they said it was a good investment since his children could also use it in their future practice. i’m happy and proud to say that we still use this microscope in our clinic opd in angeles city. his thirst for learning and improving his craft continued as he grew his practice. he did further training in facial plastic and cosmetic surgery in the 70’s at the university of california at davies sacramento usa and shirakabe clinic osaka, japan with the guidance of his mentor dr. jose mathay. he eventually set up a cosmetic surgery clinic along roxas blvd in the 80’s and was one of the founding members of the philippine society for cosmetic surgery. his core competence was rhinoplasty using silicone implant during those days. my mom, a fine arts graduate and portrait artist, helped in carving and designing the silicone implants. i must say that they were a perfect combination. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 8382 philippine journal of otolaryngology-head and neck surgery passages edilberto m. jose, md (1946 2019) otorhinolaryngologist, head & neck surgeon, mentor, friend ruzanne magiba-caro, md dr. ed jose is (and will always be) my best friend --my mentor, guidance counselor and the “kuya” that i never had. i would like to share with you his two constant reminders to me which will make us know, understand and appreciate him more. very few people can handle power. he was a prime example of “not seeking any position but rather the position seeking him.” he was chairman of the department of otorhinolaryngology, university of the philippines – philippine general hospital (uppgh) and at the same time president of the philippine society of otorhinolaryngologyhead and neck surgery. he also became chairman of the philippine board of otorhinolaryngology-head and neck surgery. at one point, he was also assistant director for health operations of up-pgh. committed to his positions, dr. jose remained humble and unassuming. he may appear “suplado” but he was always willing to help in whatever way possible. he was quite flexible believing that “rules can be bent” if it was the right thing to do at the time. one of his favorite songs was “both sides now” and indeed, he was always fair when very important decisions were made. simplify…simplify…simplify… this explains why his dedication was unwavering. dr. ed focused on three important aspects of his life: family, clinical practice and orl training. married to a pathologist (dr. rebecca tongco-jose) who passed away three years ago, his primary concern up to the end were his sons noel and ian. his world revolved around his family. the university of the philippines (up) was his way of life where he obtained his secondary, college and medical education. he took his residency at up-pgh and served as chief resident on his senior year. upon his return from fellowship in head and neck surgery at the royal nose, throat and ear hospital in england, he started teaching and training residents at up-pgh … and never stopped even after retirement. fortunately for all the residents and even young consultants in up-pgh, his clinic was just across taft avenue — so he was forever on call especially during difficult and complicated surgeries. papa ed’s presence in the or was a “confidence booster” for all of us. a true head and neck surgeon who did sharp dissection with bravado, the “thyroid and parotid expert,” the “surgeon’s surgeon” — daddy joe was very decisive and pragmatic in the management of cases. he had numerous patients and surgeries, always ready with an alternate case, and was also known as the “extension king” of up-pgh. he was a silent worker but a very witty colleague. he was abreast of all the developments in the field of orl. in fact, it was during his term as pso-hns president that the first pso-hns clinical practice guidelines were developed and disseminated. proof of his dedication to orl training was his serving as director of the pbo-hns until his demise. he made it a point to attend all the meetings, workshops, accreditation visits and other related activities (actually missing out on some social obligations). he was also on call when other directors were not available. dr. jose was very religious, a practicing roman catholic and a devotee of our lady of manaoag. he never failed to pray before seeing a patient and commencing surgery. he may seem grumpy but having known him for 35 years, he can be very playful with a very good sense of humor. recognized as the fpj of orl, he would occasionally boast of his female admirers. he declared to our family that our grandson was his “adopted apo” and he had a “pasalubong only for teo” every time he went on an accreditation visit. he was a voracious reader and a lover of history. dr. ed jose was a simple man. his only luxury was collecting cars and watches. the last time i saw dj (that is how our family calls him) prior to his hospitalization was significant because my mentor came to my clinic in quezon city to consult me regarding his ear problem. true to form, i ended up consulting him for my nasal complaint. it will not only be i who will miss dr. ed jose and his signature laughter…the entire orl community will miss their papa ed/daddy joe. he will forever remain as an inspiration and role model for any otorhinolaryngologist head and neck surgeon. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery president’s page research is the tool that unravels what people have seen and ponder on ideas which nobody else has thought. as neil armstrong stated, research is creating new knowledge. this percipience ignites development of every individual. for this reason, the philippine society of otolaryngology head and neck surgery (pso-hns) is committed to its objective of contributing insights and skills in the diagnosis and treatment of ent-head and neck ailments. fellows research grants are available to augment the expenses incurred during the process. the various research contests hosted by the society through the commendable efforts and passion of our vice-president and concurrent scientific chair dr. erasmo gonzalo d. v. llanes will continue to be the source of academic writings for the internationally recognized philippine journal of otolaryngology head and neck surgery (pjohns). our society recognizes the wisdom and leadership of the pjohns editor-in-chief dr. jose florencio f. lapeña, jr. in maintaining the international stature of our publication. however, the task should be a collaborative effort of everyone and not limited to our training institutions. we should be one in research as one pso-hns! mabuhay ang pjohns! danilo a. poblete, md, fpsohns president philippine society of otolaryngology-head and neck surgery one in research as one pso-hns philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2020; 35 (1): 33-35 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to measure the nasal mucociliary clearance (nmc) time among adults residing in two philippine communities with different air quality indices using the saccharin and methylene blue test. methods: design: cross-sectional study setting: diliman, quezon city and puerto princesa, palawan participantss: fifty (50) participants, 25 residing in an urban city with fair air quality index and 25 residing in a rural province with good air quality index. results: the mean nmc time of the urban group was 22.15±12.68 mins and was significantly longer than the nmc time of the rural group which was 5.29±2.87mins; t(48) = 6.643, p<0.0001). conclusion: increased air pollution may be associated with significant prolongation of nasal mucociliary clearance time among urban residents with fair quality air index compared to rural residents with good quality air index. keywords: nasal mucociliary clearance, naso mucociliary clearance time, air pollution, air quality index, saccharin test, methylene blue our world is undergoing a continuous wave of urban growth. as more people populate the cities and generate air pollution, its impact on the human respiratory system becomes a primary concern. the nose and sinuses protect the body against air pollution through the nasal mucociliary clearance (nmc), the process by which the ciliated nasal respiratory mucosa moves mucus, along with trapped particles or pathogens, from the nose to the pharynx where it is either swallowed or coughed.1 any disruption of this dynamic process increases the risk of sinonasal and airway infection or dysfunction.2 chronic rhinosinusitis can lead to destruction of large tracts of nasal cilia, prolonging the nmc time.3 could chronic exposure to air pollution have a similar effect? air pollution and nasal mucociliary clearance time among urban and rural residents in two philippine communities soraya n. joson, md joman q. laxamana, md department of otorhinolaryngology head and neck surgery east avenue medical center, philippines correspondence: dr. joman q. laxamana department of otorhinolaryngology – head & neck surgery 6th floor, east avenue medical center, east ave. diliman, quezon city 1100 philippines phone: (632) 8928 0611 local 324 fax: (632) 3435 6988 email: jqlaxamana@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine academy of rhinology antonio l. roxas international research contest, december 1, 2017. manila hotel, one rizal park, manila. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery original articles with the thought that measuring the nmc time among urban and rural dwellers can provide insight on the relationship between air pollution levels and nasal dysfunction, this study sought to measure the nasal mucociliary clearance time among adults residing in two philippine communities with different air quality indices using the saccharin and methylene blue test. methods with institutional ethics review board approval, this cross-sectional study was conducted in two settings. a residential area around a tertiary government hospital in diliman, quezon city with a population density of 17,759 residents/square km2 and a fair air quality index (aqi), was selected as the urban sampling location. a residential area around a primary health center in puerto princesa, palawan with a population density of only 58 residents/square km2 and a good aqi, was selected as the rural sampling location. a single investigator performed random consecutive sampling of 50 adult filipino resident volunteers, 25 from the urban site and 25 from the rural site. the participants did not belong to any single particular ethnic or tribal group. previous and active smokers, asthmatics, those with a history of upper respiratory and sino-nasal disease within one month, and those with hypertension, diabetes and previous sinonasal surgeries were excluded from the study. informed consent was obtained from all participants. all data was treated with strict confidentiality, deidentified and coded in compliance with the data privacy act. in each location, testing took place in the afternoons under similar ambient temperatures and sunny weather conditions (humidity was not measured). each participant was seated in a well ventilated, nonairconditioned room. a solution of 10ml methylene blue and 1gm saccharine was pre-prepared for all participants. a single investigator who was also a trained otorhinolaryngologist performed all procedures to decrease bias and increase reproducibility. for each participant, the investigator performed right anterior rhinoscopy using a headlight and a nasal speculum. an assistant placed one drop (0.05ml) of the solution on a commercially available metal ear loop and the investigator applied it on the medial surface of the inferior turbinate, 1cm posterior from its anterior tip. no other substance such as saline sprays, topical anesthesia or decongestant was used and the procedure was only performed once per participant. the participants were instructed to swallow every 30 seconds and were prohibited from sniffing, sneezing, coughing, eating and drinking. the participants were instructed to immediately report the moment they perceived a sweet taste. the investigator then recorded the time elapsed from placement of the saccharin/methylene blue solution to the reported perception of sweet taste as the nmc time. the reported perception was subsequently confirmed by noting the presence of methylene blue streaks on the posterior pharyngeal wall. results after exclusions, a total of 50 participants successfully completed the tests and were included in data analysis; 25 each in the urban and rural groups. nine (9) males and 16 females aged 24-45 years old (mean of 26.28 years) comprised the urban group while 15 males and 10 females aged 21-35 years old (mean of 30.96 years) comprised the rural group. chi-square test showed no significant difference between the two groups in terms of sex distribution ( χ2(1) = 2.885, p = 0.089 ). similarly, unpaired t-test showed no significant difference between the two groups in terms of mean age ( t(48) = 2.42, p = 0.575 ), with both mean ages within the young adult range. all participants were able to comply with test instructions and were confirmed to have the dye visible in their posterior pharyngeal wall following the reported perception of sweet taste. the nmc times ranged from 7 to 47mins (mean of 22.56 ± 12.68 mins) among urban participants and from 1.27 to 15mins (mean of 5.29 ± 2.87 mins) among rural participants. using unpaired t-tests, the mean nmc time of the urban group was significantly longer than the rural group ( t(48) = 6.643, p < 0.0001 ). all data was analyzed using ibm spss statistics version 25 (ibm company, armonk, ny, usa). discussion our study showed a significant prolongation of nmc time among residents of a moderately polluted urban city as opposed to those living in an unpolluted rural area in the philippines. a similar local study by ramos et al.4 in 1999 showed that urban metro manila residents have significantly longer mucus transport time (10-15mins) than rural camarines norte residents (5-10mins), but air quality data was not measured. several studies have shown that the normal adult nmc time is 5-14 minutes.5,6 in adults with allergic rhinitis and asthma, the nmc time is usually within 18 to 30 minutes while in those with chronic rhinosinusitis, it may be delayed by more than an hour.7 by this definition, several participants from the urban group had pathologically prolonged nmc times and further investigation on their nasal epithelial morphology would be noteworthy (chronic rhinosinusitis was not an exclusion criterion, and other exclusion criteria were based on history alone). despite common knowledge of the negative health effects of air pollution, there is little evidence that urban levels of pollution can damage nasal ciliated epithelial cells in humans. to our knowledge, philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery original articles there are only a few studies on the effect of some components of outdoor air pollution. one such study showed that cigarette smokers had a significantly prolonged nmc time than lifelong non-smokers.8 cigarette smoke exposure was also correlated with significantly slower ciliary beat frequency.9 outdoor pollutants such as sulfur dioxide, nitrogen dioxide and ozone could cause ciliary stasis and ciliated cell damage but only in high concentrations not seen in urban air pollution.10 only studies in lambs and rats demonstrate mucosal hypersecretion and ultrastructural ciliary damage after exposure to urban levels of air pollution.11,12 unfortunately, we found no similar morphologic studies performed on humans. although its impact on nmc is poorly understood, air pollution is known to significantly increase the risk of lung cancer13 and many countries have implemented air quality control laws. in the philippines, republic act 8749 or the philippine clean air act of 1999 mandated the establishment of continuous air quality monitoring systems, standardization of an air quality index (aqi) and creation of associated health guidelines.14 our study utilized real-time pollution data and aqi standards from the government website (air.emb.gov.ph). (table 1) the saccharin test is the simplest and most inexpensive technique that can be performed in numerous subjects to measure nmc time.15 to increase the accuracy of results, we added methylene blue to the saccharine solution as an objective confirmatory test of mucus passage references 1. delong pa, kotloff rm. an overview of pulmonary host defense. semin roentgenol. 2000;35(2):118–23. doi: 10.1053/ro.2000.6150. pubmed pmid: 10812649. 2. yasar m, sutbeyaz my, sakat ms, kilic k. evaluation of the effects on nasal mucociliary clearance of various nasal solutions applied topically in patients with sinusitis. med-science. 2018;7(1):1-4. doi:10.5455/medscience.2017.06.8655. 3. ramos rp, lagman vc , campomanes, bs. a comparison of the mucus transport time between filipinos living in urban and rural areas. philipp j otolaryngol head neck surg. 1999 julsept;14(3):2-6. 4. birdi sm, singh s, singh a. mucociliary clearance in chronic sinusitis. indian j otolaryngol head neck surg. 1998 jan; 50(1):15-9. doi: 10.1007/bf02996761. pubmed pmid: 23119370; pubmed central pmcid: pmc3451257. 5. karja j, nuutinen j, karjalainen p. radioisotopic method for measurement of nasal mucociliary activity. arch  otolaryngol head neck  surg. 1982 jan;108(2):99–101. doi: 10.1001/ archotol.1982.00790500035008. pubmed pmid: 6460494. 6. pandya vk, tiwari rs. nasal mucociliary clearance in health and disease. indian j otolaryngol head neck surg. 2006 oct 1;58(4):332-4. doi: 10.1007/bf03049581. pubmed pmid: 23120337; pubmed central pmcid: pmc3450371. 7. stanley p, wilson r, greenstone m, mackay i, cole p. abnormal nasal mucociliary clearance in patients with rhinitis and its relationship to concomitant chest disease. brit j dis  chest. 1985;79:77–82. doi: 10.1016/0007-0971(85)90010-5. pubmed pmid: 3986114. 8. stanley pj, wilson r, greenstone ma, macwilliam l, cole pj. effect of cigarette smoking on nasal mucociliary clearance and ciliary beat frequency. thorax. 1986 jul 1;41(7):519-23. doi: 10.1136/ thx.41.7.519. pubmed pmid: 3787531; pubmed central pmcid: pmc460384. 9. agius am, smallman la, pahor al. age, smoking and nasal ciliary beat frequency. clin otolaryngol allied sci. 1998 jun;23(3):227-30. doi: 10.1046/j.1365-2273.1998.00141.x. pubmed pmid: 9669071. 10. pedersen m. ciliary activity and pollution. lung. 1990 dec 1;168(1):368-76. doi: 10.1007/ bf02718154. pubmed pmid: 2117139. 11. gulisano m, marceddu s, barbaro a, pacini a, buiatti e, martini a, pacini p. damage to the nasopharyngeal mucosa induced by current levels of urban air pollution: a field study in lambs. eur respir j. 1997 mar 1;10(3):567-72. pubmed pmid: 9072986. 12. saldiva ph, king m, delmonte vl, macchione m, parada ma, daliberto ml, sakae rs, criado pm, parada pl, zin wa, böhm gm. respiratory alterations due to urban air pollution: an experimental study in rats. environ research. 1992 feb 1;57(1):19-33. doi: 10.1016/s0013-9351(05)80016-7. pubmed pmid: 1371246. 13. chen g, wan x, yang g, zou x. traffic‐related air pollution and lung cancer: a meta‐analysis. thorac cancer. 2015 may;6(3):307-18. doi: 10.1111/1759-7714.12185. pubmed pmid: 26273377. pubmed central pmcid: pmc4448375. 14. republic of the philippines, department of environment and natural resources, environmental management bureau [internet]. national air quality status report. [cited 2017 october 2] available from: https://emb.gov.ph/wp-content/uploads/2018/08/national-air-quality-statusreport-2008-2015.pdf 15. stanley p, macwilliam l, greenstone m, mackay i, cole p. efficacy of a saccharin test for screening to detect abnormal mucociliary clearance. brit j dis chest . 1984 jan 1;78:62-5. pubmed pmid: 6691910. 16. griffa a, berrone m, boffano p, viterbo s, berrone s. mucociliary function during maxillary sinus floor elevation. j. craniofac. surg. 2010 sep 1;21(5):1500-2. doi: 10.1097/scs.0b013e3181ef2be9. pubmed pmid: 20818241. 17. keller c, brimacombe j. bronchial mucus transport velocity in paralyzed anesthetized patients: a comparison of the laryngeal mask airway and cuffed tracheal tube. anesth analg. 1998 jun 1;86(6):1280-2. doi: 10.1097/00000539-199806000-00028. pubmed pmid: 9620520. to the pharynx. methylene blue has been safely used in the monitoring of mucus flow inside the maxillary sinus16 and bronchi.17 to the best of our knowledge, this is the first study to use combined saccharin and methylene blue in evaluating nmc time. further research may confirm our experience with this combination. in conclusion, our study suggests that among urban residents with fair quality air index compared to rural residents with good quality air index, air pollution may be associated with nasal mucociliary disruption. however, its pathophysiologic mechanisms need more investigation. in future studies, measurement of nmc time along with ciliary beat frequency, documentation of cellular damage and monitoring of long term disease outcomes could shed more light on the definite impact of air pollution on the nasal mucociliary function. table 1. air quality index breakpoints as mandated by philippine republic act 8749 tsp pm10 so2 o3 co no2 μg/nm3, 24-hr μg/nm3, 24-hr ppm, 24-hr ppm, 8-hr ppm, 1-hr ppm, 8-hr ppm, 1-hr 0–80 0–54 0.00 0.34 0.000 0.064 0.0 4.4 b 81 – 230 55 – 154 0.035 0.144 0.065 0.084 4.5 9.4 b 231 – 349 155 – 254 0.145 0.224 0.085 0.104 0.125 0.164 9.5 12.4 b 350 599 255 354 0.225 0.304 0.105 0.124 0.165 0.204 12.5 15.4 b 600 899 355 424 0.305 0.604 0.125 0.374 0.205 0.404 15.5 30.4 0.65 1.24 900 and greater 425 504 0.605 0.804 a 0.405 0.504 30.5 40.4 1.25 1.64 pollutant unit, averaging time very unhealthy acutely unhealthy emergency good fair unhealthy for sensitive group tsp = total suspended particulates, pm10 = particulate matter 10 micrometers or less in diameter, so2 = sulfur dioxide, o3 = ozone, co = carbon monoxide, no2 = nitrogen dioxide a = when 8-hour o3 concentrations exceed 0.374 ppm, aqi values of 301 or higher must be calculated with 1-hour o3 concentrations. b = no2 has no 1-hour term philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 31 abstract objective: crooked nose deformity is a commonly seen reason for septorhinoplasty in the otolaryngology clinic. the purpose of this study is to initially determine the different etiologies of patients with crooked nose deformities who underwent septorhinoplasty, and to describe the different types of crooked nose by their level of deviation and surgical management in our institution. methods: design: case series setting: tertiary public university hospital participants: a chart review of all patients with a crooked nose deformity who were admitted at the otorhinolaryngology ward of the national university hospital and underwent septorhinoplasty from january 2012 to january 2015 was conducted, and data consisting of age, sex, etiology of crooked nose deformity, level of deviation, cartilage source, and surgical intervention were obtained and analyzed. results: a total of 21 patients underwent septorhinoplasty for crooked nose deformity in the study period. the most common etiology for crooked nose was physical violence (13/21 or 62%), followed by sports injury (4/21 or 19%), vehicular accidents (2/21 or 9%), and accidental fall (1/21 or 5%). there were more upper and middle third deviations than lower third deviations. sixteen out of 21 patients (76%) underwent open rhinoplasty, while the rest underwent an endonasal approach. twelve (57%) underwent intervention on the nasal fracture after at least a year (old or neglected fracture) as compared to the 9 (43%) who had immediate intervention after less than two weeks. thirteen used septal cartilage, while 4 used conchal cartilage, and 1 used tragal cartilage. the most common grafts used were spreader and camouflage, followed closely by dorsal onlay, and columellar strut grafts. conclusions: the majority of crooked nose deformities that were subjected to septorhinoplasty in our department were secondary to old nasal bone fractures caused by physical violence. upper and middle third level deviations were more common, and most underwent open rhinoplasty with autologous cartilage grafts. future studies may increase our understanding of, and improve our techniques in septorhinoplasty for crooked nose deformities in filipino noses in particular, and asian noses in general. keywords: rhinoplasty, deviated nose, crooked nose, septorhinoplasty, nasal trauma crooked nose deformity, also known as deviated nose, twisted nose, asymmetric nose, and scoliotic nose1 is a common reason for otorhinolaryngology clinic consult and emergency room referral, with patients usually complaining of nasal stuffiness, nasal obstruction, or an obvious aesthetic deformity, such as a depressed nasal dorsal profile.2 often managed with septorhinoplasty, the etiologic causes of crooked nose are varied, ranging from congenital causes to post-operative complications. these have also changed over the years: infectious and toxic causes have become less frequent, while trauma and primary or secondary reduction an initial survey of septorhinoplasty in crooked nose deformities cesar v. villafuerte jr., md, mha1,2 alexander edward s. dy, md2 josé florencio f. lapeña jr., ma, md1,2 1department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila 2department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: dr. cesar v. villafuerte jr. department of otorhinolaryngology philippine general hospital ward 10 university of the philippines manila taft avenue, ermita, manila 1000 philippines telephone: (632) 554 8467; (632) 554 8400 local 2152 email address: cvillafuertemd@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2016; 31 (1): 31-34 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 32 philippine journal of otolaryngology-head and neck surgery original articles rhinoplasties now represent the main causes of these deformities.3 an extensive literature search of herdin neon, medline, and google scholar using the terms “crooked nose,” “nasal bone fracture,” “septorhinoplasty” yielded no prior local study on the prevalence of the various etiologies and profiles of crooked nose deformity patients undergoing septorhinoplasty. this lack of information hinders us from proposing guidelines to prevent this condition. thus, this study aims to initially describe the different etiologies of crooked nose, the different types of crooked nose by their level of deviation, and the different management techniques used on crooked nose deformities among patients undergoing septorhinoplasty in a tertiary public university hospital in the philippines. methods with institutional review board approval, records of all patients who were admitted to the public (charity) ward of the otorhinolaryngology department of the philippine general hospital and who had undergone any intervention for crooked nose deformity from january 2012 to january 2015 were retrieved and considered for inclusion in the series. patients who underwent septorhinoplasty were included, while those with nasal bone fractures who underwent closed reduction under local anesthesia at the emergency room and outpatient department were excluded. patients who refused any surgical intervention for the deformity were likewise excluded. age, sex, etiology of crooked nose deformity, level of deviation, cartilage source, type of surgical intervention, and onset of deformity (acute versus chronic) were recorded. the level of deviation was divided into: upper third, defined as involvement of the nasal bone and the nasal process of the upper maxillary bone; middle third, defined as involvement of the cartilaginous septum and upper lateral cartilages; and lower third, defined as involvement of the caudal septum and lower lateral cartilages.4 deformities were classified as acute if they were incurred 2 weeks or less before the contemplated intervention, and chronic if they were incurred more than 2 weeks before the contemplated intervention. data were tabulated using microsoft excel version version 16 (microsoft corporation, redmond, wa, usa) and examined for potential trends. strict confidentiality was observed, with all data encoded into electronic abstraction sheets. one sheet (the correlation tool) contained the patient name, medical record number, and patient study number. the patient study numbers were used in all subsequent data tables. the protocol was reviewed and approved by the institutional ethics review board <upmreb 2014-442-01> results a total of 21 patients who underwent septorhinoplasty for crooked nose deformity were included in the study. seventeen (81%) were male and 4 (19%) were female. ages ranged from 13 to 48 years, with the mean age being 26 years. nasal trauma was found to be the most common cause of crooked nose deformity in the population (20 out of 21 or 95%). nasal trauma occurred as a result of physical violence (13 cases), sports injuries (4 cases), vehicular accidents (2 cases), and accidental fall (1 case). among the cases associated with physical violence, 1 patient presented with both a cleft lip-nose deformity and a nasal bone fracture. one other patient was admitted for revision septorhinoplasty due to a crooked nose deformity from a previous rhinoplasty. classifying deformities according to level of deviation yielded 10 cases (48%) of upper-third deviations, 8 cases (38%) of middle-third deviations, 1 case (5%) of combined upperand middle-third deviation, and 2 cases (10%) of combined middleand lower-third deviations. none of the cases exclusively involved the lower-third level. eight of the cases (38%) were acute injuries, while 13 (62%) were chronic. of the latter, 1 had persistence of the deformity despite initial surgery. all patients underwent surgery. open rhinoplasty was the more common approach (16 cases or 75%), and this was used in all patients who required autologous cartilage grafting (for spreader grafts, camouflage or augmentation). only 5 of the surgeries (24%) employed an endonasal approach. all patients with upper-third deviations underwent lateral and medial osteotomies. none of the cases required intermediate osteotomy. all lateral osteotomies were done with infractures of the nasal bones. among the 16 patients who underwent open rhinoplasty, 10 (63%) utilized autologous cartilage grafts. of these, 3 had pure camouflage grafts, 2 had combined spreader and columellar strut grafts, 2 had combined spreader and dorsal onlay grafts, 1 had combined spreader and camouflage grafts, 1 had combined camouflage and dorsal onlay grafts, and 1 had combined spreader, camouflage and alar batten grafts. six patients did not have any cartilage grafts. the sources of cartilage grafts were as follows: septal cartilage (5 cases or 50%), conchal cartilage (3 cases or 30%), tragal cartilage (1 case or 10%), and combined septal and conchal cartilages (1 case or 10%). the results are summarized in table 1. discussion the crooked nose is both a cosmetic and a functional problem, usually affecting nasal breathing. in fact, a twisted nose frequently results in a compromised airway.5 in our patients, 15 (71%) underwent septoplasty, which was done to correct the deviated septum and improve nasal airway. all patients underwent rhinoplasty, as studies show that those who undergo only closed reduction are usually not content. also, the deviation is usually inadequately reduced, warranting another surgery.6 a majority of our patients with crooked nose deformity were males with a mean age of 26 years. this may be related to the finding that the most common etiology of this deformity was trauma, most frequently due to physical violence, followed by sports related injuries, both of which more commonly involve males.7 these data are consistent with results of previous demographic and epidemiologic studies on the asian nose.6 one of the patients had acquired the deformity from a previous rhinoplasty. removal of the dorsal nasal hump with a deviated septum philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 33 or a contraction from healing is the usual cause of deformity in postrhinoplasty patients8 and may also have been true in this patient. about half of the patients had upper third deformities, involving the paired nasal bones. all of them underwent open reduction with in-fracture osteotomies of the nasal bones on lateral osteotomy, and septoplasty. external nasal trauma causes damage to both septal cartilage and nasal bone that cannot be adequately restored by closed reduction.9 in these patients, medial and lateral osteotomies would have allowed correction of the nasal bone defects, and septoplasty could have corrected any nasal septum deflections. two of the 10 patients needed spreader grafts. spreader grafts both straighten the septal dorsum, and increase the angle at the middle vault to improve the airway.5 another 2 of the 10 patients were given camouflage grafts. this type of graft creates the illusion of a midline position or straight configuration by filling in depressions with thin cartilage.10 eight patients (38%) had middle third deformities. all of them underwent septoplasty as fractures at this level usually affect the cartilaginous septum. spreader grafts were utilized in 3 of the 8 patients. one had an additional dorsal onlay graft and another had a columellar table 1. summary of results age sex etiology level of deviation time approach grafts source of cartilage graft 36 48 19 26 13 21 45 24 27 20 20 20 19 18 37 33 24 22 36 28 17 f f m m m f m m m m m m m m f m m m m m m vehicular accident revision physical violence accidental fall sports injury vehicular accident sports injury physical violence physical violence sports injury physical violence physical violence sports injury physical violence physical violence physical violence physical violence physical violence physical violence physical violence physical violence middle middle and lower upper and middle upper middle upper upper middle middle upper upper middle upper upper lower and middle middle middle upper upper upper middle chronic chronic chronic acute chronic acute chronic chronic chronic chronic acute acute chronic acute chronic acute acute chronic chronic chronic acute open open open endonasal open endonasal open open open open endonasal endonasal open open open open endonasal open open open open spreader, camouflage none spreader, alar batten, camouflage none none none camouflage camouflage none none none none camouflage, dorsal onlay columellar strut, spreader camouflage spreader, dorsal onlay none none spreader, dorsal onlay none columellar strut, spreader septal not applicable septal not applicable not applicable not applicable conchal conchal not applicable not applicable not applicable not applicable septal septal and conchal tragal septal not applicable not applicable conchal not applicable septal strut graft. dorsal onlay grafts were used to establish nasal contour while columellar strut grafts were used to establish tip support. a few patients had nasal deformity involving more than one level. a patient who had an existing cleft lip-nose deformity had a nasal bone fracture, with the crooked nose deformity involving both upper and middle third deviations. he underwent a combined cleft rhinoplasty and septorhinoplasty using spreader grafts, alar batten grafts, and camouflage grafts. alar batten grafts add support to a weakened or pinched nasal valve. together with the spreader graft, the camouflage graft, and the alar batten graft, the tip plasty done corrected the collapsed nostril and nasal ala present in the cleft lip-nose deformity.7 two patients had both a lower third level deviation and a middle level deviation. this includes the patient whose deformity was from a previous rhinoplasty. no patient had an isolated lower level deviation probably because this level is mostly occupied by cartilage that is more resilient to damage or injury. both patients underwent open rhinoplasty, which offers the advantage of better field exposure, and better anatomical detail. however, not all combined level deviations warrant exposure. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 34 philippine journal of otolaryngology-head and neck surgery original articles four of our patients who desired augmentation of the dorsum were given an onlay septal cartilage graft. the filipino nose (like other southeast asian noses) is characterized by a depressed nasal dorsum, and augmentation rhinoplasty is needed for patients who desire a higher nasal dorsum. although the debate about open rhinoplasty versus endonasal rhinoplasty is still present, the rhinoplasty surgeon must be adept in both approaches.11 however, proficiency at open rhinoplasty is a prerequisite to performing endonasal rhinoplasty, and the latter requires a steeper learning curve. being in a teaching hospital, the majority of our cases employed an open rhinoplasty approach. only those with pure upper third bony deviations underwent endonasal septorhinoplasty. for lower third deformities, open rhinoplasty would be preferable for adequate surgical exposure, but an endonasal approach could also be performed. the advantages of utilizing an open approach are the ease of diagnosing structural problems by direct visualization, and simpler technique. it is thought to result in a more predictable outcome resulting from the surgeon’s ability to directly and systematically address each part of the nasal framework. the drawbacks include added length of procedure, nasal scars, prolonged edema, and need for more structural grafts as opening the nose results in loss of some support. a closed rhinoplasty allows more expeditious postoperative recovery and, if properly executed, produces the desired results. twelve (57%) patients underwent a form of intervention for their nasal fractures after at least a year, while 9 (43%) had intervention done in less than two weeks. thus, a majority of the cases in our population were classified as old or neglected nasal bone fractures. these deformities are harder to correct since malunion has already happened. most cases of neglected fractures are due to economic problems where the family had to prioritize more urgent needs. we utilized septal, conchal and tragal cartilages as graft donor sites in our series. septal grafts were used for spreader and columellar struts as well as dorsal onlay grafts. conchal cartilage was used for camouflage and dorsal augmentation grafts, although a double layer conchal cartilage graft can also be used as a columellar strut.12 where smaller cartilage grafts were needed (such as for camouflage), we utilized tragal cartilage which is ideal if no longer than 20mm is required.13 in our initial series, the majority of patients who underwent septorhinoplasty for deformity had crooked noses secondary to old nasal bone fractures, and the open rhinoplasty approach was used more often. patients were managed based on the level of deformity (upper, middle or lower third or mixed) with most undergoing septorhinoplasty, septoplasty, contour and/or camouflage grafting. all grafts used were autologous (septum, conchal or tragal cartilage) and were used as different types of grafts (spreader, alar batten, dorsal onlay and others); no silicone or eptfe implants were used in any of the cases. we did not have any postoperative problems with the cartilage grafts, as we did not use rib cartilage in any of our cases. rib cartilage grafts have been reported to have warping as a major complication.1 a major limitation in this initial survey was inadequate documentation and follow-up, to substantiate and compare our interventions and outcomes. this series has other limitations. first, we only described patients with crooked nose deformities who underwent septorhinoplasty, and not all patients with crooked nose deformity. this sampling bias prevents us from applying our findings to crooked nose deformities in general. second, we described levels of deformity and corresponding management, but not the reasons for choosing these approaches, nor the outcomes of these types of management. for instance, it would have been helpful to evaluate the post-operative effects of osteotomy and septoplasty on nasal bone defects and septal deflections; spreader graft effects on nasal airway; camouflage graft effects on aesthetics; dorsal onlay and columellar strut grafts on nasal contour and tip support; and alar batten grafts on the nasal valve instead of merely enumerating these interventions per level of deformity. in our lateral osteotomies we followed the high-low-high lateral osteotomy method starting at the upper part of the inferior turbinate attachment.1 this was to avoid in-fracture movement of the inferior turbinate which could contribute to post-operative nasal obstruction. moreover, a comparison of open and closed rhinoplasty outcomes for similar deformity levels or of similar procedures among fresh and neglected fractures would be helpful, and future studies should consider these. our documentation of pre-operative symptoms and deformities and post-operative outcomes should be improved in order to facilitate such studies, but we have yet to find a solution to poor follow-up by patients who are presumably happy with their outcomes, or who simply cannot afford repeated and prolonged consultations. finally, we were not able to show before and after pictures, due to lack of consent to publish photographs in full. future studies addressing these limitations may increase our understanding of, and improve our techniques in septorhinoplasty for crooked nose deformities in filipino noses in particular, and asian noses in general. references 1. jang yj. practical septorhinoplasty – an asian perspective. 1st ed, seoul: koon ja publishing inc; 2007; p210. 2. boccieri a. the crooked nose. acta otorhinolaryngol ital. 2013 jun; 33(3):163-168. 3. durbec m, disant f. saddle nose: classification and therapeutic management. eur ann otorhinolaryngol head neck dis. 2014 apr; 131(2): 99—106. 4. hussein wka. crooked nose: an update of management strategies. ejentas. 2015 mar;16(1):1-7. 5. hoffman, j. management of the twisted nose. oper tech otolaryngol head neck surg, 1999 sept; 10(3):232-237. 6. lee dh, jang yj. pediatric nasal bone fractures: does delayed treatment really lead to adverse outcomes? int j pediatr otorhinolaryngol. 2013 jan; 77(5): 726–731. 7. liu c, legocki at, mader ns, scott ar. nasal fractures in children and adolescents: mechanisms of injury and efficacy of closed reduction. int j pediatr otorhinolaryngol. 2015 dec. 10(3):232237. 8. behrbohm h, tardy me. essentials of septorhinoplasty. thieme stuttgart-new york, 2004: 162 9. haack s, gubisch w. reconstruction of the septum with an autogenous double-layered conchal l-strut. aesthetic plast surg. 2014 oct; 38(5):912-922. 10. ducic y, defatta r. closed rhinoplasty. operative techniques in otolaryngology. 2007 sept; 18(3): 233-242. 11. teymoortash a, fasunla ja, sazgar aa. the value of spreader grafts in rhinoplasty: a critical review. eur arch otorhinolaryngol. 2012 may; 269(5):1411-1416. 12. zinser mj, siessegger m, thamm o, theodorou p, maegele m, ritter l, et al. comparison of different autografts for aural cartilage in aesthetic rhinoplasty: is the tragal cartilage graft a viable alternative? br j oral and maxillof surg. 2013 dec;51(8):863-867. 13. scattolin a, d’ascanio l. grafts in “closed” rhinoplasty. acta otorhinolaryngol ital. 2013 jan;33(3):169-176. philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 president’s page greetings! research develops several virtues: inquisitiveness, attention to detail, patience, critical thinking and a passion for knowledge. research should also be relevant and timely. during the past few months, much more than at any period in our lifetime, there has been an explosion of studies, reviews, editorials, and other manuscripts released online or published in peer reviewed journals. some have been released to the media prior to the actual publication of the complete research. the covid-19 pandemic has spurred bogus, pseudo and ground-breaking research. but more than anything, the pandemic has motivated everyone to ask questions and to pay more attention to science. the philippine society of otolaryngology-head and neck surgery is committed to support all activities related to research. it hosts workshops on medical writing and sponsors the annual interesting case, descriptive, analytical and surgical technique-instrument innovation contests. its journal, thanks to the indefatigable editor-in-chief dr. lapeña, publishes papers that contribute to the promotion and enhancement of the practice of otolaryngology. the society is also grateful to all the contributors, board of editors and peer reviewers who contribute to the journal’s success. we look forward to working again with all of you in the upcoming issues. good reading to all! cecilia gretchen s. navarro – locsin, md, msc, fpsohns president philippine society of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery president’s page greetings! this year marks the 64th year of the philippine society of otolaryngology-head and neck surgery. it is a defining year, marked by both national and international events that changed and will most likely continue to change medical practice, public health policy, socio-economic concepts and structures. the sars-coronavirus-2 (covid-19) pandemic crashed into the first quarter of 2020 unannounced and with great fury. this great unknown served as the impetus for a flurry of research into every aspect of the disease – its origins, biology, clinical course and treatment. it initiated an unprecedented interest in research, not just among scientists and clinicians but most especially amongst the general population. but what is research? re-search to look again at the past with spectacles, to look at the past with new eyes, to look at the present with a microscope, and to look at the far distance with binoculars – all to better see and perhaps to find answers to our questions. research fuels the evidence base of our understanding of diseases and the principles of our clinical and surgical practice. our specialty of otolaryngology, during this time of the pandemic, will be at the forefront of an exciting time for a renewed quest for knowledge. and what better vehicle to transport us into this new and uncharted world than the philippine journal of otolaryngology head and neck surgery? it is a testament to the unparalleled dedication of the editor-in-chief and editorial staff and the enthusiasm of the contributors, that every year the pjohns publishes interesting case reports, relevant descriptive and analytical studies, papers on surgical techniques & instrument innovations, and insightful commentaries. the journal is a platform for our questions and hypotheses. the journal is a venue for our discoveries. but most importantly, the journal is a celebration of our passion for otolaryngology. good reading to all! cecilia gretchen s. navarro – locsin, md, msc, fpsohns president philippine society of otolaryngology head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 6766 philippine journal of otolaryngology-head and neck surgery under the microscope philipp j otolaryngol head neck surg 2021; 36 (1): 67-68 c philippine society of otolaryngology – head and neck surgery, inc. inverted ductal papilloma of the salivary glandjose m. carnate, jr., md department of pathology college of medicine university of the philippines manila correspondence: dr. jose m. carnate, jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st. ermita, manila, 1000 philippines phone (632) 8526 4450 telefax (632) 8400 3638 email: jmcarnate@up.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. this is a case consult of slides stated to be from an excision of a buccal mucosa mass in a 58-year-old-man. the specimen was described as a 3 cm diameter roughly oval tan-gray tissue with a 2 x 1.5 cm mucosal ellipse on the surface that has a central ulcerated punctum. cut section showed an underlying 1.7 cm diameter roughly oval well-circumscribed mass with a granular tan surface. histological sections show a papillary lesion with an orifice on the mucosal surface and with epithelial nests invaginating into the underlying lamina propria in a non-infiltrative pattern. (figure 1) the lesion is composed of papillary epithelial fronds with cleft-like spaces between the fronds. (figure 2) the papillary fronds are lined by non-keratinizing basaloid stratified squamous cells with a superficial layer of columnar glandular cells along with mucous goblet cells interspersed among the squamous cells. (figure 3) all the cellular components are devoid of cytologic atypia and mitoses. based on these microscopic features we signed the case out as inverted ductal papilloma (idp). creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. papillary lesion with an orifice on the mucosal surface (single arrow) and with epithelial nests invaginating (“inverted”) into the underlying lamina propria (double arrow). note the adjacent squamous epithelium of the oral cavity mucosa (asterisk) (hematoxylin-eosin, 40x magnification). (hematoxylin – eosin , 40x) philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 6968 philippine journal of otolaryngology-head and neck surgery ductal papillomas are uncommon benign epithelial tumors with a papillary configuration that originate from the excretory ductal system of salivary gland acini.1-3 the world health organization recognizes two sub-types depending on the growth pattern: an intraductal papilloma (ip) and an idp.1 an idp usually presents as an asymptomatic submucosal nodule, measuring about 1.5 centimeters in diameter, and most commonly involving the buccal mucosa, followed by the lips, palate, and floor of the mouth.2,3 histological sections typically show under the microscope an unencapsulated though well-circumscribed epithelial proliferation with a papillary configuration on the luminal surface, and a nodular, endophytic or invaginating (“inverted”) configuration at its interface with the underlying lamina propria.2 both the papillary and the invaginating areas are composed of basaloid, non-keratinizing stratified squamous epithelium that are often covered with a cuboidal or columnar ductal cell layer.2 scattered among these are mucous goblet cells which can form microcysts.1,2 there is an overall morphological similarity to the sinonasal inverted papilloma.3 a relationship to trauma has been proposed.1,4 association with human papilloma virus (hpv) has also been reported.1 others, however, have not been able to demonstrate this association.4 differential diagnoses primarily include ip which is differentiated from idp architecturally by being a unicystic intraluminal papillary proliferation within a dilated excretory duct 2 – and sialadenoma papilliferum – which is predominantly polypoid and pedunculated with a verrucoid surface rather than a submucosal nodule, and an over-all morphologic similarity to the cutaneous tumor syringocystadenoma papilliferum.1,4 an important differential diagnosis that has to be ruled out is mucoepidermoid carcinoma (meca) because of the presence of both squamous and mucin-secreting cells. meca is distinguished by poor circumscription, and an infiltrative solid-cystic growth pattern.2,4 idp is benign and non-recurrent. unlike the nasal tumor, there has been no report of malignant transformation.2,3 complete surgical excision is considered curative.1,2 reporting these cases is encouraged to further our knowledge of the entity and elucidate a potential association with hpv. figure 2. the lesion is composed of papillary epithelial fronds with cleft-like spaces between the fronds (hematoxylin-eosin, 100x magnification). (hematoxylin – eosin , 100x) figure 3. the papillary fronds are lined by non-keratinizing basaloid stratified squamous cells (single asterisks) with a superficial layer of cuboidal to columnar ductal-type glandular cells (double asterisk); note the presence of interspersed mucin-containing goblet cells (arrow) (hematoxylin-eosin, 400x magnification). (hematoxylin – eosin , 400x) acknowledgements the author wishes to acknowledge dr. erodulf l. petilla and dr. maximo a. saavedra for the case referral. references 1. richardson m, bell d, foschini mp, gnepp dr, katabi n. ductal papillomas. in: el-naggar ak, chan jkc, grandis jr, takata t, slootweg pj. world health organization classification of head and neck tumors. iarc: lyon 2017; p. 192-193. 2. gnepp dr, henley jd, simpson rhw, eveson j. chapter 6: salivary and lacrimal glands. in: gnepp dr. (editor) diagnostic surgical pathology of the head and neck. 2nd edition. philadelphia: saunders elsevier. 2009; p. 469-471. 3. berridge n, kumar m. an interesting case of oral inverted ductal papilloma. dent update 2016 dec;43(10):950-2. doi: 10.12968/denu.2016.43.10.950. pubmed pmid: 29155535. 4. sala-perez s, espana-tost a, vidal-bel a, gay-escoda c. inverted ductal papilloma of the oral cavity secondary to lower lip trauma. a case report and literature review. j clin exp dent 2013 apr 1;5(2):e112-6. doi 10.4317/jced.51055 pubmed pmid:  24455058 pubmed central pmcid: pmc3892218. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery president’s page much reflection was spent on how this year should be remembered. direction was established by our past presidents and i look to the same horizon. the world at our periphery is also changing, hurrying along the pace of necessity more urgently than ever. we entered the year with a deluge of surrounding agencies demanding attention followed by frenetic efforts to respond to each and every one of them on time, every time. that was when i realized that to go forward, we must pause and look inward. to reassess our resources, realign to the same goals and build greater commitment for a healthier future. this year, the pso-hns will strengthen the pillars of its own home constitutionally and administratively. we reach out to fellows in a spirit of community and togetherness. we strengthen the intellectual foundations that we have built upon for training, research, advocacies and continuing education. the pjo-hns is a crucial part of this development. through the irreplaceable leadership of dr. jose florencio lapeña as editor-in-chief, dr. erasmo llanes and the associate editors, the pjo-hns enjoys international recognition and respect. much more can be done and with continued efforts, we expect the pjo-hns to soar to greater heights. it is a humbling experience to come after the heels of great mentors in orl, and often recall the sacrifices and bravery of the 9 who started this all. every leader thereafter has left a mark; the road by which every single otorhinolaryngologist uses for guidance. though we may not always realize it, our lives have been partially led to where it is by the service of many individual orl colleagues. at the conclusion of this year, i pray that the mark we leave will be for the good of all. mabuhay ang pjo-hns! mabuhay ang pso-hns! agnes t. remulla, md president philippine society of otolaryngology-head and neck surgery looking inward philippine journal of otolaryngology-head and neck surgery 3 impact, not just impact factor: responding to the manila declaration on the availability and use of health research information manila declaration on the availability and use of health research information in and for lowand middle-income countries in the asia pacific region otorhinolaryngologic manifestations of human immunodeficiency virus infection in manila, the philippines value of the 6-hour postoperative ionized calcium slope in predicting post-thyroidectomy occurrence of hypocalcemia complications of head and neck reconstructive surgery using axial pedicled flap extended transpalatine approach for excision of juvenile angiofibroma spontaneous passage of ingested coin in children chemodectoma and tetralogy of fallot descending necrotizing mediastinitis, a dreaded complication of acute tonsillitis sinonasal ameloblastic carcinoma in a 50-year-old filipino female primary laryngeal aspergillosis in a postpartum patient a myringotomy and ventilating tube applicator: new look at a five-century-old procedure a cotton wick improves hearing in a patient with profound hearing loss stridor at birth: congenital laryngeal web hypopharyngeal, supraglottic and subglottic stenosis after 1 week intubation facial palsy and mastoiditis from fibrous dysplasia metastasizing ameloblastoma philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 contents cover images editorial 4 impact, not just impact factor: responding to the manila declaration on the availability and use of health research information lapeña jf special announcement 6 manila declaration on the availability and use of health research information in and for lowand middle-income countries in the asia pacific region original articles 8 otorhinolaryngologic manifestations of human immunodeficiency virus infection in manila, the philippines arriola acp, chua ah, abrenica rjt. 13 value of the 6-hour postoperative ionized calcium slope in predicting post-thyroidectomy occurrence of hypocalcemia cabance re, cruz es. 19 complications of head and neck reconstructive surgery using axial pedicled flap dy aes, alfanta em, chiong am. 25 extended transpalatine approach for excision of juvenile angiofibroma hernandez jg, cabungcal aa, carrillo rjc. 30 spontaneous passage of ingested coin in children estolano pjl, chua ah. case reports 34 chemodectoma and tetralogy of fallot santiago kjb, samio lmr, roldan ra, castañeda ss. 38 descending necrotizing mediastinitis, a dreaded complication of acute tonsillitis go msc, cruz ets. 43 sinonasal ameloblastic carcinoma in a 50-year-old filipino female del mundo daa. 47 primary laryngeal aspergillosis in a postpartum patient villanueva jcr, opulencia ap, calavera kz, lim wl. surgical innovations and instrumentation 50 a myringotomy and ventilating tube applicator: new look at a five-century-old procedure amable jpm, sia-vargas ll. letter to the editor 56 a cotton wick improves hearing in a patient with profound hearing loss carrillo rjd, grullo per, san agustin mlm featured grand rounds 59 stridor at birth: congenital laryngeal web pascual mvp 62 hypopharyngeal, supraglottic and subglottic stenosis after 1 week intubation reyes nks from the viewbox 65 facial palsy and mastoiditis from fibrous dysplasia bickle ic under the microscope 67 metastasizing ameloblastoma atun jml, carnate jm “plastic surgery (plastic foreign body in the throat)” by rene louie c. gutierrez, md “ameloblastoma maxilla” by rene louie c. gutierrez, md “likas na yaman sa likod ng kagubatan” by rene louie c. gutierrez, md “true vision sees beyond what seems to be invisible to others.”” by adrian f. fernando, md philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2019; 34 (2): 39-41 c philippine society of otolaryngology – head and neck surgery, inc. congenital muscular torticollis: a case reportleila marie b. villanueva, md department of otorhinolaryngology head and neck surgery university of the east ramon magsaysay memorial medical center, inc. correspondence: dr. leila marie b. villanueva department of otorhinolaryngology head and neck surgery 5th floor, hospital service bldg., uermmmc, inc. 64 aurora blvd., quezon city, 1113 philippines telephone: (632) 8715 0861 local 257 telefax: (635) 8818 1809 e-mail: leilamarierbautista@yahoo.com the author declared that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology – head and neck surgery interesting case contest, may 22, 2014, menarini, w office bldg, bonifacio high street, bgc, taguig city. abstract objective: to discuss a case of congenital muscular torticollis and its presentation, pathophysiology and management. methods: design: case report setting: tertiary private hospital patient: one results: an 11-year-old girl presented with tilting of head to the right and progressive limitation of head movement since infancy. mri showed a shortened right sternocleidomastoid muscle. the patient underwent surgical release of torticollis. full range of motion of the neck was achieved after the surgical management. conclusion: congenital torticollis is a rare condition of the head and neck region. physicians should be familiar with this entity and its presentation and it should be considered in the differential diagnosis of patients with progressive limitation of head movement in order to initiate early treatment and avoid progressive physical deformity. keywords: congenital muscular torticollis; familial spasmodic torticollis congenital muscular torticollis (cmt) is the third most common congenital musculoskeletal anomaly after dislocation of the hip and clubfoot.1 this is a rare condition which occurs in one in every 300 live births and appears to have a male predominance having a relative ratio of 3:2.2,3 surgical intervention is indicated for children who are not responsive to a non-operative treatment for a minimum of 6 months with a significant deformity after 1 year of age. the sooner the torticollis is corrected the better the chance for spontaneous correction of associated plagiocephaly and facial asymmetry.4 however, clinicians may overlook patients with congenital torticollis and this may delay treatment causing significant deformity in adulthood. this report describes a case of an 11-year-old girl with congenital muscular torticollis and its presentation, pathophysiology and management. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery case reports case report an 11-year-old girl presented with shortening of neck on the right side resulting with limitation of head movement. (figure 1) she was born via caesarean section due to breech presentation. she had no family history of congenital deformity. at birth, the patient was noted to have a bulge on the right side of the neck which spontaneously resolved at 6 months. however, her condition progressed over the years until head movement was limited with the right side of the neck visibly shortened, and she was finally brought to a physician at the age of 10. magnetic resonance imaging (mri) revealed a shortened right sternocleidomastoid muscle. she underwent extensive physical therapy for a year but no improvement of head movement was noted. the patient was referred to an otorhinolaryngologist. on physical examination, the right sternocleidomastoid was firm compared with the left sternocleidomastoid muscle. no palpable masses were noted. there was restriction of head rotation to the left as well as the lateral flexion of the head to the left. the patient underwent surgical release of the sternocleidomastoid muscle by incising the muscle at the sternal attachment. intraoperatively, a tensed sternocleidomastoid tendon and fibrotic sternal head were noted. (figure 2) immediate passive range of motion was achieved immediately after the surgical procedure. biopsy of the muscle showed fibrotic changes. postoperatively, the patient completed 6 months of aggressive physical therapy twice a week. at 1 month postoperative follow-up, the active range of motion of the patient’s neck was markedly improved in all directions. (figure 3) discussion congenital muscular torticollis usually results from the shortening or the excessive contraction of the sternocleidomastoid muscle (scm).2 numerous theories have been proposed by different authors but the true etiology has yet to be known. some have proposed that the abnormality involves endomysial fibrosis with deposition of collagen and migration of fibroblasts around individual muscle fibers that undergo atrophy. the contraction of the scm causes the head to turn to toward the affected side and cause limitation of head movement to the contralateral side which can be seen at 6 months of age when upright head posture is established.5 in the intrauterine theory, cmt is a consequence of early fetal head descent or an abnormal intrauterine position of the fetal head. this results in muscle imbalance causing compression of the surrounding extremities.6 in the vascular etiology theory, the persistent lateral flexion and rotation of the head may cause venous occlusion of the scm causing fibrosis and progressive shortening of the muscle.6 that the patient was a breech presentation at birth may suggest abnormal intrauterine conditions for developing cmt. figure 1. anterior view of the patient prior to surgical release of torticollis showing tilting of head to the right. (photo published with permission) figure 2. intraoperative findings showing a shortened right sternocleidomastoid muscle figure 3. anterior view of the patient at 1-month postoperative follow-up showing straightening of neck. (photo published with permission). philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery case reports acknowledgements i would like to thank dr. elmo lago for his insights and assistance in technical writing. references 1. bredenkamp jk, hoover la, berke gs, shaw a. congenital muscular torticollis. a spectrum of disease. arch otolaryngol head neck surg. 1990 feb;116(2):212-16. doi: 10.1001/ archotol.1990.01870020088024; pmid: 2297419. 2. hulbert kf. torticollis. postgrad med j. 1965 nov;41(481):699-701. doi: 10.1136/pgmj.41.481.699; pmid: 5840862; pmcid: pmc2483203. 3. clarren sk, smith dw, hanson jw. helmet treatment for plagiocephaly and congenital muscular torticollis. j pediatr. 1979 jan;94(1):43-6. doi: 10.1016/s0022-3476(79)80347-9; pmid: 758420. 4. mik g, drummond ds. release of the sternocleidomastoid muscle. in: wiesel s, editor. operative techniques in orthopaedic surgery. philadelphia: lippincott williams and wilkins; 2011, p.13921398. 5. robin nh. congenital muscular torticollis. pediatr rev 1996;17(10):374-5. doi: 10.1542/pir.1710-374; pmid: 8885649. 6. graham j. congenital muscular torticollis. in jones kl, editor. smith’s recognizable patterns of human deformation. philadelphia: saunders; 2007, pp. 130-140. 7. mercier l. torticollis. in ferri ff, editor; rufino a, section editor. ferri’s clinical advisor 2014. 1st edition. philadelphia: mosby elsevier; p. 1105. 8. ta j, krishnan m. management of congenital muscular torticollis in a child: a case report and review. int j pediatr otorhinolaryngol. 2012 nov;76(11):1543-6. doi: 10.1016/j.ijporl.2012.07.018; pmid: 22889576. 9. raman s, takhtani d, wallace ec. congenital torticollis caused by unilateral absence of the sternocleidomastoid muscle. pediatr radiol. 2009 jan;39(1):77-9. doi: 10.1007/s00247-0081021-8; pmid: 18839164. 10. lee i, lim h, song hs, park mc. complete tight fibrous band release and resection in congenital muscular torticollis. j plast reconstr aesthet surg. 2010 jun;63(6):947-3. doi: 10.1016/j. bjps.2009.05.017; pmid: 19539550. 11. cherian sb, nayak s. a rare case of unilateral third head of sternocleidomastoid muscle. int j morphol. 2008;26(1):99-101. 12. natsis k, asouchiduo i, vasilleiou m, papathanasiou e, noussios g, paraskevas g. a rare case of bilateral supernumerary heads of sternocleidomastoid and its clinical impact. folia morphol. 2009 feb;68(1):52-54. pmid: 19384831. 13. burch c, hudson p, reder r, ritchey m, strenk m, woosley m. cincinnatti children’s hospital medical center; evidence-based care guideline for therapy management of congenital muscular torticollis. 2009 november 19. available from http://www.cincinnatichildrens.org/ svc/alpha/h/health-policy/ev-based/otpt.htm. guideline 33, pages 1-13. 14. oleszek jl, chang n, apkon sd, wilson pe. botulinum toxin type a in the treatment of children with congenital muscular torticollis. am j phys med rehabil. 2005 oct; 84(10):813-816. doi: 10.1097/01.phm.0000179516.45373.c4; pmid: 16205437. 15. burstein fd. long-term experience with endoscopic surgical treatment for congenital muscular torticollis in infants and children: a review of 85 cases. plast reconstr surg. 2004 aug; 114(2):4913. doi:10.1097/01.prs.0000132674.74171.60 pmid:15277820. diagnosis is based on the physical examination. congenital muscular torticollis usually presents with a mass on the lateral side of the neck that can be detected until 3 months of life.7 this mass usually regresses after early infancy and can be replaced with fibrous contracted band of the sternocleidomastoid muscle.7 early detection is important for immediate correction to avoid deformities such as plagiocephaly, craniofacial asymmetry and compensatory scoliosis. among the studies conducted worldwide, the most common intraoperative finding among patients with cmt who underwent surgical release is the fibrosis of a unilateral sternocleidomastoid muscle. some authors have also described unilateral absence of the scm, short sternal or clavicular head of the scm or supernumerary bilateral scm.8-12 the management of cmt ranges from close physical therapy by cervical exercises, botulinum toxin and surgical correction.13 an evidence based guideline on the management of cmt was created at a hospital in cincinnati.13 the guideline was intended for use in patients 0 to 36 months of age diagnosed to have cmt who demonstrated cervical lateral flexion and/or rotation limitations of greater than five degrees. among the treatments included in the guideline are stretching exercises and range of motion exercises (cervical lateral flexion and rotation) conducted for 6 months. surgical consult is recommended for children who are refractory to 6 months of nonsurgical therapy.13 botulinum toxin a injection has also shown some benefit among patients younger than one year who do not respond adequately to conservative management.14 patients who fail to respond to conservative management require surgery. surgical options include unipolar release of the affected sternal or clavicular heads of the sternocleidomastoid muscle.15 in older patients with more severe deficits, bipolar release of the muscle insertion at the mastoid process with or without z-plasty is recommended to preserve the normal contour of the sternocleidomastoid muscle in the neckline.15 in conclusion, congenital muscular torticollis is a rare condition of the head and neck region. physicians should be familiar with this entity and its presentation and it should be considered in the differential diagnosis of patients with progressive limitation of head movement in order to initiate early treatment and avoid progressive physical deformity. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial “those with access to these resources — students, librarians, scientists — you have been given a privilege. you get to feed at this banquet of knowledge while the rest of the world is locked out. but you need not — indeed, morally, you cannot — keep this privilege for yourselves. you have a duty to share it with the world.” – aaron swartz1 (who killed himself at the age of 26, facing a felony conviction and prison sentence for downloading millions of academic journal articles) the philippine journal of otolaryngology head and neck surgery was accepted into the directory of open access journals (doaj) on october 9, 2019. the doaj is “a communitycurated online directory that indexes and provides access to high quality, open access, peerreviewed journals”2 and is often cited as a source of quality open access journals in research and scholarly publishing circles that has been considered a sort of “whitelist” as opposed to the now-defunct beall’s (black) lists.3 as of this writing, the doaj includes 13,912 journals with 10,983 searchable at article level, from 130  countries with a total of 4,410,788  articles.2 our article metadata is automatically supplied to, and all our articles are searchable on doaj. because it is openurl compliant, once an article is on doaj, it is automatically harvestable. this is important for increasing the visibility of our journal, as there are more than 900,000 page views and 300,000 unique visitors a month to doaj from all over the world.2 moreover, many aggregators, databases, libraries, publishers and search portals (e.g. scopus, serial solutions and ebsco) collect doaj free metadata and include it in their products. the doaj is also open archives initiative (oai) compliant, and once an article is in doaj, it is automatically linkable.4 being indexed in doaj affirms that we are a legitimate open access journal, and enhances our compliance with plan s.5 the plan s initiative for open access publishing launched in september 2018 requires that from 2021, “all scholarly publications on the results from research funded by public or private grants provided by national, regional, and international research councils and funding bodies, must be published in open access journals, on open access platforms, or made immediately available through open access repositories without embargo.”5 such open access journals must be listed in doaj and identified as plan s compliant. there are mixed reactions to plan s. a recent editorial observes that subscription and hybrid journals (including such major highly-reputable journals as the new england journal of medicine, jama, science and nature) will be excluded,6 quoting the coalition s argument that “there is no correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 telefax: (632) 8524 4455 email: lapenajf@upm.edu.ph, jflapena@up.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr. ma, md department of otorhinolaryngology college of medicine, university of the philippines manila, philippines department of otorhinolaryngology head and neck surgery east avenue medical center, diliman quezon city, philippines open access: doaj and plan s, digitization and disruption philipp j otolaryngol head neck surg 2019; 34 (2): 4-6 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial valid reason to maintain any kind of subscription-based business model for scientific publishing in the digital world.”5 as gee and talley put it, “will the rise of open access journals spell the end of the subscription model?”6 if full open access will be unsustainable for such a leading hybrid medical journal as the medical journal of australia,6 what will happen to the many smaller, lowand middle-income country (southern) journals that cannot sustain a fully open-access model? for instance, challenges facing philippine journals have been previously described.7 according to tecson-mendoza, “these challenges relate to (1) the proliferation of journals and related problems, such as competition for papers and sub-par journals; (2) journal funding and operation; (3) getting listed or accredited in major citation databases; (4) competition for papers; (5) reaching a wider and bigger readership and paper contribution from outside the country; and (6) meeting international standards for academic journal publications.”7 her 2015 study listed 777 philippine scholarly journals, of which eight were listed in both the (then) thomson reuters (tr) and scopus master lists, while an additional eight were listed in tr alone and a further twelve were listed in scopus alone.7 to date, there are 11,207 confirmed philippine periodicals listed on the international standard serial number (issn) portal,8 but these include non-scientific and non-scholarly publications like magazines, newsletters, song hits, and annual reports. what does the future have in store for small scientific publications from the global south? i previously shared my insights from the asia pacific association of medical journal editors (apame) 2019 convention (http://apame2019. whocc.org.cn) on the world association of medical editors (wame) newsletter, a private listserve for wame members only.9 these reflections on transformation pressures journals are experiencing were the subject of long and meaningful conversations with the editor of the philippine journal of pathology, dr. amado tandoc iii during the apame 2019 convention in xi’an china from september 3-5, 2019. here are three main points: 1. the real need for and possibility of joining forcesfor instance, the journal of the asean federation of endocrinology societies (jafes) currently based in the philippines has fully absorbed previous national endocrinology journals of malaysia and the philippines, which have ceased to exist.   while this merger has resulted in a much stronger regional journal, it would be worthwhile to consider featuring the logos and linking the archives of the discontinued journals on the jafes website. should the philippine journal of otolaryngology head and neck surgery consider exploring a similar model for the asean otorhinolaryngological – head and neck federation? or should individual specialty journals in the philippines merge under a unified philippine medical association journal or the national health science journal acta medica philippina? such mergers would dramatically increase the pool of authors, reviewers and editors and provide a sufficient number of higher-quality articles to publish monthly (or even fortnightly) and ensure indexing in medline (pubmed). 2. the migration from cover-to-cover traditional journals (contents, editorial, sections, etc.) to publishing platforms (e.g.  should learned philippine societies and institutions consider establishing a single platform instead of trying to sustain their individual journals)? although many scholarly philippine journals have a long and respectable history, a majority were established after 2000,7 possibly reflecting compliance with requirements of the commission on higher education (ched) for increased research publications. many universities, constituent colleges, hospitals, and even academic and clinical departments strove to start their own journals. the resulting journal population explosion could hardly be sustained by the same pool of contributors and reviewers. in our field for example, faculty members of departments of otorhinolaryngology who submitted papers to their departmental journals were unaware that simultaneously submitting these manuscripts to their hospital and/or university journals was a form of misconduct. moreover, they were not happy when our specialty journal refused to publish their papers as this would constitute duplicate publication. the problem stemmed from their being required to submit papers for publication in department, hospital and/or university journals instead of crediting their submissions to our pre-existing specialty journal. this escalated the tension on all sides, to the detriment of the new journals (some department journals ceased publication after one or two issues) and authors (whose articles in these defunct journals are effectively lost). the older specialty journals are also suffering from the increased number of players with many failing to publish their usual number of issues or to publish them on time. but how many (if any at all) of these journals (especially specialty journals) would agree to yield to a merger with others (necessitating the end of their individual journal)? would a common platform (rather than a common journal) provide a solution? 3. more radically,  the individual journal as we know it today (including the big northern journals) will cease to existas individual oa articles (including preprints) and open (including post-publication) review become freely available and accessible to all.  however proud philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery editorial references 1. swartz a. guerilla open access manifesto. 2008 july; eremo, italy. [cited 2019 november 11] available from https://archive.org/stream/guerillaopenaccessmanifesto/goamjuly2008_djvu. txt. 2. directory of open access journals. [internet]. [cited 2019 november 9] available from https:// doaj.org. 3. beall j. beall’s list of predatory journals and publishers 2016. scholarly open access. formerly available at https://scholarlyoa.com/2017/01/03/bealls-list-of-predatory-publishers-2017/; [cited 2019 october 3] available from https://beallslist.weebly.com. 4. open archives initiative. [internet] new york: cornell university library information technology; 2019. [cited 2019 october 9] available from https://www.openarchives.org. 5. coalition s. plan s: principles and implementation, part i. the plan s principles. [internet] brussels: science europe; 2019. [cited 2019 november 9] available from https://www. coalition-s.org/principles-and-implementation/. 6. gee ce, talley n. disrupting medical publishing and the future of medical journals: a personal view. med j aust. 2019 aug;211(4):167-168. doi: 10.5694/mja2.50281 doi:10.5694/mja2.50281 pmid:31422578. 7. tecson-mendoza em. scientific and academic journals in the philippines: status and challenges. sci ed 2015;2(2):73-78. doi: https://doi.org/10.6087/kcse.47. 8. international standard serial number international centre (issn ic), issn portal: the global index for continuing resources. [internet] paris: international centre for the registration of serial publications; 2019. [cited 2019 november 10]. available from: https://portal.issn.org/? q=api%2fsearch&search%5b0%5d=must%3dcountry%3dphl&search%5b1%5d=must% 3drecord%3dregister&search%5b2%5d=must%3dmedium%3dco%2cta%2ccr&size=10&search_id=3090592&currentpage=41. 9. winker m, (editor). publishing: insights from the asia pacific association of medical editors (apame) 2019 conference. [wame listserve] wame newsletter 69, october 21, 2019: apply now for grants supporting the use of research4life; challenges for young researchers in africa; what are the health consequences of predatory journals? (private listserve for wame members only). 10. degusta m. the real death of the music industry. business insider, february 19, 2011. [cited 2019 november 9] available from https://www.businessinsider.com/these-charts-explain-thereal-death-of-the-music-industry-2011-2. 11. mcdowell zj. disrupting academic publishing: questions of access in a digital environment. media practice and education. 2018 may;19(1)52-67. doi: 10.1080/14682753.2017.1362173. editors may be of the journals they design and develop from cover to cover, with all the special sections and touches that make their “babies” unique, readers access and download individual articles rather than entire journals. a similar fate befell the music industry a decade ago. from the heyday of vinyl (33 and 78 rpm long-playing albums and 45 rpm singles) and 8-tracks, to cassettes, then compact disks (cd’s) and videos, the us recorded music industry was down 63% in 2009 from its peak in the late 70’s, and down 45% from where it was in 1973.10 in 2011, degusta observed that “somewhat unsurprisingly, the recording industry makes almost all their money from full-length albums” but “equally unsurprising, no one is buying full albums anymore,” concluding that “digital really does appear to have brought about the era of the single.10 as mcdowell opines, “in the end, the digital transforms not only the ability to disrupt standard publishing practices but instead it has already disrupted and continues to break these practices open for consideration and transformation.”11 where to then, scientific journals? without endorsing either, will sci-hub (https://sci-hub.se) be to scholarly publishing what spotify (https://www.spotify.com) is to the music industry? a sobering thought that behooves action. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to evaluate the association of salivary ph and taste sensitivity among geriatric and non-geriatric patients in an otorhinolaryngology head and neck surgery out-patient clinic. methods: design: cross-sectional study setting: tertiary government training hospital participants: 40 otorhinolaryngology out-patients results: of the 40 patients aged 24 to 92 years old (mean age 59.8 years), 21 were geriatric and 19 were non-geriatric. the mean salivary ph was 6.66 (range 5 to 8) and 6.63 (range 5 to 7) for geriatric and non-geriatric groups; the difference in mean salivary ph was not statistically significant (p = .87). the salivary ph in the geriatric group showed a negative correlation with age (r=0.06), while the salivary ph in the non-geriatric group had a positive correlation with age (r=0.14). overall, increases in age among the non-geriatric group were correlated with increase in salivary ph which were not observed in the geriatric patients. in the geriatric group, among the 4 tastants, the strongest correlation between taste sensitivity and salivary ph was observed for quinine followed by sucrose and nacl, but no correlation for citric acid. in the non-geriatric group, the strongest correlation between taste sensitivity and salivary ph was observed for nacl, followed by quinine, citric acid and sucrose. conclusion: there was no significant difference between the mean salivary ph of geriatric and non-geriatric patients and both means were within normal. there was a negative correlation between age and salivary ph in the geriatric group, and a positive correlation in the non-geriatric group. salivary ph had the strongest correlation with taste sensitivity for quinine and nacl among geriatric and non-geriatric participants, respectively, but the reasons for, and significance of this cannot be inferred from the present study. keywords: salivary ph; taste sensitivity; gustatory function; geriatric salivary hypofunction is commonly believed to arise from age-associated intrinsic salivary gland dysfunction, with objective evidence that salivary glands undergo structural changes.1 decreased taste sensitivity and dry mouth are common complaints among the geriatric salivary ph and taste sensitivity among geriatric and non-geriatric patients in a tertiary hospital: a cross-sectional study miguel v. crisostomo, jr., md celso v. ureta, md department of otorhinolaryngology head and neck surgery correspondence: dr. celso v. ureta department of otorhinolaryngology head and neck surgery veterans memorial medical center north avenue, diliman, quezon city 1104 philippines phone: (632) 8927 6426 local 1359 email: enthns_vmmc@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represent honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political views or beliefs, and institutional affiliations that might lead to conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery, analytical research contest (3rd place). october 23, 2018. roma salon, the manila hotel. manila. philipp j otolaryngol head neck surg 2019; 34 (2): 11-15 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery original articles population.2,3,4 they are commonly believed to arise from age-related intrinsic changes in taste receptors. furthermore, chewing problems associated with tooth loss and the use of dentures in the geriatric population also interfere with taste sensitivity, along with reduction in saliva production.2 decrease in taste sensitivity may suppress appetite resulting in weight loss, malnutrition, impaired immunity and deterioration in medical conditions.4,5 unfortunately, taste disorders in the geriatric population are commonly overlooked, as they are not considered critical to life. data from the world health organization and global trends in aging indicate that the proportion of the population aged 65 and older is expected to increase by 10% in the next 2 decades.6 in the philippines, people aged 60 years old and over made up 6.8 percent of the 92.1 million household populations in 2010, higher than the 6.0 percent recorded in 2000.7 as otolaryngologists, we should address issues related to taste among this ageing population. because taste sensitivity has been related to dry mouth, the relationship of taste sensitivity and salivary ph is an important area of inquiry. however, to the best of our knowledge, based on a search of medline (pubmed) and herdin using the keywords “salivary ph” and “taste sensitivity” we found no study evaluating the association of salivary ph and taste sensitivity in the philippines. in order to explore such a relationship, this study aims to evaluate the association of salivary ph and taste sensitivity among geriatric and non-geriatric patients in an otorhinolaryngology-head and neck surgery out-patient clinic. methods with hospital research committee approval, this cross-sectional study was conducted at the out-patient clinic of the department of otorhinolaryngology-head and neck surgery of our hospital from january 1, 2015december 31, 2017. a sample size of 65 was calculated using the formula n = z2p(1−p)/d2 where n is the sample size, z is the statistic corresponding to level of confidence, p is expected prevalence, and d is precision (corresponding to effect size). n= [(1.65) (0.6) (10.6)]/0.012 considered for inclusion were patients seen at our out-patient clinic who were more than 15 years old and could read, write and converse in filipino and/or english. excluded were patients with chronic illnesses such as diabetes mellitus and hypertension, on multiple (2 or more) maintenance medications, had been diagnosed with allergic rhinitis or sinusitis with or without nasal polyposis, had a respiratory infection within the previous month or nasal congestion at the time of examination, had dental problems or dentures, were smokers, or had a history of head injury. written informed consent was obtained from all patients. all eligible patients were clinically assessed and classified as non-geriatric for those less than 65 years old and geriatric for those 65 years old and above. determination of salivary ph the ph of the saliva was determined using ph paper obtained from the sugar regulatory board (north avenue, quezon city, philippines). fresh saliva was collected in a 50ml pyrex beaker (sigma-aldrich, belman laboratories, singapore) using the spit method and the ph was determined immediately by dipping the ph paper into the saliva.8 determination of taste perception taste perception of the four (4) basic tastes (sweet, salty, sour, bitter) was assessed using solutions of sucrose, sodium chloride (nacl), citric acid and quinine prepared from medical grade powder (merck life science, india). taste function or sensitivity tests were conducted using tastant adsorbed filter paper strips (taste strips) according to the method of muller.9 four aqueous solutions of the compounds were prepared using serial dilutions with the following concentrations: sweet (0.4, 0.2, 0.1, 0.05g/ml), salty (0.25, 0.1, 0.04, 0.016g/ml), sour (0.3, 0.165, 0.09, 0.05g/ml), and bitter (0.006, 0.0024, 0.0009, 0.0004g/ml). deionized water was used to prepare the solutions to ensure comparability between different study centers. whatmann # 1 filter papers (sigmaaldrich, belman laboratories, singapore) of approximately 3.8x3.8 cm were soaked in the different concentrations of tastants. the papers were randomly placed on the dorsal aspect of the tongue and patients were asked to identify the taste. the procedure was repeated for each tastant using the sip-and-spit method where participants rinsed their mouth with distilled water then expectorated at the start of the session and before each new trial. only one investigator conducted the procedure throughout the course of the study. the deidentified data were collected from clinical examination and recorded in ms excel for windows v. 10 (2013, microsoft corp., redmond, wa, usa). the pearson correlation coefficient was derived and computed using scatter plot. descriptive analysis used central tendency and dispersion measures (mean and range) and inferential statistics included a two-sample welch’s t-test (gen-info.osaka-u.ac.jp/mephas, japan) for two means to compare the average difference of patients in the two treatment arms that were considered as independent samples. a p-value of less than .05 was considered statistically significant. results a total of 40 participants met inclusion criteria and completed this study. their mean age was 59.8 years old with a range of 24 to 92 years philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery original articles old. twenty-one patients (52%) were geriatric and 19 patients (48%) were non-geriatric. there were 12 males (57%) and 9 females (43%) in the geriatric group while there were 11 males (58%) and 8 females (42%) in the non-geriatric group. the mean salivary ph among the geriatric group was 6.66 with a range of 5 to 8 while the mean salivary ph in the non-geriatric group was 6.63 with a range of 5 to 7. the difference in mean salivary ph of the two groups was not statistically significant (p = .87) using welch’s t test. there was a negative correlation between age and salivary ph in the geriatric group (pearson r=0.06), while there was a positive correlation between age and salivary ph in the non-geriatric group (r=0.14). a scatterplot summarizes the results. (figure 1a, b) overall, increases in age among the non-geriatric group were correlated with increase in salivary ph which were not observed in the geriatric patients. among the 4 tastants in the geriatric group, the strongest correlation between taste sensitivity and salivary ph was observed for quinine (r=0.40) followed by sucrose (r=0.26) and nacl (r=0.17). there was no correlation between taste sensitivity and salivary ph for citric acid (r=0) (figures 2a-d). in the non-geriatric group, the strongest correlation between taste sensitivity and salivary ph was observed for the tastant nacl (r=0.38) followed by quinine (r=0.25), citric acid (r=0.17) and sucrose (r=0.12). (figures 3a-d) figure 1. relationship between age and salivary ph and; a. geriatric and; b. non-geriatric figure 2. a-d. relationship between salivary ph and tastants in the geriatric group age and salivary ph patient < 65y/o (n=19) b. 8 6 4 2 0 200 40 60 80 salivary ph y=-0.0055x+6.3123 r2=0.01964a ge (y ea rs ) salivary ph and sucrose patient ≥ 65y/o (n=21) a. 4 3 2 1 0 5 6 7 8 salivary ph y=0.2353x-0.1765 r2=0.06547 co nc en tr at io n of s uc ro se salivary ph and naci patient ≥ 65y/o (n=21) b. 4 3 2 1 0 5 6 7 8 salivary ph y=-0.1397x+2.4485 r2=0.02737 co nc en tr at io n of n ac i salivary ph and citric acid patient ≥ 65y/o (n=21) c. 4 3 2 1 0 5 6 7 8 salivary ph y = 1 r2= #n/a co nc en tr at io n of c it ri c a ci d salivary ph and quinine patient ≥ 65 y/o (n=21) d. 4 5 3 2 1 0 5 6 7 8 salivary ph y = 0.5515x-1.5074 r2= 0.16031 co nc en tr at io n of q ui ni ne age and salivary ph patient ≥ 65y/o (n=21) a. 100 80 60 40 20 0 0 2 4 6 8 10 salivary ph y=-0.6434x+77.592 r2=0.00422 a ge (y ea rs ) philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery original articles discussion in this study, the strongest correlation between taste sensitivity and salivary ph in the geriatric group was observed for quinine, followed by sucrose and nacl, compared to nacl followed by quinine, citric acid and sucrose in the non-geriatric group. there was no correlation between taste sensitivity and salivary ph for citric acid. the mean salivary ph among filipino geriatric and non-geriatric groups was observed to be within the normal range similar to findings reported by other studies.1 in the geriatric group the salivary ph tended to decrease with age, whereas in the non-geriatric group, the salivary ph tended to increase with age. this decrease in salivary ph with age in our study contrast with the findings of brawley where the geriatric group tends to have more alkaline normal resting saliva.11 however, our results are only based on a small sample population that did not meet our projected sample size. the small variations in salivary ph between geriatric and nongeriatric groups may be explained by variations in diet and activities they engaged in (although we did not investigate these diets and activities in our study). moderate exercise or activity and certain diets (e.g. sialogogues) increase saliva flow rate.11 an increase in salivary flow rate is associated with a higher bicarbonate concentration, and, thus, higher salivary ph.11 in our study, the taste sensitivity of the non-geriatric group was figure 3. a-d. relationship between salivary ph and tastants in non-geriatric group higher (lower taste threshold) at lower salivary ph for nacl than those in the geriatric group. among the 4 tastants in the non-geriatric group, the taste sensitivity for nacl had the strongest correlation with salivary ph (r=0.38). since the taste receptor is usually adapted to the salivary environment, i.e. the gustatory receptors are continuously stimulated by low levels of salt ions, we normally do not recognize a salty taste in saliva.1 in order to detect salty taste sensation, sodium ion (na+) is slightly raised above the salivary sodium concentrations with which the taste receptor is continuously stimulated.12,13 in contrast, the higher detection threshold for nacl in the elderly can be a result of atrophy or degeneration of taste receptor due to old age.14 furthermore, xerostomia, endemic in the geriatric group, and chewing problems due to loss of teeth affect taste and may increase detection threshold to taste stimulus.15 in the geriatric group, there was higher taste sensitivity at lower salivary ph for quinine than the non-geriatric group. bitter taste as elicited by alkaloid quinine is the most sensitive of all taste qualities.16 in our study, the geriatric group had higher taste sensitivity for bitter than the non-geriatric group. the sensitivity to some bitter tastes is a heritable trait.16 one of the most widely studied is the genetically mediated sensitivity to the bitter taste of 6-n-propylthiouracil (prop) and its association for greater sensitivity to bitter taste.16 this finding is supported by anatomical studies showing that tasters for bitter had salivary ph and sucrose patient < 65 y/o (n=19) a. 4 3 2 1 0 5 6 7 8 salivary ph y = 0.1923x + 0.6154 r2= 0.01435 co nc en tr at io n of s uc ro se salivary ph and quinine patient < 65 y/o (n=19) d. 4 5 3 2 1 0 5 6 7 8 salivary ph y = 0.4519x+5.1538 r2= 0.06104 co nc en tr at io n of q ui ni ne salivary ph and naci patient < 65 y/o (n=19) b. 4 3 2 1 0 5 6 7 8 salivary ph y = 0.3077x -0.6154 r2= 0.14066 co nc en tr at io n of n ac i salivary ph and citric acid patient < 65 y/o (n=19) c. 4 3 2 1 0 5 6 7 8 salivary ph y = 0.2019x-0.1538 r2= 0.02945 co nc en tr at io n of c it ri c a ci d philippine journal of otolaryngology-head and neck surgery vol. 34 no. 2 july – december 2019 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery original articles references 1. elluru r. physiology of the salivary glands. in richardson m, flint p, haughey b, lund v, niparko j, robbins k, et al. (editors). cummings otolaryngology head and neck surgery 5th edition. vol 1. philadelphia: mosby elsevier, 2010. pp. 1133-1150. 2. baskoy k. et.al. is there any effect on smell and taste functions with levothyroxine treatment in subclinical hypothyroidism? plos one 2016; 11(2): e0149979. 3. matsuo r. role of saliva in the maintenance of taste sensitivity. crit rev oral biol med. 2000; 11(2): 216-29. pmid: 12002816. 4. boyce jm, shone gr. effects of ageing on smell and taste. postgrad med j. 2006 apr; 82(966): 239-41. doi: 10.1136/pgmj.2005.039453; pmid: 16597809 pmcid: pmc2579627. 5. lundy d. geriatric care otolaryngology. american academy of otolaryngology-head a n d neck surgery foundation. alexandria. va. copyright 2006. pp. 93-94. 6. united nations (2017). world population aging. https://www.un.org/en/development/desa/ population/publications/pdf/ageing/wpa2017_ highlights.pdf. 7. philippines statistics authority (2012). the age and sex structure of the philippine population: facts from the 2010 census.https://psa.gov.ph. 8. yamuna priya, muthu prathibha. methods of collection of saliva a review: http://oaji.net/ articles/2017/1994-1508144687.pdf. 9. murat s., onuralp k., seyid a., kamil b., aytug a., muzaffer s., ferhat d., hakan t., arif y, thomas h. retroand orthonasal olfactory function in relation to olfactory bulb volume in patients with hypogonadotrophic hypogonadism. braz j otorhinolaryngol. 2018;84(5):630---637. 10. brawley re. studies of the ph of normal resting saliva: variations with age and sex. journal of dental research. 1935 feb 1; 15(1): 55-77. doi: 10.1177/00220345350150010701. 11. winkler s, garg ak, mekayarajjananonth t, bakaeen lg, khan e. depressed taste and smell in geriatric patient. j am dent assoc.1999 dec; 130(12): 1759-65. pmid: 10599179. 12. spielman ai. interaction of saliva and taste. journal of dental research. new york city university. 69(3):838-43.1990. 13. mojet j, heidema j, christ-hazelhof e. taste perception with age: generic or specific losses in supra-threshold intensities of five taste qualities? chem senses. 2003 jun; 28(5): 397-413. pmid: 12826536. 14. boyce j and g. effects of ageing on smell and taste. postgrad med j. 2006 apr; 82(966): 239–241. pmid: 16597809. 15. solemdal k, sandvik l, willumsen t, mowe m. and hummel t. glogauer m. the impact of oral health on taste ability in acutely hospitalized elderly.plos one. 2012; 7(5): e36557. published online 2012 may 3. doi: 10.1371/journal.pone.0036557. pmcid: pmc3343000. pmid: 22570725. 16. drewnowski a., henderson, s., and shore, a. genetic sensitivity to 6-n-propylthiouracil (prop) and hedonic responses to bitter and sweet tastes. human nutrition program, school of public health, the university of michigan, ann arbor, ml 48109-2029, usa. 17. kataoka s, yang r, ishimaru y, matsunami h, sevigny j, kinnamon jc, et.al. the candidate sour taste receptor, pkd2l1, is expressed by type iii taste cells in the mouse. chem senses. 2008 mar; 33(3): 243–254. doi: 10.1093/chemse/bjm083; pmid: 18156604 pmcid: pmc2642677. the most fungiform papillae, the largest number of taste buds and the highest density of taste buds per papilla.16 instead our findings can be viewed in hedonic dimension with stimuli divided into those that are preferred and those that are disliked.1 unfortunately, in our literature search, we found no study explaining the different findings in taste sensitivity between geriatric and non-geriatric. sour taste as elicited by citric acid has lower detection threshold in the general population. weak acid such as citric acid is a very effective salivary stimulant which induces large volume of saliva.1 this increase in salivary flow rate is associated with higher bicarbonate concentration which neutralizes the acid and hence increases in salivary ph and consequently diminishes sour taste perception.1 in this study, the taste sensitivity for citric acid showed no correlation with salivary ph among the geriatric group. various mechanisms have been proposed to serve in the detection of sour taste.1 these include acid-sensing ion channels (asics), hyperpolarization-activated cyclic nucleotide-gated (hcn) channels, and two pore domain k+ channels (k2p).16 despite numerous studies, a definitive description of sour receptors and mechanisms remains controversial.16 this study has several limitations. first, we did not achieve our target sample size of 65 and our findings have to be interpreted in this context. our study population could have been better-defined, accounting for such variables as diet (sialagogues), physical activity, oral mucosa condition and dental status. our source population consisted of otorhinolaryngologic out-patients, and even with our exclusion criteria, may not fairly represent the larger population of persons with no otorhinolaryngologic or other problems. these factors affect the internal and external validity of our study, and future studies should consider improvements in these areas. in conclusion, our study found that the mean salivary ph among filipino non-geriatric and geriatric groups was not significantly different, and within normal range. there was a negative correlation between age and salivary ph in the geriatric group and a positive correlation in the non-geriatric group. the strongest correlation between taste sensitivity and salivary ph was observed for quinine in the geriatric group, and for nacl in the non-geriatric group. however, the reasons for, and significance of this cannot be inferred from the present study. philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 case reports philipp j otolaryngol head neck surg 2020; 35 (2): 41-43 c philippine society of otolaryngology – head and neck surgery, inc. blindness from fungal rhinosinusitis of the paranasal sinuses: a case report daniel rico t. de jesus, md patrick joseph l. estolano, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. patrick joseph l. estolano department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: +63 917 528 0334 / (632) 8711 9491 local 320 e-mail: patrick_esto@yahoo.com the authors declared that this presents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and the author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationship, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. presented at the philippine society of otolaryngologyhead and neck surgery 1st virtual interesting case contest (1st place), july 22, 2020 and at the annual interdepartmental research forum of the jose r. reyes memorial medical center. december 4, 2019. jose r. reyes memorial medical center, manila city. abstract objective: to present a unique case of blindness resulting from fungal rhinosinusitis involving multiple sinuses mimicking a malignant process in a pregnant patient. methods: design: case report setting: tertiary government training hospital patient: one result: a 36-year-old pregnant woman developed unilateral blindness during her 20th week of gestation with a history of binocular diplopia, unilateral nasal obstruction and anosmia for 13 months during the pre-pregnancy period. sphenoid sinus malignancy was suspected on imaging. the planned biopsy was intraoperatively shifted to endoscopic sinus surgery when clay-like materials were seen involving the left maxillary sinus and bilateral sphenoid and ethmoid sinuses. histopathologic examination confirmed fungal growth. postoperatively, nasal symptoms resolved but blindness of the left eye and blurring of vision of the right eye persisted. conclusion: fungal rhinosinusitis rarely occurs in multiple sinuses and is commonly misdiagnosed. it can afflict pregnant patients and mimic a malignant process. a high index of suspicion early on, especially in the presence of nasal congestion and diplopia may prevent potentially irreversible complications. keywords: sinusitis; blindness; sphenoid sinus; maxillary sinus; pregnancy fungal rhinosinusitis is a rarely diagnosed disease affecting 12,000,000 globally1 with an incidence of 5.4 and 8.2% in south korea and japan, respectively.2 sinus fungus ball is a noninvasive type that is predominantly unilateral in presentation and grows in wet, moist, cavities of the paranasal sinuses, mostly in females and elderly hosts with normal immunologic status.3 since symptoms are non-specific, its presentation is indistinguishable from usual chronic bacterial rhinosinusitis and may only be discovered incidentally.4 in some cases, it may even mimic a malignant tumor especially when the orbit is involved.5 we present the insidious development of common non-specific nasal symptoms towards blindness in a pregnant patient with sinus fungus ball. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 case reports case report a 36-year-old g4p2 (2-0-1-2) woman presented with a 13-month history of binocular diplopia and gradually progressing to blurring of vision. she also complained of occasional headache, left nasal obstruction and anosmia. no nasal discharge, epistaxis or difficulty of breathing were noted. she had an unremarkable past medical history and lived in a small apartment home with poor ventilation. her worsening blurring of vision prompted her to consult. a plain cranial computed tomography (c t ) scan revealed a lobulated soft tissue mass with coarse calcifications occupying the clivus, sphenoid, posterior ethmoid, sellar and suprasellar region (figure 1a) and left maxillar y sinus (figure 1b) with primar y consideration of a pituitar y neoplasm. she was unable to obtain the fur ther workups requested. she was admitted under the neurology ser vice on her 20th week of gestation due to left eye blindness and severe headaches ( vas score 8/10). ophthalmologic examination revealed absent light perception in the left eye and hand perception in the right eye. both eyes were medially deviated with lateral rectus palsy more noticeable on the left. fundoscopic examination revealed pale optic disc with no papilledema on the left eye. an mri of the head with diffusion weighted imaging revealed bony expansion and thinning of bilateral sphenoid sinuses and the left maxillar y sinus, heterogeneously-enhancing foci occupying the nasal area displacing the sella, pituitar y gland, optic chiasm and ner ves superiorly hence a suspicion of sphenoid sinus malignancy was enter tained. (figure 2a, b) she was referred to ear, nose, throat head and neck surger y (ent-hns) for evaluation of the suspected paranasal sinus mass. physical examination revealed left nasal congestion with clear water y discharge on anterior rhinoscopy, and facial tenderness over the left maxillar y area on palpation. nasal videoendoscopy showed a suspicious nasophar yngeal bulge but punch biopsy revealed chronic inflammation only. hence, maxillary antrostomy with exploration of the other sinuses via endoscopic sinus surgery was done. (figure 3a) intraoperative findings showed clay-like material filling the left maxillar y sinus, bilateral ethmoid and sphenoid sinuses. (figure 3b, c, d) hematoxylin-eosin and gomorimethenamine staining confirmed fungal growth of the acquired specimen. (figures 4a and 4b, respectively). serum galactomannan to determine the specific organism involved was not facilitated due to financial constraints. both mother and fetus tolerated the procedure well. antifungal medications were not given post-operatively due to pregnancy considerations. post-operatively, nasal congestion, facial tenderness, headache and anosmia resolved. ophthalmologic examination revealed no a b figure 1. plain cranial ct scan, axial view: a. lobulated soft tissue mass with coarse calcifications occupying the clivus, sphenoid, posterior ethmoid, sellar and suprasellar region; b. lobulated soft tissue mass occupying the left maxillary sinus. a b figure 2. mri of the head with dwi and contrast: a. heterogeneously enhancing foci with bony expansion and thinning at the level of the left maxillary sinus; b. at the level of the sphenoid sinuses displacing the parasellar structures. a c b d figure 3. intraoperative findings: a. left maxillary sinus showing fungus ball upon opening of the anterior maxillary wall accessed thru gingivobuccal incision; and endoscopic views showing aggregates of fungus ball in the b. left maxillary sinus, c. sphenoid sinus and; d. ethmoid sinus. philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 case reports improvement of her vision. she was discharged home with no other complications. on follow-up, she had delivered her baby at term via normal spontaneous deliver y with no feto-maternal complications. discussion as shown in our case, blindness can be an unfortunate sequela of fungus ball. a medline (pubmed) search using the keywords “fungus ball” and “blindness” revealed a report by kim et al. on a patient with blindness secondary to a sphenoid sinus fungus ball.6 using the same keywords, a search of herdin plus, the asean citation index, global index medicus ( western pacific region index medicus, wprim and index medicus of the south east asia region, imsear), directory of open access journals (doaj) and google scholar yielded no other similar cases published locally. the most common organisms causing fungus ball are aspergillus fumigatus, aspergillus flavus, alternaria, and mucor species.7 they are usually found in just one sinus; the maxillary sinus as the most frequently involved (94%) followed by the sphenoid sinus (4–8%).7 the ethmoid sinus (3%) is most often a continuous involvement from the maxillary sinus.7 fungal rhinosinusitis rarely occurs in multiple sinuses and is commonly misdiagnosed.7 mostafa et al. associated a small apartment floor, poor air conditioning, and exposure to dust and cockroaches with higher incidence of fungal rhinosinusitis due to humid environment and less exposure to sunlight.8 our patient lived in similar circumstances with no other comorbidities that could lead to her condition. fungal rhinosinusitis has a non-specific presentation which may lead to confusion in diagnosis. in our case, an initial impression of a nasopharyngeal tumor was considered due to the nasal endoscopic findings of a nasopharyngeal bulge and the patient’s diplopia. in about 57% of patients with nasopharyngeal carcinoma and diplopia, it was observed that the infiltrating nature of the mass to extend intracranially could have involved cranial nerve vi.9 in general, the visual disturbance in compressive lesions similar to our patient is attributed to the interruption of the blood supply to acknowledgements we thank dr. gil m. vicente and dr. alexander s. dy who served as scientific advisors for this report. references 1. bongomin f, gago s, oladele r, denning d. global and multi-national prevalence of fungal diseases—estimate precision. j fungi (basel). 2017 oct 18;3(4):57. doi:10.3390/jof3040057. pubmed pmid: 29371573; pubmed central pmcid: pmc5753159. 2. j s kim, s s so, s h kwon. the increasing incidence of paranasal sinus fungus ball: a retrospective cohort study in two hundred forty-five patients for fifteen years. clin otolaryngol.  2017 feb;42(1):175-179. doi: 10.1111/coa.12588. pubmed pmid: 26576036. 3. jiang r-s, huang w-c, liang k-l. characteristics of sinus fungus ball: a unique form of rhinosinusitis. clin med insights ear nose throat. 2018 aug 3; 11:1179550618792254. doi:10.1177/1179550618792254; pubmed pmid: 30090023; pubmed central pmcid: pmc6077877. 4. bhowmik b. fungal sinusitis clinical presentation, latest management: a review update. journal of science foundation. 2014 jan;12(1):1728-7855. doi: https://doi.org/10.3329/jsf.v12i1.23460. 5. ferguson b, lee s. fungal rhinosinusitis. in: flint p, haughey b, lund v, niparko j, robbins k, regan thomas j. et al., editors. cummings otolaryngology head and neck surgery. 6th ed. london: saunders; 2014. p.735-736. 6. kim js, kim bk, hong sd, kim hj, kim hy. clinical characteristics of sphenoid sinus fungal ball patients with visual disturbance. clin exp otorhinolaryngol. 2016 dec;9(4):326-331. doi: 10.21053/ceo.2015.01571. epub 2016 may 3. pubmed pmid: 27136367; pubmed central pmcid: pmc5115146. 7. grosjean p,  weber r. fungus balls of the paranasal sinuses: a review. eur arch otorhinolaryngol.  2007 may; 264(5):461-70. doi: 10.1007/s00405-007-0281-5; pubmed pmid: 17361410 8. mostafa be, el sharnoubi mmk, el-sersy haa, mahmoud msm.  environmental risk factors in patients with noninvasive fungal sinusitis. scientifica (cairo). 2016;2016:5491694. doi: 10.1155/2016/5491694; pubmed pmid: 27274885; pubmed central pmcid: pmc4870367. 9. ilhan o, sener ec, ozyar e. outcome of abducens nerve paralysis in patients with nasopharyngeal carcinoma. eur j ophthalmol. 2002 jan-feb; 12(1):55-9. pubmed pmid: 11936446. 10. goldenberg-cohen n, ehrenberg m, toledano h, kornreich l, snir m, yassur i, michowiz s.  preoperative visual loss is the main cause of irreversible poor vision in children with a brain tumor. front neurol. 2011 sep 30; 2:62. doi: 10.3389/fneur.2011.00062; pubmed pmid: 21994502; pubmed central pmcid: pmc3183350. 11. gorovoy ir, kazanjian m, kersten rc, kim hj, vagefi mr. fungal rhinosinusitis and imaging modalities. saudi j ophthalmol. 2012 oct; 26(4):419-26. doi: 10.1016/j.sjopt.2012.08.009; pubmed pmid: 23961027; pubmed central pmcid: pmc3729552. the optic nerve with secondary ischemic optic atrophy, as confirmed by the fundoscopic findings of a pale optic disc.10 it has been posited that accumulation of viscous eosinophilic mucin by nasal congestion can cause obstruction of sinus outflow tracts, which then allows inflammatory mediators to cause gradual sinus expansion and bony erosion.11 hence, the bilateral bony expansion of the sphenoid sinus seen on mri may have caused compression on the optic nerve, supported by the yellow-brownish friable fungus ball seen intraoperatively. definitive treatment for fungal rhinosinusitis involves restoration of normal sinus drainage by removal of the fungus ball, extirpation of allergic mucin, and long-term nasal steroids to prevent recurrence.11 antifungal medications were no longer initiated as they have not been proven to be beneficial in treatment11 and could place the pregnancy and fetus at risk. in conclusion, our case has shown that fungal rhinosinusitis can afflict a pregnant patient with non-specific nasal symptoms and ophthalmic complications mimicking a malignant process. multiple sinus involvement of fungal rhinosinusitis, although rare, should also be considered as a differential diagnosis even in pregnant patients. a high index of suspicion early on, especially in the presence of nasal congestion and diplopia may prevent potentially irreversible complications. figure 4. histopathologic slides: a. hematoxylin and eosin stains showing fungal elements on high power view (white arrow) b. histopathologic slides using gomori methenamine staining showing collection of fungal elements in low power view (arrow). a b philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 7372 philippine journal of otolaryngology-head and neck surgery passages marlon v. del rosario, md (1956 – 2021) alberto f. calderon, md middle of all the commercial and infrastructure developments. and as his practice started to thrive, he tempered his success with kindness and compassion, earning him more prominence in his hometown. he was also a music aficionado. while many of us are only recently going back to the turntable and vinyl records, he never let go of his turntable set up. he was a bit of a snob when it came to music. he found tapes and digitized sound inferior to vinyl records, and his vinyl record collection is still an envy of many. he appreciated all forms of music, but the genre he truly loved (like a true caviteño) was rock and roll. his love for music did not stop there. he was a musician as well and played a mean guitar. this is illustrated by the manner in which his family arranged the altar where his urn was placed. amidst the flowers on the altar was a picture of a grinning marlon with a guitar slung over his shoulder. his treasured guitars were right beside him: his acoustic guitar placed on one side of the altar and his electric guitar on the other. his true crowning glory however, was his family. he became a family man at the tender age of 21. his family was his foundation and inspiration. his lovely and ever supportive wife ellie held the fort while he was away in manila to study medicine and undergo residency training. they were blessed with 3 boys whom he was extremely proud of. his eldest son marc (43 years old) is a us trained interventional cardiologist who practices in several large medical institutions around metro manila and cavite. michael (40 years old) is an associate professor of entrepreneurship and marketing at de la salle university – dasmariñas and currently completing his requirements for his doctorate degree in business administration and management. the youngest son mikko (32 years old) seems to have a special interest in local cavite politics. indeed, marlon’s life was colorful and complete. nonetheless, it was still too soon for him to embark on this final journey. but such is life and we just have to accept it. my dear friend and compadre marlon, i raise my glass of your favourite japanese single malt whiskey and congratulate you for a life well-lived. godspeed and rest easy. marlon graduated from the university of santo tomas (ust) faculty of medicine and surgery in 1982. he completed his internship at the ospital ng maynila medical center (ommc) the following year. he then proceeded to complete the ommc residency training program in otolaryngology-head and neck surgery (then chaired by the venerable dr. angel enriquez). in 1988, he attained the title of diplomate in otolaryngology-head and neck surgery. marlon established his private practice in his hometown of tanza, cavite. it is also here where he co-founded the divine grace medical center, the first tertiary medical facility in this part of cavite. in 1989, with the encouragement of dr. joselito “che” jamir, a respected fellow caviteño otolaryngologist, he joined the faculty of de la salle medical and health sciences institute in dasmariñas, cavite, serving for 30 years as assistant professor. he also served as an associate board examiner for the philippine board of otolaryngology-head and neck surgery until 2016. with this short statement alone, one can already see the exemplary medical career marlon had. but to properly pay tribute to him, one must see and know the man behind the endoscope, the man beneath the white tailored medical overcoat. marlon’s character was a bit of a paradox. he was a humble and modest person despite his substantial resources. he was unassuming yet self-assured. he was reserved but gregarious at the same time. for instance, in our conventions or other gatherings of fellows, he would most likely be seated at the farthest portion of the meeting quietly and attentively listening to the proceedings. but once outside the session hall when he gets to meet up with his buddies, he transforms and takes center stage in what will eventually be a boisterous exchange of banter. the usual suspects in these animated gatherings were drs. arsenio “boy” pascual, howard enriquez, tomas “tom” antonio and diosdado “dado” uy. indeed, he was the epitome of someone who worked hard and played hard. he was a man with foresight. instead of investing in clinic spaces in large and established medical centers in metro manila and cavite, he staked his money on building the divine grace medical center, a tertiary medical center in what was then a sleepy town of tanza, cavite. this sleepy town is now a commercial and financial hub in the northwestern part of cavite, with his hospital located right in the philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 philippine journal of otolaryngology-head and neck surgery 53 case reports philipp j otolaryngol head neck surg 2016; 31 (1): 53-56 c philippine society of otolaryngology – head and neck surgery, inc. abstract objective: to present a case of mandibular ameloblastoma with pulmonary metastasis after ten years and discuss the possible pathophysiology, diagnostic and therapeutic options. methods: design: case report setting: tertiary private hospital patient: one results: a 27-year-old woman diagnosed with follicular variant ameloblastoma underwent left segmental mandibulectomy with iliac bone reconstruction in 2004. the titanium plates were removed in 2008 because of a recurrent orocutaneous fistula. she was apparently well until 2014, when she complained of intermittent, non-radiating, sharp and piercing, right upper back pains. work-ups revealed multiple bilateral lung nodules. a ct scan-guided percutaneous needle biopsy of the right upper lung nodule revealed metastatic ameloblastoma. opting for observation instead of chemoradiation, she remains asymptomatic on regular follow-ups with medical oncology, pulmonary medicine and otorhinolaryngology. conclusion: though benign, ameloblastoma has a high propensity for local invasion and may metastasize. it is difficult to predict metastasis, even with adequate treatment of the primary lesion. there is no standard protocol to prevent or detect metastatic ameloblastoma, but regular and close follow up may ensure early diagnosis. keywords: ameloblastoma, metastatic ameloblastoma, lung metastasis, follicular type ameloblastoma, odontogenic tumor ameloblastoma is a benign, slow-growing odontogenic tumor with locally aggressive behavior and a high recurrence rate in 50%-72% of cases.1 it accounts for 1% of all tumors and cysts in the jaw, with the angle of the mandible as the most common primary site affected. since over half of resected tumors recur, many consider ameloblastoma locally malignant but not metastasizing.2 metastases, however, have been reported to occur in up to 2%.3 over 80% of such metastases involve the lungs, followed by cervical lymph nodes (15%-28%), vertebrae, and less mandibular ameloblastoma with lung metastasis 10 years after resection justin iohanne siy rabo, md allan b. carpella, md eutrapio s. guevara jr., md joel a. romualdez, md department of otolaryngology head and neck surgery saint luke’s medical center correspondence: dr. allan b. carpella department of otolaryngology head and neck surgery st. luke’s medical center 279 e. rodriguez ave., quezon city 1102 philippines phone: (632) 727 5543 fax: (632) 723 1199 (h) email: slmcearnosethroat@yahoo.com the authors declare that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest presented at the clinical case report contest (1st place), philippine society of otolaryngology-head and neck surgery, menarini office, 4/f w bldg. 11th ave. cor. 28th st. bonifacio high st. bgc taguig, june 2, 2015. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports 54 philippine journal of otolaryngology-head and neck surgery frequently, the skull, liver, parotid gland, diaphragm, and brain.4 we present a case of a mandibular ameloblastoma with lung metastasis and discuss the possible pathophysiology, diagnostic and therapeutic options. case report a 27-year-old woman with no known co-morbidities consulted in 2004 for a gradually enlarging left mandibular mass since 2002. wedge biopsy revealed ameloblastoma and a segmental mandibulectomy with iliac bone reconstruction was performed that same year. the final histopathology revealed ameloblastoma, follicular variant. a postoperative orocutaneous fistula was repaired twice, in november and december 2004. she remained apparently well (with normal routine annual chest x-rays) on regular follow-ups until 2008, when the fistula recurred. the titanium plates and screws were removed, and the fistula was repaired. her condition allegedly improved and she was lost to follow-up thereafter. she was reportedly well until 2014, 10 years after the first surgery, when she noted intermittent, non-radiating, sharp and piercing, right upper back pains with no associated symptoms. bilateral multiple pulmonary nodules were seen on chest x-rays. her otorhinolaryngologic and chest examinations were unremarkable with symmetrical chest expansion, no lag, and and clear, equal breath sounds. considering an infectious process versus metastasis from a primary neoplasm, a high resolution chest ct scan with contrast showed “multiple varied-sized, non-calcified, non-enhancing pulmonary and pleural-based nodules/masses in both lungs.” the largest on the right was located in the anterior basal segment of the right lower lobe measuring approximately 2.2 x 3.3 cm. (figure 1) the findings were compatible with metastases. a ct scan-guided percutaneous needle biopsy of right upper lung nodule yielded “highly cellular smears with spindle cells, scattered singly and in tight and loose clusters admixed with atypical epithelial cells, set in a bloody background,” (figure 2) with chondromyxoid stroma in some clusters. the cell block showed “stellate reticulum-like cells in clusters with peripheral palisading columnar cells, some exhibiting reverse polarization.” (figure 3) final histopathology results were signed out as “cytomorphologic findings consistent with metastatic ameloblastoma.” plain ct scans revealed no recurrence of the osseous tumor in the left mandibular body. (figure 4) she was given oral analgesics for the back pain, and offered chemotherapy and radiotherapy. she opted to observe her condition with regular monitoring instead, since she was then asymptomatic. she is currently well and is being monitored by medical oncology, pulmonary medicine and otorhinolaryngology. anterior posterior right left figure 1. high resolution contrast ct scan of the chest (febuary 2014). note multiple varisized non-calcified pulmonary and pleural-based nodules/masses randomly scattered in both lungs. the largest on the right is located in the anterior basal segment of the right lower lobe measuring approximately 2.2 x 3.3 cm (thick arrow), while the largest on the left is noted in the inferior lingula measuring 1.9 x 1.9 cm (thin arrow). figure 2. histopathologic slides of ct-guided needle biopsy of pulmonary nodules, hematoxylin – eosin, showing clusters of spindle cells and epithelial cells in both low power (a) and high power (b) views b. high power view, 40x (hematoxylin – eosin, 40x) a. low power view, 10x (hematoxylin – eosin, 10x) philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 philippine journal of otolaryngology-head and neck surgery 55 case reports primary and metastatic tissues demonstrating benign histological features; whereas an ameloblastic carcinoma exhibits malignant features, such as cellular atypia and mitosis.7 metastatic ameloblastoma is rare with about 70 reported cases.8 both the gnathic primary tumor and the metastatic foci have typical morphologies of a benign ameloblastoma with bland nuclei and absent to rare mitosis.8 this histopathologic features of metastatic ameloblastoma are consistent with our case, although atypical epthithelial cells were noted, this is a focal type of atypia which can sometimes also be seen in benign cases.9 there is no definite pathophysiologic basis for how ameloblastoma can metastasize, but three routes are mentioned in the literature: hematogenous, lymphatic, and by aspiration.10 another possible mode of metastasis is tumor implantation during surgical procedures.11 other studies theorized that multiple surgeries can significantly increase the risk of metastases, and that curettage opens pathways for dissemination of the tumor to adjacent structures, which may lead to surgical seeding.12 in our case, metastasis could have been due to two routes: first, hematogenous since the tumor was diffusely scattered in both lung fields; and second by aspiration from the endotracheal tube during her previous surgery. because the exact mechanism of metastasis remains unknown, only speculations can be made. we are not aware of any report on the specific signs and symptoms (hematoxylin – eosin, 10x) a. low power view, 10x (hematoxylin – eosin, 40x) b. high power view, 40x figure 3. histopathologic slides of cell block, hematoxylin – eosin, showing clusters of stellate reticulate-like cells with peripheral palisading columnar cells in both low power (a) and high power (b) views. discussion of all swellings of the oral cavity, 9% are odontogenic tumors, and ameloblastoma accounts for 1% of lesions within this group.5 ameloblastoma frequently arises from rests of primitive dental lamina located in the gingiva, in the alveolar bone above the teeth apices, and in the follicular walls of unerupted teeth.6 the most common primary site affected is the mandible, specifically, its angle.5 occurring with equal frequency in both sexes, usually between the third and fifth decade of life, it is asymptomatic in most cases, and presents only as an incidental finding.5 histological classification subdivides it into follicular, plexiform, acanthomatous and granular ameloblastoma.5 the world health organization (who) defines metastatic ameloblastoma as an ameloblastoma which metastasizes, with the figure 4. plain ct scan (june 2014) surgical defects are seen in the left mandibular body (arrow) likely relating to the previous surgical site. there are no signs for recurrence of an osseous tumor. anterior posterior right left philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 case reports 56 philippine journal of otolaryngology-head and neck surgery references 1. ciment lm, ciment aj. malignant ameloblastoma metastatic to the lungs 29 years after primary resection: a case report. chest. 2002 apr; 121(4):1359-1361. 2. inoue n, shimojyo m, iwai h, ohtsuki h, yasumizu r, shintaku m, et al. malignant ameloblastoma with pulmonary metastasis and hypercalcemia. am j clin pathol. 1988 oct; 90 (4):474-481. 3. mathew s, rappaport k, ali sz, busseniers ae, rosenthal dl. ameloblastoma: cytologic findings and literature review. acta cytol. 1997 jul-aug; 41(4):955-960. 4. newman l, howells gl, coghlan km, dibiase a, williams dm. malignant ameloblastoma revisited. br j oral maxillofac surg. 1995 feb; 33(1):47-50. 5. lee sk, kim ys, current concepts and occurrence of epithelial odontogenic tumors: i. ameloblastoma and adenomatoid odontogenic tumor. korean j pathol. 2013 jun; 47(3): 191202. 6. adekeye eo. ameloblastoma of the jaws: a survey of 109 nigerian patients. j oral surg. 1980 jan; 38(1):36–41. 7. gilijamse m, leemans cr, winters hah, schulten eajm, van der waal i. metastasizing ameloblastoma. int j oral maxillofac. surg. 2007 may; 36(5): 462–464. 8. atun jm, carante j. metastasizing ameloblastoma. philipp j otolaryngol head neck surg. 2015 jul-dec; 30 (2): 67-68. 9. rosai j. roasai and ackerman’s surgiacl pathology 10th edition. st louis: elsevierhealth science division: 2011. p. 276-278. 10. henderson jm, sonnet jr, schlesinger c, ord ra, pulmonary metastasis of ameloblastoma: case report and review of the literature. oral surg oral med oral pathol oral radiol endod. 1999 aug; 88(2):170-176. 11. kunze e, donath k, luhr hg, engelhardt w, de vivie r. biology of metastasizing ameloblastoma. pathol res pract. 1985 nov; 180(5):526-535. 12. zwahlen ra, gratz kw. maxillary ameloblastomas: a review of the literature and of a 15-year database. j craniomaxillofac surg. 2002 oct; 30(5):273279. 13. laughlin eh. metastasizing ameloblastoma. cancer. 1989 aug; 64(3):776-780. 14. scannell j, lees b, hopper c. can radiofrequency ablation be used as a treatment modality for the management of pulmonary metastatic ameloblastoma? radiol case rep. 2009; 4:249. 15. grünwald v, le blanc s, karstens jh, weihkopf t, kuske m, ganser a, et al. metastatic malignant ameloblastoma responding to chemotherapy with paclitaxel and carboplatin. ann oncol. 2001 oct; 12(10):1489–91. 16. georgakas i, lazaridou m, dimitrakopoulos i, tilaveridis i, sekouli a, papakosta, d. et al. pulmonary metastasis in a 65-year-oldman with mandibular ameloblastoma: a case report and review of the literature. j oral maxillofac surg. 2012 may; 70(5):1109-1113. of metastatic ameloblastoma, and most cases of ameloblastoma are asymptomatic. in this case, our patient only presented with an intermittent, non-radiating, sharp and piercing, right upper back pains. diagnosis is usually due to incidental findings on ct scan or chest x-ray, which prompts further work-up. the diagnosis of metastatic ameloblastoma can only be made in retrospect; hence, it is difficult to predict which cases would metastasize and which would not. there may be a role for routine annual chest x-rays (which in our patient’s case were a social service requirement), but as also seen in our case, were negative for five years. the prognosis of metastatic ameloblastoma is poor. henderson et al. reported a median survival of approximately 2 years after the detection of metastasis.10 the mean survival of patients who did not receive any treatment or who were treated with multi-agent chemotherapy was 1.1 years.13 another study that reviewed 29 cases of ameloblastoma with lung metastases concluded that median survival was longer at around 6.6 years when surgical resection was performed compared to other treatment modalities or close monitoring.13 because of the rarity of metastatic ameloblastoma, the clinical course and appropriate treatment are not yet established. close observation, surgical resection, and chemotherapy/radiotherapy are treatment options.14 adequate treatment of the primary lesion is the most important element in the management of ameloblastoma. for isolated and discrete lung metastatic ameloblastoma, particularly in the lung periphery, treatment may be via open thoracotomy and wedge resection, or by lobotomy, depending on the number of lesions and their location.4 significant resection, with preservation of as much viable lung tissue as possible, is the treatment of choice.4 surgical resection was not an option for our patient since multiple nodules were noted in both lungs, as it is best considered if the lesion is solitary and peripherally located. other treatment modalities, such as chemotherapy and radiotherapy, are yet to be defined. chemotherapy has shown variable results, in some cases achieving only a reduction in tumor size, but producing no effective improvement in most cases.10 currently there is no single-agent or combination chemotherapy regimen that can be recommended for palliation in patients with unresectable metastases. however, there are some reports showing metastatic ameloblastoma to the lungs that responded well to carboplatin/paclitaxel, suggesting benefits for systemic treatment in cases with inoperable disease.15 radiotherapy has been recommended for inoperable metastatic deposits, but because the response is unpredictable, it should be used only for palliative care.16 because the tumor is unresectable and the patient has no signs of disease progression, her choice to forego chemoradiation in favor of close monitoring and symptomatic relief of symptoms is the best treatment option at the moment. though benign, ameloblastoma has a high propensity for local invasion and may rarely metastasize, most commonly to the lungs. it is difficult to predict metastasis, even with adequate treatment of the primary lesion, as there is no sign or symptom specific for metastatic ameloblastoma. there is no standard protocol to prevent or detect metastatic ameloblastoma, but regular and close follow up and monitoring, even years after primary resection, may ensure early diagnosis. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 2 july – december 2016 philippine journal of otolaryngology-head and neck surgery 3 contents the physician’s pledge: promises at dawn, passages in darkness on shoulders of giants: a message from an elder fellow to new diplomates the effectiveness of intravenous tranexamic acid on blood loss and surgical time during endoscopic sinus surgery: a systematic review pneumococcal conjugate vaccine (non-typeable haemophilus influenzae (nthi) protein d, diphtheria or tetanus toxoid conjugates) in prevention of acute otitis media in children: a cohort study association of the laterality of chronic suppurative otitis media and sinonasal disease based on temporal bone ct scans and lund mackay scoring system adult acute epiglottitis: an eight year experience in a philippine tertiary government hospital accuracy of fine needle aspiration biopsy in diagnosing parotid gland malignancy motorcycle related cranio-maxillofacial injuries at a tertiary hospital in the philippines granulation tissue mimicking a glomus tumor in a patient with chronic middle ear infection rhinofacial conidiobolomycosis in a 16-year-old girl relapsing polychondritis initially presenting with hoarseness and difficulty breathing in a 21-year-old male a 15-year occult foreign body in the subglottic area of a 50-year-old woman true congenital macroglossia surgically managed using a modified kole technique medialization thyroplasty using a pocket and silicone implant technique meningioma in the middle ear: an unusual case of hearing loss spontaneous middle fossa encephalocele low-grade cribriform cystadenocarcinoma of the parotid gland tierry f. garcia, md (1919-2016): the most good for the most people sarah d. moral-ramos, md (1979-2016): an old soul, gone too soon cover images editorial 4 the physician’s pledge: promises at dawn, passages in darkness lapeña jf commentary 6 on shoulders of giants: a message from an elder fellow to new diplomates llamanzares tp review article 8 the effectiveness of intravenous tranexamic acid on blood loss and surgical time during endoscopic sinus surgery: a systematic review ligon jme, almazan na original articles 13 pneumococcal conjugate vaccine (non-typeable haemophilus influenzae (nthi) protein d, diphtheria or tetanus toxoid conjugates) in prevention of acute otitis media in children: a cohort study chu tg, cachola drr iii, regal mas, llamas acg, martinez nv, santos wr 16 association of the laterality of chronic suppurative otitis media and sinonasal disease based on temporal bone ct scans and lund mackay scoring system adan wc, cruz, ets 20 adult acute epiglottitis: an eight year experience in a philippine tertiary government hospital cruz mgy, almazan na 24 accuracy of fine needle aspiration biopsy in diagnosing parotid gland malignancy santiago kjb, roldan ra, castañeda ss 27 motorcycle related cranio-maxillofacial injuries at a tertiary hospital in the philippines de la cruz rar, tuazon rs case reports 31 granulation tissue mimicking a glomus tumor in a patient with chronic middle ear infection ong kmc, labra pjp, ricalde rr, manasan cvc, carnate jm 36 rhinofacial conidiobolomycosis in a 16-year-old girl parilla xvc, cachuela je 41 relapsing polychondritis initially presenting with hoarseness and difficulty breathing in a 21-year-old male padua pf, lim wl 47 a 15-year occult foreign body in the subglottic area of a 50-year-old woman segocio djl, dayanghirang cd, cachuela je surgical innovations and instrumentation 51 true congenital macroglossia surgically managed using a modified kole technique smith jc, vicente gm 54 medialization thyroplasty using a pocket and silicone implant technique taningco mmf, ibay el featured grand rounds 58 meningioma in the middle ear: an unusual case of hearing loss lim dmd, yang nw from the viewbox 63 spontaneous middle fossa encephalocele yang nw under the microscope 65 low-grade cribriform cystadenocarcinoma of the parotid gland carnate jm passages 67 tierry f. garcia, md (1919-2016): the most good for the most people chiong cm 68 sarah d. moral-ramos, md (1979-2016): an old soul, gone too soon ong eav “huuuuge craniofacial av malformation” by adrian f. fernando, md “helping hands: ex utero intrapartum treatment to airway” by daryl anne a. del mundo, md “fruits and orange juice” 33”x43” acrylic on hardboard by mariano b. caparas, md “air by-pass” by rene louie c. gutierrez, md philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to present our surgical experience and technique in performing endoscopic sinus surgery for vascular sinonasal tumors without pre-operative embolization using intraoperative ligation of the external carotid artery or its distal branches. methods: design: retrospective series setting: tertiary private teaching hospital participants: seven patients results: out of 7 patients (5 males, 2 females, aged 12 to 64 years old) with non-embolized vascular sinonasal tumors, 2 had juvenile angiofibroma, 3 had a benign vascular tumor (hemangiopericytoma, hemangioma and a vasoformative solitary fibrous tumor), and 2 had a malignancy (rhabdomyosarcoma, squamous cell carcinoma). four (57.1%) had external carotid artery ligation, two (28.6%) had internal maxillary artery ligation and one (14.2%) had sphenopalatine artery ligation. the mean intraoperative blood loss was 2447.1 ml (range 900ml to 5,000ml) and average operation duration was 7.6 hours (range 2.9 hours to 14.5 hours). the average amount of transfused blood products was 1785.7ml (zero to 3,000ml). the average hospital stay was 7 days (range 2 to 13 days) with one post-operative complication (icu admission for hypotension from intraoperative blood loss). conclusion: intraoperative ligation of the eca or its distal branches to disrupt the vascular supply of sinonasal tumors may provide a viable means of preventing excessive intraoperative blood loss in patients with non-embolized vascular sinonasal tumors. keywords: endoscopic approach; ligation of blood supply; non-embolized; vascular sinonasal tumors vascular sinonasal tumors are neoplasms that include hemangiomas, angiofibromas and malignancies.1 the most documented of these is the juvenile angiofibroma (ja), with a range of presentation of around 9-19 years of age.2 various techniques have been used to treat sinonasal vascular tumors, with open techniques being replaced by endoscopic techniques due to decreased operative time and morbidity.2-3 more often than not, surgical excision involves preoperative super selective embolization (sse) to decrease intraoperative blood loss,3-6 making excision with sse the gold standard of treatment for sinonasal vascular tumors.7 however, sse has endoscopic management of sinonasal vascular tumors without embolization: our experience with vessel ligation vincent paolo k segovia, md peter simon r. jarin, md gianele ricca g. sucgang, md ear, nose, throat, head and neck institute the medical city correspondence: dr. peter simon r. jarin ear, nose, throat, head and neck institute the medical city ortigas avenue, pasig city 1605 philippines phone: +63 917 622 5176 email: jarinmd@msn.com the authors declared that this represents original material that is not being considered or publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by both authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest presented at philippine society of otolaryngology head and neck surgery descriptive research contest. november 8, 2021 philipp j otolaryngol head neck surg 2022; 37 (1): 23-26 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles its drawbacks, with complication rates as high as 20%, including such sequelae as blindness and stroke.7 aside from complications, the lack of ready availability and high costs of preoperative embolization pose challenges to both surgeon and patient. there are other techniques to reduce intraoperative blood loss in non-embolized sinonasal vascular tumors, but these are rarely documented. they include intraoperative external carotid artery (eca) ligation,2 sphenopalatine artery (spa) ligation,8 and (ligation/s performed by borghei et al.).9 however, to the best of our knowledge, based on a search of herdin plus, the asean citation index (aci), who global index medicus (western pacific region index medicus and index medicus of the southeast asia region), directory of open access journals, medline (pubmed) and google scholar, there are no local studies on such other techniques to reduce intraoperative blood loss in non-embolized sinonasal vascular tumors. in this paper, we report our surgical experience with endoscopic excision of sinonasal vascular tumors without pre-operative embolization, using intraoperative ligation of the eca or its distal branches. methods with institutional review board approval, this retrospective review of patient data considered for inclusion all patients who had a nonembolized vascular sinonasal tumor who underwent vessel ligation with endoscopic excision. cases evaluated for possible inclusion were derived from our census of surgical procedures performed over the past 2 years (2019 march 2021 january) at the medical city. the planned study population included all patients operated on by the authors with non-embolized vascular sinonasal tumors with intraoperative vessel ligation, from all age groups. exclusion criteria included records with incomplete descriptions of intraoperative technique or lack of immediate postoperative outcome documentation. an electronic chart review was performed to retrieve patient information. information such as profile, diagnostic procedures, intraoperative findings, and postoperative course in the wards were retrieved from the medical information documentation and access system (midas). retrieved information were tabulated in a microsoft excel for windows version 2202 build 16.0.14931.20118 (microsoft corp., redmond wa, usa) spreadsheet with specific alphanumerical coding. to protect patient confidentiality, all patient identifiers and associated data were only made accessible to the authors (pj, gs, vps). alphabetical coding was assigned to patients included in the study. data were tabulated according to their age, sex, diagnosis, type of vessel ligation, operative blood loss, operative duration, and postoperative outcome. measures of central tendency were used to present continuous variables while frequencies and percentages were used for categorical data. results a total of seven patients were operated on with non-embolized vascular sinonasal tumors using intraoperative vessel ligation during the study period. there were 5 males and 2 females, with ages ranging between 12 to 64 years old (median age 42 years; interquartile range 30 years). of the seven patients, 2 had a diagnosis of ja (stages iic and iiia), 3 had a benign vascular tumor with specific diagnoses of hemangiopericytoma, hemangioma and a vasoformative solitary fibrous tumor, while 2 had a malignancyrhabdomyosarcoma and squamous cell carcinoma stage iii (t3n0m0). of the seven, four (57.1%) patients had external carotid artery ligation, two (28.6%) had internal maxillary artery ligation and one (14.2%) had sphenopalatine artery ligation. in addition, various techniques were employed intraoperatively for hemostasis, including use of epinephrine as a decongestant and vasoconstrictor, use of bipolar cautery and harmonic scalpel for dissection of the tumor, and application of adsorbable hemostatic dressing such as oxidized regenerated cellulose (surgicel®) during the dissection. sevoflurane was administered to four out of seven patients (57.1%) while the remaining three patients (42.9%) received total intravenous anesthesia (tiva) with propofol. the mean intraoperative blood loss of the patients was 2447.1 ml, with a largest recorded blood loss of 5,000ml and a lowest blood loss of 900ml. the average operation duration was 7.6 hours (sd=4.3), with the shortest finished in 2.9 hours and the longest taking 14.5 hours. the average amount of transfused blood products was 1785.7ml. with a largest amount of 3,000ml while one of the seven patients did not need blood transfusion. the average hospital stay was 7 days (sd=4.2), the shortest being 2 days while the longest was 13 days. six out of seven patients did not experience postoperative complications (85.7%), while one experienced hypotension and was admitted in icu due to intraoperative blood loss. discussion the results of our experience in endoscopic excision of nonembolized vascular tumors suggest that intraoperative ligation of the eca or its terminal branches may be a viable alternative to embolization with a mean blood loss of 2447.1ml and an operative duration of 7.6 hours. these averages have a wide range with the lowest blood loss recorded at 900ml and highest at 5,000ml. operative duration had a wide range as well with the shortest duration at 2.9 hours and the longest at 14.5 hours. our numbers are higher than those reported by borghei et al. in philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles 600ml and 1,000ml.10 gupta et al. also described intraoperative blood loss in patients that underwent preoperative embolization for highstage ja with radkowski stage iiia or greater with an average blood loss of 1,500ml.6 lim et al. described their experience with embolized endoscopic excision of various sizes of ja with an average blood loss of 1000ml and range of 700ml to 1,500ml.5 in their study, tumors with radkowski stage i to iii had an average operative time of 2 hours whereas a radkowski stage iv tumor had an operative duration of 6 hours.5 operative duration for the present series for similarly staged jna tumors was more than twice the duration at 14 hours for ja stage iic and 10 hours for ja stage iiia. for the case of sinonasal hemangioma included in our present study, a blood loss of 1,000ml was noted. no pre-operative embolization was performed. instead, identification of the internal maxillary artery (figure 2) and bipolar electrocauterization (figure 3) was performed figure 2. internal maxillary artery prior to ligation: after performing a caldwellluc procedure to enter the maxillary sinus, the posterior maxillary wall was drilled to identify the feeding internal maxillary artery (arrow). figure 3. internal maxillary artery after electrocautery: bipolar electrocauterization of the internal maxillary artery prior to transection of the vessel (charred area). figure 1. ct scan of radkowski stage iic ja; axial cut a. and coronal cut b. occupying posterior half of nasal cavity, entire nasopharynx, pterygopalatine fossa, infratemporal fossa and floor of inferior orbital fissure. a b terms of blood loss, with 1,068ml for ja stage iia and 1,310ml for ja stage iib.9 however, it is important to consider the higher staging of ja included in the present series at stage iic (figure 1) with 2,000ml blood loss and iiia with 4,300ml blood loss. there is an even bigger discrepancy in the blood loss between our current study and the study of janakiram et al. who reported an average blood loss of 67.2ml and an average operative duration of 1 hour and 42 minutes.8 their study, however only included jna with tumor sizes up to radkowski stage iia.8 the difference in included tumor sizes and surgeon skill may definitely play a part in the discrepancies in blood loss between our current study and these two studies.8,9 compared to studies wherein preoperative embolization was performed, our current study also has higher blood losses and operative durations. kilde et al. reported 2 cases of sinonasal hemangioma wherein preoperative embolization was performed with blood losses of philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles acknowledgements we thank our medical city colleagues who provided insight and expertise that helped our research. we acknowledge the diligent documentation of the surgical teams involved. we thank mr. reginald arimado for his assistance with tabulation of and calculations on the collected data, and the consultant staff of the ear nose throat head and neck institute for their comments that greatly improved our research protocol and manuscript. references 1. fassih m, taali l, abada a, rouadi s, roubal m, mahtar m, et al. vascular tumors of the nasal cavities: a retrospective study of 10 cases. rev laryngol otol rhinol (bord). 2012;133(2):87-92. pubmed pmid: 23393743. 2. parsana m, patel k, gugliani a. endoscopic excision of juvenile nasopharyngeal angiofibroma: case series of 20 patients.  bengal journal of otolaryngology and head neck surgery. 2020 apr;28(1):76-79, doi:10.47210/bjohns.2020.v28i1.177. 3. oliveira jaa, tavares mg, aguiar cv, azevedo jf, sousa jr, almeida pc, et al. comparison between endoscopic and open surgery in 37 patients with nasopharyngeal angiofibroma. braz j otorhinolaryngol. 2012 feb;78(1):75-80. doi: 10.1590/s1808-86942012000100012; pubmed pmid: 22392242. 4. hassan s, abdullah j, abdullah b, wd sj, jaafar h, abdullah s. appraisal of clinical profile and management of juvenile nasopharyngeal angiofibroma in malaysia. malays j med sci. 2007 jan;14(1):18-22. pubmed pmid: 22593647; pubmed central pmcid: pmc3351213. 5. lim ly, mohamad i, tang ip. endoscopic excision of juvenile nasopharyngeal angiofibroma: a case series. egyptian journal of ear, nose, throat and allied sciences. 2016 dec; doi:10.1016/j. ejenta.2016.12.007. 6. gupta v, goyal s. endonasal endoscopic technique in management of juvenile nasopharyngeal angiofibroma our experience. global journal of otolaryngology. 2017 feb; doi:10.19080/ gjo.2017.03.555620. 7. garca mf, yuca sa, yuca k. juvenile nasopharyngeal angiofibroma. eur j gen med. 2010 oct;7(4):419-425 doi:10.29333/ejgm/82897. 8. janakiram tn, sharma sb, panicker vb. endoscopic excision of non-embolized juvenile nasopharyngeal angiofibroma: our technique. indian j otolaryngol head neck surg. 2016 sep;68(3):263-9. doi:10.1007/s12070-016-1013-1; pubmed pmid:  27508124; pubmed central pmcid: pmc4961649. 9. borghei p, baradaranfar mh, borghei sh, sokhandon f. transnasal endoscopic resection of juvenile nasopharyngeal angiofibroma without preoperative embolization. ear nose throat j. 2006 nov;85(11):740-3, 746. pubmed pmid: 17168151. 10. kilde jd, rhee js, balla aa, smith mm, smith tl. hemangioma of the sphenoid and ethmoid sinuses: two case reports. ear nose throat j. 2003 mar;82(3):217-21. pubmed pmid: 12696244 prior to transection to cut off the blood supply and decrease blood loss. dissection was carried out at the tumor attachment with a microdebrider, simultaneously using surgicel® for hemostasis. in our series, the vessel to be ligated or transected was selected by careful pre-operative evaluation of contrast ct scans to identify feeding vessels. for larger vascular tumors with more than one identified feeding vessel on the ct scan, external carotid artery ligation was performed through a 4cm horizontal incision over the lateral neck. after identification of the common carotid artery and its bifurcation, the external carotid artery was identified by tracing the superior thyroid artery. ligation of the external carotid artery was performed distal to the superior thyroid artery with two silk 2-0 sutures. no electrocautery or transection of the artery was done after ligation. our experience in this series suggests that the steps mentioned for hemostasis in non-embolized cases may be acceptable compared to preoperative embolization in terms of blood loss without any post-operative mortality. meticulous pre-operative planning with identification of feeding vasculature using ct scans is vital in determining the most appropriate vessel to ligate or transect. the combined use of bipolar cautery and harmonic scalpel in advanced stage ja tumors yielded successful outcomes without post-operative morbidity or mortality. the lack of financial resources or absence of facilities (instruments and equipment) for preoperative embolization should not prevent definitive treatment of sinonasal vascular tumors, by carrying out meticulous pre-operative planning and intraoperative measures needed to control bleeding. our study has several limitations. despite being conducted in a tertiary hospital, the review of records over the past 4 years only retrieved data on endoscopic excision of non-embolized vascular tumors with vessel ligation starting in march 2019. this yielded a small sample size. the study was likewise performed retrospectively wherein various factors were not explicitly recorded such as specifics on the type of anesthesia used, patient position during the operation, whether supine or reverse trendelenburg, and amount of decongestant used, to name a few. performing a prospective study to include more patients and taking note of the aforementioned variables may provide a more controlled dataset to describe the differences in performing surgery without embolization. furthermore, comparing patients operated on with and without embolization under the same surgeon can provide data for analysis between the two techniques. the mean blood loss and operative duration in the current series still exceeds reported numbers for patients who underwent preoperative embolization. however, the outcomes wherein no mortality was reported (with one morbidity of transient hypotension and temporary icu admission) suggest that ligation without embolization may provide physicians with an alternative surgical approach. despite its not being the accepted gold-standard of treatment for vascular sinonasal tumors, our surgical technique may offer an alternative treatment when there is a lack of resources. in conclusion, our initial series suggests that intraoperative ligation of the eca or its distal branches to disrupt the vascular supply of sinonasal tumors may provide a viable means of preventing excessive intraoperative blood loss in patients with non-embolized vascular sinonasal tumors. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery contents authorship controversies: gift, guest and ghost authorship morbidity outcomes of prophylactic central neck dissection with total thyroidectomy versus total thyroidectomy alone in patients with node-negative papillary thyroid cancer: a meta-analysis of observational studies levothyroxine versus levothyroxine with iodine in reduction of thyroid nodule volume: a double-blind randomized controlled trial the use of bony septum as an extended spreader graft in primary and secondary rhinoplasty clinical profile of filipino patients with epistaxis in a university hospital advanced laryngotracheal stenosis patients in a tertiary provincial government hospital: a prospective case series cover images editorial 4 authorship controversies: gift, guest and ghost authorship lapeña jf meta-analysis 6 morbidity outcomes of prophylactic central neck dissection with total thyroidectomy versus total thyroidectomy alone in patients with node-negative papillary thyroid cancer: a meta-analysis of observational studies sison czi, fernando af, gutierrez tmdg original articles 14 levothyroxine versus levothyroxine with iodine in reduction of thyroid nodule volume: a double-blind randomized controlled trial segocio djd, cachuela je 20 the use of bony septum as an extended spreader graft in primary and secondary rhinoplasty que-ansorge c, yap ec 26 clinical profile of filipino patients with epistaxis in a university hospital gutierrez tmd, lerma fjv 30 advanced laryngotracheal stenosis patients in a tertiary provincial government hospital: a prospective case series villanueva jvm, soriano rg 34 maxillary sinus squamous cell carcinoma in a tertiary hospital in the philippines hernandez akm, cabungcal aca 38 usability of a smartphone application for preoperative facial analysis for rhinoplasty among ent surgeons padua pfc, dela cruz apic, pascual rc, cambe smm case reports 44 aggressive tuberculous otitis media in a young child canta lab, dizon apje, abes fllb 48 non-traumatic cerebrospinal fluid leak from a sphenoid sinus midline roof defect previously managed as allergic rhinitis formalejo jpd, amable jpm 52 arteriovenous malformation of the mandible in a young postpartum woman mercado gag, delovino kae, carpela ab 56 intraosseus arteriovenous malformation of the mandible: extracorporeal curettage and immediate replantation tongol ea, pontejos aqy, fullante pb, cabungcal aca, ong kmc surgical innovation and instrumentation 60 autologous tracheal cartilage composite graft for a subglottic defect after laryngotracheal resection for invasive papillary thyroid carcinoma crisostomo mv, ureta cv featured grand rounds 64 solitary fibrous tumor of the larynx and anterior neck pabayos gs, chiong am under the microscope 68 intracapsular carcinoma ex pleomorphic adenoma carnate jm, masalunga mc “face mass” computer tomography digital imaging using mimics by rene louie c. gutierrez, md “stuck on you foreign body fish spine” karl storz endocam by rene louie c. gutierrez, md “mastoidectomy” sony rx100 m4 by aileen crystel d. abueva, md “shhh huwag mo akong ituro sa taya” canon powershot a620 by hypte raymund v. aujero, md “senile cat” 9x12 acrylic on hardboard by anna carlissa arriola-aujero, md maxillary sinus squamous cell carcinoma in a tertiary hospital in the philippines usability of a smartphone application for pre-operative facial analysis for rhinoplasty among ent surgeons aggressive tuberculous otitis media in a young child non-traumatic cerebrospinal fluid leak from a sphenoid sinus midline roof defect previously managed as allergic rhinitis arteriovenous malformation of the mandible in a young postpartum woman intraosseus arteriovenous malformation of the mandible: extracorporeal curettage and immediate replantation autologous tracheal cartilage composite graft for a subglottic defect after laryngotracheal resection for invasive papillary thyroid carcinoma solitary fibrous tumor of the larynx and anterior neck intracapsular carcinoma ex pleomorphic adenoma philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles philippine journal of otolaryngology-head and neck surgery 23 abstract objective: to determine if the anatomic dimensions (length, cross-sectional width, cortical thickness) of the filipino fibula are ideal for mandibular reconstruction. methods: design: cross-sectional study setting: anatomy dissection laboratory participants: 40 fibulas from 20 adult cadavers results: morphometric examination showed the mean length of the harvested fibulas was 33.5 cm. the mean horizontal (a-d) and vertical (b-c) widths of the proximal cross-section (point b) were 15.1 ± 0.28 mm and 9.9 ± 0.15 mm respectively. the mean horizontal (a-d) and vertical (b-c) widths of the distal cross-section (point d) were 15.4 ± 0.24 mm and 10.3 ± 0.49 mm, respectively. the mean cortical thickness of the anterior (a), lateral (b), posterior (c) and medial (d) aspects of the proximal cross-section (point b) were 5.2 ± 0.1 mm, 3.2 ± 0.04 mm, 3.6 ± 0.01 mm, and 2.9 ± 0.06 mm, respectively. the mean cortical thickness of the anterior (a), lateral (b), posterior (c) and medial (d) aspects of the distal cross-section (point d) were 5.1 ± 0.21 mm, 3.1 ± 0.11 mm, 3.5 ± 0.04 mm, and 2.9 ± 0.09 mm, respectively. conclusion: our findings show that the filipino fibulas studied have dimensions that are ideal for mandibular reconstruction. keywords: mandibular reconstruction, fibula, free flaps, fibular bone dimensions, filipino over the past years, the fibular free flap has been considered the workhorse for mandibular reconstruction, having all the ideal features of adequate length, width, bone quantity and quality, and good success rate.1 in the philippines, the fibular free flap has been previously described for head and neck reconstruction particularly for segmental mandibular defects and as a condylar autograft since 2005.2 although great success has been encountered locally in terms of its survival, evaluation of its dimensions especially for dental restoration remains a challenge. fibular dimensions for mandibular reconstruction among filipinos nikkoh p. muñoz, md1 adrian f. fernando, md1 samantha s. castañeda, md1,2 department of otorhinolaryngology head and neck surgery1 the medical city ateneo school of medicine and public health2 correspondence: dr. adrian f. fernando department of otorhinolaryngology head and neck surgery the medical city ortigas avenue, pasig city 1600 philippines phone: (632) 635 6789 local 6250 fax: (632) 687 3349 email: ent@medicalcity.com.ph the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2017; 32 (1): 23-26 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 24 philippine journal of otolaryngology-head and neck surgery original articles to the best of our knowledge, based on a search of medline pubmed, wprim and google scholar using the keywords “mandibular reconstruction,” “fibula,” “free flap/s,” and “fibular bone dimensions,” data on the anatomic dimensions of the filipino fibula has not yet been published to show if it meets ideal dimensions for mandibular reconstruction. this study aims to determine the suitability of anatomic dimensions of harvested fibulae for mandibular reconstruction in filipinos in terms of length (cm) from fibular head to the lateral malleolus, cross-sectional width (mm) along pre-determined segments and cross-sectional cortical bone thickness (mm) along pre-determined segments. methods with institutional review board approval, 40 fibulas of 20 formalinpreserved cadavers consisting of 12 males and 8 females located in the anatomy dissection laboratory of the ateneo school of medicine and public health were harvested and measured. the number of available cadavers determined our sample size. measurement of fibular length the fibulas were exposed along their length. for each fibula, the apex of the fibular head and apical margin of the lateral malleolus were referred to as ‘a’ and ‘e’, respectively. (figure 1) the segment a-e was divided into 4 segments. point ‘c’ was midline and point ‘b’ and ‘d’ were marked 4 cm above and below point ‘c’ corresponding to the standard osteotomy sites in harvesting the fibula for free tissue marked with points “a”, “b”, and “c” referred respectively as its anterior margin, medial crest and lateral margins. (figure 2) the mid portion from points “b” and “c” was marked as point “d”. the distance between points “a” and “d” was used to measure the vertical width of the fibular cross section while the distance from points “b” and “c” was used to measure its horizontal width. measurements of cross-sectional width were sequentially obtained by two separate observers using a single 3.5” castroviejo caliper (braun aesculap inc., pa, usa) and recorded in millimeters, averaged and tabulated. figure 1. transverse view of fibula showing segments used as reference transfer. measurements were sequentially obtained by two separate observers using a single soft tape measure (tr-13w tailor’s tape, the perfect measuring tape company, portland, or, usa) and recorded in millimeters. a single recorded discrepancy above 10mm was verified by re-measurement and consensus before recorded measurements were averaged and tabulated. measurement of cross-sectional width osteotomies were performed on each fibula using a single oscillating saw (mopec autopsy saw, stryker®, mi, usa) at points ‘b’ and ‘d’ corresponding to the actual osteotomy sites for fibular harvesting. the cross section of the segmentally osteotomized fibula were figure 2. model showing how cross-sectional width was determined figure 3. model showing how cross-sectional cortical bone thickness was determined measurement of cross-sectional cortical bone thickness at points b and d of each fibular segment, cortical bone thickness was sequentially measured by two separate observers using the same caliper at its anterior, lateral, posterior and medial aspects that were respectively marked as points [a], [b], [c], and [d]. (figure 3) philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles philippine journal of otolaryngology-head and neck surgery 25 statistical analysis each distance was separately measured by 2 observers and encoded on ms excel 2010 (microsoft corporation, redwood wa, usa) for statistical data analysis using percentages, means and standard deviation. discrepancies in measurements obtained by the two observers were insignificant (sub-centimeter) and simply averaged, except for the previously mentioned readings of fibular length of >10 mm that were re-measured to obtain a consensus. results forty fibulas were successfully harvested and measured from 20 cadavers, of which there were 12 males (60 %) and 8 females (40 %) with a 3:2 male to female ratio. fibular length and cross-sectional width at various segments the mean length of the harvested fibulas was 33.5 cm. the mean horizontal (a-d) and vertical (b-c) widths of the proximal cross-section (point b) were 15.1 ± 0.28 mm and 9.9 ± 0.15 mm, respectively. the mean horizontal (a-d) and vertical (b-c) widths of the distal crosssection (point d) were 15.4 ± 0.24 mm and 10.3 ± 0.49 mm, respectively. (figure 2) thickness of cortical bone in various cross-sectional levels the mean cortical thickness of the anterior (a), lateral (b), posterior (c) and medial (d) aspects of the proximal cross-section (point b) were 5.2 ± 0.1 mm, 3.2 ± 0.04 mm, 3.6 ± 0.01 mm, and 2.9 ± 0.06 mm respectively. the mean cortical thickness of the anterior (a), lateral (b), posterior (c) and medial (d) aspects of the distal cross-section (point d) were 5.1 ± 0.21 mm, 3.1 ± 0.11 mm, 3.5 ± 0.04 mm, and 2.9 ± 0.09 mm, respectively. (figure 3) discussion the osteocutaneous fibula free flap (offf) presents numerous advantages. the bony architecture is similar to that of the mandible, which on cross section shows a marble-like bone structure of thick compact layer giving an excellent anchorage for dental implants unlike iliac crest or scapula.3 the fibula also shows similarity to mandibular width and shape, and this also facilitates the insertion of dental implants. a study by huryn et al.4 showed that fibula free flaps behave like an edentulous mandible. thus, osseointegration can generally be expected. the grafts can easily be adjusted to the curvature of the mandible using osteotomy or the intersection technique. owing to its extensive vascular network, the diaphysis of the fibula can be osteotomized into different segments without danger of necrosis. germain et al.5 reported that the fibula can provide up to 25 cm of bone for harvesting and it is necessary to preserve 6 – 7 cm of bone distally and proximally to maintain the integrity of the knee and ankle joint. uchiyama et al.6 showed that it is necessary to preserve at least 6 cm of bone and that the distal fibula is responsible for stabilizing the ankle mortise during external rotation and inversion. the fibula is a long thin non weight-bearing bone of the lower extremity. frodel et al.7 measured the height and weight of the fibula and the cortical thickness in transverse cross sections. it is one of the strongest bones available for transfer due to its tubular shape with thick cortical bone around the entire circumference.7 analysis of our data suggests that the filipino fibulas sampled have adequate length for mandibular reconstruction. the average length was noted to be 33.5 cm. sparing the necessary 6 cm (proximally and distally) to retain stability of the knee and ankle joint would still leave 21.5 cm of bone for mandibular reconstruction. a study by apinhasmit et al.8 showed mean total fibular length and mean length of harvested fibulae were 34.2 +/2.3 cm and 18.2 +/2.3 cm, respectively. a harvested fibula of 16 to 20 cm in length is sufficient to provide bone for reconstructing mandible defects.8 the fibulas were also noted to have a cross-sectional width of no less than 8 mm with the greatest diameter at segment a-d (15.4 mm). this was consistent with the study by matsuura et al.,9 where segment a-d was the longest in cross sections at c, d and e. the a-d segment or the anterior margin of the fibula is often used to reconstruct the alveolar crest and the lateral surface of the fibula or the b-c segment is used to reconstruct the labiobuccal aspect. these findings should be useful for mandibular reconstruction. in our study, the greatest cortical thickness was noted to be 6.5 mm with a mean of 5.2 mm at point a. this is again consistent with the study of matsuura et al.9 which showed the greatest cortical thickness at apex a (4.1 mm). this is useful for osseointegrated implants, considering that osseointegrated implants have a width of 4 mm, the fibula then has adequate cortical bone to surround the implant for better stability and thus success of the osseointegration.10 the use of osseointegrated implants restores both function and aesthetics. according to anne-gaelle et al.,11 the success rate for osteointegration ranges from 86% to 99%. mandibular reconstruction by microvascular fibula free flap has dramatically improved the quality of life of patients treated by surgery. the offf has its limitations. because of its limited height (rarely more than 15 mm) compared with the height of the mandible, vertical distance between the reconstructed segment and the occlusal plane can be substantial. to address this, choo-lee et al.12 showed that vertical philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 26 philippine journal of otolaryngology-head and neck surgery original articles references 1. akheel m, tomar ss, bhargava a. vascularized free fibula flap for reconstruction of mandibular defects. j surg. special issue: craniofacial surgery. 2014 dec; 2(6-1): 1-5. doi: 10.11648/j. js.s.2014020601.11. 2. yao m, castaneda s, david j, alonzo d. condylar autograft with fibular free flap for mandibular reconstruction. philipp j otolaryngol head neck surg. 2005; 20 (1-2): 31-38. 3. stoll p. indications and technical considerations of different fibula grafts. in: greenberg am, prein j (editors). craniomaxillofacial reconstructive and corrective bone surgery: principles of internal fixation using the ao/asif technique. ny: springer-verlag; 2002. 327-334. 4. huryn jm, zlotolow jm, piro jd, lenchewski e. osseointegrated implants in microvascular fibula free flap reconstructed mandible. j prosthet dent. 1993;70:443. pmid: 8254548. germain ma, gomez ng, demers g, hureau j. anatomic basis of mandibular reconstruction by 5. free vascularized fibula graft. surg radiol anat 1993;15:213–214. pmid: 8235966. uchiyama e, suzuki d, kura h, yamashita t, murakami g. distal fibular length needed for ankle 6. stability. foot ankle int. 2006 mar; 27(3): 185-189. doi: 10.1177/107110070602700306; pmid: 16539900. frodel jl jr, funk gf, capper dt, fridrich kl, blumer jr, haller jr, et al. osseointegrated implants: 7. a comparative study of bone thickness in four vascularized bone flaps. plast reconstr surg 1993 sep;92:(3): 449-455. pmid: 8341743. apinhasmit w, sinpitaksakul p, chompoopong s. anatomical considerations of the thai fibula 8. used as a fibula osteocutaneous free flap in mandibular reconstruction and dental implant placement. j med assoc thai. 2012 apr; 95(4): 561-8. pmid: 22612012. matsuura m, ohno k, michi k, egawa k, takiguchi r. clinicoanatomic examination of the fibula: 9. anatomic basis for dental implant placement. int j oral maxillofac implants. 1999 nov-dec; 14(6): 879–884. pmid: 10612927. teoh kh, huryn jm, patel s, halpern j, tunick s, wong hb, et al. implant prosthodontic 10. rehabilitation of fibula free-flap reconstructed mandibles: a memorial sloan-kettering cancer center review of prognostic factors and implant outcomes. int j oral maxillofac implants. 2005 sep-oct; 20(5):738-46. pmid: 16274148. anne-gaelle b, samuel s, julie b, renaud l, pierre b. dental implant placement after 11. mandibular reconstruction by microvascular free fibula flap: current knowledge and remaining questions. oral oncol. 2011 dec; 47(12):1099-104. epub 2011 aug 27. doi: 10.1016/j. oraloncology.2011.07.016. pmid: 21873106. cho-lee gy, naval-gías l, martos-díaz pl, gonzález-garcía r, rodríguez-campo fj. vertical 12. distraction osteogenesis of a free vascularized fibula flap in a reconstructed hemimandible for mandibular reconstruction and optimization of the implant prosthetic rehabilitation. report of a case. med oral patol oral cir bucal. 2011 jan 1;16(1):e74-8. pmid: 20711151. distraction osteogenesis of free vascularized flaps is a reliable technique that optimizes implant positioning for ideal prosthetic rehabilitation, after mandibular reconstruction following tumor surgery. despite the sample size limitation imposed by the availability of cadavers, our study shows that the anatomic dimensions (length, cross-sectional width, cortical thickness) of the filipino fibulas studied are sufficient for mandibular reconstruction. however, the sample of cadavers dissected may not be representative of the larger filipino population, limiting the generalizability of our findings. subsequent studies that are more representative may be more generalizable. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 case reports philipp j otolaryngol head neck surg 2021; 36 (2): 36-39 c philippine society of otolaryngology – head and neck surgery, inc. approach to a sewing needle in the parapharyngeal space: a case report vishaka bettadahalli, ms (ent), mrcsed (ent)1,2 rahul bhargava, ms (ent), dnb1,3 sunil kumar, ms (ent), dnb1 1department of ent and head neck surgery lady hardinge medical college 2department of ent the queen elizabeth hospital king’s lynn nhs foundation trust 3smi saroj medical institute, delhi correspondence: dr. vishaka bettadahalli department of ent the queen elizabeth hospital king’s lynn nhs foundation trust gayton road, king’s lynn, pe30 4et united kingdom phone: +4474 4800 3822 email: vishakab.l@gmail.com the authors declared that this presents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and the author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationship, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international abstract objective: to describe a unique situation of a sewing needle lodged in the parapharyngeal space and elucidate the problems encountered in its successful removal. methods: design: case report setting: tertiary private hospital patient: one result: a 24-year-old male tailor accidentally swallowed a sewing needle that pierced the oropharyngeal wall and was wedged in the parapharyngeal space. after a thorough physical examination, 70 degree rod endoscopy, radiography and doppler ultrasonography and intraoperative c-arm x-ray for intraoperative localization and as a guide for extraction all yielded less than optimal guidance. although an intra-oral approach was initially taken, the transcervical approach provided the best access. conclusion: removal of a sharp foreign body in the parapharyngeal space should be considered a surgical emergency owing to its close proximity to vital structures and the potential for serious complications. identifying the exact location may require a variety of imaging modalities, and foreign body extraction may entail multiple surgical approaches. keywords: foreign body; sewing needle; parapharyngeal space; surgical emergency although common in the pediatric population, aero-digestive foreign bodies are infrequent in adults. commonly encountered pharyngeal foreign bodies are coins, batteries, fishbones, chicken bones, buttons, dentures, pins and earrings.1 foreign bodies in the parapharyngeal space are mainly dental needles, suture needles, broken implants, a third molar and broken toothbrush.1–3 a sewing needle piercing the pharyngeal wall to lodge in the parapharyngeal space is a very uncommon foreign body.3–5 there have been instances of needle and fishbone philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 case reports foreign bodies migrating into the posterior cervical space, lodging in deep neck spaces, posterior pharyngeal wall, hypopharynx, thyroid gland and even piercing the carotid reported in the literature.6–8 we report the case of a foreign body sewing needle embedded in the parapharyngeal space. case report a 24-year-old male tailor was referred from a secondary care center to our tertiary care ent emergency with complaints of accidental displacement of a sewing needle into his mouth while he was holding it between the lips. he complained of a pricking sensation in his right tonsillar fossa with odynophagia for 6 hours. there were no other symptoms such as pain associated with neck movements or any neck swellings. after a thorough examination, the oral cavity, oropharynx and neck were unremarkable. the foreign body was neither seen nor could it be palpated in the tonsillar fossa or base of the tongue. a 70-degree rod endoscopy of the oropharynx, hypopharynx and larynx did not reveal any foreign body. a plain soft tissue neck x-ray showed a metallic sewing needle lying obliquely in the right parapharyngeal region opposite c1-c3 vertebra with its eye superiorly near the skull-base and the sharp end towards the tonsillar fossa. (figure 1) doppler ultrasonography of the neck revealed the needle lying close to the great vessels in the parapharyngeal space. (figure 2) considering the symptoms, the nature of the foreign body and potential complications, an urgent removal was planned. under general anesthesia, futile attempts were made to palpate the right tonsillar fossa and the base of the tongue. the anteroposterior image from the c-arm suggested that the sharp end could be embedded in the tonsillar fossa. (figure 3) therefore, right unilateral tonsillectomy was done, and the tonsillar fossa was explored to see and palpate the needle. however, nothing was palpated and the incision was extended over the retromolar trigone and anterior pillar to provide better exposure of the parapharyngeal space but the needle was not traced. intraoperative c-arm guidance was also used to delineate the needle in the parapharyngeal space (figure 3), but we could not locate the needle with accuracy since it did not provide a 3-dimensional picture. thereafter, a transcervical approach was undertaken through a horizontal neck crease incision. the anterior border of the sternocleidomastoid and posterior belly of the digastric were identified and soft tissue dissected to approach the parapharyngeal space. a curved mosquito forceps was used as a marker during the c-arm imaging to locate the site of the needle. (figure 4) however, the needle still could not be located. angular mandibulotomy was performed and the ramus of the mandible was retracted anteriorly for better exposure. once the ramus of the mandible was retracted anteriorly we were able to locate the needle medial to the styloid process at the skull-base. (figure 5) the 4.2 cm needle was removed carefully without any vascular or neurological complications. (figure 6) the mandibulotomy was fixed with mini plates and the wound closed in layers. the postoperative period was uneventful and the patient was discharged on the 4th postoperative day. discussion fishbone and chicken bone are the most commonly encountered pharyngeal foreign bodies in adults.2,9,10 a sharp metallic foreign body migrating into the parapharyngeal space has seldom been reported in the literature.3,6,10 to the best of our knowledge, based on a search of pubmed (medline; pubmed central), google scholar, scopus, and index medicus using the search terms “parapharyngeal space,” “sewing needle,” “needle,” and “sharp foreign body,” this is only the second case of a sewing needle migrating into the parapharyngeal space posing a threat to major vessels in the neck. the parapharyngeal space is an inverted pyramidal-shaped space lateral to the constrictor muscles of the pharynx with its base at the skull-base and apex at the greater cornu of the hyoid bone. it is a potential space which is filled with loose connective tissue and neurovascular bundle. its major contents are the carotid sheath and its contents, sympathetic chain, glossopharyngeal, hypoglossal, accessory nerves and a part of the maxillary artery.6,10 a foreign body in the parapharyngeal space can cause injury to these vital structures. a sharp foreign body can migrate into this space and further into other spaces. it is postulated that the contraction of the pharyngeal musculature and the movement of the viscera are responsible for the migration of sharp objects in these spaces.3,4,8,10,11 a foreign body lodged in the parapharyngeal space can lead to deep neck abscess, jugular vein thrombosis, internal carotid artery aneurysm, and fistula.8,9,12 a sharp foreign body can migrate through the pharynx into other surrounding spaces. therefore, any sharp foreign body should be treated as a surgical emergency. migration of foreign body through carotid and jugular vein and injury to the cranial nerves has been reported earlier in the literature.4,8 foreign body sensation in the throat, dysphagia, odynophagia, neck swelling and pain associated with neck movements are the frequently encountered symptoms.9 dyspnea has been seen in cases with delayed presentations involving the hypopharynx and retropharyngeal area.9 a plain x-ray should be the first investigation ordered in such cases. sometimes a small piece of chicken bone or fishbone and a radiolucent foreign body might be missed in a plain x-ray. doppler ultrasound may help in identifying the relation of the vital structures in the neck to the foreign body as in the present case. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 case reports the parapharyngeal space can be reached externally through transcervical, submandibular and transparotid approaches.10,13 in the present case, we removed the needle through a transcervical approach with angular mandibulotomy since we were unable to locate the needle using a transoral approach. the external approach provided good exposure compared to the transoral approach. the external approach also provided better control over the surgical field in the event of any vascular injuries. angular mandibulotomy and anterior retraction of the mandibular ramus provided better exposure of the parapharyngeal space. the external approach has been recommended as the method of choice for removal of large foreign bodies of the parapharyngeal space by burduk, providing good exposure to the neurovascular structures in the space.12 although an intra-operative c-arm could be used for guidance to localize the site of the foreign body, it was not much help to us in this case, perhaps also because we seldom use the c-arm in ent at our center. further paraphernalia associated with its use was also very cumbersome. there is no consensus regarding the usage of c-arm guidance for such cases in the literature.3 while a preoperative ct scan may help in localizing the site, approximating the size and its relation to the adjacent structures in a radiolucent foreign body,12 significant scatter artifacts are a limitation of ct for metallic objects. in retrospect, an intraoperative x-ray with application of markers to determine the relative position and distances of the foreign body in the surgical field may have been simpler and more helpful. sharp foreign bodies embedded in the parapharyngeal space are extremely rare. this report highlights the difficulties faced by the surgeons in managing such a case in a setting with limited resources. hopefully, readers will be able to easily identify these and plan well to manage such cases. even though this report may not add any new figure 1. lateral plain soft tissue neck x-ray showing the sewing needle opposite c1-3 vertebrae figure 3. intraoperative c-arm image (anteroposterior) showing needle with sharp end in right tonsil fossa (asterisk) figure 2. doppler ultrasonogram showing the needle (2-head arrow) and its relation to great vessels (asterisk) figure 4. intraoperative c-arm image (lateral) with curved mosquito forceps marker figure 5. needle in parapharyngeal space, medial to tip of styloid process (arrow); ramus of mandible retracted anteriorly (asterisk); posterior belly of digastric reflected posteriorly (lower retractor) figure 6. needle after extraction, measuring 4.2cm philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 case reports references 1. arora s, sharma jk, pippal sk, sethi y, yadav a, brajpuria s. an unusual foreign body (sewing needle tip) in the tonsils. braz j otorhinolaryngol. nov-dec 2009;75(6):908. doi: 10.1016/s18088694(15)30558-9; pubmed pmid: 20209296. 2. goswami s. the head of a broken toothbrush in the parapharyngeal space: a rare case report. j indian soc periodontol. jan-feb 2016;20(1):79-81. doi: 10.4103/0972-124x.164763; pubmed pmid: 27041844; pubmed central pmcid: pmc4795142. 3. okumura y, hidaka h, seiji k, nomura k, takata y, suzuki t, et al. unique migration of a dental needle into the parapharyngeal space: successful removal by an intraoral approach and simulation for tracking visibility in x-ray fluoroscopy. ann otol rhinol laryngol. 2015 feb;124(2):162–7. doi: 10.1177/0003489414547106; pubmed pmid: 25139135. 4. joshi aa, bradoo ra. a foreign body in the pharynx migrating through the internal jugular vein. am j otolaryngol. mar-apr 2003;24(2):89-91. doi: 10.1053/ajot.2003.20; pubmed pmid: 12649822. 5. yi g, bai z, shi j. [a case of foreign bodies in parapharyngeal space]. zhonghua er bi yan hou tou jing wai ke za zhi. 2007 dec;42(12):938. pubmed pmid: 18335754. 6. ho as, morzaria s, damrose ej. management of intraoral needle migration into the posterior cervical space. auris nasus larynx. 2011 dec;38(6):747–9. doi: 10.1016/j.anl.2011.01.003; pubmed pmid: 21324618. 7. borisov aa, loba mm. [removal of a sewing needle from the soft tissues of the posterior wall of the pharynx]. zh ushn nos gorl bolezn. nov-dec 1975;(6):86-7. pubmed pmid: 1227148. 8. johari hh, khaw b-l, yusof z, mohamad i. migrating fish bone piercing the common carotid artery, thyroid gland and causing deep neck abscess. world j clin cases. 2016 nov 16;4(11):375– 9. doi: 10.12998/wjcc.v4.i11.375; pubmed pmid: 27900327; pubmed central pmcid: pmc5112358. 9. unadkat sn, talwar r, tolley n. the eye in the neck: removal of a sewing needle from the posterior pharyngeal wall. case rep med. 2010;2010:608343. doi: 10.1155/2010/608343; pubmed pmid: 21209816; pubmed central pmcid: pmc3014824. 10. aydogan b, soylu l, tuncer u, akçali a. parapharyngeal foreign body. otolaryngol head neck surg. 2001 oct;125(4):424–5. doi: 10.1067/mhn.2001.115763; pubmed pmid: 11593189. 11. osinubi oa, osiname ai, pal a, lonsdale rj, butcher c. foreign body in the throat migrating through the common carotid artery. j laryngol otol. 1996 aug;110(8):793–5. doi: 10.1017/ s0022215100134991; pubmed pmid: 8869621. 12. burduk pk. parapharyngeal space foreign body. eur arch otorhinolaryngol. 2006 aug;263(8):772– 4. doi: 10.1007/s00405-006-0068-0; pubmed pmid: 16786366. 13. gao j, zhang b, zheng d, luo x. [surgical treatment experience of different approaches in eight cases with parapharyngeal space foreign bodies]. lin chung er bi yan hou tou jing wai ke za zhi. 2015 nov;29(21):1903–5. pubmed pmid: 26930916. knowledge to what is already known, it demonstrates how these cases could be handled (or handled differently) in a setting with limited resources. our experience suggests that all cases with a history of foreign body ingestion should be examined thoroughly with a high index of suspicion and anteroposterior and lateral soft tissue neck x-ray views with markers be initially obtained. management of a sharp foreign body should be considered a surgical emergency owing to its close proximity to vital structures and the potential for serious complications. identifying the exact location may require a variety of imaging modalities, and foreign body extraction may entail multiple surgical approaches. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 8382 philippine journal of otolaryngology-head and neck surgery passages carlos potenciano reyes, md (1940 2020) little-known but significant pioneer generoso t. abes, md, mph consultants and more senior coresident physicians at the philippine general hospital (pgh) would call him “caloy.” hardly would i hear anybody (including our ent department secretary) address him as dr. reyes. this was not because he was not a respected faculty member. rather, he was everybody’s friend and he probably preferred to be addressed by his nickname. dr. carlos p. reyes was a tall, friendly guy, easily recognizable while walking through the short pgh corridor stretching from the old ent ward (ward 3) to the old ent operating room (or) called floor 15, later designated as the pgh nursing office. he would almost always be holding either an expensive photography camera, electronic gadget, ent or instrument, or car magazines – suggesting his varied interests aside from having good knowledge of otolaryngology, particularly otology. he would usually stop and chat with an acquaintance about his new medical or non-medical interests. i first met dr. caloy when i was the first year resident assigned to the otology section. he would call me “ging” while presenting the ear patients at the outpatient department (opd) ear clinic, only to learn later that he would address all unfamiliar persons by that name. he was kind, helpful and very understanding. equipped with ample information in otology he gathered from postgraduate studies abroad, he would selflessly share these with the residents in order to sharpen our diagnostic acumen. he would instruct us to rely on concise yet complete clinical examination, involving audiologic evaluation tools and meager radiologic information in considering differential diagnoses. he was quite willing to assist us in our learning processes, particularly on how to distinguish middle ear from inner ear disorders, and cochlear versus retrocochlear diseases. since we did not have any audiologist at that time, he admonished us to carry out the needed audiometric evaluations on our ear patients ourselves in order to learn both the techniques of the procedures and their limitations. hence, after the opd clinic we would not only perform routine pure tone and speech audiometric tests but also special examinations like the bekesy test, short increment sensitivity index (sisi) test, alternate binaural loudness balance (ablb) test and the test for tone decay. we would then discuss the test results during our next ear clinic and we would listen and be amazed at how dr. caloy would integrate the information and arrive at the complex diagnosis. dr. caloy was our mentor at the time when refinements in tympanoplasty and mastoidectomy aroused the excitement and imagination of budding otologists worldwide. whereas canal down mastoidectomy was the usual norm to safely remove common mastoid pathology like cholesteatoma, dr. caloy introduced the concept of intact canal wall mastoidectomy that avoids or mitigates recurrent postoperative cleaning of the mastoid bone. the period was also the dawn of neuro-otology when dr. william house popularized the transmastoid approach for acoustic neuroma and the endolymphatic mastoid shunt as treatment for meniere’s disease. in order to teach us the anatomical and surgical principles of performing these procedures, dr. caloy set up the first temporal bone dissection laboratory in the country at the mezzanine above the ent conference room. he would offer the course to all ent residents-in-training and consultants nationwide. he practically revolutionized the method of otologic surgery by requiring ent surgeons to practice doing ear surgery in the temporal bone dissection lab prior to performing ear surgeries in the operating room. in addition, he advocated the use of the operating microscope and dental drills in place of the old bone gouges, chisels and bone ronguers. his ideas were later adopted by other ent training institutions as we see today. the requirement that every ent resident must undergo temporal bone dissection in the course of his training obviously stemmed from the efforts of dr. caloy. many senior ent consultants who are still with us today were former students of dr. caloy in his temporal bone lab. unfortunately, before finishing my residency training, dr caloy expeditiously left the pgh ent department for unknown reasons. he then set up his private clinic in quezon city and later joined the ent department of university of santo tomas. reflecting on the significant yet probably unknown achievements of dr. caloy toward the advancement of otology and neuro-otology in our country, i realize how blessed i was to be one of his students during that brief period when he was still with us at up-pgh. with our profound gratitude sir, we will always remember you. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 7372 philippine journal of otolaryngology-head and neck surgery passages oliverio o. segura, md (1933-2021) through a son’s eyes – a tribute to dad peter paul r. segura, md pgh in the late 50’s, he hinted that if i finished my medical schooling in cdcm that i consider otorhinolaryngology as a residency program and that up-pgh would be a good training center. i ended up inheriting the orl practice of my dad mostly, who taught me some of ophthalmology outpatient procedures. dad showed me clinical and surgical techniques in ent management especially how to deal with patients beyond being a doctor! you don’t learn this in books but from experience. i learned a lot from my dad. just so lucky i guess! he actually designed and made his own ent treatment unit, which i’m still using to this day (with some modifications of my own). and he created a certain electrically powered ‘eye magnet’ with the help of my cousin (who’s an engineer now in chicago) which can attract metallic foreign bodies from within the eyeball to the surface so they can easily be picked out – it really works! dad loved to travel in his younger years especially abroad for conventions or just simply leisure or vacations, most of the time with my mom. but as he was getting older, travels became uncomfortable. his last travel with me was in 2012 for the aao-hns convention in washington dc. it was a great time as we then proceeded to a us navy airshow in nearby virginia after the convention, meeting up with my brother who is retired from the usn. then we took the train to new york and stayed with my sister who is a picu nurse in ny presbyterian. then off to missouri and ohio visiting the national museum of the us air force, the largest military aircraft museum in the world. for years, dad had been battling with heredofamilial-hypercholesterolemia problem which took its toll on his liver and made him weak and tired but still he practiced and continued teaching and sharing his knowledge until he retired at the age of 80. by then, my wife and i would take him and my mom out on weekends, he loved to be driven around and eat in different places. i really witnessed and have seen how he suffered from his illness in his final years. but he never showed it or complained, never even wanted to use a cane! he didn’t want to be a burden to anyone. what most affected me was that my dad passed and i wasn’t even there. i had helped call for a physician to rush to the house and had oxygen cylinders to be brought for him as his end stage liver cirrhosis was causing cardio-pulmonary complications (non-covid). amidst all this i was the one admitted for 14 days because of covid-19 pneumonia. my dad passed away peacefully at home as i was being discharged from the hospital. he was 88. i never reached him just to say good bye and cried when i reached home still dyspneic recovering from the viral pneumonia. i realized from my loved ones who told me that dad didn’t want me to stress out taking care of him, as i’ve been doing ever since, but instead to rest and recuperate myself. i cried again with that thought. in my view, he was not only a great physician and surgeon but also the greatest dad. he lived a full life and touched so many lives with his treatments, charity services and teaching new physicians. it’s seeing, remembering and carrying on what he showed and taught us that really makes us miss him. i really love and miss my dad and with a smile on my face, i see he’s also happy to be with his brothers and sisters who passed on ahead. and that he’s rested. he is a man content, i remember he always said this, ‘ as long as i have a roof over my head and a bed to rest my back, i’m okay!” i was born and raised in the old mining town of barrio das (don andres soriano), lutopan, toledo city where atlas consolidated mining and development corp. (acmdc) is situated. dad started his practice in the company’s hospital as an eent specialist in the early 60’s and was the ‘go to’ eent doc not only of nearby towns or cities (including cebu city) but also the surrounding provinces in the early 70’s. in my elementary years, he was assistant director of acmdc hospital (we lived just behind in company housing, only a 3-minute walk). i grew interested in what my dad did, sometimes staying in his clinic an hour or so after school, amazed at how efficiently he handled his patients who always felt so satisfied seeing him. at the end of the day, there was always ‘buyot’ (basket) of vegetables, live chickens, freshwater crabs, crayfish, catfish or tilapia. i wondered if he went marketing earlier, but knew he was too busy for that (and mom did that) until i noticed endless lines of patients outside and remembered when he would say: “being a doctor here you’ll never go hungry!” i later realized they were pfs (professional fees) of his patients. as a company doctor, dad received a fixed salary, free housing, utilities, gasoline, schooling for kids and a company car. it was the perfect life! the company even sponsored his further training in johns-hopkins, baltimore, usa. a family man, he loved us so much and was a bit of a joker too, especially at mealtimes. dad’s daily routine was from 8 am – 5 pm and changed into his tennis, pelota, or badminton outfit. he was the athlete, winning trophies and medals in local sports matches. dad wanted me to go to the university of the philippines (up) high school in the city. i thought a change of environment would be interesting, but i would miss my friends. anyway, i complied and there i started to understand that my dad was not just an eent practicing in the mines but was teaching in cebu institute of medicine and cebu doctors college of medicine (cdcm) and was a consultant in most of the hospitals in cebu city. and still he went back up to the mountains, back to lutopan, our mining town where our home was. the old acmdc hospital was replaced with a new state-of-the-art hospital now named acmdc medical center, complete with burn unit, trauma center and an observation deck in the or for teaching interns from cdcm. dad enjoyed teaching them. most of them are consultants today who are so fond of my dad that they always send their regards when they see me. my dad loved making model airplanes, vehicles, etc. and i realized i had that skill when i was 8 years old and i made my first airplane model. he used to build them out of balsa wood which is so skillful. i can’t be half the man he was but i realized this hobby enhanced his surgical skills. my dad was so diplomatic and just said to get an engineering course before you become a pilot (most of dads brothers are engineers). i actually gave engineering a go, but after 1 ½ years i realized i was not cut out for it. i actually loved biology and anything dealing with life and with all the exposure to my dad’s clinic and hospital activities … med school it was! at this point, my dad was already president of the orl central visayas chapter and was head of ent products and hearing center. as a graduate of the up college of medicine who finished otorhinolaryngology residency with an additional year in ophthalmology as one of the last eents to finish in upphilippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 6968 philippine journal of otolaryngology-head and neck surgery doknet’s world captoons assistant professor william u. billones, md de la salle health sciences institute creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery contents peer review and the pjohns: principles, problems and promise endoscopic sinus surgery perioperative outcomes after intravenous tranexamic acid: a double blind randomized controlled trial posterior nasal neurectomy in treatment of intractable rhinitis: a preliminary series reliability and validity of the filipino sino-nasal outcome test (snot) 22 evaluation of the newborn hearing screening program in the medical city based on joint commission on infant hearing (jcih) 2007 position statement quality indicators operative time and tympanic membrane graft uptake in endoscopic transcanal versus microscopic post-auricular tympanoplasty for chronic otitis media histopathologically positive regional neck node metastasis among patients with laryngeal squamous cell carcinoma inverted papilloma of the middle ear presenting as an aural polyp extranasopharyngeal angiofibroma: a diagnostic dilemma multiple myeloma presenting as a parotid mass double ectopic thyroid gland in a 10-year-old filipino boy bilateral cricoarytenoid joint ankylosis with a perplexing etiology post-operative temporal lobe encephalocele ameloblastic fibrosarcoma of the mandible mariano b. caparas, md (1932-2017) cover images editorial 4 peer review and the pjohns: principles, problems and promise lapeña jf original articles 6 endoscopic sinus surgery perioperative outcomes after intravenous tranexamic acid: a double blind randomized controlled trial quiroga jmc, jarin psr 12 posterior nasal neurectomy in treatment of intractable rhinitis: a preliminary series vo mc, pham hk, nguyen mh 17 reliability and validity of the filipino sino-nasal outcome test (snot) 22 maningding cac, roldan ra 21 evaluation of the newborn hearing screening program in the medical city based on joint commission on infant hearing (jcih) 2007 position statement quality indicators que mhb, reyes-quintos mrt 25 operative time and tympanic membrane graft uptake in endoscopic transcanal versus microscopic postauricular tympanoplasty for chronic otitis media escalderon jrdj, lim wl 30 histopathologically positive regional neck node metastasis among patients with laryngeal squamous cell carcinoma soliman egl, pontejos aqy case reports 34 inverted papilloma of the middle ear presenting as an aural polyp caro djc 39 extranasopharyngeal angiofibroma: a diagnostic dilemma gupta n, dass a, saini v, pol sa, mittal l 43 multiple myeloma presenting as a parotid mass borbe bb, castañeda ss 47 double ectopic thyroid gland in a 10-year-old filipino boy mendez tjc, navarro – locsin cg featured grand rounds 51 bilateral cricoarytenoid joint ankylosis with a perplexing etiology sagun jrm, cruz ets from the viewbox 56 post-operative temporal lobe encephalocele bickle ic, salim f under the microscope 58 ameloblastic fibrosarcoma of the mandible go jt, carnate jm passages 61 mariano b. caparas, md (1932-2017) pontejos aqy “kids swallow the darndest things” by michael joseph c. david, md “surhano” canon 5d mark ii 17-40 by rene louie c. gutierrez, md “campomanes bay, negros occidental” fujifilm x-t1, 18mm f/3.6 iso800 by michael joseph c. david, md “head-sized ameloblastoma” by michael joseph c. david, md “fetus” 16.5” x 11.5”, poster paint on recycled carton by hypte raymund v. aujero, md philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the prevalence of eosinophilic and non-eosinophilic nasal polyps in filipino patients with chronic rhinosinusitis with nasal polyposis (crswnp) who underwent endoscopic sinus surgery. methods: design: retrospective chart review setting: tertiary government training hospital participants: a consecutive sample of adult patients who underwent endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis at the rizal medical center from 2015-2019. results: out of 66 patients who underwent endoscopic sinus surgery during the study period, 36 (54.55%) had an eosinophilic endotype while 30 (45.45%) had a non-eosinophilic endotype. conclusion: the slight predominance of eosinophilic nasal polyps found in our sample may suggest a contrasting trend compared to our asian neighbors, who have a predominantly noneosinophilic endotype – indonesia (90.47%), thailand (81.9%), south korea (66.7%) and china (53.6%). however, this predominance is still lower than the 78-88% eosinophilia reported among caucasians. larger series may confirm these preliminary findings. keywords: chronic rhinosinusitis; paranasal sinuses; sinusitis; nasal polyps; eosinophilic polyps; noneosinophilic polyps; endotype chronic rhinosinusitis (crs) is the symptomatic inflammation of the nose and paranasal sinuses of at least 12 weeks duration arising from complex inflammatory processes triggered by an array of exogenous agents.1 it is a common medical condition with a prevalence of 10.9% across different countries in europe,2 11.9% in the united states,3 8% in china, and 8.6% in south korea.4 clinically, crs is generally divided into two broad categories— crs with nasal polyposis (crswnp) and crs without nasal polyposis (crssnp). over the past decade, research has revealed unique cytokine and cellular inflammatory profiles in crswnp to further classify nasal polyps as those with a th2 response that have an eosinophil cellular predominance, and those with a th1/th17 response with a neutrophil (non-eosinophil) cellular predominance.5 the mechanism of inflammation in each individual which leads to the activation of different types of t-helper predominant endotype of nasal polyps in a sample of filipinos following endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis karla victoria nable-llanes, md rodante a. roldan, md department of otorhinolaryngology head and neck surgery rizal medical center correspondence: dr. rodante a. roldan department of otorhinolaryngology head and neck surgery rizal medical center, pasig blvd., pasig city 1609 philippines phone: (632) 8865 8400 local 207 email: raroldanmd@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery 1st virtual descriptive research contest (1st place), october 21, 2020 philipp j otolaryngol head neck surg 2021; 36 (1): 28-32 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles cells causing eosinophilic or non-eosinophilic patterns of inflammation is expressed as their endotype.6 the prevalent inflammatory profiles have been shown to vary across different countries with western countries mostly showing a th2 predominance (france 88%,7 belgium 78%8) and asian countries showing a th1/th17 predominance (indonesia 90.47%,9 thailand 81.9%,10 south korea 66.7%,11 china 53.6%12). the presence of mucosal eosinophilia is frequently associated with more severe disease and recurrence of nasal polyps after surgery.13 we could find no published data on the prevalent inflammatory profile for nasal polyps among filipinos based on a search of herdin plus, the asean citation index, global index medicus, or pubmed (medline, pmc). thus, the aim of this study is to determine the prevalence of eosinophilic and non-eosinophilic nasal polyps in filipino patients with crswnp who underwent endoscopic sinus surgery in our hospital in order to determine the predominant inflammatory profile that may inform treatment, prognostication, and monitoring for response and recurrence post-treatment. methods with institutional review board approval (2019-orl-#71-rp-1.ii), this retrospective study consecutively reviewed the hospital records of all adult patients with chronic rhinosinusitis with nasal polyposis (crswnp) who underwent endoscopic sinus surgery over a five-year period from january 2015 to december 2019. the diagnosis of crswnp was based on patient history, clinical examination, nasal endoscopy, and computed tomography (ct) of the sinuses. excluded were records of those with immunodeficiency or in an immunocompromised state, blood dyscrasias, auto-immune diseases or genetic disorders affecting mucociliary clearance (i.e. cystic fibrosis, primary ciliary dyskinesia), non-invasive fungal balls and invasive fungal disease, cocaine abuse, antrochoanal polyps, septal perforations, trauma to the facial skeleton (except for the mandible), neoplasia, nasal malignancies, aspirinexacerbated respiratory disease, or pregnancy. preoperative demographic data and medical histories were obtained from the medical records, including age, sex, history of prior sinus surgery, history of asthma and/or allergic rhinitis, history of other types of atopy such as food allergies and/or atopic dermatitis, as well as smoking history. polyps were graded using the lund-mackay score:14 grade 1, polyps in middle meatus only; grade 2, polyps beyond the middle meatus but not blocking the nose completely; grade 3, polyps completely obstructing the nose. all participants had been assessed for symptom severity prior to surgery using the sino nasal outcome test (snot-22)15 and underwent guideline-directed treatment including but not limited to intranasal corticosteroids, pre-operative oral steroids for 1 week and post-operative oral steroids for 1 week. the raw data acquired from the review of patient inpatient and outpatient charts was evaluated for measures of central tendencies and percentages. post-operative surgical pathology reports of nasal polyp specimens routinely contain eosinophil counts in our institution since 2015 and undergo the same processing according to hospital protocol. nasal polyps of patients with crswnp removed during endoscopic sinus surgery were fixed immediately in 10% formalin and sent for processing by the histopathology section. histopathologic analysis was done through examination of the areas of densest cellular infiltrates, counting the number of eosinophils in the mucosa under high-power field (hpf, 400x). counting was performed for 3 separate hpfs and the 3 counts were then averaged to calculate the average number of mucosal or polyp eosinophils per hpf. all specimens were examined microscopically by a board-certified pathologist unaware of the clinical data and the eosinophil count was routinely included in the final report. post-operative histopathology reports were collected and reviewed to determine the endotype. in this study, the official surgical pathology reports were reviewed and nasal polyps were classified according to the system proposed by kountakis et al.; eosinophilic nasal polyps are those that are histologically confirmed to have more than 5 eosinophils/hpf in the densest area of infiltration, while non-eosinophilic nasal polyps are those that are histologically-confirmed to have less than or equal to only 5 eosinophils/hpf in the densest area of infiltration.16 the raw data acquired from the review of inpatient and outpatient charts was collated using microsoft excel version 14.7.7 (microsoft corporation, redmond, wa, usa) and evaluated for measures of central tendencies and percentages. results a total of 79 patients underwent endoscopic sinus surgery in rizal medical center from 2015-2019. of these, eight (8) and two (2) patients were excluded due to antrochoanal polyps and malignancy, respectively. the histopathology results of three (3) patients could not be found, and these were further excluded. a total of 66 complete patient records with surgical pathology reports were included in the final consecutive sample. the mean age was 42.73 (range 20-71 years old), with 53 (80.3%) males and 13 (19.7%) females. thirty-three patients (50%) were smokers or had a history of smoking, 10 (15.15%) had a history of previous sinus surgery while 56 (84.85%) underwent primary sinus surgery. out of the 66 patients, 36 (54.55%) had an eosinophilic endotype while 30 patients (45.45%) had a non-eosinophilic endotype. of the 36 patients with eosinophilic endotype, 7 (19.44%) and 15 (41.67%) respectively had a history of asthma or other forms of atopy. other philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles forms of atopy present in the eosinophilic group were allergic rhinitis in 9 (25%) and food and/or drug allergies in 6 (16.67%). in contrast, none of the 30 patients with a non-eosinophilic endotype had a history of asthma while 7 (23.33%) had a history of other forms of atopy. other forms of atopy present in the non-eosinophilic group were allergic rhinitis in 4 (13.33%) and food and/or drug allergies in 3 (10%). (figure 1) the data revealed outliers, hence the mean was not used to report the results. the median of the pre-operative snot-22 score of the eosinophilic group was 50.5 (range 9-112, iqr 38.25), while the median of the non-eosinophilic group was 38 (range 7-103, iqr 30.25). thirty percent (30%) of the non-eosinophilic group had prior sinus surgery with an average interval between surgeries of 18.33 years (range 1-37). in the eosinophilic group, only 1 patient had prior sinus surgery with an interval of 9 years between surgeries. conversely, 9 (90%) of those who had prior sinus surgery were classified to have the non-eosinophilic endotype. the summary of nasal polyp grading is reported in table 1. discussion the data revealed that the sample of patients with crswnp who underwent endoscopic sinus surgery in rizal medical center between 2015-2019 had a prevalence of 54.55% eosinophilic endotype, and 45.45% non-eosinophilic endotype. these findings are similar to the unpublished observations of javierto et al. in this same institution which found a prevalence of 53% favoring eosinophilic endotype in filipino nasal polyps from 2008-2012.17 notably, the predominance of this endotype differs from our asian counterparts who reported predominance of the non-eosinophilic endotype.9-12 in contrast, western countries are of the same endotype, however the prevalence of eosinophilic nasal polyps in filipinos are far below their reported rates.7,8 this discrepancy may be due to differences in genetics, and/or be attributed to the differing parameters and cut-off values utilized in their respective studies. the literature is rife with different cut-off values to determine mucosal eosinophilia, ranging from >5/hpf to >350/hpf.7-12,18,19 we selected the cut-off value proposed by kountakis et al., as their immunohistochemical studies for eg2, a marker for activated eosinophils, stained positive in all nasal polyp tissue specimens with more than 5 eosinophils/hpf, while those with 5 eosinophils or less did not stain positive for eg2.16 eosinophilic crswnp is also associated with decreased likelihood of surgical success and recurrence of disease within 5 years after surgical intervention with a positive predictive value of 87.5%.20 studies correlate the eosinophilic endotype with more severe disease and a higher association with recurrence and need for revision sinus surgery.16 the opposite was observed in this study where 90% of the table 1. distribution of nasal polyp grading for eosinophilic and non-eosinophilic groups polyp grade right, left eosinophilic n (%) non-eosinophilic n (%) 3, 3 3, 2 2, 2 2, 1 2, 0 1, 1 3, 1 total 8 (22.22) 14 (38.89) 11 (30.56) 1 (2.78) 1 (2.78) 1 (2.78) 0 (0.00) 36 9 (30.00) 12 (40.00) 5 (16.67) 1 (3.33) 3 (10.00) 0 (0.00) 0 (0.00) 30 figure 1. endotype classification and history of asthma or other forms of atopy in each endotype legend: *crswnp chronic rhinosinusitis with nasal polyposis; †ess endoscopic sinus surgery; ‡snot-22 sinonasal outcome test-22 patients who had prior sinus surgery were classified under the noneosinophilic endotype. the retrospective nature of this study, precludes determining why this is so, but a possible explanation could be routine use of intranasal corticosteroids in crswnp patients which would benefit the eosinophilic group and control their symptoms, whereas the non-eosinophilic group would not have benefited as much. furthermore, demographics may also play a role in this finding since this study was done in a tertiary government hospital which serves patients of the lower socioeconomic ladder. review of charts revealed frequent reference to financial constraints as a cause of treatment delay, and may also be contributory to the lengthy interval between primary and revision surgeries (eosinophilic group 9 years; non-eosinophilic philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles group mean 18.33 years, range 1-37), however, a causal relationship cannot be determined in this paper. despite the controversy in the role of allergy in crswnp, this study has found that the eosinophilic group demonstrated a higher prevalence of asthma and atopy. of the total study population, all patients with asthma and most patients with other forms of atopy (68.18%) were subsequently classified under the eosinophilic endotype. this observation is to be expected having set the cut-off value based on positivity to eg2 immunohistochemical staining as this is also a clinically useful indicator for asthma.21 a significant limitation of this study is that the diagnosis of bronchial asthma and other forms of atopy was established clinically, as objective tests such as spirometry with bronchodilator challenge and specific ige testing (e.g., skin prick testing, serum specific ige testing) would have been preferred but are unavailable in our institution. the listed conditions in the exclusion criteria were ruled out clinically through history, physical examination as well as the routine pre-operative diagnostics (paranasal sinus ct scan, cbc, coagulation studies, chest x-ray, etc.) wherein symptoms, medical history or objective parameters that would increase suspicion of the listed criteria would undergo further investigation. in this study however, all patients had normal blood tests with no signs of immunodeficiency or coagulopathies, none of the listed conditions on history taking, no ct findings of prior craniofacial trauma or invasive fungal disease, unremarkable chest x-ray with no situs inversus, no endoscopic findings of septal perforation or fungus ball as well as no histopathologic findings of hyphae within the tissue specimens. in this population, there was no note of a patient with aspirin-exacerbated respiratory disease (aerd) however one patient presented with asthma and allergy to non-aspirin nsaids, specifically ibuprofen and mefenamic acid. upon review of the patient’s chart, aerd was not listed as a co-morbidity, history of previous intake of aspirin was not elicited, nor oral aspirin provocation test performed. futhermore, this patient’s eosinophil count on histopathology was the highest of the population (215/hpf on the left, 135/hpf on the right). aerd is a difficult diagnosis to establish when relying on patient history alone. the prevalence of aerd in patients with or without asthma and crswnp was 23% upon evaluation with oral aspirin provocation test.5 however, since this is a retrospective review, the researchers cannot ascertain this diagnosis – another limitation in this study and possibly an avenue of further research. quality of life (qol) among patients with eosinophilic crswnp has been shown to be worse than among patients with non-eosinophilic crswnp.22 this can be observed in our study population where patients with the eosinophilic endotype had higher pre-operative snot22 scores (median 50.5), while the group with the non-eosinophilic endotype had lower scores (median 38). the results for pre-operative scores were presented using median as a measure of central tendency since there were extreme outliers noted in the data collected of the non-eosinophilic group which would skew the results and would not have been representative of each subtype. in this study, the sinonasal outcome test 22 (snot-22) was performed in both english and filipino between 2017-2019 since the validated filipino version23 was only published in 2017. prior to that (2015-2017), the snot-22 was only administered in english. post-operative snot-22 scores were not included in this study, also another limitation. while this study only looked at tissue eosinophilia to determine endotype, other measures may also be employed in future studies. the use of blood eosinophil count could be a good marker for mucosal eosinophilia in nasal polyps24 however local data is lacking and could be a useful avenue for further research. interestingly, there are studies that show that peripheral eosinophilia significantly correlated with eosinophil infiltration in nasal polyps.16 other measures to determine endotypes of crswnp could include the determination of severity using ct and endoscopy scores as well as rates of disease recurrence. this study has determined a prevalence of 54.55% favoring the eosinophilic endotype, as opposed to western countries (78-88% eosinophilic)7,8 and in contrast to our east asian and south-east asian neighbors, who have a predominantly non-eosinophilic endotype (53.6-90.47%).9-12 determination of endotype of patients with chronic rhinosinusitis have promising uses in the prognostication of these patients which further have implications in post-operative management. by knowing the endotype, the clinician will be able to individualize treatment. once a patient has been diagnosed to have crswnp and the eosinophilic endotype has been determined, the clinician can then proceed with a more aggressive management of these patients in terms of frequency of follow-up, medication prescribed, screening for recurrent disease and patient education and counseling. without knowing the endotype and with the consideration of the prevalence of this study, we may miss out on prescribing longterm low dose macrolides which is appropriate for the non-eosinophilic endotype. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles acknowledgements we would like to thank our department research head, dr. giancarla ambrocio, and department chair, dr. samantha castañeda, for their invaluable advice and assistance in keeping our progress on schedule. our special thanks are extended to the staff of the rizal medical center hospital information management department for their assistance in retrieving charts and histopathology results for this study. references 1. kern r, liddy w. pathogenesis of chronic rhinosinusitis. in flint pw, haughey b, lund v, niparko j, robbins k, regan thomas j et al., editors. cummings otolaryngology head & neck surgery. philadelphia: elsevier; 2014 p.714. 2. jarvis d, newson r, lotvall j, hastan d, tomassen p, keil t, et al. asthma in adults and its association with chronic rhinosinusitis: the ga2len survey in europe. allergy. 2012 jan;67(1):918. doi: 10.1111/j.1398-9995.2011.02709.x; pubmed pmid: 22050239. 3. hirsch ag, stewart wf, sundaresan as, young aj, kennedy tl, greene js et al nasal and sinus symptoms and chronic rhinosinusitis in a population-based sample. allergy. 2017 feb;72(2):274-281. doi: 10.1111/all.13042; pubmed pmid: 27590749; pubmed central pmcid: pmc5497579. 4. zhang y, gevaert e, lou h, wang x, zhang l, bachert c, et al. chronic rhinosinusitis in asia. j allergy clin immunol. 2017 nov;140(5):1230-1239. doi: 10.1016/j.jaci.2017.09.009; pubmed pmid: 28987810. 5. chaaban mr, walsh em, woodworth ba. epidemiology and differential diagnosis of nasal polyps. am j rhinol allergy. 2013 nov-dec;27(6):473-8. doi: 10.2500/ajra.2013.27.3981; pubmed pmid: 24274222; pubmed central pmcid: pmc3899526. 6. koennecke m, klimek l, mullol j, gevaert p, wollenberg b. subtyping of polyposis nasi: phenotypes, endotypes and comorbidities. allergo j int. 2018;27(2):56-65. doi: 10.1007/s40629017-0048-5; pubmed pmid: 29564208; pubmed central pmcid: pmc5842507. 7. jankowski r, bouchoua f, coffinet l, vignaud jm. clinical factors influencing the eosinophil infiltration of nasal polyps. rhinology 2002 dec; 40(4), 173–178; pubmed pmid: 12526243 8. vlaminck s, vauterin t, hellings pw, jorissen m, acke f, van cauwenberge p, et al. the importance of local eosinophilia in the surgical outcome of chronic rhinosinusitis: a 3-year prospective observational study. am j rhinol allergy. 2014 may-jun;28(3):260-4. doi: 10.2500/ ajra.2014.28.4024; pubmed pmid: 24980239. 9. indrawati lpl. expressions of eosinophil in chronic rhinosinusitis patients with nasal polyp. otolaryngology online journal june 2018 [cited 2020 aug.20];8(2) available from: http://www. alliedacademies.org/articles/expressions-of-eosinophil-in-chronic-rhinosinusitispatients-withnasal-polyp-10389.html. 10. jareoncharsri p, bunnag c, muangsomboon s, tunsuriyawong p, assanasane p. clinical and histopathological classification of nasal polyps in thais. siriraj med j nov 2002. [cited 2020 aug.20];54(11):689-97. available from: https://he02.tci-thaijo.org/index.php/sirirajmedj/ article/view/245323. 11. kim jw, hong sl, kim yk, lee ch, min yg, rhee cs. histological and immunological features of non-eosinophilic nasal polyps. otolaryngol head neck surg. 2007 dec;137(6):925-30. doi: 10.1016/j.otohns.2007.07.036; pubmed pmid: 18036422. 12. cao pp, li hb, wang bf, wang sb, you xj, cui yh, et al. distinct immunopathologic characteristics of various types of chronic rhinosinusitis in adult chinese. j allergy clin immunol. 2009 sep;124(3):478-84, 484.e1-2. doi: 10.1016/j.jaci.2009.05.017; pubmed pmid: 19541359. 13. shah sa, ishinaga h, takeuchi k. pathogenesis of eosinophilic chronic rhinosinusitis. j inflamm. 2016 apr;13:11. doi: 10.1186/s12950-016-0121-8; pubmed pmid: 27053925; pubmed central pmcid: pmc4822241. 14. lund vj, mackay is. staging in rhinosinusitus. rhinology. 1993 dec;31(4):183-4. pubmed pmid: 8140385. 15. hopkins c, gillett s, slack r, lund vj, browne jp. psychometric validity of the 22-item sinonasal outcome test. clin otolaryngol. 2009 oct;34(5):447-54. doi: 10.1111/j.1749-4486.2009.01995.x; pubmed pmid: 19793277. 16. kountakis se, arango p, bradley d, wade zk, borish l. molecular and cellular staging for the severity of chronic rhinosinusitis. laryngoscope. 2004 nov;114(11):1895-905. doi: 10.1097/01. mlg.0000147917.43615.c0; pubmed pmid: 15510011. 17. javierto ab, roldan ra, gosingan a. the prevalence of eosinophilic and non-eosinophilic nasal polyp in patients who underwent functional endoscopic sinus surgery in rizal medical center from year 2008-2012. unpublished observations. 18. lou h, zhang n, bachert c, zhang l. highlights of eosinophilic chronic rhinosinusitis with nasal polyps in definition, prognosis, and advancement.  int forum allergy rhinol.  2018 nov;8(11):1218–1225. doi: 10.1002/alr.22214; pubmed pmid:  30296011; pubmed central pmcid: pmc6282610. 19. nakayama t, yoshikawa m, asaka d, okushi t, matsuwaki y, otori n, et al. mucosal eosinophilia and recurrence of nasal polyps–new classification of chronic rhinosinusitis. rhinology. 2011 oct;49(4):392-6. doi: 10.4193/rhino10.261; pubmed pmid: 21991563. 20. matsuwaki y, ookushi t, asaka d, mori e, nakajima t, yoshida t, et al chronic rhinosinusitis: risk factors for the recurrence of chronic rhinosinusitis based on 5-year follow-up after endoscopic sinus surgery. int arch allergy immunol. 2008;146 (suppl 1):77-81. doi: 10.1159/000126066; pubmed pmid: 18504412. 21. kamada y, kayaba h, ito w, ueki s, kobayashi y, yamada y, et al. eg2 expressed by eosinophils as a clinically useful indicator of asthma. allergy asthma proc. 2008 nov-dec; 29(6):609-13. doi: 10.2500/aap.2008.29.3171; pubmed pmid: 19173787. 22. soler zm, sauer da, mace j, smith tl. relationship between clinical measures and histopathologic findings in chronic rhinosinusitis. otolaryngol head neck surg. 2009 oct;141(4):454-61. doi: 10.1016/j.otohns.2009.06.085; pubmed pmid: 19786212; pubmed central pmcid: pmc2766519. 23. maningding cac, roldan ra. reliability and validity of the filipino sino-nasal outcome test (snot) 22. philipp j otolaryngol head neck surg. 2018 jan-jun; 33(1):17-20. doi: 10.32412/ pjohns.v33i1.51. 24. sun c, ouyang h, luo r. distinct characteristics of nasal polyps with and without eosinophilia. braz j otorhinolaryngol. 2017 jan-feb;83(1):66-72. doi: 10.1016/j.bjorl.2016.01.012; pubmed pmid: 27166273. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2020; 35 (1): 46-50 c philippine society of otolaryngology – head and neck surgery, inc. prognostic value of thyroidectomy and tracheostomy in anaplastic thyroid carcinoma carlo victorio l. garcia, md arsenio claro a. cabungcal, md alfredo quintin y. pontejos, jr., md department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: dr. arsenio claro a. cabungcal ward 10, department of otorhinolaryngology philippine general hospital, taft ave., manila 1000 philippines phone: (632) 8554 8400 local 2152 email: aacabungcal@up.edu.ph (email address may be published) the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the 4th european otolaryngology-ent surgery conference, august 15-17, 2019, rome, italy. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest. december 6, 2019. palawan ballroom, edsa shangri la hotel, mandaluyong city. abstract objective: to determine the prognostic value of surgical interventions done among patients with anaplastic thyroid carcinoma (atc) methods: a five-year retrospective chart review of 25 patients was done and baseline characteristics determined. patients discharged alive as of the time of last chart entry were followed up by phone interview or personal visit. overall survival was the main outcome measure which was plotted as kaplan-meier estimates and compared via log-rank test. the incidence of complications surrounding tracheostomy and thyroidectomy were also noted. methods: design: ambispective cohort study setting: tertiary national university hospital participants: all private and public (charity) patients seen at the wards or clinics diagnosed with atc via fine needle cytology or tissue histopathology. results: all patients presented with either stage iv-b or stage iv-c disease. a significant difference in survival curves was noted when comparing between the two stages (p<.05). subgroup analysis per stage revealed no significant difference in overall survival when comparing patients who did not undergo surgery, those who underwent tracheostomy or those who underwent thyroidectomy for both iv-b (p=.244) or iv-c (p=.165) disease. the incidence of complications for tracheostomy was 60%, the most common being mucus plugging. for thyroidectomy, the incidence of complications was 80% with hypocalcemia being the most common. conclusion: the current available data fails to demonstrate any significant survival advantage of tracheostomy or thyroidectomy when performed among similarly staged patients. keywords: anaplastic thyroid cancer; thyroidectomy; tracheostomy; survival creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery original articles of all the known malignancies, anaplastic thyroid carcinoma (atc) carries one of the worst prognosis with a 5-year survival rate of only 5.6-11.4% and a median life expectancy of only 2-12 months.1-5 the incidence of atc is pegged at 1 to 2 cases per million people.2 despite being the least common thyroid malignancy, it accounts for roughly 50% of all thyroid cancer deaths.6 all anaplastic cancers are automatically stage iv upon diagnosis: iv-a is disease limited to the thyroid, iv-b is tumor invading through thyroid capsule and/or regional metastasis and iv-c involves distant metastasis. at least 90% of patients with atc are elderly (>60 years) at presentation.7,8 because of this, and the advanced disease at presentation, surgical efforts at complete resection remain controversial as they are associated with significant morbidity and reduced quality of life. in our institution, most of these patients are treated with palliative rather than curative intent with most of the procedures geared towards relief of airway obstruction. recently however, cohort studies with sizeable patient pools in italy and korea have shown significant survival benefit for curative resection when performed among appropriately selected patients.9,10 a search of local literature via medline (pubmed) and herdin only yielded two descriptive studies on atc among filipinos. sunga et al. performed a retrospective study of 17 patients from 1973-1994 and compared the outcomes of thyroidectomy and radiotherapy in resectable atc versus tracheostomy and radiotherapy in unresectable atc.11 although they determined that combined thyroidectomy and radiotherapy resulted in a longer mean survival, this was not analyzed with respect to staging.11 a more recent study by lo et al. detailed the symptomatology, demographics and clinical course of these patients. however, it did not describe the survival benefit of surgical interventions done on these patients nor did it mention the complications or morbidities surrounding these procedures.12 considering recent evidence that refocuses our attention on surgery as the primary modality for curative efforts, we aim to validate if this was applicable at the local setting as well. this study aims to determine the prognostic value of surgical interventions done among patients with anaplastic thyroid carcinoma (atc) in our institution. methods with institutional review board approval, this ambispective cohort study was conducted among all patients with cytologically or histopathologically confirmed anaplastic thyroid carcinoma admitted at the in-patient ward or seen at the out-patient clinic of the department of otorhinolaryngology of the philippine general hospital from january 2013 to january 2018. securing informed consent was waived for patients who expired while admitted and whose death certificate was already available in the records. for patients who were discharged alive but died sometime after, informed consent was obtained from the nearest kin. all the inpatient and outpatient charts of patients with either initial cytopathologic diagnosis of atc via fine needle biopsy and/ or final histopathologic confirmation of atc within the study period were reviewed. excluded were patients with an initial diagnosis of atc refuted by subsequent histopathological examination. patient demographics and baseline characteristics were obtained from the selected charts. patients were further classified into one of 3 groups: 1) no surgical intervention, 2) tracheostomy with or without debulking, 3) total thyroidectomy/wide excision of tumor with or without neck dissection. the rates of intraoperative and postoperative complications were determined for each surgical intervention done. disease-specific mortality was the primary endpoint. if the chart reflected that the patient was discharged alive as of the time of last admission/consult, the current status was verified by a recorded phone call to the contact person identified in the records or a personal visit at the listed address. information gathered was limited to the date of death (if applicable) and cause of death (if applicable). if the patient or contact person was not reachable through listed channels (through phone or personal visit at listed address), they were censored in the final analysis. kaplan-meier disease-specific survival curves were generated comparing each stage followed by subgroup analysis per stage of the different interventions the patients received. survival estimates were compared via log-rank test using spss 17 (spss inc., chicago il). results a total of 25 patients had charts available for review for the time period covered. there was a 3:1 female to male preponderance and a median age of presentation of 59 years old (range of 44 to 87 years old). the baseline characteristics and the surgical interventions performed for each patient are summarized in table 1. the primary outcome was determined in only 13 of the 25 patients. the rest were censored as of the time of last chart entry or clinic visit. the top causes of death among stage iv-b patients were sepsis/ respiratory failure from pneumonia, arrhythmia from myocardial infarction and upper airway obstruction. the top causes of death among stage iv-c patients were sepsis from pneumonia and multiorgan dysfunction from tumor metastasis. the mean overall survival of stage iv-b patients was 5 weeks while that of iv-c patients was only 2 weeks. figure 1 shows the kaplan-meier curves grouped according to stage. as expected, log-rank test showed that the survival probability of stage iv-b patients was significantly different from iv-c patients (p value =.01). figures 2 and 3 show a subgroup analysis per stage and compared philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery original articles the various surgical interventions done on these patients. comparing same stage patients, the data shows that neither tracheostomy nor thyroidectomy significantly altered the survival of patients compared to those who did not undergo any surgical intervention (p value = .21 for iv-b, p value = .17 for ivc). thyroidectomies were associated with postoperative hypocalcemia 40% of the time. tracheostomies were associated with complications 62% of the time and the most common was mucus plugging. other tracheostomy complications included tube infiltration by tumor, surgical site infections and bleeding per stoma. discussion this study corroborates the previous findings of lo et al. that demonstrated similar symptomatology among their cohort of patients.12 aside from a rapidly enlarging neck mass, dysphagia was the next most common complaint, occurring in 72% of patients. table 1. clinical characteristics of 25 atc patients and enumeration of surgical interventions performed per stage factors cases (n=25) gender female age <60 years ≥60 years number of symptomatic months prior to diagnosis <1 month 1-3 months >3 months nodal metastasis no yes resectability of primary tumor yes no equivocal stage iv-b iv-c 19 13 12 2 13 10 10 15 11 9 5 15 10 iv-b iv-c surgical intervention none 3 2 tracheostomy (with or without debulking) 8 7 thyroidectomy (with or without neck dissection) 4 1 figure 1. kaplan-meier curves showing the effect of staging on overall survival figure 2. kaplan-meier curves showing effect of surgical interventions on overall survival of stage ivb patients figure 3. kaplan-meier curves showing effect of surgical interventions on overall survival of stage ivc patients philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery original articles in our cohort, dyspnea was also a common complaint (68%) followed by hoarseness (64%). lateral neck node (levels ii-iv) involvement was observed in 60% of patients. involvement of the central nodal basin was more difficult to determine due to confluence with the anterior neck mass. distant metastasis was most commonly found in the lungs which presented as multiple nodules/masses (“cannonball” lesions) readily apparent on chest radiography or computed tomography. pulmonary metastasis contributed to prolonged mechanical ventilation and significant respiratory difficulty, even post-tracheostomy. bony and hepatic metastasis was also apparent in 30% and 10% of patients, respectively. there is little debate that atc confined within the thyroid gland (stage iv-a) is best treated with total thyroidectomy but unfortunately, none of our patients were staged iv-a on diagnosis. the treatment of iv-b disease is more controversial. several studies have identified prognostic factors that predict the success of surgical resection: age<6070 years, tumor within thyroid capsule and absence of leukocytosis.13,14 as seen in our cohort, patients rarely fulfilled these prognostic criteria. half of our cohort presented in the elderly (>60-year-old) population. they had sizeable primaries which grew rapidly, sometimes in as fast as two weeks. these factors underscore the need for surveillance and expeditious workup of any rapidly enlarging neck mass or sudden enlargement of previous goiter. there is an emerging body of evidence that surgery still confers longer cumulative survival even in patients with negative prognostic factors given that the longest survivors had surgical resection as part of their treatment.15,16 in our cohort, tumor resectability was defined as any tumor without 270 degree encasement of the common carotid artery or prevertebral fascia extension. this definition is based on the 2002 american joint committee on cancer definition for a t4b tumor which was the convention for determining resectability.17 for patients with iv-b disease, tumor was already deemed unresectable in a third of cases. despite having theoretically resectable tumors in 7 patients, thyroidectomy was only performed in four patients. two of them also underwent therapeutic bilateral neck dissection for n1b disease. although there were no serious intraoperative morbidities, postoperative hypocalcemia was a common occurrence. patients who underwent resection continue to have survival curves similar to patients treated with palliative tracheostomy or those who did not undergo any surgical intervention. a probable reason for this is the difficulty in achieving r0 or even r1 margins. the national comprehensive cancer network thyroid cancer guidelines even mention that r0/r1 resection is achieved usually incidentally for thyroidectomies for other causes.18 the difficulty in achieving clear margins puts patients at risk for early recurrence and distant tumor dissemination. although external beam radiotherapy is a viable treatment for tumor residuals, its effectivity is still unassessed in our setting as patients rarely initiate treatment either due to preference or limitation of funds. in our cohort, all patients who underwent total thyroidectomy were unable to initiate radiotherapy treatment. thyroidectomies were rarely performed among iv-c patients due to their poor health status at presentation and the dismal prognosis. in our series, only one patient with metastatic disease underwent thyroidectomy. most only consented to palliative airway management with tracheostomy. like the iv-b subgroup, surgical interventions do not seem to significantly improve overall survival in iv-c patients. airway obstruction in atc can be due to extrinsic compression by tumor, direct laryngotracheal invasion or vocal cord paralysis. stridor occurs in 20-30% of patients and the degree of obstruction may worsen during the patient’s clinical course i.e. during radiotherapy, upon endotracheal manipulation, or onset of pulmonary infection.19 the latest american thyroid association 2015 guidelines advised against prophylactic tracheostomy in non-obstructed patients due to the significant reduction in their quality of life.20 in our institution, we often do it prophylactically due to the rapidly progressive nature of the disease and concern for lack of airway specialists in their home area. however, it is not a procedure without risk, as tracheostomy can pose unique challenges when done in this population, both in the intraoperative and postoperative settings. in most instances, the size of the tumor precludes easy exposure of the trachea and the airway may be considerably displaced by the mass. prior computed tomographic evaluation is highly recommended to guide the surgeon as to the route of access. the tumor can be debulked to expose the trachea underneath and we routinely send tissue samples for histopathological confirmation of disease. this procedure is ideally done in the operating room and never at bedside. in this cohort, only one patient succumbed to acute upper airway obstruction when endotracheal intubation and emergent tracheostomy failed to secure a patent airway. the postoperative course of these tracheostomized patients can also be troubling. in our cohort, 40% of patients experienced recurrent bouts of mucus plugging refractory to routine nursing care which necessitated multiple referrals to the attending otolaryngologist. the occurrence of this complication is due to the design of the tracheostomy tube we use for these patients. we favor an extended tube with a neck flange that can be adjusted anywhere along the length of the tube (tracoe® vario, ref 451 tracoe medical gmbh, nieder-olm, germany). this bidirectionality affords the surgeon greater flexibility: proximal extension for anterior neck bulk and distal extension for intraluminal tracheal involvement. the trade-off is the absence of an inner cannula philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery original articles references 1. aschebrook-kilfoy b, ward mh, sabra mm, devesa ss. thyroid cancer incidence patterns in the united states by histologic type, 1992–2006. thyroid. 2011 feb;21(2):125-34. doi: 10.1089/ thy.2010.0021; pmid: 21186939; pmcid: pmc3025182. 2. gervasi r, orlando g, lerose, ma, amato b, docimo g, zeppa p, et al. thyroid surgery in geriatric patients: a literature review. bmc surg. 2012; 12 suppl 1: s16. doi: 10.1186/1471-2482-12-s1s16; pmid: 23173919; pmcid: pmc34992693. 3. are c, shaha ar. anaplastic thyroid carcinoma: biology, pathogenesis, prognostic factors, and treatment approaches. ann surg oncol. 2006 apr;13(4):453-64. doi: 10.1245/aso.2006.05.042; pmid: 16474910. 4. neff rl, farrar wb, kloos rt, burman kd. anaplastic thyroid cancer. endocrinol metab clin north am. 2008 jun;37(2);525-38. doi: 10.1016/j.ecl.2008.02.003: pmid: 18502341. 5. nagaiah g, hossain a, mooney cj, parmentier j, remick sc. anaplastic thyroid cancer: a review of epidemiology, pathogenesis, and treatment. j oncol. 2011;2011:542358. doi: 10.1155/2011/542358; pmid: 21772843 pmcid: pmc3136148. 6. hundahl sa, fleming id, fremgen am, menck hr. a national cancer data base report on 53,856 cases of thyroid carcinoma treated in the u.s., 1985-1995. cancer 1998 dec 15; 83(12):2638-48. doi: 10.1002/(sici)1097-0142(19981215)83:12<2638::aid-cncr31>3.0.co;2-1; pmid: 9874472. 7. green ld, mack l, pasieka jl. anaplastic thyroid cancer and primary thyroid lymphoma: a review of these rare thyroid malignancies. j surg oncol. 2006 dec 15;94(8):725-36. doi: 10.1002/ jso.20691; pmid: 17131397. 8. chiacchio s, lorenzoni a, boni g, rubello d, elisei r, mariani g. anaplastic thyroid cancer: prevalence, diagnosis and treatment. minerva endocrinol. 2008 dec;33(4):341-57. pmid: 18923370. 9. polistena a, monacelli m, lucchini r, triola r, conti c, avenia s, et al. the role of surgery in the treatment of thyroid anaplastic carcinoma in the elderly. int j surg. 2014; 12 suppl 2:170-76. doi: 10.1016/j.ijsu.2014.08.347; pmid: 25167852. 10. baek sk, lee mc, hah jh, ahn sh, son yi, rho ys, et al. role of surgery in the management of anaplastic thyroid carcinoma: korean nationwide multicenter study of 329 patients with anaplastic thyroid carcinoma, 2000 to 2012. head neck. 2017 jan;39(1):133-139. pmid: 27534388 doi: 10.1002/hed.24559. 11. sunga pal, cortez er, ampil idc ii. survival of patients with anaplastic thyroid cancer treated with total thyroidectomy plus radiotherapy, or tracheostomy plus radiotherapy. philipp j surg spec. 1995; 50(4): 149-51. 12. lo te, jimeno ca, paz-pacheco e. anaplastic thyroid cancer: experience of the philippine general hospital. endocrinol metab (seoul). 2015 jun; 30(2): 195-200. doi: 10.3803/enm.2015.30.2.195; pmid: 26194079; pmcid: pmc4508264. 13. kebebew e, greenspan fs, clark oh, woeber ka, mcmillan a. anaplastic thyroid carcinoma. treatment outcome and prognostic factors. cancer 2005 apr 1; 103(7): 1330-35. doi: 10.1002/ cncr.20936; pmid: 15739211. 14. akaishi j, sugino k, kitagawa w, nagahama m, kameyama k, shimizu k, et al. prognostic factors and treatment outcomes of 100 cases of anaplastic thyroid carcinoma. thyroid. 2011 nov;21(11):1183-89. doi: 10.1089/thy.2010.0332; pmid: 21936674. 15. junor ej, paul j, reed ns. anaplastic thyroid carcinoma: ninety-one patients treated by surgery and radiotherapy. eur j surg oncol. 1992 apr; 18(2): 83-88. pmid: 1582515. 16. haigh pi, ituarte ph, wu hs, treseler pa, posner md, quivey jm, et al. completely resected anaplastic thyroid carcinoma combined with adjuvant chemotherapy and irradiation is associated with prolonged survival. cancer. 2001 jun 15; 91(12): 2335-42. pmid: 11413523. 17. greene fl, page dl, fleming id, fritz ag, balch cm, haller dg, morrow m, editors. american joint committee on cancer (ajcc) cancer staging manual, 6th ed. new york: springer-verlag; 2002. p 18. 18. national comprehensive cancer network. thyroid cancer (version 1.2019). [accessed 2019 sep 6]. available from: http://www.nccn.org/professionals/physician_gls/pdf/thyroid.pdf. 19. shaha ar, ferlito a, owen rp, silver ce, rodrigo jp, haigentz m jr, et al. airway issues in anaplastic thyroid carcinoma. eur arch otorhinolaryngol. 2013 sep;270(10):2579-83. doi: 10.1007/s00405013-2556-3; pmid: 23689802. 20. smallridge rc, ain kb, asa sl, bible kc, brierley jd, burman kd, et al. american thyroid association guidelines for management of patients with anaplastic thyroid cancer. thyroid. 2012 nov;22(11):1104-39. doi: 10.1089/thy.2012.0302; pmid: 23130564. that makes the management of tracheal secretions more problematic. furthermore, peristomal bleeding and direct intraluminal extension of the tumor are frequent occurrences that can contribute to intermittent periods of airway obstruction and hypoxemia. all these factors pose significant risks and raise the question whether routine stomal nursing care can be safely done at home. our study has several limitations. the primary outcome of diseasespecific mortality, was only reliably determined in 52% of patients despite extensive efforts to track patients and determine their status. better follow-up and patient tracking can lead to more reliable data which may translate to more robust conclusions. another limitation was that we were only able to ascertain postoperative complications from inpatient records. it is highly probable that patients may have suffered other postoperative complications after discharge such as tube displacement/obstruction. future research should investigate the prognostic value of other interventions such as chemotherapy and/or radiotherapy rendered to patients who did not undergo any surgery. currently, we can conclude that the data at hand is insufficient to affirm that tracheostomy or thyroidectomy significantly alter the survival of similarly staged patients. these findings caution us surgeons to be more pragmatic in offering interventions to these patients. they must be advised about the proven benefits and risks surrounding the procedure. supportive care without surgery is an acceptable alternative if the patient so desires. ultimately, it is about enabling patients to make informed decisions regarding their care, especially since current treatment efforts continue to be disappointing and the prognosis continues to be grim. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery contents cover images editorial 4 people giving hope in the time of covid-19: they also serve who care and share lapeña jf review article 6 otorhinolaryngology out-patient practice in the “post”covid-19 era: ensuring a balance between service and safety lapeña jf, abes fl, gomez mat, villafuerte cvl, roldan ra, fullante pb, carrillo rjc, paber jel, isla at, alcances inocencio r, cabazor jb, caro rm, guzman mfp original articles 30 radiologic study of the nasal septal swell body and its relationship to septal deviation mendoza vm, gelera je, sison czi, dizon fad, manalo jml 33 air pollution and nasal mucociliary clearance time among urban and rural residents in two philippine communities joson sn, laxamana jq 36 post-operative bleeding in tonsillectomy versus tonsillectomy with fossa closure in a tertiary military hospital: a cohort study reyes nks 39 transoral endoscopic thyroidectomy vestibular approach (toetva) for thyroid nodules: a series of the first 10 patients in a single institution maliwat ly, malahito rrg, llanes egdv 46 prognostic value of thyroidectomy and tracheostomy in anaplastic thyroid carcinoma garcia cvl, cabungcal aca, pontejos aqy 51 effectiveness of the philippine health insurance corporation case rate system for thyroidectomy in a tertiary government hospital ramos jap, untalan fmb case reports 56 primary intraosseous carcinoma of the mandible: a case report doroy gar, gelbolingo nl 60 bilateral facial nerve (bell’s) palsy in a 24-year-old woman: a case report tolentino cq, cruz ets 63 thyroglossal duct carcinoma with concurrent papillary thyroid carcinoma: a case report lahoz acf, grullo per, carrillo rjc practice pearls 66 techniques in the safe use of polycaprolactone in structural rhinoplasty yap ec featured grand rounds 71 gorlin-goltz syndrome: multiple basal cell carcinoma, bifid rib, palmar and plantar pits in a 50-year-old woman balatibat em, borbe bb, castañeda ss from the viewbox 74 eye movement autophony: a unique presenting symptom of semicircular canal dehiscence syndrome yang nw under the microscope 76 botryoid odontogenic cyst carnate jm letters to the editor 78 surviving covid-19 pneumonia at home: covid case #1906 flor jf 80 on the representative ct image of an otic-disrupting fracture yang nw 81 response from the authors chua r, lacanilao r passages 82 edilberto m. jose, md (1946-2019): otorhinolaryngologist, head and neck surgeon, mentor, friend caro rm 83 carlos p. reyes, md (1940 2020): little-known but significant pioneer abes gt “plain ct scan, axial view showing antral soft-tissue density” by dann joel c. caro, md “curimao house” oil on canvass, 19.5” x 29.5” by ruzanne m. caro, md “old customs, new technology” fujifilm x-t1, 35mm f2.0 by michael joseph c. david, md “bosyo” sony rx 100 m4 by lyndon henry t. dacanay, md “3d printed skull” polylactic acid material by rene louie c. gutierrez, md people giving hope in the time of covid-19: they also serve who care and share otorhinolaryngology out-patient practice in the “post”-covid-19 era: ensuring a balance between service and safety radiologic study of the nasal septal swell body and its relationship to septal deviation air pollution and nasal mucociliary clearance time among urban and rural residents in two philippine communities post-operative bleeding in tonsillectomy versus tonsillectomy with fossa closure in a tertiary military hospital: a cohort study transoral endoscopic thyroidectomy vestibular approach (toetva) for thyroid nodules: a series of the first 10 patients in a single institution prognostic value of thyroidectomy and tracheostomy in anaplastic thyroid carcinoma effectiveness of the philippine health insurance corporation case rate system for thyroidectomy in a tertiary government hospital primary intraosseous carcinoma of the mandible: a case report bilateral facial nerve (bell’s) palsy in a 24-year-old woman: a case report thyroglossal duct carcinoma with concurrent papillary thyroid carcinoma: a case report techniques in the safe use of polycaprolactone in structural rhinoplasty gorlin-goltz syndrome: multiple basal cell carcinoma, bifid rib, palmar and plantar pits in a 50-year-old woman eye movement autophony: a unique presenting symptom of semicircular canal dehiscence syndrome botryoid odontogenic cyst surviving covid-19 pneumonia at home: covid case #1906 on the representative ct image of an otic-disrupting fracture and response from the authors edilberto m. jose, md (1946-2019): otorhinolaryngologist, head and neck surgeon, mentor, friend carlos p. reyes, md (1940 2020): little-known but significant pioneer president’s page greetings to all ent fellows! when i became a member of the board of trustees during the presidency of dr. cesar anthony yabut in 2012, i surmised how concerned and dedicated the board was in supporting and funding researches of fellows-whether they were descriptive, analytical, surgical innovations and instrumentations -through the pso-hns research committee. amendments to the research paper contest guidelines were made to give way to the advent of information technology in synchronization with the electronic journal management system of the philippine journal of otolaryngology head and neck surgery (pjohns). online review and corrections were implemented to maximize time and efforts of the judges and the authors. this was given emphasis during the administration of dr. wilfredo batol in 2013. well, these are all done for academic excellence. under dr. howard enriquez’ administration in 2014, research still remained one of the priorities of pso-hns. each and every paper submitted passed through the eye of the needle of the editorial board of pjohns. it may be a lot of hard work and effort for the researchers, judges and editors but it is worth the hard work. perseverance is the key! just choose a “worth-knowing” topic and write a “worth-publishing” paper. if it is rejected, just try again. be patient with the corrections and revisions-in the end, the fruit of your labor is a sweet success. an orl-hns specialist should be equipped with this trait to really cope with the ever changing needs of our society whether it is surgically or research oriented as evidenced by our very own pjohns. it is with great pride and honor that i render a message in our prestigious journal. i would like to take this opportunity to express my sincere gratitude and congratulations to my colleague, dr. joey lapena, and the same is true for the editorial staff and members for their never ending dedication and hard work in making a journal that is equally competitive and accepted in the 21st century. mabuhay! armando m. chiong, jr., md president philippine society of otolaryngology-head and neck surgery 2 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 30 no. 1 january – june 2015 perseverance is the key philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 featured grand rounds pyoderma gangrenosum (pg) was first described in 1916 as “phagedenisme geometrique”, after a french dermatologist observed rapidly progressing, cutaneous necrotic lesions with sharp borders.1 in 1930, brunsting and his colleagues at the mayo clinic coined the term pyoderma gangrenosum, because it was initially thought to arise from staphylococcal and streptococcal infections which were observed in 5 of their patients.2 the exact etiology and pathogenesis is still unknown. to date, only a few cases of pg have been shown to affect the ears, all showing no gender or age predilection.3 we report another such case. case report a three-year-old girl presented at the emergency room with a non-healing, erythematous papule over her left ear lobule, allegedly following an ear piercing one month prior. she was initially treated at another institution with oral antibiotics. despite treatment, her mother noted rapid worsening of the lesion, eventually developing into a painful ulceration and affecting the left eyelid as well. at the time of examination, the patient presented with a painful, necrotic plaque around the left eyelid with serpiginous borders (figure 1) and ear lobule with erythematous, advancing borders (figure 2a, b). there were no systemic co-morbidities noted. the working diagnosis then was necrotizing fasciitis and she was immediately started on systemic intravenous antibiotics which she did not respond to. laboratory tests showed elevated crp, but procalcitonin, c-anca and ana were all normal. tissue cultures of both eyelid and earlobe, as well as blood cultures, revealed no growth. wedge biopsy of the eyelid ulceration revealed neutrophilic dermatitis. biopsy of the ear lobule revealed suppurative granulomatous dermatitis with secondary leucocytoclastic vasculitis. further workups for infection and possible systemic diseases were all unremarkable. a pathergy test was negative. a diagnosis of pyoderma gangrenosum was made after excluding systemic and infectious causes. the patient was started on systemic prednisone at a dose of 1mg/kg/day which she slowly responded to. surgical reconstruction of the earlobe was to be planned once the ulceration completely healed; unfortunately, this patient was lost to follow-up. pyoderma gangrenosum initially presenting as an ulceration of the ear lobule correspondence: dr. agnes tirona remulla department of otolaryngology head and neck surgery college of medicine philippine general hospital university of the philippines manila ermita, manila 1000 philippines phone: (632) 8526 4360 email: antironaremulla@up.edu.ph the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. heather grace dulnuan, md carlo victorio garcia, md agnes tirona-remulla, md department of otolaryngology head and neck surgery philippine general hospital university of the philippines manila philipp j otolaryngol head neck surg 2021; 36 (2): 52-54 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 featured grand rounds discussion pyoderma gangrenosum is rare in childhood, with approximately 4% of pg cases seen in infants and children usually affecting the head and perineal area.4 studies have also shown that there is a female preponderance because reactive neutrophilic dermatoses are known to affect females.5 the disease arising from a neutrophilic process is the well-accepted etiology. with advances in biologic therapies, it has been found that it may be related to overexpression of growth factors il-8, il-18, il-16, and tnf-α. metabolic oscillations and aberrant neutrophil trafficking is also observed.6 clinically, it begins as a painful nodule that may be seen after episodes of trauma. pain is a prominent feature in the pediatric population. in the classic lesion, the pustule progresses to a necrotic ulceration with irregular, red-purplish inflammatory borders and a purulent or bloody exudate.7 they may present anywhere in the body, usually in multiples sites, as compared to the adult population where lesions are solitary and observed in the extremities.8 aside from the classic presentation, other pg subtypes are pustular, bullous, vegetative, peristomal, genital, infantile and extracutaneous.9 in most cases, a biopsy is warranted to rule out other causes for the cutaneous lesion. specimens can also be sent for bacterial and fungal cultures. around 20% of patients present with pathergy, where inciting trauma (such as a biopsy or venipuncture) forms a new lesion.10 the histopathologic findings seen in the classic lesion is ulcerative associated with dense neutrophilic infiltrates. su et al.10 proposed a diagnostic criterion for pg, where the major criteria is a rapidly enlarging, painful ulceration in the absence of any other cause for the lesion. since then, modifications to this criterion have been made; however, pg remains to be a diagnosis of exclusion.10 the key to diagnosis is a thorough history with emphasis on a history of pathergy, associated pain, and the presence of associated systemic diseases. when present in the head and neck, differential diagnoses such as infected preauricular cysts or sinuses, dissecting folliculitis, ulcerating basal cell carcinoma, and trigeminal trophic syndrome should be considered.11 pg often occurs in isolation but may be associated with other systemic conditions in up to 50% of cases.3 in pediatric patients, it is most commonly associated with inflammatory bowel disease (ibd), warranting investigation of gastrointestinal symptoms and further examination through endoscopy.8 it is also associated with hematologic disorders, such as myelodysplastic syndromes, leukemias and lymphoma.8 in the pre-adolescent population, pg is often idiopathic or associated with hematologic disorders, while ibd and papa (pyogenic arthritis, pyoderma gangrenosum and acne) are seen in the adolescent population.8 in the philippines, one of the cases of pg published in literature is that of an adult female suffering from acute myelogenous leukemia who presented with the bullous type of the disease.11 pg may also be the initial presentation of vasculitis such as behcet disease and takayasu’s arteritis, rheumatoid arthritis, and neoplasms.12 due to the rarity of the disease, there is no definite effective therapy for pg, and treatment has mainly been empiric. treatment goals include relieving pain, controlling the inflammatory process and managing the underlying disease.9 oral corticosteroids with a usual dose of 0.5-1mg/ figure 1. ulcerative lesions around an erythematous margin and serpiginous borders involving the upper eyelid figure 2. rapidly progressive ulceration with areas of necrosis around the left a. preauricular; and b. post auricular area. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 featured grand rounds references 1. farhi d. the clinical and histopathological description of geometric phagedenism (pyoderma gangrenosum) by louis brocq one century ago.  arch dermatol.  2008 jun;144(6):755. doi:10.1001/archderm.144.6.755 pubmed pmid: 18559764. 2. brunsting la, goeckerman wh, o’leary pa. pyoderma (echthyma) gangrenosum: clinical and experimental observation in five cases occurring in adults. arch dermatol syphilol. 1930 oct; 22(4):655–680. doi: 10.1001/archderm.1930.01440160053009. 3. dos santos sousa mc, lima lemos, ef, oliveira de morais o, silva leite coutinho as, martins gomes c. pyoderma gangrenosum leading to bilateral involvement of ears. j clin aesthet dermatol. 2014 jan;7(1):41–43. pubmed pmid: 24563696. pubmed central pmcid: pmc3930540. 4. powell fc, schroeter al, su wp. pyoderma gangrenosum: a review of 86 patients. q j med. 1985 may;55(217):173–186. pubmed pmid: 3889978. 5. von den driesch p. pyoderma gangrenosum: a report of 44 cases with follow-up. brit j dermatol. 1997;137(6);1000–1005. doi:10.1046/j.1365-2133.1997.20022083.x. 6. adachi y, kindzelskii al, cookingham g, shaya s, moore ec, todd rf 3rd, petty hr. aberrant neutrophil trafficking and metabolic oscillations in severe pyoderma gangrenosum. j invest dermatol. 1998 aug;111(2):259-68. doi: 10.1046/j.1523-1747.1998.00311.x. pubmed pmid: 9699727. 7. schoch jj, tolkachjov sn, cappel ja, gibson le, davis dm. pediatric pyoderma gangrenosum: a retrospective review of clinical features, etiologic associations, and treatment. pediatr dermatol. 2017 jan;34(1):39-45. doi: 10.1111/pde.12990. pubmed pmid: 27699861. 8. kechichian e, haber r, mourad n, el khoury r, jabbour s, tomb r. pediatric pyoderma gangrenosum: a systematic review and update. int j dermatol. 2017 may;56(5):486-495. doi: 10.1111/ijd.13584. pubmed pmid: 28233293. 9. ruocco e, sangiuliano s, gravina ag, miranda a, nicoletti g. pyoderma gangrenosum: an updated review. j eur acad dermatol venerol. 2009 sep;23(9):1008-17. doi: 10.1111/j.14683083.2009.03199.x. pubmed pmid: 19470075. 10. su wpd, davis mdp, weenig rh, powell fc, perry ho. pyoderma gangrenosum: clinicopathologic correlation and proposed diagnostic criteria. int j dermatol. 2004 nov;43(11):790–800. doi: 10.1111/j.1365-4632.2004.02128.x pubmed pmid: 15533059. 11. snyder ra. pyoderma gangrenosum involving the head and neck. arch dermatol. 1986 mar;122(3):295-302. pubmed pmid: 2869733. 12. ramos vme, chamberlin cvs, dofitas bl. a rare case of bullous pyoderma gangrenosum in a patient with acute myelogenous leukemia. acta medica philippina. 2020;54(3):336-339. doi: https://doi.org/10.47895/amp.v54i3.1687. 13. powell fc, perry ho. pyoderma gangrenosum in childhood.  arch dermatol 1984;120(6):757– 761. doi:10.1001/archderm.1984.01650420067018. kg/day have been widely used in the pediatric and adult population due to the rapid response to treatment.9 other reported systemic treatments are immunosuppressive drugs, thalidomide, minocycline, sulphasalazine, and dapsone. infliximab and other biologic treatments have also been reported to provide clinical improvement after one infusion.8 local wound care and pain control are also necessary. in summary, pediatric pyoderma gangrenosum may present in multiple sites, and in atypical areas such as the head and neck. as a diagnosis of exclusion, a thorough workup is imperative to diagnose other etiologies and evaluate co-morbidities associated with the disease. once diagnosed, aggressive immunosuppression should be started to facilitate complete recovery. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 8180 philippine journal of otolaryngology-head and neck surgery letters to the editor response from the authors dear sir: thank you for that pointing it out. all the ct images were read and reread by an experienced radiologist whose skill is beyond reproach and experience unquestionable. the results of the study therefore are verifiable and it, too, will stand scrutiny. there were no mistakes or mislabelling of the ct scan images of each patient. the reported result of only 3 otic-involved fractures out of 41 patients included in the study stands and is spot on. upon review of the images in the article, it was determined that the image used in fig. 1 was erroneously inserted and used in the space for fig. 4. truly yours, rene c. lacanilao, md ruben j. chua, jr., md department of otolaryngology – head and neck surgery amang rodriguez memorial medical center sumulong highway, sto. niño, marikina city 1800 philippines editorial note: this letter is published as it was received. an editorial offer to revise the response was declined: “yes it was deliberately worded that way because the letter to the editor was too heavy handed.” the authors were reminded that as they approved the final galley proofs before publication, “the image used in fig. 1 was” not “erroneously inserted and used in the space for fig. 4” by the journal and an editorial note would have to be made to that effect. they replied: “yes. the erroneous insertion was on our part. it managed to escape scrutiny. please include your note.” heretofore are 2 ct images of the patients with otic-involved temporal bone fractures: (thin arrows point to the evident fracture lines) philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the incidence of post-operative bleeding among patients who underwent tonsillectomy alone versus tonsillectomy with fossa closure at the victoriano luna medical center from january 2015 to december 2017. methods: design: retrospective cohort study setting: tertiary military hospital patients: medical records of 83 patients that underwent tonsillectomy under the department of otorhinolaryngology – head and neck surgery between january 2015 to december 2017 were retrospectively reviewed for data regarding sex, age, tonsillectomy with or without fossa closure and post-operative bleeding. cases of tonsillectomy alone versus tonsillectomy with fossa closure were compared (particularly with respect to post-operative bleeding), tabulated and statistically analyzed using risk ratio and t-test. results: there were 57 cases of tonsillectomy alone versus 26 cases of tonsillectomy with fossa closure. the incidence of bleeding in all cases of tonsillectomy whether tonsillectomy alone or with fossa closure was 4.8%. the incidence of bleeding was higher in cases of tonsillectomy with fossa closure at 11.5% (versus 1.8% in tonsillectomy alone). post-operative bleeding was 0.1 times more likely to occur in patients who underwent tonsillectomy alone than those who underwent tonsillectomy with fossa closure but there was no statistically significant difference in the risk of post-operative bleeding between the two. conclusion: although the incidence of bleeding was higher in cases of tonsillectomy with fossa closure, our results suggest that there is no statistically significant difference in risk for postoperative bleeding between tonsillectomy alone or tonsillectomy with fossa closure. keywords: tonsillectomy; postoperative bleeding; tonsil pillars; suturing tonsillectomy involves excision of the tonsils, whether bilateral or unilateral, leaving the pillars behind without suturing the anterior and posterior pillars together. it is indicated for tonsillar cancer, severe airway obstruction and a curative measure for recurrent tonsillitis.1 post-operative bleeding in tonsillectomy versus tonsillectomy with fossa closure in a tertiary military hospital: a cohort study niel khangel s. reyes, md department of otorhinolaryngology head and neck surgery victoriano luna medical center armed forces of the philippines health service command correspondence: dr. niel khangel s. reyes department of otorhinolaryngology head and neck surgery victoriano luna medical center armed forces of the philippines health service command (vlmc afphsc) 7th floor vlmc afphsc, v. luna avenue quezon city 0840 philippines phone: (632) 8426 2701 local 6172 email: nielkhangel_reyes@yahoo.com /ent_afpmc@yahoo.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery, analytical research contest. october 23, 2018. roma salon, the manila hotel. manila. philipp j otolaryngol head neck surg 2020; 35 (1): 36-38 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery original articles the most common and most serious complication is post-operative bleeding2-4 while other possible complications include aspiration, pulmonary edema, atlantoaxial subluxation, injury to the eustachian tube, velopharyngeal insufficiency, nasopharyngeal stenosis, and even psychological trauma depending on the age of the patient.5 common symptoms experienced post-operatively include fever, dehydration, uvular edema, otalgia or odynophagia.5 numerous techniques to improve post-operative outcomes have been sought for decades and one method is tonsillectomy with fossa closure.6 however, to the best of our knowledge there are no previous local studies regarding the relationship between post-operative hemorrhage after tonsillectomy alone or tonsillectomy with fossa closure based on our search of the herdin database. thus, this study sought to determine the incidence of post-operative bleeding among patients who underwent tonsillectomy alone versus tonsillectomy with fossa closure in our institution from january 2015 to december 2017, and whether there was a significant relationship between post-operative bleeding and the surgical procedure. methods with institutional review board approval, this retrospective cohort analysis of patients that underwent tonsillectomy from january 2015 to december 2017 at the victoriano luna medical center of the armed forces of the philippines was conducted. data regarding age, sex, indication, procedure (tonsillectomy with or without fossa closure) and post-operative bleeding (presence of oozing or active bleeding from the post-operative site that may or may not warrant return to the operating room) were gathered from patient records of the department of otorhinolaryngology – head and neck surgery. patients were grouped according to age less than 18 years old, 18-40 years old and above 40 years old. other variables such as the health status of patients, co-morbidities (hypertension, diabetes, blood dyscrasias, history of bleeding), and compliance with medications or pre-existing treatment regimens for other diseases, were excluded from the data gathered. all data were encoded using microsoft excel version 14.6.3 (microsoft corp., redmond, wa, usa). descriptive statistics were used to summarize the gathered data. a two-sample t-test assuming unequal variances was used to test if there was a significant relationship between surgical technique and risk of post-operative bleeding. the relative risk ratio was computed to estimate the extent of the relationship between surgical technique (tonsillectomy alone versus tonsillectomy with fossa closure) used and the occurrence of post-operative bleeding. the confidence interval was set at 95%. results records of a total of 83 patients (62 males, 21 females) were included in this study. their ages ranged from 3 to 54 years old with an average age of 27 years. fifteen (18.07%) patients were under the <18 age group while 60 (72.28%) were in the 18-40 age group, and the remaining 8 (9.63%) were in the >40 age group. indications for tonsillectomy were recurrent tonsillitis in 44 (53.01%), enlarged (brodsky grades iii and iv) tonsils in 31 (37.35%), and obstructive sleep apnea in 8 (9.64%). fifty-seven (68.67%) underwent tonsillectomy alone and 26 (31.32%) had tonsillectomy with fossa closure. there were only four (4) post-operative hemorrhages (4.8%) overall, 3 among 26 patients who had tonsillectomy with fossa closure and 1 among 57 patients with tonsillectomy alone, with incidence rates of 11.5% and 1.8%, respectively. while our findings suggest that postoperative bleeding was 0.1 times more likely to occur in patients who underwent tonsillectomy alone than those who underwent tonsillectomy with fossa closure, there was no statistically significant difference in the risk of post-operative bleeding between the two (risk ratio [rr] 6.58; 95% confidence interval [ci] 0.72 to 60.26; p = .089). discussion the overall incidence of postoperative tonsillectomy hemorrhage in this study regardless of procedure was 4.8% which is consistent with the reported rates of 0.28 20 % in other studies,7 including another local study with a 5.6% incidence rate for post-operative bleeding.8 the incidence of post-operative bleeding among patients who underwent tonsillectomy alone versus tonsillectomy with fossa closure was 1.8 % and 11.5%, respectively, which fails to reject the null hypothesis of this study. our findings contrast with those of foreign studies that suggested there were lesser incidences of post-operative hemorrhage in cases wherein fossa closure was done.7,9,10 there are several limitations to this study. in our institution, the main surgeons for tonsillectomies were second year residents assisted by first year residents, under the supervision of thirdor fourth year residents. although surgical competence in tonsillectomy may be achieved in the second year of training,11 the uniformity of surgical technique as well as skill of the surgeon were not accounted for by the study design. all three cases of post-operative bleeding in tonsillectomy with fossa closure were brought back to the operating room for evacuation of hematoma and ligation of bleeders while the single case of postoperative bleeding in tonsillectomy alone was managed through application of direct pressure and chemical cauterization using silver nitrate stick only. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery original articles unfortunately, we did not determine the reasons behind surgeons choosing to perform tonsillectomy with fossa closure versus tonsillectomy alone. if fossa closure was performed for tonsillectomies that were bloodier than usual, or that were deemed to potentially bleed postoperatively, that would be an important intervening variable for consideration and should be explored in future studies. confounders including past medical history (including bleeding disorders and anti-coagulant medication intake), family history (of bleeding diathesis), personal and social history (including smoking and ethanol ingestion), co-morbidities (such as hypertension, blood dyscrasias, diabetes, and other chronic illnesses), and laboratory results (including platelet count, prothrombin time, liver function tests) were not included in the data gathered, because we presumed that patients cleared for the procedure were stable and any co-morbidity would have been controlled or accounted for at that point. however, we suggest that such variables be investigated in further studies since they may indirectly affect surgical techniques, as well as postoperative hemorrhage. in conclusion, although the incidence of bleeding was higher in cases of tonsillectomy with fossa closure, our study found no statistically significant difference in risk for post-operative bleeding between tonsillectomy alone or tonsillectomy with fossa closure. references 1. galindo torres bp, de miguel garcia f, whyte orozco j. tonsillectomy in adults: analysis of indications and complications.  auris nasus larynx. 2018 jun; 45(3); 517-521. doi: 10.1016/j. anl.2017.08.012; pmid: 28927847. 2. myssiorek d, alvi a. post-tonsillectomy hemorrhage: an assessment of risk factors. int j pediatr otolaryngol. 1996 sep; 37(1): 35-43. pmid: 8884405. 3. walker p, gilles d. post-tonsillectomy hemorrhage rates: are they techniquedependent?  otolaryngol head neck surg. 2007 apr; 136(4 suppl: s27-s31. doi: 10.1016/j. otohns.2006.10.022; pmid: 17398338. 4. windfuhr jp. serious complications following tonsillectomy: how frequent are they really? orl j otorhinolarygol relat spec. 2013;75(3): 166-173. doi: 10.1159/000342317; pmid: 23978803. 5. gallagher tq, wilcox l, mcguire e, derkay cs. analyzing factors associated with major complications after adenotonsillectomy in 4776 patients: comparing three tonsillectomy techniques.  otolaryngol head neck surg. 2010 jun; 142(6): 886-892. doi: 10.1016/j. otohns.2010.02.019; pmid: 20493363. 6. matt bh, krol bj, ding y, juliar be. effect of tonsillar fossa closure on postoperative pain and bleeding risk after tonsillectomy.  int j pediatr otolaryngol. 2012 dec; 76(12): 1799-1805. doi: 10.1016/j.ijporl.2012.09.004; pmid: 23021465. 7. elkholy ta. modified surgical technique with pillars repair in reducing post tonsillectomy haemorrhage. int inv j med sci. 2016 jun 3(6): 108-114. 8. moral sd, barlin akc, acuin jm. clinical profile of post-tonsillectomy bleeding; a 30-month institutional review. philipp j otolaryngol head neck surg. 2010 jul-dec 25(2):14-17. 9. senska g, schröder h, pütter c, dost p. significantly reducing post-tonsillectomy haemorrhage requiring surgery by suturing the faucial pillars: a retrospective analysis. plos one. 2012; 7(10): e47874. doi: 10.1371/journal.pone.0047874; pmid: 23118902; pmcid: pmc3485309. 10. wulu ja, chua m, levi jr. does suturing tonsil pillars post-tonsillectomy reduce postoperative hemorrhage: a literature review. int j pediatric otorhinolaryngology. 2019 feb; 117:204-209. doi: 10.1016/j.ijporl.2018.12.003; pmid: 30611028. 11. ahmed a1, ishman sl, laeeq k, bhatti ni. assessment of improvement of trainee surgical skills in the operating room for tonsillectomy. laryngoscope. 2013 jul;123(7):1639-44. doi: 10.1002/ lary.24023. pmid: 23483535. philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 featured grand rounds the nasal skin is the most common site of malignancy in the face accounting for as much as 25.5 percent by virtue of its location and propensity for direct exposure to ultraviolet radiation from the sun.1-3 among the various cutaneous malignancies, basal cell carcinoma is the most common, but other types of cancer such as squamous cell carcinoma, cutaneous malignant melanoma, and basosquamous carcinoma are also common.4 following surgical resection of a malignant lesion, the defect calls for a reconstructive option that will restore aesthetics and function. we present a squamous cell carcinoma of the nasal alar skin which underwent excision and reconstruction of the defect using a superiorly based nasolabial flap. case report a 66-yearold man consulted at the outpatient clinic due to a nasal alar mass on the right. the mass star ted one year prior to consult as a pimple -like lesion on the right nasal ala. there was no histor y of manipulation or trauma to the aforementioned area. he consulted at a local hospital where he was given unrecalled antibiotics that did not cure the lesion. instead, he noticed that it gradually enlarged, and a deep ulceration developed within the mass. this prompted consult at our outpatient clinic where a 3 x 2 cm ulcerating mass with crusting and necrotic areas was noted on his right nasal ala. (figure 1) anterior rhinoscopy showed an intact mucosa in the right nostril with no gross evidence of tumor involvement. there were no enlarged cervical lymph nodes palpated in the neck. a wedge biopsy revealed a well-differentiated squamous cell carcinoma. he claimed that he had no family history of cutaneous malignancy. however, he had a 20 pack-year history of smoking and was a heavy alcoholic beverage drinker. he previously worked as an electrician and denied chronic exposure to sunlight. he consequently underwent excision of the right nasal alar mass with 5-mm margin. (figure 2a, b) a histologic evaluation of the margins revealed that the borders and tumor base were negative for malignancy. the alar cartilage was not involved by tumor. reconstruction of the defect was done using a superiorly based nasolabial flap on the right. (figure 3a, b, c) two weeks postoperatively, the patient came in for follow-up with a healed, aesthetically pleasing, and well-coaptated wound. (figure 4) he remains free of any evidence of recurrence after 1 year. reconstruction of large nasal alar squamous cell carcinoma defect using a superiorly based nasolabial flap correspondence: dr. jan caezar b. cordero department of otorhinolaryngology head and neck surgery 6th floor, east avenue medical center east avenue, diliman, quezon city 1100 philippines mobile: (632) 923 676 8784 phone: (632) 8928 0611 local 324 fax: (632) 435 6988 email: jan_caezar7018@yahoo.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery inter-hospital grand rounds. november 15, 2018. manila doctors hospital, manila city. jan caezar b. cordero, md department of otorhinolaryngology head and neck surgery east avenue medical center philipp j otolaryngol head neck surg 2020; 35 (2): 55-58 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 featured grand rounds figure 1. a 3 x 2 cm ulceration on the right nasal ala with areas of crusting and necrosis. figure 2. a. skin markings for incision with 5mm margins from the site of induration; b. defect after excision of the mass with borders and base negative for malignancy on frozen section. a discussion cancers of the face and of the skin in general are categorized either as melanoma and nonmelanoma skin cancers (nmsc).5,6 nonmelanoma skin cancers are comprised of basal cell carcinmoma (bsc) and cutaneous squamous cell carcinoma (cscc) as the more common histologic types.6 cutaneous scc is the second most common skin malignancy after basal cell carcinoma and comprises 20 percent of all cutaneous malignancies.6-9 risk factors for the development of cscc include: chronic ultraviolet radiation exposure from the sun, frequent exposure to tanning lamps, hpv and hiv infections, inflammatory diseases of the skin, and previous burn scars.7,8,10 our patient did not have any of the aforementioned risk factors. cutaneous scc usually affects the head and neck region as it is commonly exposed to direct uv light from the sun.11,12 the ears, cheek, and frontotemporal area are the most common sites of head and neck cscc, but the nose is also one of the major anatomical sites involved.13,14 our patient developed cscc of the right nasal ala. lesions on the nose are included in area h which constitutes high-risk lesions for recurrence and metastasis.15 the diagnosis of cscc is primarily based on a complete history and physical examination, head and neck exam, and histologic diagnosis of the skin lesion.16 staging of cscc is based on the tumor-node-metastasis (tnm) classification by the american joint committee on cancer (ajcc) for prognostication and predicting survival outcomes.17 based on a wedge biopsy, our patient’s tumor was stage ii (t2n0m0). the treatment of cscc depends on whether the tumor is low-risk or high-risk for recurrence and metastasis.17 low-risk cscc are welldefined primary tumors in an immunocompetent person that are less than 20-mm in the trunk and extremities, less than 10mm in the cheeks, forehead, scalp, neck, and pretibial, and without prior history of site irradiation or presence of neurologic symptoms.15 these are managed by standard excision with 4to 6-mm margins and depth to include the mid-subcutaneous adipose tissue.17 high-risk cscc are tumors that develop in the face, genitalia, hands, and feet coupled with poor clinical factors opposite of the characteristics of a low risk cscc.15 the lesion on our patient’s nose was considered a high-risk cscc. high-risk cscc may be treated with standard excision and subsequent reconstruction as long as the margins are clear of malignant cells. however, the recommended treatment for high-risk cscc is moh’s micrographic surgery (mms) wherein a thin layer of tissue around and deep to the margins are removed and examined.17 if the removed tissue is positive for malignant cells, the process is repeated until the obtained specimen is histologically negative for tumor.18 mms was not performed on our patient due to the lack of equipment and personnel in our institution to facilitate the procedure. alternatively, a standard surgical excision b philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 featured grand rounds was carried out with 5-mm margins from the site of er ythema and induration. histologic evaluations of specimens from the peripher y and base of the tumor were all negative for tumor infiltration. the resulting circular defect involved the right nasal ala, inferior portion of the right nasal side wall, soft tissue facet, part of the nasal dorsum, and right half of the nasal tip. as we desired to perform a single-stage procedure, reconstruction of the defect was performed immediately. the american academy of dermatology recommends that when a standard excision is performed, skin grafting, linear repair, or healing by secondary intention should be the preferred methods of repair while reconstruction by tissue rearrangement may be performed as long as the histologic margins are clear.17 reconstruction of the nose takes into consideration the different nasal aesthetic subunits.19 the subunit principle in nasal reconstruction is essentially the removal of the whole aesthetic subunit for defects with more than 50 percent subunit loss.20 this technique allows the incision lines to be placed along the border of the subunit, thereby camouflaging the scar lines.20 despite the popularity of the subunit principle, other schools of thought on nasal reconstruction include half subunit replacement, the modified subunit principle, and the defect-only reconstruction which provide equally good outcomes.21,22 for this patient, we decided to preserve the defect as it was after we had obtained clear margins without strictly following the subunit principle. the defect already involved the entire right nasal ala but less than 50 percent of the tip, dorsum, and sidewall. moreover, we wanted to preserve the remaining normal tissue and prevent the creation of a figure 3. a. planning; b. elevation; and c. inset and suturing of the nasolabial flap onto the nasal defect. a b c figure 4. nasolabial flap two weeks postoperatively. note that the symmetry, texture and contour of the nose are maintained. philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 featured grand rounds acknowledgements the author would like to thank dr. armando chiong, jr., dr. roberto claridad, dr. charles malapit, and dr. reden aldea for their invaluable help in the planning and execution of the surgery and dr. karina vel dizon for presenting the case orally during the grand rounds. references 1. salgarelli ac, cangiano a, sartorelli f, bellini p, collini m. the bilobed flap in skin cancer of the face: our experience on 285 cases. j craniomaxillofac surg. 2010 sep;38(6):460-464. doi: 10.1016/j.jcms.2009.10.022 pubmed pmid: 19939690. 2. kim yh, yoon hw, chung s, chung yk. reconstruction of cutaneous defects of the nasal tip and alar by two different methods. arch craniofac surg. 2018 dec;19(4):260-263. doi: 10.7181/ acfs.2018.02271 pubmed pmid: 30613087 pubmed central pmcid: pmc6325337. 3. salgarelli ac, bellini p, multinu a, magnoni c, francomano m, fantini f, et al. reconstruction of nasal skin cancer defects with local flaps. j skin cancer. 2011;2011:181093. doi: 10.1155/2011/181093. pubmed pmid: 21773033 pubmed central pmcid: pmc3135072. 4. kaya i̇, uslu m, apaydın f. defect reconstruction of the nose after surgery for nonmelanoma skin cancer: our clinical experience. turk arch otorhinolaryngol. 2017 sep;55(3):111-118. doi: 10.5152/tao.2017.2513. pubmed pmid: 29392067 pubmed central pmcid: pmc5782988. 5. dourmishev la, rusinova d, botev i. clinical variants, stages, and management of basal cell carcinoma. indian dermatol online j. 2013 jan;4(1):12-7. doi: 10.4103/2229-5178.105456. pubmed pmid: 23439912; pubmed central pmcid: pmc3573444. 6. ouyang yh. skin cancer of the head and neck. semin plast surg. 2010 may;24(2):117-26. doi: 10.1055/s-0030-1255329. pubmed pmid: 22550432; pubmed central pmcid: pmc3324239. 7. badash i, shauly o, lui cg, gould dj, patel km. nonmelanoma facial skin cancer: a review of diagnostic strategies, surgical treatment, and reconstructive techniques. clin med insights ear nose throat. 2019 jul 24;12:1179550619865278. doi: 10.1177/1179550619865278. pubmed pmid: 31384136; pubmed central pmcid: pmc6657122. 8. howell jy, ramsey ml. squamous cell skin cancer. [updated 2020 aug 8]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2020 jan-.  available from: https://www. ncbi.nlm.nih.gov/books/nbk441939/. 9. mcguire jf, ge nn, dyson s. nonmelanoma skin cancer of the head and neck i: histopathology and clinical behavior. am j otolaryngol. 2009 mar-apr;30(2):121-33. doi: 10.1016/j. amjoto.2008.03.002. pubmed pmid: 19239954. 10. fahradyan a, howell ac, wolfswinkel em, tsuha m, sheth p, wong ak. updates on the management of non-melanoma skin cancer (nmsc). healthcare (basel). 2017 nov 1;5(4):82. doi: 10.3390/healthcare5040082. pubmed pmid: 29104226; pubmed central pmcid: pmc5746716. 11. johnson tm, rowe de, nelson br, swanson na. squamous cell carcinoma of the skin (excluding lip and oral mucosa). j am acad dermatol. 1992 mar;26(3 pt 2):467-84. doi: 10.1016/01909622(92)70074-p. pubmed pmid: 1564155. 12. ho t, byrne pj. evaluation and initial management of the patient with facial skin cancer. facial plast surg clin north am. 2009 aug;17(3):301-7. doi: 10.1016/j.fsc.2009.04.002. pubmed pmid: 19698912. 13. vauterin tj vauterin tj, veness mj, morgan gj, poulsen mg, o’brien cj. patterns of lymph node spread of cutaneous squamous cell carcinoma of the head and neck. head neck. 2006 sep;28(9):785-91. doi: 10.1002/hed.20417. pubmed pmid: 16783833. 14. leibovitch i, huilgol sc, selva d, hill d, richards s, paver r. cutaneous squamous cell carcinoma treated with mohs micrographic surgery in australia i. experience over 10 years. j am acad dermatol. 2005 aug;53(2):253-60. doi: 10.1016/j.jaad.2005.02.059. pubmed pmid: 16021120. 15. national comprehensive cancer center. nccn clinical practice guidelines in oncology; squamous cell carcinoma (v1.2017). available at: www.nccn.org. accessed november 2, 2019. 16. gurudutt vv, genden em. cutaneous squamous cell carcinoma of the head and neck. j skin cancer. 2011;2011:502723. doi: 10.1155/2011/502723. pubmed pmid: 21461387 pubmed central pmcid: pmc3064996. 17. amin mb, greene fl, edge sb, compton cc, gershenwald je, brookland rk, et al. the eighth edition ajcc cancer staging manual: continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging. ca cancer j clin. 2017 mar;67(2):93-99. doi: 10.3322/caac.21388. pubmed pmid: 28094848. 18. prickett ka, ramsey ml. mohs micrographic surgery. [updated 2019 mar 26]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2019 jan-.  available from: https://www. ncbi.nlm.nih.gov/books/nbk441833/. 19. sheu mc, bloom jd, constantinides m.  aesthetic subunits of nose. in: kountakis se. (editor). encyclopedia of otolaryngology, head and neck surgery. berlin / heidelberg: springer; 2013. p. 110-112. doi: 10.1007/978-3-642-23499-6_327. 20. burget gc, menick fj. the subunit principle in nasal reconstruction. plast reconstr surg. 1985 aug;76(2):239-47. doi: 10.1097/00006534-198508000-00010 pubmed pmid: 4023097. 21. shumrick ka, campbell a, becker ff, papel id. modification of the subunit principle for reconstruction of nasal tip and dorsum defects. arch facial plast surg. 1999 jan-mar;1(1):9-15. doi: 10.1001/archfaci.1.1.9. pubmed pmid: 10937068. 22. rohrich rj, griffin jr, ansari m, beran sj, potter jk. nasal reconstruction--beyond aesthetic subunits: a 15-year review of 1334 cases. plast reconstr surg. 2004 nov;114(6):1405-16; discussion 1417-9. doi: 10.1097/01.prs.0000138596.57393.05. pubmed pmid: 15509926. 23. thornton jf, griffin jr, constantine fc. nasal reconstruction: an overview and nuances. semin plast surg. 2008 nov;22(4):257-68. doi: 10.1055/s-0028-1095885. pubmed pmid: 20567702 pubmed pmcid: pmc2884875. 24. moolenburgh se, mclennan l, levendag pc, munte k, scholtemeijer m, hofer so, mureau ma. nasal reconstruction after malignant tumor resection: an algorithm for treatment. plast reconstr surg. 2010 jul;126(1):97-105. doi: 10.1097/prs.0b013e3181da872e. pubmed pmid: 20220560. 25. kerem h, bali u, sönmez e, manavbaşı yi, yoleri l. the cranially based contralateral nasolabial flap for reconstruction of paranasal and periorbital surgical defects. j plast reconstr aesthet surg. 2014 may;67(5):655-61. doi: 10.1016/j.bjps.2014.01.027. pubmed pmid: 24529694. 26. shao y, zhang d, zhao z, jin h, rong l. [reconstruction of large nasal defects with lateral nasal artery pedicled nasolabial flap]. zhongguo xiu fu chong jian wai ke za zhi. 2010 may;24(5):5525. [chinese]. pubmed pmid: 20540258. 27. levine pa. reconstruction of large nasal defects with a subcutaneous pedicle nasolabial flap. an underutilized technique. arch otolaryngol. 1985 sep;111(9):628-30. doi: 10.1001/ archotol.1985.00800110106014. pubmed pmid: 4026683. larger defect which could necessitate a more complex reconstructive option and longer operative time. after obtaining clear margins, the next step is to decide on what reconstructive option to use to cover the nasal defect. since we had a relatively large defect the recommended reconstructive option was the forehead flap.3,7,22-24 the forehead flap is considered the gold standard for reconstruction of large alar, tip, hemi-nasal, and even total nasal defects.23,24 we chose to reconstruct the defect with a superiorly-based nasolabial flap instead of a paramedian forehead flap as we could not persuade our patient to undergo a second stage procedure on top of his concern over an apparent scar in the forehead. the nasolabial flap is usually recommended for skin-only alar defects of less than 2 cm in diameter and is based on the perforators from the angular and facial arteries.24 although this type of flap has been recommended for small alar defects, it has been utilized to reconstruct defects up to 5 cm in diameter.25-27 in our patient, the large defect was adequately covered by the nasolabial flap while maintaining symmetry with the contralateral side of the nose. because of its tendency to trap-door and contract, the flap recreates the natural convexity of the ala and restores the natural alar crease.3,24 together with the matched skin color and texture of the donor site to the nose, this flap may be a good option and alternative for the reconstruction of large nasal alar defects involving adjacent subunits. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the self-reported assessment of initial implementation of the 3 domains of outcome-based education in accredited otolaryngology head and neck surgery residency training programs in the philippines by consultants and residents and explore any associations between their demographic profiles and assessments. methods: design: mixed method research design setting: multicenter 30 accredited orl-hns residency training institutions in the philippinesnational capital region (ncr) 19, luzon 7, visayas 2, and mindanao 2. participants: a total of 129 consultants and 82 second to fourth year residents in training were included in the study by convenience sampling. first-year residents who started their residency training in january 2020 were excluded. respondents answered self-reported questionnaires to assess implementation of the 3 domains of obe: intended learning outcomes (ilo), teaching and learning activities (tla) and assessment tasks (at) using the 4-point scale score from “fully implemented” (4) to “not implemented” (1). results of questionnaires were confirmed using open-ended questions on the challenges of obe with a focused group discussion among 4 consultants and 1 resident. results: the self-reported assessment of respondents on obe implementation was “fully implemented” in the 3 domains. however, low numerical scores were seen for “managing community health and social need” in the ilo and “laboratory activities and workshops” in the tla for both consultants and residents, in the assessment task (at “multisource feedback by nurses and administrative staff ” for the consultants, and “direct observation of performance skills for patient encounter” for residents. among the 7 modules, “research methodology” had the lowest score for both consultants’ and residents’ self-perception. challenges of obe revealed included “mastery,” “time” and “data keeping.” consultants younger than 60 years of age who had been in the department longer than 3 years and residents who attended an obe workshop / lecture tended to give higher scores. conclusion: two years after distribution of the manual on obe to orl-hns residency training institutions, the consultants’ and residents’ self-reported assessment on implementation in all the 3 domains of obe was “fully implemented.” keywords: outcome-based education; outcome process assessment; health care; otolaryngology; health plan implementation; formative feedback; internship and residency; teaching; medical graduate education self-reported assessment of outcome-based education in philippine otolaryngology head and neck surgery residency training programs by consultants and residents maria natividad a. almazan, md, msc, phd school of graduate studies manila central university correspondence: dr. maria natividad a. almazan school of graduate studies manila central university research and development office filemon d. tanchoco medical foundation edsa, caloocan city 1400 philippines phone: (632) 8367-2031 local 1226 email: natividadarceoalmazan@gmail.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. funding: no funding support was received for this study. this paper is condensed from the dissertation submitted to the faculty of the school of graduate studies of the manila central university filemon d. tanchoco medical foundation in partial fulfillment of the requirements for the degree of doctor of philosophy in education last july 30, 2020. philipp j otolaryngol head neck surg 2021; 36 (1): 15-23 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery original articles outcome-based education (obe) emphasizes the output and defines what the learner is answerable for any teaching and learning program.1 obe is precisely designed towards the global call for transformative scale up of health professions education and to respond to society’s needs.2 in the united states, the accreditation council for graduate medical education (acgme) mandated new structural changes in residency education with its newly created core competencies and an emphasis on outcomes-based education.3 canadian higher education institutions started to show a significant shift towards obe in order to stay globally competitive.4 the association of southeast asian nations (asean) joint coordinating committee on medical practitioners (jccmp) decided on regional economic community integration in 2014 with outcome based training in residency training. specifically, it means transforming the member-countries into a single market production base, highly competitive economic region with equitable economic development that is fully integrated into the global economy. the enhanced basic education act of 2013, the philippine qualifications framework, the commission on higher education memorandum order number 46 and the global call for transformative education serve as precursors of outcome based education (obe) in the philippines.2 in preparation for asean integration, the professional regulation commission board of medicine (prc bom) communicated with the different specialty board societies in 2015. the philippine college of surgeons (pcs) sent the bases for the specialty curriculum formed by the joint coordinating council on accreditation and certification (jccac) to the philippine society of otolaryngology head and neck surgery (pso-hns) in january 2016. an ad hoc committee on outcome based education was formed by the philippine board of otolaryngology head and neck surgery (pbohns) and the philippine society of otolaryngology head and neck surgery (pso-hns) together with the different heads of the subspecialty groups convened to come up with the orl-hns obe manual.5 this was sent to the professional regulation commission board of medicine (prc bom) in 2016 and distributed to all 34 orl residency training institutions in 2017 to standardize the obe program and focus on its aim to graduate locally and internationally competent and competitive general otolaryngologists. more than 2 years after the distribution of the obe manual, there is a need to assess perception of the consultants and residents on initial implementation of the 3 domains of obe in the orl-hns residency training institutions. these domains are the intended learning outcomes (ilo), teaching and learning activities (tla) and assessment tasks (at). the knowledge on its implementation will benefit the stakeholders: the administrators of the accredited orl-hns training departments, their obe coordinators, consultants, residents, ad hoc committee on obe, the pso-hns, and the patients. this is the first study on implementation of obe program in orlhns that was introduced only in the middle of 2017 and results of the paper will be used to create guidelines to monitor progress of obe program. the objective of this study is to determine the self-reported assessment of initial implementation of the 3 domains of outcome based education in accredited otolaryngology -head and neck surgery residency training programs in the philippines by consultants and residents and explore any associations between their demographic profiles and assessments. methods this is a multicenter study that sought to involve the 34 accredited residency-training programs in orl-hns all over the philippines from january to june 2020. the eligible respondents were the consultants and second to fourth year residents in training who experienced the obe program prepared by the pbo-hns and the pso-hns in 2017. first year residents were excluded because they only started residency training in 2020. the study focused on the consultants’ and residents’ self-reported assessment on implementation and the challenges of obe in the residency training of orl-hns. institutional review board (irb) /ethics committee approval was granted at the following institutions: manila central university fdtmf (2020-03), east avenue medical center (2020-06) and veterans memorial medical center (2020-08). finally, since this was an academic research paper, it received a certificate of exemption from the single joint research ethics board (sjreb-2020-12) of the department of health. informed consent with data privacy was obtained from the respondents. the study used a mixed method research design. the first part was quantitative (descriptive, correlational, comparative); the second part was qualitative. the descriptive process depicted consultants’ and residents’ profiles and their self-reported assessments on implementation of the 3 domains of obe: intended learning outcome (ilo), teaching and learning activities (tla), and assessment tasks (at). correlational analysis was used to determine associations between the profiles of the consultants and residents with their self-reported assessment on implementation. comparisons were used to determine differences between the consultants’ and residents’ profiles and their assessment on implementation of obe in orl-hns residency training. the qualitative process utilized an interview among selected consultants and residents to confirm the quantitative data. the study was carried out as a qualitative work based on a descriptive phenomenological approach. purposive sampling was utilized for the recruitment of participants selected from several accredited hospital institutions. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery original articles open-ended questions on the challenges of obe were asked during a one-on-one interview via viber platform. the investigator wrote down the answers and data collected were grouped based on pre-planned coding. data analysis used the saturation method coming up with the themes and subthemes. for the quantitative part of the study, there were 2 sets of researchermade questionnaires, one for consultants and one for residents in training. the first part obtained demographic data of the respondents and the second part focused on implementation of the 3 domains of obe taken from the manual of the obe in orl-hns in 2017. the questionnaires were constructed in consonance with the constructive alignment of the 3 domains proposed by dr. william spady, father of obe:6 (figure 1) first, the focal point of the learning process are the intended learning outcomes (ilo). all teaching and learning activities (tla) and assessment tasks (at) must be aligned with the learning outcomes. this supports the learners in their progress (formative assessment) and validates the achievement of the intended learning outcomes at the end of the process (summative assessment).7 the first domain of intended learning outcomes (ilo) included 12 core competencies recommended by the professional regulation commission board of medicine (prc bom) for all residency training programs in the philippines that were incorporated in the 7 modules (6 subspecialties and research methodology) of orl-hns residency training. these were all reflected in the questionnaires. the second domain of teaching and learning activities (tla) covered 8 activities: case-based discussion conferences; lectures; laboratory activities and workshops; patient encounters at the out-patient department, emergency room, wards and operating room; ward rounds; subspecialty and multidisciplinary meetings; specialty rotations; and instructional courses and workshops. the third domain covered the 12 assessment tasks (at) such as “direct observation of performance skills for patient encounter” and “multisource feedback form.” these tasks are reflected in 12 formative assessment forms (1 to 12) that are designed to elicit feedback to improve learning throughout the year while a summative assessment is performed on a summary of these forms at the end of the year for each resident, and placed in their learning portfolio. the questionnaires also mentioned the objective of the study, instructions how to answer, and that results would be fed back to respondents and stakeholders for recommendations on creation of guidelines to monitor the obe program. the questionnaires were validated for face and content validity by 3 experts, a psychometrician and a grammarian. from the pre-validated questions, 41 questions were revised, 7 added and 20 accepted. pilot testing was done among 16 consultants and residents at a government orl-hns department in luzon. the computed cronbach’s alpha for internal and external reliability testing was .969. the self-reported researcher-made questionnaires were answered by the respondents in their respective institutions in hard copies at the weekly and national conferences of the orl-hns departments after the informed consent was obtained, with data privacy assured. electronic mails using google forms were used to send the questionnaire to those who were not able to answer in hard copies. all efforts were exhausted to include 34 institutions in the study. the results of the self-reported questionnaires were used to prepare open-ended questionnaires for the focus group discussion (fgd) among a small number of 4 consultants and 1 resident to confirm the quantitative data. the “saturation principle” established the themes on the challenges and problems of obe implementation. the questionnaire sought the demographic profile of the respondent consultants and residents of the departments of orl-hns of the accredited institutions. for the consultants, these included the following: age, sex, training institution category of hospital, number of years in the department, appointment designation, number of hospital affiliations and attendance in a workshop on obe. for the residents in training, these included: age, sex, residency year level, training institution category and attendance in an obe workshop. the questionnaire assessed the implementation of obe in the 3 domains of education: intended learning outcome (ilo), teaching and learning activities (tla) and assessment tasks (at) among consultants and residents as well as the difference between the 2 groups. subsequent data analysis explored associations between variables in the demographic profiles of consultants and residents, and their assessments on implementation of obe. data analysis also determined differences in consultants’ and residents’ assessments on implementation when grouped according to their demographic profiles. associations and differences were tested using a criterion of p ≤ 0.05 level of significance. sample size was computed using the proportion of doctors who have attended the obe workshop (set at 50%) based on a preliminary study. however, since the sample size of 462 participants was too big compared to the source population size of 327 (200 and 127 consultants and residents respectively), a finite population correction (fpc) was applied to the computed sample size. after fpc, a sample size of at least 192 was computed. the computed number of respondents allocated proportionately to consultants and residents was at least 118 consultants and 74 residents respectively to meet the computed sample size of 192 participants. for the validation interviews, the respondents were chosen from both consultants and residents in government and private institutions who consented to answer questions of exact wording and sequence on their obe experience. purposive sampling was utilized for the philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery original articles recruitment of 4 consultants and 1 resident. the participants were selected from 4 metro manila institutions and one from visayas after the quantitative data were collected and analyzed. to validate the quantitative results of the study and expound on the challenges of the obe, open-ended questions were asked during a one on one interview privately between the researcher and the participant via viber call. the researcher obtained a permission to record the answers in writing. data collected was collated based on the pre-planned coding on the raw data on the challenges of the 3 domains of obe, the intended learning outcome, teaching learning activities (tla) and the assessment tasks (at). data was analyzed using the saturation principle coming up with the themes and subthemes. data collection and analysis were performed using microsoft office excel 2007 version 12.0.4518.1014 (microsoft corp., redmond wa usa). statistical analysis was performed using spss version 10.0.5 722680 (ibm corp., armonk ny usa) with the following statistical tools: descriptive statistical tool of frequency and percentage for the profile of the respondents, weighted mean for the computation of the assessment on implementation of obe using a 4-point rating scale, chisquare for the inferential relationship of the profile of the respondents and the assessment of the implementation of the obe, independent-t test for the inferential difference of the implementation of obe between the 2 groups of respondents when grouped according to their profile and difference between the 2 groups and lastly, analysis of variance (anova) for the difference between the profile and the assessment of implementation of obe among the consultants and residents. results a total of 211 respondents participated in this study, 129 consultants (65%) and 82 residents (65%). they represented 30 out of the 34 accredited orl-hns residency training institutions in the philippines: 19 in the national capital region (ncr), seven in luzon, two in the visayas and two in mindanao. most of the consultants (47; 36.43%) were between 40-49 years of age, followed by 35 (27.13%) who were between 50-59 years of age. there were more males (85; 65.89%) than females (44; 34.11%). most (74; 57.36%) were in the government sector and 121 (93.8%) had been with their department for more than 3 years. in terms of appointment designation, 80 (62.02%) were tenured and had a permanent item, mostly in government hospitals (74; 57.36%). there were 80 (62.02%) with only one hospital affiliation, 39 (30.23%) with 2-3 hospital affiliations, and 10 (7.5%) with 4 hospital affiliations. eighty-one (62.79%) had administrative positions in the department: chairman (23; 17.83%), vicechairman (6; 4.65%), training officer / obe coordinator (25; 19.38%) and subspecialty head (27; 20.93%). the number of respondents with attendance in an obe workshop or lecture was 78 (60.47%). more than half of the residents (45; 54.88%) were between 2529 years of age, newly licensed physicians of the philippine board of medicine. there was a similar number of males (43; 52.44%) and females (39; 47.56%). except for less sophomores, the distribution by year level was equivalent, with 30 (36.59%) second year, 21 (25.61%) third year, and 30 (36.59%) fourth year residents. there was one fifth year respondent who was the chief resident in one institution. the respondents were mostly from government hospitals (69; 84.15%). there were 51 respondents (62.20%) had attended a workshop or lecture on obe. the self-reported assessments of the consultants and residents on implementation of obe in orl-hns rated the first domain of intended learning outcome (ilo) as “fully implemented” (fi). (table 1) the weighted means of the 4-point rating scales for perceptions of the consultants ranged from 3.47 to 3.78. among the residents, the weighted means ranged from 3.54 to 3.81. the highest score was the ability to demonstrate clinical and surgical competence and engaging in professional development among the consultants. among the residents, it was exhibiting professionalism. the core competency on “managing community health and social needs’ had the lowest score among both consultants and residents, at 3.47 and 3.54, respectively. table 2a shows the self-reported assessment of consultants and residents on implementation of obe in orl-hns for the second domain, teaching and learning activities (tla). the consultants and residents perceived this domain as “fully implemented” (fi). the weighted means of the 4-point rating scales for perceptions of consultants ranged from 3.47 to 3.88. among the residents, the weighted means ranged from 3.46 to 3.79. the highest score on the teaching and learning activities was case-based discussion conferences among the consultants. among the residents, it was patient encounter at the opd, er and ward. lowest scores were laboratory activities and workshops for both consultants and residents, at 3.47 and 3.46 respectively. table 2b shows the self-reported assessment of consultants and residents on implementation of the eight (8) teaching and learning activities (tla) for the seven (7) modules of orl-hns residency training (6 subspecialties and the research methodology). the consultants and residents alike perceived this domain as “fully implemented.” the weighted means on the 4-point rating scale on the perception among the consultants ranged from 3.57 to 3.85. among the residents, the weighted means ranged from 3.51 to 3.82. the highest score on the 7 modules was on general otorhinolaryngology among the consultants and among the residents, it was otology, neuro-otology and audiology. the activity on the module of research methodology had the lowest philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery original articles score among the consultants and the residents’ perception, 3.57 and 3.51 respectively. table 3 shows the self-reported assessment of consultants and residents on implementation on the third domain, assessment tasks (at). this domain was perceived as “fully implemented” by both consultants and residents. for the consultants’ perception of implementation for all the 12 assessment task forms, the weighted means ranged from 3.28 to 3.74. the highest score was on presentation skill assessment and the lowest score was on the multisource feedback form, accomplished by the nurses or the administrative staff. for the residents’ perception, the weighted means ranged from 3.32 to 3.69. the highest score was the basic lecture assessment and the lowest score was on direct observation of performance skills for patient encounter. among the consultants’ demographic profiles, there was a significant association (x2=10.10, df=3, p<.01) between age and perception of implementation for all the 3 domains of obe intended learning outcome (ilo), teaching and learning activities (tla) and assessment tasks (at). consultants aged between 40 to 49 years old comprised the majority of respondents (47/129; 36.43%) who answered “fully implemented” (fi). consultants younger than 60 years tended to give higher scores in the implementation of obe in orl-hns. a significant correlation was seen in the following: 30-39 years vs. 60 years and above (x2=7.24, df=1, p=.01); 40-49 years vs 60 years and above (x2=6.18, df=1, p=.01), and 50-59 years vs. 60 years and above (x2=6.10, df=1, p=.01). there was also a significant correlation between consultants’ number of years in the department and their perception of implementation of the third domain of obe, the assessment tasks (at ) (x2=15.52, df=6, p<.01). consultants who had been in the department longer than 3 years tended to give higher ratings ( positive correlation) for the assessment tasks (at ). on the other hand, sex (x2=3.96, df=3, p<.27), sector category of the hospital (x2=4.401, df=6, p<.62), appointment designation (x2=3.39, df=3, p<.34), number of training hospital affiliations (x2=9.83, df=3, p<.13) and attendance to lecture or workshop on obe (x2=3.42, df=3, p<.33) were not significantly associated with perception of obe implementation among the consultants. among the residents, there was a significant association between attendance in a workshop or lecture on obe and the perception of obe implementation for the domain of intended learning outcome (ilo) (x2=6.009, df=2, p<.05). therefore, there was a positive correlation. there was no significant association between the demographic profile of residents in terms of age (x2=5.45, df=4, p<.24), sex (x2=2.28, df=2, p<.32), residency training level (x2=2.47, df=2, p<.87), category sector, (x2=0.23, df=2, p<.89) and position in the department (x2=0.31, df=2, p<.86) and their perception of implementation of obe in orl-hns residency training in the intended learning outcome (ilo). the study also checked on the comparison between consultants’ and residents’ self-reported assessments of implementation of obe in orl-hns residency training. using t-test at 0.05 level of significance, there was no significant difference noted in the assessment of intended learning outcome (ilo) (t=0.23, df=209, p=.82), teaching and learning activities (tla) (t=0.85, df=209, p=.402), and assessment tasks (at) (t=0.49, df=209, p=.62) between consultants and residents. both of them reported the assessment of the obe as “fully implemented (fi) in the 3 domains. a qualitative study based on descriptive phenomenological approach showed the following results. throughout the interview, in-depth, semi-structured open questionnaires were asked “tell me about some of the challenges and problems in obe implementation in general”, “what are the challenges in implementation in terms of the 1st domain on intended learning outcome as recommended by prc bom and the different modules?” “what are the challenges in terms of the learning objectives?” and “what are the challenges in terms of the assessment tasks?” to motivate the participants to share deeper information, probing questions were also asked, such as “tell me more” and “can you give me an example.” immediately after conducting each interview, the researcher actively transcribed and reviewed the words of the participants in the interview. statements and phrases were extracted and the core meaning was collected in terms of the 3 domains of obe and its challenges. data saturation was achieved after interviews with 5 participants. three main themes were extracted from the interviews and emerged in the participants’ experiences. the 3 themes were 1) “mastery of intended learning outcome”, 2) “time factor contributing to the implementation of the teaching and learning activities” and, 3) “ data keeping of the assessment forms.” quotations from the participants were also used writing the descriptions and the explanations of the 3 subthemes of for each of the 3 themes for a total of 9 subthemes. (table 4) discussion the philippine board of otolaryngology and philippine society of otolaryngology head and neck surgery complied with the prc bom mandate on outcome-based training for asean integration with a manual on obe distributed to the accredited institutions in 2017. after 2 years, there was a need for consultants and residents to assess the implementation of obe in orl-hns residency training and form guidelines for better monitoring to graduate competent and competitive orl-hns doctors. the sample respondents in this study represent trainers, trainees and residency training programs in the philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles residents on all 3 domains of obe using the 4-point scale score was “fully implemented.” the first domain on intended learning outcome (ilo) included all 12 core competencies mandated by the prc bom to all postgraduate residency training. among these core competencies, the expected result was that managing community health and social needs will have the lowest score. although orl-hns is a surgical specialty with residency training in a hospital setting, the perception of the respondents was that exposure to this core competency occurs only in medical and surgical missions outside the hospital. other means of community and social needs like advocacies in orl-hns like silip tenga, silip lalamunan, and community hearing evaluation in the hospitals are table 1. consultants’ and residents’ assessment of the extent of implementation of the obe in the orlhns residency training in terms of intended learning outcome (ilo) intended learning outcomes (ilo) core competencies residents (n = 82) wm/vi consultants (n = 129) wm/vi 3.78/fi 3.73/fi 3.58/fi 3.54/fi 3.74/fi 3.54/fi 3.78/fi 3.83/fi 3.53/fi 3.57/fi 3.47/fi 3.68/fi 3.65/fi ability to demonstrate clinical and surgical competence displaying effective communication and interpersonal skills exhibiting effective leadership and management skills engaging in evidence-based practice exhibiting inter-professionalism engaging in health systems-based practice engaging in continuing professional development exhibiting professionalism demonstrating nationalism and internationalism practicing social accountability managing community health and social needs competency in the curricular goals divided into 3: introduce, practice and demonstrate the different modules depending on the year level of residency training. overall weighted mean/fi 3.71/fi 3.73/fi 3.57/fi 3.56/fi 3.70/fi 3.62/fi 3/63/fi 3/81/fi 3.58/fi 3.54/fi 3.51/fi 3.63/fi 3.63fi wm – weighted mean; vi – verbal interpretation fully implemented (fi) 3.26 4.00; partially implemented (pi) 2.51 3.25; minimally implemented (mi) 1.76 2.50 not implemented (ni) 1.0 – 1.75 table 2a. consultants’ and residents’ assessment of the extent of implementation of the obe in the orlhns residency training in terms of teaching and learning activities (tla) teaching and learning activities (tla) extent of implementation residents (n = 82) wm/vi consultants (n = 129) wm/vi 3.88d/fi 3.77/fi 3.47/fi 3.81/fi 3.77/fi 3.57/fi 3.58/fi 3.70/fi case-based discussion conferences lectures laboratory activities and workshops patient encounter at the opd, er, ward and or ward rounds subspecialty and multidisciplinary meetings specialty rotations instructional courses and workshops 3.76/fi 3.64/fi 3.46/fi 3.79/fi 3.76/fi 3.70/fi 3.61/fi 3.63/fi wm – weighted mean; vi – verbal interpretation fully implemented (fi) 3.26 4.00; partially implemented (pi) 2.51 3.25; minimally implemented (mi) 1.76 2.50 not implemented (ni) 1.0 – 1.75 table 2b. consultants’ and residents’ assessment of the extent of implementation of the obe in the orlhns residency training in terms of teaching and learning activities (tla) in the seven modules the teaching and learning activities (tla) in 7 modules residents (n = 82) wm/vi consultants (n = 129) wm/vi 3.85/fi 3.78/fi 3.77/fi 3.77/fi 3.82/fi 3.81/fi 3.57/fi 3.73/fi general otorhinolaryngology otology, neuro-otology, audiology rhinopharyngology, allergy, oral cavity and sleep surgery laryngobronchoesophagology head and neck surgery craniomaxillofacial, plastic and reconstructive surgery research methodology overall weighted mean (owm) 3.77/fi 3.82/fi 3.67/fi 3.68/fi 3.76/fi 3.73/fi 3.51/fi 3.69/fi wm – weighted mean; vi – verbal interpretation fully implemented (fi) 3.26 4.00; partially implemented (pi) 2.51 3.25; minimally implemented (mi) 1.76 2.50 not implemented (ni) 1.0 – 1.7 philippines with the aim to standardize residency training program and to graduate competent and competitive medical specialists locally and internationally. the study was done at 30 accredited institutions in the philippines from january to may 2020. the evaluation tool used was a researchermade questionnaire with self-reported assessment of the consultants and residents on implementation of the obe in orl-hns. a focused group discussion among 4 consultants and one resident with openended questionnaire confirmed the results on the assessment of implementation and added information on the challenges of obe in orl-hns. constructive alignment is defined as the teaching design for outcome-based education clearly and explicitly linked in 3 domains: intended learning outcome (ilo), teaching and learning activities (tla) and, assessment task (at).6,8 the self-reported perception of the consultants and the residents’ assessment on implementation of obe in orl-hns used the 4-point rating scale evaluation tool. the self-reported assessment of both the consultants and the philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles part of the intended learning outcome at manuals on obe for all.5 the orl-hns residency training adapted this in 2017 with the distribution of the manual of obe in orl-hns. for the second domain on 8 teaching and learning activities (tla), the perception of both consultant and resident respondents on implementation using the 4-point scale score was “fully implemented.” the lowest score among these activities was reported on the laboratory activities and workshops. in orl-hns residency training, surgical excellence is of utmost importance so without the laboratory activities and workshops, opportunity to introduce simulation is missed. simulation in a surgical specialty is a preparation to be adept and avoid complications in actual patients. good simulations offer immediate opportunities for feedback and additional crucial “soft’ skills. not all simulation workshops are offered in all training institutions so there is a need to strengthen in-house activities at all accredited institutions. the teacher’s fundamental task to get students engaged in learning activities that are likely to result in their achieving specific learning outcomes for all the 7 modules in orl-hns is important in the constructive alignment of the teaching activities and the outcomes. obe enables students to learn the desired outcome in an effective manner.11 the learning process is fully enhanced with the application considered a part of the core competency on managing community health and social needs so there is a need to reiterate this to the stakeholders for better understanding. as stated by the accreditation council for graduate medical education, the core competencies ensure residents are properly trained to practice medicine successfully.9 as seen in this study, the perception of the trainers and trainees on the core competencies with high scores were on engagement in continuing professional development and demonstration of clinical and surgical competence. the surgical training programs in the usa and in canada also emphasized these competencies with medical and technical knowledge, clinical decision-making and motor skills in surgical expertise.10 with the obe in place, the prc bom mandated the core competencies in the residency training programs in 2015 to be table 4. main theme and secondary themes of obe challenges as perceived by the consultants and residents (interview results) main theme secondary theme mastery of intended learning outcome in the participants’ experiences time factor contributing to the implementation of the teaching and learning activities data keeping of the assessment forms 1. comprehension of the core competencies set by the prcbom 2. familiarity of the set core competencies and the modules from the orlhns manual 3. knowledge of the different modules and the core competencies from both the prcbom and the orlhns 1. conflict of time to teach and practice among consultants 2. duration of time spent for the learning activities among residents 3. time management of both consultants and residents for all the learning activities for the different modules 1. record –keeping of the assessment forms by residents 2. safeguard and protection of data of the assessment forms accomplished by consultants 3. monitoring of data kept in each portfolio of the residents table 3. consultants’ and residents’ assessment of the extent of implementation of the obe in the orlhns residency training in terms of assessment tasks (at) assessment tasks (at) extent of implementation residents (n = 82) verbal interpretation consultants (n = 129) weighted mean 3.74/fi 3.63/fi 3.58/fi 3.47/fi 3.28/fi 3.57/fi 3.46/fi 3.45/fi 3.47/fi 3.45/fi 3.48/fi 3.38/fi 3.43/fi 3.49/fi presentation skill assessment (form 1) basic lecture assessment (form 2) direct observation of performance scale (dops) on procedural skills (form 3) dops for patient encounter (form 4) multi-source feedback (form 5) accomplished by nurses and administrative staff dops for operative performance (form 6) research skills assessment (form 7) the self global assessment (form 9) give opportunity for self-reflection and insight of own performance of the residents the peer global assessment (form 10) articulates the residents’ perception of the performance of their co-trainees the global assessment for consultants (form 11) provides feedback of their contribution to the residency training. the residency training program global assessment (form 12) by the consultants and residents helpful in planning strategies in implementation the formative assessment (forms 1-12) allows feedback for better learning summative assessment is done at the end of the year for each resident by the department overall weighted mean (owm) 3.67/fi 3.69/fi 3.45/fi 3.32/fi 3.40/fi 3.41/fi 3.54/fi 3.64/fi 3.61/fi 3.56/fi 3.56/fi 3.49/fi 3.52/fi 3.53/fi wm – weighted mean; vi – verbal interpretation fully implemented (fi) 3.26 4.00; partially implemented (pi) 2.51 3.25; minimally implemented (mi) 1.76 2.50 not implemented (ni) 1.0 – 1.75 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles of obe instruction in improving communication skills and acquiring a lot of fun with the learning and teaching activities, both for the trainers and the trainees.12 among the teaching and learning activities, the consultants’ self-reported assessment showed high scores in case-based discussion conferences and among the residents, patient encounter at the emergency room, outpatient department, operating room and the wards. again, the strength of training was clinical and surgical exposure to different orl-hns cases. among the 7 modules, the perception of the respondents on the assessment was “fully implemented” but research methodology had the lowest score. research in the residency training needs cooperation of the training institution and department to provide support in terms of time, training, facilities, and finances to the residents in training. residency training in university hospitals has research incentives and funding with time off to do research. however, in most training institutions, research perks are not available. according to the acgme, the research curriculum program already takes into account scholarly activity requirements for residents and teaching faculty. some programs have additional requirements to improve training in research methodology13 and this has to be monitored among the different accredited institutions. for the third domain on assessment tasks (at), the perception of the consultants on implementation using the 4-point scale score was “fully implemented.” among the assessment tasks, the lowest score was the multi-source feedback accomplished by nurses and administrative staff. its goal is to look at the residents’ work from a variety of perceptions that will give a complete picture of performance, not only from the colleagues.14 the doctors in residency training are still not used to being assessed by non-colleagues at this point in time in the philippines. the evaluation of other co-workers is a way to balance work relationships among the health care workers for the benefit of the patients. the perception of the residents on implementation of the assessment task (at) was “fully implemented” but the lowest score was on direct observation of performance skills at the operating room, outpatient department, emergency room and the wards. before the advent of obe, evaluation and grading of residents’ performance relied more on later recall of the trainers and were not immediately documented regularly in writing. with the introduction of the obe, documentation of each domain from the teaching and learning activities to assessment on the intended learning outcomes are documented and kept in a portfolio for each resident. the paper trail was mandated by the accreditation council for graduate medical education to fully integrate assessment tools into the obe curriculum and provide a comprehensive evaluation of all areas of the core competencies. 9 among the assessment tasks, the highest scores were seen on presentation skills and on basic lectures. these were done frequently at grand rounds and regularly meetings of the department. evaluation and assessment has become an integral process of any educational institution toward an improved and quality learning experience.15 the 3 domains on obe, the intended learning outcomes (ilo), teaching and learning activities (tla) and the assessment tasks (at) was constructively aligned in orl-hns. the consultants and the residents’ perception on implementation after 2 years are “fully implemented” among the accredited orl-hns residency institutions in the philippines. although all domains were fully implemented, the low scores have to be monitored and improved for the success its aim in orl-hns residency training and, that is to graduate competent and competitive doctors. this study also showed that there was no difference in the consultants and residents self-reported assessment on implementation of the obe in orl-hns two years after the introduction to the departments. the focused group discussion among a small number of respondents confirmed the results that the obe was “fully implemented.” the challenges of the obe were grouped to the 3 themes on mastery and familiarization of the intended learning outcome, the time spent for the teaching and learning activities and lastly is the data keeping of the assessment forms. the perception on implementation of obe was associated with age in all the 3 domains of obe. most of those who answered the questionnaire were young consultants in the 40 to 49 year-old-age group because orl-hns is a relatively young specialty. at this age group, educators are more likely to be optimistic, positive or open to educational changes like the introduction of obe. in a local study of an english class, teachers’ age and number of years in teaching were positively related to the their attitude towards outcome-based education (obe).16 this was seen in our study. there was also an association of the consultants ‘number of years in the department and the implementation of the assessment tasks (at).’ most of those who answered the survey were already present in the department for more than 3 years. it takes time to master a new program and the longer and more frequent they practice answering the assessment forms, the more it becomes a habit. the habit then becomes part of the system of the department. among the residents, there was an association of the attendance to obe workshop or lecture and the perception on implementation. obe program in the orl-hns residency program is something new with a lot of documentation and paperwork to assess the residents in training. commitment to a new curriculum is important. preparing teachers for change precedes training. when there is a need for change in the philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles references 1. hague m. outcome based medical education – a brief commentary. natl j physiol pharm pharmacol. 2017 apr 09; 7(9): 881-885. doi: 10.5455/njppp.2017.7.0411203052017. 2. sana ea, roxas ab, reyes alt. introduction of outcome based education in philippine health professions education setting. phil j health res dev. 2015 mar; 19(1):60-74. 3. accreditation council for graduate medical education (acgme) general competencies. [cited 2020 aug 7] available from: https//www.acgme.org. 4. mousavihejazi b, borja de mozato b. value of design competencies within an outcome based education. in: 11th european academy of design conference. france: boulogne billancourt; 2015. 5. outcome based education manual in residency training in otorhinolaryngology-head and neck surgery (orl-hns). phil. society of otolaryngology head and neck surgery and philippine board of otolaryngology head and neck surgery, 2016. 6. spady wg, uy fa. outcome-based education: critical issues and answers: maxor publishing house, inc., 1994; isbn 978-971-0167-41-8. 7. crespo r, najjar j, dernti m, leony d, neumann s, oberhuemer p, et al. aligning assessment with learning outcomes in outcome based education. ieee xplore. 2010 may; 1239-1246. doi: 10.1109/educon.2010.5492385. 8. biggs j. aligning teaching and assessing to course objectives. teaching and learning in higher education: new trends and innovations. university of aveiro, 2003 april; 13-17. 9. bancroft gn, basu cb, leong m, mateo c, hollier lh, stal s. outcome-based residency education: teaching and evaluating the core competencies in plastic surgery. plast reconstr surg. 2008 jun; 121(6): 441e-448e. doi: 10.1097/prs.0b013e318170a778; pubmed pmid: 18520871. 10. grober e, jewett m. the concept and trajectory of “operative competence” in surgical training. can j surg. 2006 aug; 49(4): 238-40. pubmed pmid: 16948880; pubmed central pmcid: pmc3207565. 11. caguimbal d, delacion d, medina ag, mendoza m. mendoza rj, sanche m. level of awareness of the maritime students on the outcomes-based education. educ res int. 2013 aug; 2(1); 7-12. 12. an il. impact of outcome based education instruction to accountancy students in an asian university. asia pacific journal of education, arts and sciences. 2014 nov; 1(5): 48-52. available from: http://apjeas.apjmr.com/wp-content/uploads/2014/11/apjeas-2014-1-085.pdf. 13. accreditation council for graduate medical education (acgme) common program requirements (residency). acgme-approved focused revision: february 3, 2020; effective july 1, 2020. 14. lockyer j. multisource feedback in the assessment of physician competencies. j contin educ health prof. winter 2003; 23(1): 4-12. doi: 10.1002/chp.1340230103; pmid: 12739254. 15. bay be, subido, h. dreem is real: dental students learning environment in an asian university, international journal of academic research in business and social sciences. 2014 aug; 4(7); 620 635. doi: 10.6007/ijarbss/v4-i7/1060. 16. ortega ra, ortega, dela cruz r. educators’ attitude towards outcomes-based educational approach in english second language learning. am j educ res. 2016; 4(8): 597-601. doi: 10.12691/education-4-8-3. http://pubs.sciepub.com/education/4/8/3. 17. shamsuddin a. chan cm, suratkon a. implementation of obe in a mot program. lesson learned. proceedings of the 2015 international conference on operations excellence and service engineering. 2015 sept; 10-11. curriculum, teachers had to be empowered.17 the activity of the psohns in reaching out to the different accredited institutions to guide the departments with a lecture and guide to the manual was indeed effective in the understanding of the new obe program. getting a good background of the constructive alignment of the 3 domains of obe and familiarization of the manual given by the ad hoc committee on obe in orl-hns showed that there was more understanding of what is expected in the assessment of residents in training. the following are the limitations of the study. there are few published studies on obe in postgraduate training (which was introduced only about 5 years ago compared to obe in medical education). the accuracy measures with a self-reported questionnaire can be quite low so a focused group discussion in a small number of respondents was done to confirm the results and add other questions on challenges on implementation. the author is a member of the philippine board of otolaryngology head and neck surgery, accrediting body of the residency training, but not a member of the ad hoc committee on obe in orl-hns. the obe coordinators or the chief residents of the accredited departments supervised the conduction of the data collection. due to time constraints and lockdown because of the covid 19 pandemic, data gathering from 4 out of 34 institutions were not done, however the number of respondents exceeded the recommended sample size of 192. it is recommended that because the self-reported implementation may or may not necessarily correspond to the true implementation extent, there is a need to monitor the lowest scores in the core competency of community health and social needs, laboratory activities and workshops, module on research methodology and assessment of multisource feedback and direct observation of performance skills of patient encounter at the operating room, emergency room, out-patient department and wards. the challenges on mastery, time and data keeping in a portfolio as revealed on the focus group discussion among the respondents will be relayed to the committee on obe in orl-hns in the creation of guidelines to monitor the program. future researches on knowledge, attitudes and perception among stakeholders as well as use of measured monitoring tools on implementation are also recommended. in conclusion, this study showed that two years after the distribution of the manual on obe to the orl-hns residency training institutions, the consultants and residents’ self-reported assessment is that implementation in all the 3 domains of obe has been “fully implemented.” philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the association of anosmia and positive sars-cov-2 (covid-19) rt-pcr test results among patients in a tertiary government hospital in metro manila. methods: design: cross-sectional study setting: tertiary government training hospital participants: patients aged 18 years old and above who consulted or were admitted with covid-19 symptoms at the quezon city general hospital in the philippines from july to september 2020 answered an offline version of the american academy of otolaryngology head and neck surgery aao-hns covid-19 anosmia reporting tool prior to undergoing (covid-19) rt-pcr testing. results: out of 172 participants, 63 (36.6%) presented with anosmia. sixty (95.2%) out of 63 of those with anosmia had a positive covid-19 rt-pcr test result. forty-one (65%) participants reported anosmia as the first symptom while the most common associated symptoms were fever (59%), cough (50%), and rhinorrhea (31%). there was a significant association between anosmia and positive sars-cov-2 (covid-19) rt-pcr tests (x2=33.85, df=1, p<.0001). a significantly higher proportion of patients with anosmia were positive for covid-19 than those without anosmia at 95.2% and 52.3% respectively. the risk for covid-19 among patients with anosmia was almost two times higher than those without anosmia (rr=1.82; 95%ci:1.51 – 2.20; p<.0001). conclusion: anosmia was associated with a positive sars-cov-2 (covid-19) rt-pcr test in more than 95% of those who reported the symptom. anosmia should be considered as a red flag sign which should be included in the screening of persons suspected of being infected with covid-19 to help mitigate further spread of the virus. keywords: anosmia; olfactory dysfunction; loss of sense of smell; coronavirus; sars-cov-2; pandemic; 2019-ncov; covid-19 according to the johns hopkins university coronavirus resource center, there have been 33.4 million cases of the coronavirus disease (covid-19) globally with over 1 million deaths recorded worldwide as of this writing.1 the world health organization has reported 33.2 association of anosmia and positive sars-cov-2 (covid-19) rt-pcr test results among patients in the quezon city general hospital jeff james p. alega, md emmanuel tadeus s. cruz, md department of otorhinolaryngology head and neck surgery quezon city general hospital correspondence: dr. emmanuel tadeus s. cruz department of otorhinolaryngology head and neck surgery quezon city general hospital seminary rd., bgy. bahay toro, quezon city 1106 philippines phone: (+632) 8863 0800 local 401 email: orl_hns_qcgh@yahoo.com.ph the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery covid-19 research forum 2020 (2nd place), nov 18, 2020. philipp j otolaryngol head neck surg 2021; 36 (1): 33-36 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery original articles million cases with over 999,000 deaths recorded.2 in the philippines, there were 309,303 confirmed cases and 5,448 deaths by the end of september 2020 with the national capital region consistently having the most number of covid-19 positive individuals.3 transmission has been increasing at an exponential rate, and early detection and prompt testing are crucial to control the spread of the disease. various studies have shown that apart from fever, cough, and dyspnea, anosmia (loss of sense of smell) is an early symptom that may have a role in screening for covid-19.4-6 lechien and colleagues showed that 85.6% of covid-19 cases presented with olfactory dysfunction.4 another study showed that 11.8% of patients reported anosmia early in the course of the disease preceding other clinical manifestations.5 the american academy of otolaryngology-head and neck surgery (aaohns) released the initial findings of the covid-19 anosmia reporting tool (https://www.entnet.org/content/reporting-tool-patients-anosmiarelated-covid-19) that reported anosmia was observed in 73% of cases prior to diagnosis and that 26.6% of patients reported anosmia as their initial symptom.6 in the absence of local studies, this study was initiated to establish a basis for using anosmia as a possible early screening symptom to identify patients with covid-19 in our setting. the objective of this study was to determine the association of anosmia and positive sars-cov-2 (covid-19) rt-pcr tests among patients in our tertiary hospital in metro manila. methods this cross-sectional study was approved by the planning, development, education and research office / hospital training office of the quezon city general hospital. all patients (including healthcare workers) aged 18 years old and above with covid-19 symptoms such as cough, fever, and difficulty of breathing who consulted and/or were admitted in the quezon city general hospital from july to september 2020 were considered for inclusion. excluded were those with nasal problems (sinusitis, nasal mass, nasal polyps, nasopharyngeal cancer, history of nasal trauma), pre-existing olfactory dysfunction, and those with altered states of consciousness or who were in cardiorespiratory distress and were not able to understand and answer the covid-19 anosmia reporting tool. the sample size was computed using a 95% level of confidence and 80% power of the study. with an estimated proportion of patients with loss of smell among those positive and negative for covid-19 of 59.41% and 18.97%, respectively. based on the study by menni et al.,7 at least 19 patients per group was needed. a 20% allowance was added to come up with at least 23 patients per group. where: n = is the number of subjects needed p1 = proportion of patients with loss of taste and smell among those covid-19 (+) = = 59.41% = 0.5941 q1 = 1 – p1 = 1 – 0.5941 = 0.4059 p2 = proportion of patients with loss of taste and smell among those covid-19 (-) = = 18.97% = 0.1897 q2 = 1 – p2 = 1 – 0.1897 = 0.8103 p = (p1+p2)/2 = 0.3919 q = 1 – p = 1 – 0.3919 = 0.6081 zα = 95% confidence level = 1.96 zβ = 80% power of the study = 1.28 informed consent was obtained prior to inclusion, and enrolled participants were administered a bilingual version of the aao-hns covid-19 anosmia reporting tool prior to undergoing the covid-19 rt-pcr swab test. (figure 1) permission to utilize an offline bilingual version of the tool was obtained from the aao-hns anosmia team. participants were assisted in accomplishing the reporting tool if they had questions or clarifications. the aao-hns created the covid-19 anosmia reporting tool for clinicians in march 2020 and published it online with the purpose of acquiring data from healthcare providers around the world to serve as a database for emerging data on covid-19 related anosmia.6 experts from the aao-hns infectious disease and patient safety and quality improvement committees developed this tool, ensuring adequate face validity. the bilingual study version of this tool was not validated, as the filipino annotations were only added without changing the english elements. after answering the questionnaire, participants underwent covid-19 rt-pcr swab test using one of the following testing kits, depending on the institution to which the specimens were sent: genamplifytm covid-19 rrt-pcr detection kit (manila healthtek, inc., marikina, philippines), sansure biotech inc. 2019-ncov nucleic acidbased diagnostic reagent kit, pcr-flourescence probing (hunan, people’s republic of china), or the genesig® real-time pcr coronavirus covid-19 (ce ivd) kit (chandler’s ford, uk). specimens at the time were sent to department of health (doh) approved testing facilities such as philippine genome center, chinese general hospital and medical center, and st. luke’s medical center. per hospital protocol, the covid-19 rt-pcr test results were retrieved by the qcgh department of pathology for documentation and safe-keeping, and copies of results were sent to those tested through e-mail with printed copies sent to the concerned outpatient clinic or in-patient ward for admitted patients. the clinic or ward copies were those accessed for this study. 4 methods this cross-sectional study was approved by the planning, development, education and research office / hospital training office of the quezon city general hospital. all patients (including healthcare workers) aged 18 years old and above with covid19 symptoms such as cough, fever, and difficulty of breathing who consulted and/or were admitted in the quezon city general hospital from july to september 2020 were considered for inclusion. excluded were those with nasal problems (sinusitis, nasal mass, nasal polyps, nasopharyngeal cancer, history of nasal trauma), pre-existing olfactory dysfunction, and those with altered states of consciousness or who were in cardiorespiratory distress and were not able to understand and answer the covid-19 anosmia reporting tool. the sample size was computed using a 95% level of confidence and 80% power of the study. with an estimated proportion of patients with loss of smell among those positive and negative for covid-19 of 59.41% and 18.97% respectively. based on the study by menni et al.,7 at least 19 patients per group was needed. a 20% allowance was added to come up with at least 23 patients per group. , where: n = is the number of subjects needed p1 = proportion of patients with loss of taste and smell among those covid-19 (+) = = 59.41% = 0.5941 q1 = 1 – p1 = 1 – 0.5941 = 0.4059 p2 = proportion of patients with loss of taste and smell among those covid-19 (-) = = 18.97% = 0.1897 q2 = 1 – p2 = 1 – 0.1897 = 0.8103 2 2 [ 2 1 1 2 2] ( 1 2) z pq z p q p q n p p a b+ + = 1 2( ) 2 + = p p p 1q p= philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery original articles responses were tabulated and collated using ms excel for mac version 16.13 (microsoft corporation, redmond, wa, usa). participants with incompletely accomplished covid-19 anosmia tool for clinicians and those whose rt-pcr tests turned out “invalid” (due to insufficient specimen collection) were further excluded from the study. stata 13.1 (statacorp llc, college station, tx, usa) was used for data analysis. descriptive statistics were used to summarize the demographic characteristics of participants. frequencies and proportions were used for categorical variables and mean and sd for normally distributed continuous variables. the independent sample t-test and chi-square test were used to determine the difference of mean and frequency between patients with and without covid-19, respectively. relative risk and corresponding 95% confidence intervals were computed to determine the association of anosmia and covid-19. null hypotheses were rejected at 0.05 α-level of significance. results a total of 172 participants suspected of covid-19 infection who underwent rt-pcr test were included in the study. one hundred seventeen (68%) were positive for covid-19 while 55 (32%) were negative. ages ranged from 19 to 88 years with a mean of 42.55 years. almost 53% were ≤40 years old. using independent t-test, there was a significant difference in the age of patients who were positive and negative for covid-19 (t=3.79, df=170, p=<.001). the age of patients positive for covid-19 was significantly higher than those with negative results, with a mean of 45.58 years and 36.12 years respectively. there were 81 (47.1%) males and 91 (52.9%) females. sixty-one out of 81 (75.3%) and 56 out of 81 (61.5%) were rt-pcr positive for males and females respectively. there was a significant difference in the proportion of males and females with or without covid-19 (x2=3.74, df=1, p=.05). using chi-square test, there was a significant association between anosmia and sars-cov-2 rt-pcr (covid-19) test results (x2=33.85, df=1, p<.0001). a significantly higher proportion of patients with anosmia were positive for covid-19 than those without anosmia at 95.2% and 52.3% respectively. the risk for covid-19 among patients with anosmia was almost two times higher than those without anosmia (rr=1.82; 95%ci:1.51 – 2.20; p<.0001). out of 172 patients included in the study, 63 (36.6%) reported having anosmia and all of these manifested prior to diagnosis. sixty (51.2%) out of 117 covid-19 positive individuals reported loss of smell as one of their symptoms. anosmia was the first symptom in 41 (65%) of these patients. for the 22 (34.9%) patients who had other symptoms prior to onset of anosmia, the most common were fever (59%), cough (50%), and rhinorrhea (31%). of the 63 patients with anosmia, 60 (95.2%) had a positive covid-19 rt-pcr test result while 3 (4.7%) were negative. discussion the study showed that there was a significant association between anosmia and positive covid-19 rt-pcr test results. more than 50% of diagnosed covid-19 patients in the present study presented with anosmia. in the literature, the incidence of anosmia varies from a low 12 figure 1. aao-hns covid-19 anosmia reporting tool (bilingual adaptation). reproduced and used with permission from: aao-hns anosmia team figure 1. aao-hns covid-19 anosmia reporting tool (bilingual adaptation). reproduced and used with permission from: aao-hns anosmia team of 22.7 to as high as 85.6%.4,7-8 these reports support the inclusion of anosmia as part of the constellation of symptoms of covid-19 infection. in the current study, more than 95% of patients who presented with anosmia had a positive covid-19 rt-pcr test result. taking into consideration the likelihood of getting a positive covid-19 rt-pcr philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery original articles test result for patients who present with anosmia, it appears that the prevalence is high, with a risk for covid-19 infection being two times higher than those without anosmia. this suggests that anosmia is highly associated with a positive covid-19 rt-pcr test result and may be a strong predictor of covid-19 infection. anosmia was the first symptom reported by more than 60% of patients in this study. in contrast, only 11.8, 27, and 35.5% of patients had anosmia as the initial presenting symptom reported in the studies of kaye, lechien, and beltran-corbellini, respectively.4,6,10 other symptoms included fever, cough, rhinorrhea, nasal congestion, malaise/fatigue, and dyspnea. when it comes to symptoms frequently associated with anosmia, our results were similar to those of wee and colleagues which revealed fever as the most common, followed by cough, and rhinorrhea.8 in the study by kaye, only 27% of patients with anosmia noted improvement within a mean time of 7.2 days while majority (85%) noted improvement within 10 days.6 however, the diagnosis of some patients was only presumed and not confirmed. lechien and colleagues noted olfactory dysfunction related to covid-19 in 85.6% of their sample population – 79.6% of which were anosmic and 20.4% were hyposmic.4 early olfaction recovery rate was noted in 44% while olfactory function was recovered in 72.6% of cases, occurring within 8 days upon resolution of the disease. anosmia persisted even after resolution of other symptoms in 63% of cases.4 in the present study, anosmia resolved in 38 (60.3%) patients while 25 (39.7%) claimed to have persistence of loss of smell. almost three quarters of patients in the present study reported that their symptoms worsened after the onset of anosmia, early in the disease timeline. it would be worthwhile to monitor and follow up the course of anosmia of each patient. the exact mechanism of how sars-cov-2, the etiologic agent for covid-19, inflicts olfactory dysfunction is yet to be elucidated but a theory posits that direct extension through the nasal mucosa and to the olfactory bulb contributes to the neuroepithelial dysfunction brought about by this virus.4-6,9 the virus appears to have an affinity for angiotensin-converting enzyme 2 (ace2) receptors which are abundant in goblet and ciliated cells in the nasal and respiratory tract epithelium, and sustentacular and basal cells in close proximity with olfactory receptors cells.4-6,9,11 these are viable theories underlying anosmia in covid-19 infection with more avenues and facets remaining to be explored. this adds to the list of viruses that affect nerves in the otolaryngologic domain such as herpes zoster oticus, ramsay hunt syndrome, and bell’s palsy to name a few. our study has certain limitations. a full physical and endoscopic examination of the patients was not performed to exclude anatomical or other conditions which may cause anosmia apart from nasal problems listed as exclusion criteria. participants did not undergo objective tests to evaluate olfactory function and confirm the subjective reports of anosmia. such tests were made more difficult by existing protocols to minimize exposure and avoid close contact to prevent further spread of infection. the study used a cross-sectional design, hence, disease progression from the participants’ point of entry in the study until resolution of the condition were not monitored and documented. in addition, since participants were asked to look back at the preceding events in their history, certain details may not be recalled clearly. we recommend that anosmia be included in local covid-19 symptom checklists and that it be utilized or considered as a screening symptom in various screening tools, such as health declaration forms. a nationwide, multicenter study on anosmia related to covid-19 infection may be undertaken to better characterize its onset, relation and course. in conclusion, our study showed that anosmia was associated with a positive sars-cov-2 (covid-19) rt-pcr test in more than 95% of those who reported the symptom. anosmia should be considered as a red flag sign which should be included in the screening of persons suspected of being infected with covid-19 to help mitigate further spread of the virus. references 1. covid-19 dashboard by the center for systems science and engineering at johns hopkins university [internet]. johns hopkins university & medicine. [updated 2020 sept 29; cited 2020 sept 29]. available from: https://coronavirus.jhu.edu/map.html. 2. who coronavirus disease (covid-19) dashboard [internet]. world health organization. [updated 2020 sept 16; cited 2020 sept 16]. available from: https://covid19.who.int. 3. covid-19 tracker: philippines [internet]. republic of the philippines department of health. [updated 2020 sept 29; cited 2020 sept 29]. available from: https://www.doh.gov.ph/ covid19tracker. 4. lechien jr, chiesa-estomba cm, de siati dr, horoi m, le bon sd, rodriguez a, et al. olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (covid-19): a multicenter european study. eur arch otorhinolaryngol. 2020 aug;277(8):2251-2261. doi:10.1007/s00405-020-05965-1 pubmed pmid:  32253535 pubmed central pmcid: pmc7134551. 5. lechien j, cabaraux p, chiesa-estomba c, khalife m, plzak j, hans s, et al. objective olfactory testing in patients presenting with sudden onset olfactory dysfunction as the first manifestation of confirmed covid-19 infection. medrxiv. 2020 apr 18 [cited 2020 sept 16]. available from: https://doi.org/10.1101/2020.04.15.20066472. 6. kaye r, chang cwd, kazahaya k, brereton j, denneny jc. covid-19 anosmia reporting tool: initial findings. otolaryngol head neck surg. 2020 jul 1;163(1):132-134. doi: 10.1177/0194599820922992 pubmed pmid: 32340555. 7. menni c, valdes am, freidin mb, sudre ch, nguyen lh, drew da, et al. real-time tracking of self-reported symptoms to predict potential covid-19. nat med. 2020 jul;26(7):1037-1040. doi: 10.1038/s41591-020-0916-2. epub 2020 may 11. pubmed pmid: 32393804; pubmed central pmcid: pmc7751267. 8. wee le, chan yfz, teo nwy, cherng bpz, thien sw, wong hm, et al. the role of self-reported olfactory and gustatory dysfunction as a screening criterion for suspected covid-19. eur arch otorhinolaryngol. 2020 apr 24:1-2. [cited 2020 sept 16]. available from: http://doi.org/10.1007/ s00405-020-05999-5. pubmed pmid: 32328771 pubmed central pmcid: pmc7180656. 9. tong jy, wong a, zhu d, fastenberg jh, tham t. the prevalence of olfactory and gustatory dysfunction in covid-19 patients: a systematic review and meta-analysis. otolaryngol head neck surg 2020 jul;163(1):3-11. doi: 10.1177/0194599820926473 pubmed pmid: 32369429. 10. beltran-corbellini a, chico-garcia jl, martinez-poles j, rodriguez-jorge f, natera-villalba e, gomez-corral j, et al. acute-onset smell and taste disorders in the context of covid-19: a pilot multicenter polymerase chain reaction based case-control study.  eur j neurol. 2020 sep;27(9):1738-1741. doi: 10.1111/ene.14273. pubmed pmid:  32320508 pubmed central pmcid: pmc7264557. 11. lechner m, chandrasekharan d, jumani k, liu j, gane s, lund vj, philpott c, jayaraj s. anosmia as a presenting symptom of sars-cov-2 infection in healthcare workers – a systematic review of the literature, case series, and recommendations for clinical assessment and management. rhinology. 2020 aug 1;58(4):394-399. doi: 10.4193/rhin20.189 pubmed pmid: 32386285 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 19 abstract objectives: axial flap surgery is associated with numerous complications. the purpose of this study is to determine the frequency of these complications, and identify possible factors contributory to their occurrence. methods: design: cross-sectional study setting: tertiary public university hospital subjects: records of all patients who underwent axial pedicled flap reconstruction at the otorhinolaryngology ward of our tertiary public university hospital from january 2013 to july 2015 were retrospectively reviewed, and data consisting of age, sex, diagnosis, disease stage, smoking history, alcohol intake, co-morbidities, past operations, pre-operative hemoglobin and albumin, total operative time, total blood loss, location and total area of the surgical defect and length of hospitalization were tabulated. all complications were listed. data were analyzed for any potential trends. results: a total of 38 patients underwent axial pedicled flap reconstruction in the study period. nineteen out of 38 (50%) cases involved complications. the most common complication was infection. most of the complications occurred in males with history of alcohol intake, advanced cancer stage, significant blood loss, recurrent tumors, low pre-operative hemoglobin and albumin levels, and a large area of surgical defect. conclusions: the complication rate for axial flap surgery in our series was significant at 50%. potential risk factors identified were male gender, advanced cancer stage, tumor recurrence, alcohol intake, low pre-operative hemoglobin and albumin levels, significant blood loss, longer operative time and a larger surgical defect. keywords: surgical flaps, myocutaneous flap, axial flap, complications, risk factors every year 550,000 new cases of head and neck malignancies are diagnosed throughout the world.1 in the philippines, they comprise the 4th most common newly-diagnosed cancer, causing at least four thousand deaths annually.2 treatment usually involves complete surgical excision with histopathologically proven tumor-free margins. due to poverty and / or poor health-seeking behavior, a vast majority present in advanced stages, requiring large areas of excision, and resulting in extensive surgical defects no longer suitable for primary closure.3 however, immediate or early closure is vital in the surgical management of these cases for several reasons: it maintains alimentary tract integrity to allow feeding; ensures protection of the vital structures in the region, complications of head and neck reconstructive surgery using axial pedicled flap alexander edward s. dy1 eduard m. alfanta2 armando m. chiong jr. 1 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2philippine academy of facial plastic and reconstructive surgery correspondence: dr. alexander edward s. dy department of otorhinolaryngology philippine general hospital ward 10 university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 554 8400 local 2152 email address: asdy@up.edu.ph reprints will not be available from the authors. the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by the authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest (1st place), september 24, 2015. the patriot bldg, paranaque city. philipp j otolaryngol head neck surg 2015; 30 (2): 19-24 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles 20 philippine journal of otolaryngology-head and neck surgery lowering the risk for life-threatening complications such as blowout of the great vessels of the neck; and allows for facial reconstruction, restoring the patient’s ability to communicate by facial expression.4 thus, the use of flaps for reconstruction becomes necessary. head and neck reconstructive procedures are also indicated in various other conditions such as trauma, infection, osteoradionecrosis and congenital anomalies.5 although the present trend globally is to use free flaps in the reconstruction of extensive defects, this method requires both specialized expertise that is not always available in all centers, and longer operative time.6 because of limited experience in and lack of resources for this procedure, and the need to optimize operative time, axial pedicled flaps remain the more commonly-used flap type in our institution. the use of axial flaps in reconstructive surgery was introduced in the country in the seventies.7 a significant number of complications associated with these are encountered up to the present. consolidated reports of the otorhinolaryngology department of a tertiary government institution from 2006 to 2013 showed that of an average of ten cases of axial flap surgery per year, approximately 1 in 5 developed complications.8 previous studies have suggested the correlation of such factors as smoking history,9 location in the oral cavity, previous radiation therapy10 and tumor size11 with the occurrence of complications. to the best of our knowledge, there has been no locally reported study on such risk factors. an extensive literature search of herdin neon, medline and google scholar yielded no prior local study on complications of axial flap surgery. this paucity of data limits attempts to address and prevent these problems. thus, this study aims to determine the frequency of complications in axial pedicled flap surgery in our institution and identify potential factors that may be contributory to their occurrence. methods this is a retrospective, cross-sectional study of axial pedicled flap surgery complications. all patients who had undergone axial pedicled flap reconstruction in the public otorhinolaryngology ward of our institution from january 2013 to july 2015 were included in the study. records were retrospectively reviewed, and age, sex, diagnosis, stage of disease, type of disease (newly-diagnosed or recurrent), comorbidities, history of smoking and alcohol intake were recorded. preoperative hemoglobin and albumin were listed. the type of operation, total operative time, total blood loss, location and size of defect and length of hospital stay were likewise determined. complications were pre-defined as one or more of the following: infection, dehiscence, congestion and/or flap failure, and were recorded. the data were tabulated and examined for any potential trends. strict confidentiality was observed with all data encoded into electronic abstraction sheets using microsoft excel 2010 version 14 (microsoft corporation, wa, usa). one sheet (the correlation tool) contained the patient name, medical record number and patient study number. the patient study numbers were used in all subsequent data tables. the protocol was reviewed and approved by the ethics review board of the institution. results a total of 38 patients underwent pedicled axial flap surgery in our department from january 2013 to july 2015. there were 25 males (66%) and 13 females (34%), aged 23 81 years (mean 57 years). there were 16 (42%) nonsmokers and 22 (58%) smokers, 7 (18%) of whom had a smoking history of greater than 10 pack years. eighteen (47%) had a history of alcoholic beverage intake. two (5%) were diabetic, 14 (37%) were hypertensive, and 7 (14%) had pulmonary disease. squamous cell carcinoma was the most common histopathologic diagnosis, seen in 17 patients (45%), followed by basal cell carcinoma, seen in 8 (21%), as demonstrated in figure 1. staging according to the 2010 american joint committee on cancer (ajcc) classification is listed in table 1. twenty-two patients (61%) were in stages iii to iv, while 10 (28%) were in stage ii. four of the malignant cases were recurrent tumors. the 2 patients diagnosed with hemangioma, a benign disease were not assessed for stage or recurrence. the predominant flap reconstructive technique used was the pectoralis major myocutaneous flap (pmmf). the distributions according to type of flap reconstruction are shown in figure 2. the most common area of defect was in the oral cavity at 42%. the distributions according to disease localization are shown in figure 3. the mean operative time was 577 minutes, mean blood loss was 992 ml and mean hospitalization period was 29 days. of the 38 patients who underwent pedicled axial flap surgery, 19 (50%) developed one or more flap-related complications. the most common complication was infection (11 out of 19). other complications were dehiscence (9), congestion (7) and flap failure (2). fourteen out of 25 males (56%) and 5 out of 13 females (38%) developed flap complications. complications and non-complications in each age group were almost equal (table 2). in terms of flap location, those in the oral cavity and face had higher percentages of complications than those in the nasal and paranasal regions. only 1 case involved the neck, and this developed complications (table 3). among the patients with malignancy as the indication for surgery, 2 out of 10 cases (20%) in stage ii, 1 out of 4 cases (25%) in stage iii and 13 out of 18 cases (72%) in stage iv developed flap complications. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 21 table 1. distribution of patients according to stage of malignancy and tnm classification number (percent)stage of malignant disease (n=36) tnm stage (n=32) stage i stage ii stage iii stage iv recurrence 1 2 3 4 0 1 2 0 1 0 10 (28%) 4 (11%) 18 (50%) 4 (11%) 1 (3%) 8 (25%) 5 (16%) 18 (56%) 14 (44%) 5 (16%) 13 (41%) 31 (97%) 1 (3%) t n m intake, 12 (67%) developed complications, compared to 7 (35%) in those without history of alcohol intake. classification of cases according to the presence of co-morbidities, particularly diabetes, hypertension, and pulmonary disease, yielded no demonstrable trend in the occurrence of complications (table 6). of the 20 cases that used pectoralis major myocutaneous flaps, 14 (70%) developed complications (table 7). the group that developed flap complications had a lower mean pre-operative hemoglobin of 123 g/l, compared to the group that did not develop complications with a mean pre-operative hemoglobin of 136 g/l. likewise, the group that developed flap complications had a lower mean pre-operative serum albumin of 27 g/l, relative to the group that did not develop complications, with a mean pre-operative serum albumin of 35.3 g/l. the mean operative time for cases that resulted in flap complications was longer, lasting 653 minutes, while that for cases that did not develop flap complications was 498 minutes. mean blood loss among flap complication cases was greater (1282 ml) than among noncomplication cases (703 ml). patients who developed flap complications had a longer mean hospital stay of 35 days, as opposed to those who did not develop flap complications, who had a mean hospital stay of 23 days. the mean area of defect in the cases that developed flap complications was greater (84 cm2) than that in the cases that did not develop flap complications (64 cm2). standard deviations for each parameter are shown in table 8. occurrences of complications in the various tnm classifications are also listed in table 4. out of the 4 cases of tumor recurrence, 3 (75%) developed complications while out of the 32 cases of non-recurrent tumor, 16 (50%) developed complications. occurrence of complications varied among the different pack-year ranges of smoking history (table 5). in patients with a history of alcohol figure 1. distribution of patients according to histopathologic diagnoses philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles 22 philippine journal of otolaryngology-head and neck surgery figure 3. distribution of patients according to location of disease table 2. age in relation to complications complications no complicationsage 0 to 20 21 to 40 41 to 60 61 to 80 more than 80 0 3 8 8 0 0 4 7 6 2 figure 2. distribution of patients according to type of flap reconstruction discussion a review of the compiled annual institutional reports over the last eight years showed that only approximately 20% of reconstructive pedicled axial flap surgeries developed complications.8 however, this study showed that in the years 2013 to 2015, 19 out of 38 cases (50%) resulted in flap complications, a rate comparable to other institutions abroad.12 this suggests that complications of axial flap surgery may have been previously underreported, possibly due to unclear and subjective definitions of what comprise complications, and incomplete documentation. among the reconstructive axial flap surgeries performed during these years, the pectoralis major myocutaneous flap was most commonly employed. touted as the workhorse of head and neck reconstruction, the pectoralis major muscle is the easiest to access, is technically simple to use, has an abundant vascular supply, and requires minimal specialized instrumentation and training.12 it is not surprising that most of the axial flap surgeries involved the oral cavity, as cancer of the oral cavity is the most common type of head and neck cancer.13 many of the proven risk factors for carcinogenesis – namely, smoking, alcoholism, betel nut chewing, periodontal disease and ill-fitting dentures – involve this site.14 furthermore, squamous cell carcinoma emerged as the most common indication for surgery among the cases reviewed, consistent with worldwide data that this cancer is the most common malignancy in the head and neck. comparing the complication rates of the different groups of patients classified according to the various pre-set parameters yielded some interesting findings. the incidence of complication in males (56%) was slightly higher than that in females (38%). review of related literature revealed that men have a statistically higher risk of developing post-operative complications possibly due to the immune-suppressive effects of high testosterone and low estradiol levels.15 advanced stage of cancer appeared to be linked with increased risk of complication. seventytwo percent of patients with stage iv malignancy developed flap-related complications, compared with 20 to 25% in the patients with lower stages of philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 23 table 3. location of disease in relation to complications complications no complications totalsite of disease oral cavity parotid and periparotid nasal and paranasal neck 9 (56%) 8 (53%) 1 (17%) 1 (100%) 7 (44%) 7 (47%) 5 (83%) 0 16 (100%) 15 (100%) 6 (100%) 1 (100%) table 7. comparison in relation to complications complications no complications totaltype of flap pectoralis major myocutaneous inferiorly based trapezius cervicopectoral deltopectoral lateral forehead nasolabial paramedian forehead 14 (70%) 2 (50%) 1 (25%) 1 (33%) 1 (33%) 0 0 6 (30%) 2 (50%) 3 (75%) 2 (67%) 2 (67%) 2 (100%) 2 (100%) 20 (100%) 4 (100%) 4 (100%) 3 (100%) 3 (100%) 2 (100%) 2 (100%) table 5. smoking history in relation to complications complications no complications totalsmoking (pack years) 0 1-5 6-10 >10 unspecified 9 (50%) 3 (75%) 2 (50%) 2 (29%) 3 (60%) 9 (50%) 1 (25%) 2 (50%) 5 (71%) 2 (40%) 18 (100%) 4 (100%) 4 (100%) 7 (100%) 5 (100%) table 4. tnm staging in relation to complications tnm stage (n=32) complications no complications total 1 2 3 4 0 1 2 0 1 0 1 (12%) 1 (20%) 14 (78%) 4 (29%) 4 (80%) 8 (62%) 15 (48%) 1 (100%) 1 (100%) 7 (88%) 4 (80%) 4 (22%) 10 (71%) 1 (20%) 5 (38%) 16 (52%) 0 1 (100%) 8 (100%) 5 (100%) 18 (100%) 14 (100%) 5 (100%) 13 (100%) 31 (100%) 1 (100%) t n m table 6. co-morbidities in relation to complications complications no complications totalco-morbidities hypertension yes no diabetes yes no pulmonary disease yes no 7 (50%) 12 (50%) 1 (100%) 18 (49%) 2 (29%) 17 (55%) 7 (50%) 12 (50%) 0 (0%) 19 (51%) 5 (71%) 14 (45%) 14 (100%) 24 (100%) 1 (100%) 37 (100%) 7 (100%) 31 (100%) table 8. surgical parameters no complicationscomplications pre-op hemoglobin pre-op albumin mean or time (minutes) blood loss (ml) hospitalization (days) area of defect (cm2) 123 (+/14) 27 (+/6.9) 653 (+/195) 1282 (+/645) 35 (+/22) 84 cm2 (+/52) 136 (+/15) 35.3 (+/6.5) 498 (+/205) 703 (+/507) 23 (+/13) 64cm2 (+/74) be warranted to establish whether an association between malignancy stage and the rate of flap-related surgical complications is indeed present. although only 4 out of the 36 cases (11%) were classified as tumor recurrence, it is remarkable that 3 of these 4 cases developed complications. tumor recurrence is known to signify poor prognosis even in patients who underwent salvage treatment,17 and usually warrants palliative care.18 a history of alcohol intake seems to be worth investigating, as 67% of patients who reported intake of alcohol developed complications, while only 35% of those without alcohol intake developed complications. published studies suggest that significant alcohol intake not only reduces immune capacity at the cellular level, but also causes prolonged bleeding time.19 pre-operative albumin and hemoglobin levels both show a possible association with increased risk of flap complications. the patients who developed complications had a lower mean pre-operative albumin level and a lower mean pre-operative hemoglobin level than those who did not. pre-operative albumin has been shown to be one of the most important determinants of surgical outcome, largely because hypoalbuminemia is an indicator of malnutrition and disease.20 studies have likewise suggested that pre-operative anemia is a significant risk factor for developing complications in various surgical cases.21 this may be due in part to the association between anemia and the presence of malignancy. although association between cancer stage and operative risk has not been clearly established, and previous studies have reported no significant difference in the rate of post-operative complications among groups divided according to disease stage,16 further study may philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 24 philippine journal of otolaryngology-head and neck surgery original articles references 1. jemal a, bray f, center mm, ferlay j, ward e, forman d. global cancer statistics. ca cancer j clin. 2011 mar-apr; 61(2):69-90. 2. laudico av, medina vm, mirasol-lumague mr, mapua ca, redaniel mtm, valenzuela fg, pukkala e. 2010 philippine cancer facts and estimates. philippine cancer society. 2010. 3. ward e, jemal a, cokkinides v, singh gk, cardinez c, ghafoor a, thun a. cancer disparities by race/ethnicity and socioeconomic status. ca cancer j. clin. 2004 mar-apr; 54(2):78-93. 4. chim h, salgado cj, seselgyte r, wei fc, mardini s. principles of head and neck reconstruction: an algorithm to guide flap selection. semin plast surg. 2010 may; 24(2):148-154. 5. eckardt a, meyer a, laas u, hausamen je. reconstruction of defects in the head and neck with free flaps: 20 years’ experience. br j oral maxillofac surg. 2007 jan; 45(1):11-15. 6. kokot n, mazhar k, reder l, peng gl, sinha uk. the supraclavicular artery islang flap in head and neck reconstruction. jama otolaryngol head neck surg. 2013 nov; 139(11):1247-1255. 7. ariyan s. the pectoralis major myocutaneous flap. a versatile flap for reconstruction in the head and neck. plast reconstr surg. 1979 jan; 63(1):73-81. 8. consolidated reports of the department of otorhinolaryngology. cy 2006 to 2013. college of medicine philippine general hospital, university of the philippines manila. (unpublished) 9. patel kg, jm sykes. concepts in local flap design and classification. oper tech otolaryngol head neck surg. 2011 mar; 22(1):13-23. 10. righi pd, weisberger ec, slakes sr, wilson jl,kesler ka, yaw pb. the pectoralis major myofascial flap: clinical applications in head and neck reconstruction. am j otolaryngol. 1998 mar-apr; 19(2):96-101. 11. vartanian jg, carvalho al, carvalho sm, mizobe l, magrin j, kowalski lp. the pectoralis major myofascial flap: clinical applications in head and neck reconstruction. head neck. 2004 dec; 26(12):1018-23. 12. kekatpure vd, trivedi np, manjula bv, mohan am, shetkar g, kuriakose ma. pectoralis major flap for head and neck reconstruction in era of free flaps. int j oral maxillofac surg. 2012 apr; 41(4):453-457. 13. shah j. about head and neck cancers. [accessed on march 20, 1015]. available from: http:// www.mskcc.org/cancer-care/adult/head-neck/about-head-neck” 14. spitz mr. epidemiology and risk factors for head and neck cancer. semin oncol 1994 jun; 21(3):281-8. 15. offner pj, moore ee, biffl wl. male gender is a risk factor for major infections after surgery. arch surg. 1999 sep; 134(9):935-940. 16. sakai a, okami k, onuki j, miyasaka m, furuya h, iida m. statistical analysis of post-operative complications after head and neck surgery. tokai j exp clin med. 2008 sep 20; 33(3):105-109 17. amar a, chedid hm, rapoport a, dedivitis ra, cernea cr, brandao lg, curioni oa. update of assessment of survival in head and neck cancer after regional recurrence. j oncol. vol. 2012: article id 154303. doi:10.1155/2012/154303 18. vermorken jb, specenier p. optimal treatment for recurrent/metastatic head and neck cancer. ann oncol. 2010 oct; 21(7):252-261. 19. tonnesen h, nielsen pr, lauritzen jb,moller am. smoking and alcohol intervention before surgery: evidence for best practice. br j anaesth. 2009 mar; 102(3):297-306. 20. gibbs j, cull w, henderson w, daley j, hur k, khuri sf. preoperative serum albumin level as a predictor of operative mortality and morbidity. arch surg. 1999 jan; 134(1):36-42. 21. pierson dj. preoperative anemia and postoperative outcomes in the elderly. crit care. 2007 aug; 15(5):36. 22. halm ea, wang jj, boockvar k, penrod j, silberzweig sb, magaziner j, koval kj, siu al. the effect of perioperative anemia on clinical and functional outcomes in patients with hip fracture. j orthop trauma. 2004 jul; 18(6):369-74. 23. chaukar da, deshmukh ad, majeed t, chaturvedi p, pai p, d’cruz ak. factors affecting wound complications in head and neck surgery: a prospective study. indian j med paediatr oncol. 2013 oct; 34(4):247-51. 24. oliveros h, linares eb. preoperative hemoglobin levels and outcomes in cardiovascular surgical patients; systematic review and meta-analysis. rev colomb anestesiol. 2012 feb; 40(1):27-33. underlying co-morbid illness and low physiologic reserves.22 another possible reason is the detrimental effect of being in a relatively hypoxemic state.23 patients who had complications had a noticeably larger mean area of defect, a longer operative time and a significantly higher amount of blood loss. it may be speculated that this is because larger areas of defect necessitate larger surgical flaps and longer, more complicated operations imposing higher demands for vascular perfusion and yielding higher risks of infection. longer operative time usually implies a more technically difficult surgery and presents the challenge of maintaining field sterility, possibly increasing susceptibility to infection.23 lastly, greater blood loss denotes decreasing hemoglobin counts and consequently, relative hypoxemia, known to be unfavorable in any major surgical procedure.24 as could be expected, patients who developed complications had a longer hospital stay likely because more time was required to address the post-operative problems. surgeries employing a pectoralis major myocutaneous flap appeared to have the highest rate of complications among the various types of flap. this may be because it was the most commonly employed type of flap in the study population (50%). the number of cases employing other types of flap was likely too low to show any interesting trends. furthermore, the pectoralis major myocutaneous flap is usually used for large surgical defects, and thus the occurrence of complications may be related to the larger defect size. on grouping the cases according to location, complication rates were lowest in the nasal/paranasal region. this may be due in part to smaller defect size. however, due to the large variation in the number of cases in each location, further studies are needed to establish any potential association between flap location and the occurrence of complications. surprisingly, examination of smoking history showed no distinct pattern to suggest the possibility of an association with risk of complication. age also did not seem to affect the complication rate in this study, likely due to the small sample size and wide distribution among groups. finally, the presence of co-morbidities, particularly hypertension, diabetes and/or pulmonary disease showed no demonstrable effect on the rate of complications in our series. in summary, 50% of axial pedicled flap surgeries done at the public otorhinolaryngology ward of our institution from january 2013 to july 2015 resulted in flap-related complications. the most frequent complication was infection. factors that may contribute to the increased risk of complication are: male sex, advanced cancer stage, tumor recurrence, alcohol intake, low pre-operative hemoglobin and albumin levels, significant blood loss, longer operative time, and a larger surgical defect. the study was limited by the retrospective design and small sample size. information gathered depended on the recorded subjective assessments of the surgical residents-in-charge. it is recommended that further analytical, prospective research be done to determine the actual risk posed by the factors identified. the statistical differences among the variables can be computed using multiple logistic regressions to determine exact effect of each variable in future studies. ultimately, this study may alert surgeons to perform a more thorough preoperative evaluation, allow for possible risk-modification, and facilitate comprehensive patient education. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2022; 37 (1): 15-19 c philippine society of otolaryngology – head and neck surgery, inc. epidermal growth factor application versus observation on healing of acute tympanic membrane perforations: a randomized open label clinical trial arlex michael o. atanacio, md emily grace teodoro-estaris, md department of otolaryngology-head and neck surgery baguio general hospital and medical center correspondence: dr. emily grace teodoro-estaris department of otolaryngology-head and neck surgery baguio general hospital and medical center upper governor pack road, baguio city 2600 philippines phone: +63 74 244 5042 fax: +63 74 442 3809 email: emdestaris@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at baguio general hospital annual research contest 2019 podium presentation (1st place). bghmc cancer center conference hall, baguio city. december 4, 2019. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international abstract objective: to compare the effect of topical epidermal growth factor (egf) instillation versus observation alone on healing of acute tympanic membrane perforations in terms of closure and hearing test results. methods: design: randomized, open label, clinical trial setting: tertiary government training hospital participants: seventeen (17) ent-hns opd patients aged between 18 to 65 years old diagnosed with acute tympanic membrane perforation were included in the study. group a underwent observation while group b was treated with recombinant human egf solution. followup was on a weekly basis (7th, 14th, 21st and 28th days) where video otoscopy for documentation and measurement of perforation using imagej™ software was done. pure tone audiometry was used to compare hearing improvement pre and post study in both observation and treatment groups. results: at baseline, there was no significant difference in the sizes of perforations: 24.20 ± 9.95 (treatment) vs. 32.64 ± 11.62 (observation) with a p-value of .131. following treatment, mean changes in perforation size were significantly greater in the treatment group compared to the observation group from baseline to day 7 (m = -9.08, n = 15.11 vs. m = -1.06, n = 31.58); p = .009; day 7 to 14 (m = -6.37, n = 13.78 vs. m = -0.79, n = 30.79); p = .003; and from day 14 to 21 (m = -5.65, n = 10.89 vs. m = -0.72, n = 30.07); p = .004 but not from day 21 to 28 (m = -4.16, n = 13.99 vs. m = -0.36, n = 29.71; p = .021. from baseline pure tone averages, four participants with mild hearing loss and two with moderate hearing loss achieved normal hearing in the treatment group (while one each with moderate and severe hearing loss did not improve). none of the observation group participants had improved hearing. conclusion: based on our limited experience, topical egf can be used for traumatic tympanic membrane perforation and otitis media with dry ear perforation during the acute phase or within 3 months of perforation. keywords: tympanic membrane perforation; ear trauma; otitis media; hearing impairment; human epidermal growth factor; tympanic membrane rupture; wound healing the baguio general hospital and medical center (bghmc) had a total of 309 tympanic membrane (tm) perforations in 2017, 164 in 2018, and 156 from january to july 2019 alone.1 based on our average data, a 10-year projection for patients with chronically perforated tm and hearing loss may reach 2,880. this condition may result from previous infection, traumatic philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery original articles manipulation, and barotrauma like diving or through air travel.2 moreover, persistent allergies, upper respiratory tract infection or presence of a suppurative ear discharge may prevent healing within 3 months. perforations of the tm may present with active infection or a dry ear perforation. based on location, they are classified as either central or peripheral; and in terms of duration, are considered acute when present for less than 3 months and chronic when present more than 3 months.3 management in our institution consists of instilling antibiotic otic drops, treating co-morbid conditions, and achieving a safe dry ear, and a ‘watch and wait’ policy is the practiced standard of care for dry tm perforations. patients who fail to attain full closure within the 3-month observation period are advised paper patch and fat graft tympanoplasty, but the success rates for these procedures vary. moreover, data on follow-up for progress of healing, transition to chronicity, and hearing status is limited. recombinant human epidermal growth factor (egf) is a potent stimulator of epithelial and endothelial cells and fibroblast proliferation which has potential as healing agent that has been used in acute and chronic tm perforations.4-6 various clinical and experimental studies have suggested that topical application of egf improves closure rate and shortens closure time in tm perforations, with closure rates ranging from 71.42% to 97.8%7-8 and no significant side effects reported.9 with the intention of exploring the use of egf on tm perforations in our practice, this study aimed to compare the effect of topical epidermal growth factor instillation versus observation alone on healing of acute tympanic membrane perforations in terms of closure and hearing test results. we hypothesize that the topical application of egf on acute tympanic membrane perforation would accelerate healing and closure compared to observation. methods with baguio general hospital and medical center (bghmc) research ethics committee approval (bghmc-rec-2019-31), this study used a randomized open label clinical trial design. adult patients aged 18 to 65 years who were diagnosed with acute tympanic membrane perforation at the bghmc otorhinolaryngology head and neck surgery (orl-hns) outpatient department (opd) from august to september 2019 were serially considered for inclusion in the study. inclusion criteria were ≤ 50% perforated tympanic membrane (tm). excluded were patients with active ear infection, persistently untreated allergic rhinitis, those who underwent otologic surgical management, females who were pregnant or who planned to conceive for the entire duration of the study. informed consent was obtained from prospective participants meeting inclusion and exclusion criteria. the sample size was computed at 95% confidence interval, 80% power, 5% margin of error, and 81% exposed with outcome using openepi version 3.01 (open-source epidemiologic statistics for public health, www.openepi.com, updated 2013/04/06). the total sample size was computed at 16. due to the varying range of efficacy for epidermal growth factor (egf), the sample size computation was based on the initial study done by amoils10 where the exposure outcome was based on the lowest possible successful treatment using topically applied egf of 81% without manipulation of the perforated tympanic membrane. one researcher (amoa) provided an audio-visual presentation of the materials, drug, procedure, and table of follow-up schedules in a manner or language that the prospective participants understood. a directed clinical history was obtained, and thorough physical examination was performed, including basic otoscopy and tuning fork testing using 512 hz, with information on the causes of the perforation collected. pure tone audiometry was performed by a 2nd year orlhns resident using an interacoustics diagnostic audiometer, (ad226, interacoustics a/s audiometer allé 1 5500 middelfart, denmark). randomization was made via coin flip, heads for the control/ observation group (a), tails for the treatment group (b). those randomized to group a were instructed to come for weekly follow-ups and documentation or as the need arose (e.g., when there was an upper respiratory tract infection, immersion in water or ear discharge). those randomized to group b were treated with egf (as described below) and were advised to follow up on a weekly basis for evaluation or when there were concerns. the tympanic membrane was photographed using a digital video camera (medone innotech, ll 250m, ccu 1500 with camera, gyeonggido, korea) attached to a 4mm x 100mm rigid 00 endoscope (tianjian bolang science-technology development co., ltd, 2018, tian jin shi, china), the perforation size was recorded using imagej™ version 1.52 software (wayne rasband, us national institutes of health https:// imagej.nih.gov/) where the equation generated was as follows: p t x 100 percent = percentage perforation where: p is the area (in pixels2) of the tympanic membrane perforation t is the total area (in pixels2) of the tympanic membrane the size, site and adequate margins of the perforated tympanic membrane and external auditory canal were documented. after performing physical examination, leaflets on proper ear care were given to each participant with the proper advice on how to maintain a dry ear. attached to the leaflet were follow-up schedules and the contact person for any concerns. evaluation of perforation and application of egf was carried out by a bghmc orl-hns graduate, a medical officer iv. after screening for any history of adverse drug reactions, an initial topical application of 3 drops of the test drug on the antecubital area with a 1 x 1 cm diameter surrounded by a black surgical hypoallergenic pen skin marking with the date and time was performed. a photograph of the topical skin application and skin marking was obtained, with waiting time of 30-60 minutes to note for any adverse reaction. for the egf (treatment) group, each participant was asked to lie down on an opd bed with the affected ear superior (lateral recumbent). the external auditory canal was cleaned using a cotton pledget soaked with povidone-iodine. the affected ear received treatment of 0.4ml (5 drops) of recombinant human egf solution (rhegf; 0.20mg/200mcg; easyef, daewoong pharmaceuticals, philippines), and the position was philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery original articles maintained for 30 minutes to allow adequate contact of the drug and the tympanic membrane. patients were then asked to sit up at the side of the examination bed and monitored for any untoward reactions for 30-60 minutes. the control group on the other hand was advised to keep their ears dry, monitor for any discharge and come for regular follow-up. measurement of the percentage of closure was performed weekly for both groups. those who failed to attain full tympanic membrane closure after the 28th day of monitoring were asked to continue followup every 14 days thereafter. pure tone audiometry was repeated at the fourth week by a 2nd year orl-hns resident using the same audiometer. data analysis descriptive and inferential statistics were utilized for the description and analysis of data, respectively. data was encoded using microsoft excel office professional plus 2019 (microsoft corp., redmond wa, usa). descriptive statistics made use of means and was used in determining the average differences in perforation size of both the control and treatment group. also, frequencies and percentages were used in the pre and post pta of the patients. test of normality was conducted using the kolmogorov-smirnov and shapiro-wilk tests to determine the appropriate test statistics that would be applied. wilcoxon signedranks test was used to determine whether the differences between pre and post treatment observations were significant. a p-value of ≤ .05 was considered significant. results out of 24 potential participants who met inclusion and exclusion criteria and were initially considered for this study, a total of 17 participants completed it. there were 6 males and 11 females, with ages ranging from 18 to 65 years old. eight were randomized to the treatment group (4 males, 4 females) and nine to the observation group (3 males, 6 females). the mean ages for the treatment and observation groups were 45.5 (sd: 9.12) and 36.7 (sd 14.26), respectively. there was only one tm perforation per participant, eight (8) left ear perforations and nine (9) right ear perforations. all perforations for both groups were central. baseline sizes for perforations in the treatment group were 14, 34, 31, 19, 38, 10, 20 and 24 %. (figure 1) for the observation group, perforation sizes were 38, 41, 35, 41, 29, 13, 35, 13 and 45 %. (figure 2) the treatment group had four (4) traumatic membrane perforations and four (4) otitis media with dry ear perforations. the control group had four (4) traumatic ear perforations and five (5) otitis media with dry ear perforations. figures 1 and 2 show hte serial tympanic membrane photographs for the treatment and observation groups, respectively. table 1 compares the observation and treatment groups in terms of mean sizes of perforation on initial evaluation (baseline), and days 7, 14, 21, and 28. at baseline, there was no significant difference in the sizes of perforations: 24.20 ± 9.95 (treatment) vs. 32.64 ± 11.62 (observation) with a p-value of .131. in both observation and treatment groups, there was a significant decrease in mean perforation size from baseline on day 7, 14, 21, and 28. however, comparison from paired periods showed no significant table 1. mean perforation size for observation and treatment groups: baseline, day 7, 14, 21 and 28 baseline day 7 day 14 day 21 day 28 observation treatment observation treatment observation treatment observation treatment observation treatment 32.64 24.20 31.58 15.11 30.79 13.78 30.07 10.89 29.71 13.99 11.625 9.950 11.753 12.657 12.284 11.032 11.726 10.696 11.803 4.245 .131 .014 .017 .011 .007 group mean std. deviation p-value a1 a2 a3 a4 a5 figure 1. treatment group serial tympanic membrane photos, top to bottom, patients a to h (rows). left to right, numbered 1 (baseline), 2 (day 7), 3 (day 14), 4 (day 21), and 5 (day 28). for example, b3 is a tympanic membrane photo of patient b on day 14. b1 b2 b3 b4 b5 c1 c2 c3 c4 c5 d1 d2 d3 d4 d5 e1 e2 e3 e4 e5 f1 f2 f3 f4 f5 g1 g2 g3 g4 g5 h1 h2 h3 h4 h5 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery original articles wilcoxon signed rank test revealed that mean changes in perforation size were significantly greater in the treatment group compared to the observation group from the initial application of egf to day 7 of perforation size evaluation (m = -9.08, n = 15.11 vs. m = -1.06, n = 31.58); p = .009; from the 7th to the 14th day of evaluation (m = -6.37, n = 13.78 vs. m = -0.79, n = 30.79); p = .003; and from the 14th to the 21st day of evaluation (m = -5.65, n = 10.89 vs. m = -0.72, n = 30.07); p = .004 but not from the 21st to the 28th day of evaluation (m = -4.16, n = 13.99 vs. m = -0.36, n = 29.71; p = .021 (table 6) table 2. observation group differences in perforation size from baseline: day 7, 14, 21 and 28 day 7 day 14 day 21 day 28 1.063 1.854 2.570 2.929 1.232 1.687 1.413 2.225 .032 .011 .001 .004 period mean difference std. deviation of differences p-value table 3. observation group differences of size perforation from paired periods day 7 and 14 day 14 and 21 day 21 and 28 0.791 0.716 0.359 1.255 0.955 1.216 .095 .055 .402 paired periods mean difference std. deviation of differences p-value table 5. treatment group differences of size perforation from paired periods table 6. comparative analysis of mean changes in perforation size between treatment group and observation groups baseline to day 7 day 7 to 14 day 14 to 21 day 21 to 28 -9.08 -6.37 -5.65 -4.16 -1.06 -0.79 -0.72 -0.36 2.598 2.946 2.867 2.311 .009* .003* .004* .021* time interval treatment observation mean changes in perforation size test statistic p-valuea negative values indicate decrease in the perforation size awilcoxon singed-ranks test *significant @ p-value ≤ .05 decrease in perforation size from one period to the next for the observation group, while there was a significant decrease in perforation size from day 7 to 14 and from day 14 to 21 in the treatment group, but no significant decrease in perforation size from day 21 to 28. table 2 shows a significant decrease in mean perforation size in the observation group from baseline on day 7, 14, 21, and 28. however, table 3 shows no significant decrease in perforation size from one period to the next for the observation group on paired period comparisons. table 4 shows a significant decrease in the mean size of perforation from baseline on day 7, 14, 21 and 28 in the treatment group. table 5 shows significant decreases in perforation size from day 7 to 14 and from day 14 to 21, but not from day 21 to 28 on perforation size comparisons from paired periods for the treatment group. figure 2. observation group seriel tympanic membrane photos, top to bottom, patients a to i (rows). left to right, numberecd 1 (baseline), 2 (day 7), 3 (day 14), 4 (day 21), and 5 (day 28). for example, c4 is a tympanic membrane photo of patient c on day 21. a1 a2 a3 a4 a5 b1 b2 b3 b4 b5 c1 c2 c3 c4 c5 d1 d2 d3 d4 d5 e1 e2 e3 e4 e5 f1 f2 f3 f4 f5 g1 g2 g3 g4 g5 h1 h2 h3 h4 h5 i1 i2 i3 i4 i5 table 4. treatment group differences in perforation size from baseline: day 7, 14, 21 and 28 day 7 day 14 day 21 day 28 9.083 10.020 14.802 18.480 10.890 2.810 4.274 5.324 .050 .000 .001 .027 period mean difference std. deviation of differences p-value day 7 and 14 day 14 and 21 day 21 and 28 6.367 5.652 4.157 2.931 3.428 2.860 .003 .021 .128 paired periods mean difference std. deviation of differences p-value philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery original articles references 1. annual statistical report out-patient department 2018, baguio general hospital & medical center. (unpublished). 2. olowookere sa, ibekwe ts, adeosun aa. pattern of tympanic membrane perforation in ibadan: a retrospective study. annals of ib postgrad med. 2008 dec;6(2):31-3. doi:10.4314/aipm. v6i2.64048; pubmed pmid: 25161451: pubmed central pmcid: pmc 4111000. 3. adegbiji wa, olajide gt, olajuyin oa, olatoke f, nwawolo cc. pattern of tympanic membrane perforation in a tertiary hospital in nigeria. niger j clin pract. 2018 aug;21(8):1044-1049 doi: 10.4103/njcp.njcp_380_17; pubmed pmid: 30074009. 4. yang j, lou zh, lou zc. a retrospective study of egf and ofloxacin drops in the healing of human large traumatic eardrum perforation. am j otolaryngol. 2016 mar; 37(4):294-298 doi:10.1016/j.amjoto.2016.03.005; pubmed pmid: 27105974. 5. dvorak dw, abbas g, ali t, stevenson s, welling db. repair of chronic tympanic membrane perforations with long-term epidermal growth factor. laryngoscope. 1995 dec; 105(12 pt 1):1300-04. doi:10.1288/00005537-199512000-00007; pubmed pmid: 8523981. 6. lou zh, lou zi, tang y. comparative study on the effects of egf and bfgf on the healing of human large traumatic perforations of the tympanic membrane. laryngoscope. 2016 jan; 126(1):e23-8. doi: 10.1002/lary.25715; pubmed pmid: 26451761. 7. bhat vk, veetil bv, mathad vk. effect of silver nitrate and epidermal growth factor on nonhealing tympanic membrane perforations: a randomized controlled study. ann otol neurotol. 2018;1(1):29-33. doi: 10.1055/s-0037-1612644. 8. lou zc, lou z. efficacy of egf and gelatin sponge for traumatic tympanic membrane perforations: a randomized controlled study. otolaryngol head neck surg. 2018 dec;159(6): 1028-1036 doi: 10.1177/0194599818792019; pubmed pmid: 30060707. 9. afshari m, larijani b, fadayee m, darvishzadeh f, ghahary a, pajouhi m, et al. efficacy of topical epidermal growth factor in healing diabetic foot ulcers. therapy. 2005; 2(5) 759-65. doi:10.1586/14750708.2.4.759. 10. amoils cp, jackler rk, lustig lr. repair of chronic tympanic membrane perforations using epidermal growth factor. otolaryngol head neck surg. 1992 nov; 107(5) 669-83. doi: 10.1177/019459989210700509; pubmed pmid: 1437205. 11. nayak ps, harugop as, patil ph, prasad tvrk, goswami l. treatment of tympanic membrane perforation with topical epidermal growth factor: progress towards clinical application. int j otorhinolaryngol head neck surg. 2021 may;7(5):768-71. doi: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20211567. 12. santos f, shu e, lee dj, jung d, quesnel a, stankovic km, et al. topical fibroblast growth factor-2 for treatment of chronic tympanic membrane perforations. laryngoscope investig otolaryngol. 2020 may; 5(4): 657-65. doi:  10.1002/lio2.395; pubmed pmid:  32864435; pubmed central pmcid: pmc7444771. table 7. pre and post pure tone audiometry results of treatment and observation groups normal mild moderate severe normal mild moderate severe 4 (100.0) 2 (66.7) 1 (100.0) 1 (100.0) 1 (33.3) 6 (100.0) 1 (100.0) 1 (100.0) baseline pta baseline pta treatment group observation group normal normal mild mild moderate moderate severe severe post pta post pta pure tone averages in the treatment group included four (4) mild hearing loss, three (3) moderate hearing loss, and one (1) severe hearing loss. after egf treatment, six (6) participants had improvement in pure tone average from mild and moderate hearing loss to normal hearing thresholds. two (2) participants with moderate and severe hearing loss respectively did not have significant improvement in pure tone average. pure tone averages for the observation group had one (1) normal hearing, one (1) mild hearing loss, six (6) moderate hearing loss, and one (1) severe hearing loss. after observation, no difference in pure tone averages was noted. however, these samples were not adequate to draw inferences from. (table 7) discussion healing of the tympanic membrane occurs spontaneously in 88% of traumatic perforations without intervention, as injury around the perforation triggers proliferation of the squamous epithelium along with various growth factors to induce healing.10 our study suggests that egf seems effective in terms of decreasing the size of the perforation and promoting the growth of epithelial tissue. overall, the treatment group presented significant epithelial growth in healing acute tympanic membrane perforations. our study suggests the same outcome by lou, et al.6 where patients who received egf treatment showed accelerated rate of tympanic membrane closure compared to observation alone. in terms of clinical applications,11 egf could benefit patients in need of immediate clearance for physical examination such as applicants to the philippine national police and philippine military academy as well as those at risk of chronic water exposure such as members of the navy, swimmers, and chronic users of in-ear or over the ear headphones such as those in the field of telecommunication or business process outsourcing (bpo) companies. improvement in hearing corroborated the findings of lou, et al.6 where morphology of the healed tympanic membrane would not affect the final structure of the tm in terms of sound conduction. as seen in previous studies, the final structure of the healed perforation of the tympanic membrane neared that of the normal tympanic membrane compared to the observation group where there was a deficient fibrous layer of the tympanic membrane.5,6,10 this could explain the difference between the egf treatment group and observation group where there was an improvement of hearing in the treatment group as documented by their audiometric results. this study was limited to the observation of the morphology of the healed perforations since we could not evaluate the histology of human tympanic membranes. ⁶ likewise, the observation period was limited to one month. we could extend the follow-up period to at least three months to check for reperforations or increase in the perforation size of those which partially healed¹² and to check also for the development of granulation tissue of the eac6 or formation of cholesteatoma in the middle ear. 5 as we limited our study to acute perforations, future studies can investigate the use of egf in chronic tympanic membrane perforations, where it has shown significant closure rates and hearing gain.11, 12 the unavailability of egf is another limitation as it is not readily available in the locality and not listed in the philippine national drug formulary (pndf). it cannot be prescribed for out-patient use and has to be instilled by a trained physician. other limitations of the study include the small sample size, and the generalizability of the outcome needs to have a greater number of participants to attain a better comparison of the efficacy of the intervention drug. double blinding future studies with the use of egf could also decrease bias. meanwhile, based on our limited experience, topical egf can be used for traumatic tympanic membrane perforation and otitis media with dry ear perforation during the acute phase or within 3 months of the perforation. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the effectiveness of the philippine health insurance corporation (philhealth) case rate system in reducing out-of-pocket expenses among non-no balance billing (nbb) patients undergoing thyroidectomy under the department of otorhinolaryngology – head and neck surgery of the baguio general hospital and medical center from february to september 2018. methods: design: prospective crosssectional setting: tertiary government hospital participants: sixty-four (64) randomly selected patients with philhealth who underwent thyroidectomy who agreed to participate and reveal their statements of accounts results: among the study population, 20% belonged to the no balance billing (nbb) category, with zero out-of-pocket expenses during their confinement. eighty percent (80%) belonged to the non-nbb category and also incurred zero hospital charges. in addition, there was no significant difference in the individual categories of the hospital expenses between the two groups except for the surgical procedures (p= .018, 95% ci). the accumulated total expenses also did not significantly differ between the two groups (p= .063, 95% ci). the minimum amount billed was php 1,984.95, while the maximum amount charged was php 38,898.65, with a median of php 18,703.28 and interquartile range of php 4,251.78 (x u : php 20,848.74, x l : php 16,596.96). there were no reported out-of-pocket expenses from non-nbb patients. the actual cost of thyroidectomy did not differ significantly from the case rate provided by philhealth among all the rvs categories. conclusion: the philhealth case rate system is effective in reducing out-of-pocket expenses among non-nbb patients who underwent thyroidectomy in our institution during the study period. keywords: out-of-pocket expenses; thyroidectomy; health care financing; health expenditures: universal health coverage effectiveness of the philippine health insurance corporation case rate system for thyroidectomy in a tertiary government hospital josephine ann p. ramos, md frederick mars b. untalan, md department of otorhinolaryngology head and neck surgery baguio general hospital and medical center correspondence: dr. frederick mars b. untalan department of otorhinolaryngology head and neck surgery baguio general hospital and medical center 1 governor pack road, baguio city, benguet 2600 philippines phone: (+63) 9175066551 e-mail: tongmd@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest (2nd place). december 6, 2019. palawan ballroom, edsa shangri la hotel, mandaluyong city. philipp j otolaryngol head neck surg 2020; 35 (1): 51-55 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery original articles the creation of the philippine health agenda in 2016 has re emphasized the need for accessible health care through a universal health insurance.1 the philippine health insurance corporation (philhealth) was seen as the gateway to free affordable care using no balance billing (nbb) for the poor or basic accommodation and fixed copayment for nonbasic accommodation.2 the nbb policy provides that no other fees or expenses shall be charged or paid for by indigent patients above and beyond the packaged rates during their confinement period.3 the limited depth and breadth of coverage, however, has resulted in high levels of out-of-pocket payments, which continue to rise despite the enormous programmatic and policy reforms in the health financing system. this problem has been observed in our local setting. among the 600 patients who underwent surgery in the department of otorhinolaryngologyhead and neck surgery during the previous year, a significant percentage of non-nbb patients was noted to have large out-of-pocket expenses for a myriad of reasons. these unnecessary expenses can be highly catastrophic and impoverishing. patients were noted to have a higher risk to forgo care, delay health seeking and become noncompliant. this study aims to determine the effectiveness of the philhealth case rate system in reducing out-of-pocket expenses among nonnbb patients undergoing thyroidectomy. this may be used to create a standardized process by which hospital charges can be based. once standardized, process defects, as well as processing time will be reduced. policies can be created to reduce out-of-pocket expenses to rational levels. strategies may be identified to expand philhealth benefits to cover a broader range of services. these can help make health care more equitable, inclusive, transparent and accountable in line with the philippine health agenda for 20162022. methods this is a prospective cross-sectional study carried out in a tertiary public hospital. the population was composed of the statements of accounts of public (charity) patients who underwent thyroidectomy from february to september 2018. the charts of patients that were included in the study must have fulfilled the following criteria: (1) must have philhealth listed as the health insurance; (2) must indicate that the patient underwent any of the following types of thyroidectomy: (a) partial thyroid lobectomy, unilateral, with or without isthmusectomy (rvs: 60210), (b) partial thyroid lobectomy, unilateral, with contralateral subtotal lobectomy, including isthmusectomy (rvs:60212), (c) total thyroid lobectomy, unilateral, with or without isthmusectomy (rvs: 60220), (d) total thyroid lobectomy, unilateral, with contralateral subtotal lobectomy, including isthmusectomy (rvs: 60225), (e) thyroidectomy, total or complete (rvs: 60240), (f ) thyroidectomy, removal of all remaining thyroid tissue following previous removal of thyroid (rvs: 60260) or (g) thyroidectomy, total or subtotal for malignancy, with limited neck dissection (rvs: 60252). the following exclusion criteria were applied: (1) use of other health insurances aside from philhealth; (2) presence of other co-morbid conditions in the final diagnosis; (3) more complicated types of thyroidectomy, including the following: (a) thyroidectomy, total or subtotal for malignancy, with radical neck dissection (rvs: 60254), (b) thyroidectomy, including substernal thyroid gland; sternal split or transthoracic approach (rvs: 60270) or (c) thyroidectomy, including substernal thyroid gland; cervical approach (rvs: 60271); and (4) incomplete charts. we limited the study to 64 billing statements which was computed using the prevalence of patients that underwent thyroidectomy for the year 2016 (n=76), a confidence interval of 95%, a margin of error of 5% and a power of 80%. the billing statements were selected using a table of random numbers. after obtaining approval from the institutional technical review board and research ethics committee, informed consent was obtained from the participants. upon admission, data such as employment (unemployed/ contractual/ selfemployed/ employed), salary in philippine pesos (php) per month (no fixed income/ less than php 10,000/ php 10,000 19,999, php 20,000 – 29,999, php 30,000 and above), philhealth membership classification (employed/ individually paying/ overseas filipino worker/ sponsored/ indigent/ lifetime/ senior citizen) and billing classification (nbb/ non-nbb), were obtained using a questionnaire. on the day of the patient’s discharge, the procedure performed (i.e., type of thyroidectomy) and statement of account were obtained, including particular expenses (room and board, drugs and medicine, supplies, radiology, laboratory and ancillary procedures, use of the operating room, and surgical procedures) and any outofpocket payments. descriptive statistics were calculated including the comparison of the cost of hospitalization and the philhealth case rate. descriptive summary measures for continuous variables were presented in terms of mean ± standard deviation or median and interquartile ranges; and for categorical variables, summaries were presented in frequency counts and proportions. comparisons between the cost of hospitalization among nbb and non-nbb patients and associations of the items included in the philhealth case rate and actual cost of thyroidectomy utilized the independent t-test. all data were encoded in microsoft excel for mac 2011 version 14.4.0 (microsoft corporation, redmond, philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery original articles wa, usa). statistical analysis was performed using ibm spss statistics for windows version 20.0 (ibm corp., armonk, ny, usa). all hypotheses tests used a 0.05 αlevel of significance. results a total of 64 patients met the inclusion criteria and consented to participate in the study. the profile of the participants based on the employment status, monthly income, philhealth membership classification, billing classification and procedure performed is presented in table 1. the comparison of the average cost of hospitalization between nbb and non-nbb patients indicate that there was no significant difference in the individual categories of hospital expenses, except for the surgical procedures (p= .018, 95% ci). the accumulated total expenses also did not differ significantly between the two groups (p= .063, 95% ci) as shown below in table 2. the minimum amount billed was php 1,984.95 while the maximum amount charged was php 38,898.65 with a median of php 18,703.28 and interquartile range of php 4,251.78 (x u : php 20,848.74, x l : php 16,596.96). there were no reported out-of-pocket expenses from nonnbb patients. the comparison of the average actual cost of thyroidectomy and the philhealth case rate is also shown in table 3. based on the average cost of thyroidectomy procedures, rvs 60225 (total thyroid lobectomy, unilateral, with contralateral subtotal lobectomy including isthmusectomy) had the highest average cost at php 21,556.30 while rvs 60220 (total thyroid lobectomy, unilateral, with or without isthmusectomy) had the lowest value at php 16,282.12. the actual cost of thyroidectomy did not differ significantly from the case rate provided by philhealth among all the rvs categories. discussion the philippine health agenda was launched to achieve universal health care for all filipinos through the achievement of three health system goals.1 among these, financial risk protection through the national health insurance program (nhip) is philhealth’s primary responsibility.4 this aims to protect filipinos especially the marginally poor against the catastrophic cost of illness. through the nhip, resources need to be generated to improve the provision of public health services to consequently achieve the millennium development goals.5 health insurance coverage is measured at the individual level to include both public insurance (though philhealth) and private insurance table 1. clinicodemographic profile of patients who underwent thyroidectomy at the baguio general hospital and medical center from february to september 2018 employment frequency proportion (%) unemployed contractual selfemployed employed no fixed income < php10,000 php 10,000 19,999 php 20,000 – 29,999 ≥php 30,000 employed individually paying ofw sponsored indigent lifetime senior citizen nbb nonnbb rvs 60210 partial thyroid lobectomy, unilateral, with or without isthmusectomy rvs:60212 partial thyroid lobectomy, unilateral, with contralateral subtotal lobectomy, including isthmusectomy rvs: 60220 total thyroid lobectomy, unilateral, with or without isthmusectomy rvs: 60225 total thyroid lobectomy, unilateral, with contralateral subtotal lobectomy, including isthmusectomy rvs: 60240 thyroidectomy, total or complete rvs: 60260 thyroidectomy, removal of all remaining thyroid tissue following previous removal of thyroid rvs: 60252 thyroidectomy, total or subtotal for malignancy, with limited neck dissection 35 0 25 4 31 11 20 2 0 7 35 0 2 13 0 7 13 51 4 0 14 2 25 14 5 54.7 00.0 39.1 06.3 48.4 17.2 31.3 03.1 00.0 10.9 54.7 00.0 03.1 20.3 00.0 10.9 20.3 79.7 06.3 00.0 21.9 03.1 39.1 21.9 07.8 =64 =64 procedure performed billing classification philhealth membership classification monthly salary =64 =100 =64 =100 =64 =100 =64 =100 =64 =100 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery original articles be charged or be paid for by indigent patients above and beyond the packaged rates during their confinement period.3 among the patients who underwent thyroidectomy from february to september 2018, 20% belonged to the nbb category with zero out-of-pocket expenses during their confinement. eighty percent (80%) belonged to the nonnbb category which also incurred zero hospital charges. the average cost of hospitalization did not differ significantly between the nbb and nonnbb patients. this, however, seems to contradict the fact that patients still complain of the high cost of out-of-pocket expenses in the outpatient department especially for laboratories, clearances and medications prior to their surgery. the compensation provided for by the philhealth case rate for thyroidectomy covers only the expenses during the patient’s confinement. it excludes those incurred during the patient’s consult in the outpatient department. the current setup for patients scheduled for thyroidectomy is to perform all diagnostic workups on an outpatient basis. these include but are not limited to neck ultrasound, thyroid function tests (ft4, tsh), fine needle aspiration biopsy (fnab), complete blood count (cbc), urinalysis (ua), 12-lead electroardiogram (ecg) and chest x-ray. should there be any derangement in the patient’s laboratory results that would warrant treatment, the patients are prescribed medications and are advised to have their laboratory tests repeated at the out-patient department (opd) on followup. a patient who needs to undergo treatment for abnormalities in thyroid function (i.e., hyperthyroidism or hypothyroidism) for instance, would need to take medications daily for 2-6 weeks before a repeat laboratory testing could be done. such expenditures were therefore not considered “outof-pocket expenses” in this study since they were incurred prior to the patient’s confinement. despite a uniform case rate for simple thyroidectomy cases, there exists a wide standard deviation in the hospital bill charged ranging from php 1, 984.95 to php 38, 898.65. variations in charges commonly came from procedures, drugs and medicine, and operating room supplies like oxygen, which could be caused by the lack of a uniform system of charging in the materials used. each particular expenditure category (i.e., room and board, drugs and medicines, supplies, radiology, laboratory and ancillary procedures, use of the operating room, and surgical procedures) could not be compared to a standard, since the given philhealth case rate does not include a breakdown of its coverage. nevertheless, the case rate provided by philhealth for all rvs cases used in this study is effective in terms of reducing the out-ofpocket expenses among non-nbb patients during their confinement. our study limitations include design bias, since it did not account for all of the expenses incurred for thyroidectomy particularly the out-of-pocket expenses in the outpatient department. the lack of a table 2. comparison of the average cost of hospitalization between nbb and non-nbb patients undergoing thyroidectomy particulars nbb in php (n=51) non-nbb in php (n=13) p-value professional fee surgical procedures use of operating room radiology, laboratory and other ancillary procedures/ clinical laboratory expenses medical supplies drugs and medicine room and board accumulated total expenses 0.00 2,576.63 4,569.23 786.08 1,522.83 2,002.74 1,879.69 13,337.20 .000 .018 .415 .434 .165 .113 .169 .063 0.00 2,176.97 4,661.96 545.76 1,273.73 2,138.92 1,769.23 12,556.57 table 3. comparison of the actual cost of thyroidectomy and philhealth case rate average actual cost of thyroidectomy (php) case rate from phic (php) p-value rvs 60210* rvs 60220+ rvs 60225≠ rvs 60240§ rvs 60260¶ rvs 60252# 31,000.00 31,000.00 31,000.00 31,000.00 31,000.00 31,000.00 .210 .212 .208 .210 .203 .209 18,660.85 16,282.12 21,556.30 19,857.07 21,200.26 20,800.98 *partial thyroid lobectomy, unilateral, with or without isthmusectomy. +total thyroid lobectomy, unilateral, with or without isthmusectomy. ≠total thyroid lobectomy, unilateral, with contralateral subtotal lobectomy, including isthmusectomy. §thyroidectomy, total or complete. ¶thyroidectomy, removal of all remaining thyroid tissue following previous removal of thyroid. #thyroidectomy, total or subtotal for malignancy, with limited neck dissection. (through private health maintenance organizations (hmos).6  out-ofpocket health expenditure is defined as direct purchases by households of health services or goods, like medicines, hospital room charges, consultation fees and diagnostic tests. it excludes dental charges, food supplements, various alternative therapies and transportation for medical care.6 purchasing of health services is particularly relevant in the thrust of financial risk protection.5 the focus of social health insurance in the philippines has long been on expanding membership, but as coverage approached 80-90 percent of the population, this has shifted to increasing the reimbursement rate (or the so-called “support value”). through this, health insurance indeed reduced a household’s probability of falling into poverty due to a member’s illness.7 along with the introduction of case payment is the introduction of the no balance billing (nbb) policy, which provides that no other fees or expenses shall philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery original articles acknowledgements we would like to thank dr. mary jane t. lubos for her supervision in editing the manuscript, and mr. emmanuel j. bacud for his assistance in statistical analysis. references 1. romualdez aj jr., rosa jfed, flavier jda, quimbo sla, hartigan-go ky, lagrada lp, et al. the philippines health system review [internet]. the philippines health system review. health systems in transition; 2011 [cited 2017 may 18]; 1(2): available from: http://www.wpro.who.int/ philippines/areas/health_systems/financing/philippines_health_system_review.pdf. 2. cabral ei. department of health. all for health towards health for all: philippine health agenda 2016-2022 [internet]. manila (philippines): department of health; 2016 [ cited 2017 may 16]; 54(2) : available from: https://www.doh.gov.ph/sites/default/files/basicpage/philippine%20 health%20agenda_dec1_1.pdf. 3. philippine health insurance corporation. philhealth members [internet]. manila (philippines): philippine helath insurance corporation; 2014 [cited 2017 may 16]. available from: https:// www.philhealth.gov.ph/members. 4. department of health. the philippine health situation at a glance [internet]. manila (philippines): department of health; 2015 [cited 2017 may 16]. available from: https://www. doh.gov.ph/sites/default/files/basic-page/chapter-one.pdf. 5. picazo of, ulep vgt, pantig im, ho bl. a critical analysis of purchasing of health services in the philippines: a case study of philhealth [internet]. pids discussion paper series; 2015 dec [cited 2017 may 21]. available from: https://dirp3.pids.gov.ph/websitecms/cdn/publications/ pidsdps1554.pdf. 6. bredenkamp c, buisman lr. financial protection from health spending in the philippines: policies and progress. health policy plan. 2016 sep; 31(7): 919-27. doi: 10.1093/heapol/czw011; pmid: 27072948. 7. obermann k, jowett m, kwon s. the role of national health insurance for achieving uhc in the philippines: a mixed methods analysis. glob health action. 2018;11(1):1483638. doi: 10.1080/16549716.2018.1483638; pmid: 29914319; pmcid: pmc6008596. standard by which expenditure categories could be compared to also pose another limitation. it is therefore our recommendation to include all outpatient expenses in the case rate coverage to reduce the outof-pocket expenditures further. there should also be a standardized system of charging of supplies used to maximize the case rate, probably through the use of or packages for thyroidectomy. further studies are also encouraged to determine if the philhealth case rate is effective for private patients undergoing thyroidectomy and for other conditions or procedures. in conclusion, the philhealth case rate system is effective in reducing out-of-pocket expenses among non-nbb patients who underwent thyroidectomy in our institution from february to september 2018. philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 35 philipp j otolaryngol head neck surg 2016; 31 (1): 35-38 c philippine society of otolaryngology – head and neck surgery, inc. prevalence of nasopharyngeal carcinoma among patients with nasopharyngeal mass in a philippine tertiary training hospital hasmin hannah r. lara, md angelo monroy, md department of otorhinolaryngology head & neck surgery university of santo tomas hospital correspondence: dr. angelo monroy department of otorhinolaryngology-head & neck surgery university of santo tomas hospital españa street, sampaloc, manila 1015 philippines phone: (632) 731 3001 local 2224 email: ust_enthns@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at philippine society of otolaryngology-head and neck surgery, descriptive research contest, september 19, 2013, natrapharm, the patriot bldg., km 18 slex, parañaque city. abstract objectives: to determine the prevalence and identify the types of nasopharyngeal carcinoma (npca) among patients with nasopharyngeal mass seen at a tertiary university training hospital in the philippines from january 2006 – july 2012 and identify possible factors associated with nasopharyngeal carcinoma. methods: a retrospective cross-sectional study was performed at a tertiary university training hospital among cases (n=179) seen with nasopharyngeal mass at the ent outpatient department. histopathology results and patient medical charts were collected and reviewed after irb approval. the age at diagnosis, sex, place of residence, occupation and chief complaint was compared among patients with positive histopathology of npca only. design: retrospective, cross sectional study setting: tertiary private university training hospital participants: one hundred seventy nine (179) patients with nasopharyngeal mass results: ninety six (54%) cases with nasopharyngeal mass seen at the ent outpatient department were positive for nasopharyngeal malignancy. the remaining 83 (46%) cases with nasopharyngeal mass had a benign histopathology. npca was more common among males (58%) than females (42%). the most common form of npca was non-keratinizing undifferentiated npca (47%) followed by poorly differentiated squamous cell carcinoma in 18 (19%). the most common chief complaint was a neck mass, followed by decreased hearing. conclusion: there was a higher proportion of nasopharyngeal malignancy among male patients with nasopharyngeal mass, and the most common chief complaint was a neck mass. future research should integrate data with other hospital institutions to obtain more accurate demographic data of the local prevalence of npca. a detailed record of the ethnicity, diet, occupation, smoking history and family history of cases should be obtained to correlate possible risk factors of npca among patients with nasopharyngeal mass in our setting. keywords: nasopharyngeal carcinoma, nasopharyngeal mass, epidemiology, prevalence creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 36 philippine journal of otolaryngology-head and neck surgery original articles ear, nose and throat (ent) physicians see patients who consult for diverse chief complaints in the head & neck with subsequent finding of a nasopharyngeal mass. if with clinical suspicion for nasopharyngeal carcinoma, biopsy is advised to rule out a malignant process. however, there is little evidence that a nasopharyngeal biopsy should be performed in the presence of a nasopharyngeal mass. nasopharyngeal carcinoma (npca) is an epithelial neoplasm arising most often from the fossa of rosenmüller.1 it r e p r e s e n t s about 0.7% of global cancer with an age-standardized incidence rate for both males and females of <1 per 100,000 person-years. incidence rates are much higher (10-20 per 100,000 personyears in males, 5-10 per 100,000 person-years in females) in cantonese regions of southern china and southeast asia.2 in manila (philippines), the incidence rates from 1993 1997 were 7.2 per 100,000 person-years among males and 2.5 per 100,000 personyears in females.3 in contrast, the philippine cancer society reported an incidence of 1.2 per 100,000 person years in 2010, while a recent study by sarmiento and mejia found an incidence of 2.07 per 100,000 person years.4 these studies show variying incidences and data for npca in the country. the objective of this study is to determine the prevalence, classify the types of npca and associate the potential risk factors for nasopharyngeal carcinoma among patients with nasopharyngeal mass at a tertiary univeristy training hospital from january 2006 to july 2012. methods with institutional review board approval, this retrospective crosssectional study considered all patients seen at the ent outpatient service under the clinical (public) division of a tertiary university training hospital in manila from january 2006 to july 2012 who were diagnosed with a nasopharyngeal mass for the first time and on whom subsequent nasopharyngeal biopsy was performed. histopathologic examinations were performed at the department of anatomic pathology of the same institution and reviewed by different assigned pathologists. group concurrence among a particular set of pathologists was applied if there were issues with difficult to diagnose cases. each entire specimen or a representative sample processed and stained with hematoxylin eosin was examined under high power and low power scanning magnification. for this study, only the initial histopathology result was considered, and no special stains were considered for inconclusive histopathology results. histopathologic results and medical records of patients were collected by the principal investigator. the age at diagnosis, sex, place of residence, occupation and chief complaint were recorded and correlated among patients with positive histopathology of npca only. table 1. table 1. histologies of biopsied nasopharyngeal masses at the ent-opd from january 2006 – july 2012 (n=179) 96 n malignant histologies 54 % nasopharyngeal carcinoma (81.3%) undifferentiated carcinoma non-keratinizing carcinoma1 keratinizing carcinoma2 squamous cell carcinoma, grade not specified other carcinomas (1%) adenoid cystic carcinoma lymphoid malignancies (7.3%) non-hodgkin’s lymphoma atypical lymphoid proliferation malignant neoplasm, unspecified (10.4%) undifferentiated malignancy round cell malignancy benign histologies inflammatory lesions (86%) acute inflammation chronic inflammation caseating granulomatous inflammation lymphoid hyperplasia others3 benign neoplasms (6%) cystadenoma lymphomatosum angiofibroma polyp benign nasopharyngeal tissue (6%) 45 18 6 9 1 2 5 7 3 83 1 54 7 9 1 1 3 2 5 47 19 6 9.3 1 2.1 5.2 7.3 3.1 46 1 65 8 11 1 1 4 2 6 1poorly differentiated (squamous cell) carcinomas 2moderately and well-differentiated (squamous cell) carcinomas 3non specific inflammation with focal dysplasia; reactive (lymphoid) hyperplasia the prevalence of npca based on the 1991 who classification was also determined. records with incomplete data were excluced. data analysis the data gathered was encoded in microsoft excel version 14.0 worksheet (office 2010, microsoft corporation, redmond, wa, usa) and tallied in spss version 10 (spss-x) for windows (spss inc. 1983, chicago, il, usa). descriptive statistics were generated for all variables. for nominal data frequencies and percentages were computed. for numerical data, mean ± sd were generated. analysis of the different philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 original articles philippine journal of otolaryngology-head and neck surgery 37 while 83 (46%) were reported as benign. a total of 78 (81.3%) had a histopathologic diagnosis of npca. among those with npca, the most common form was non-keratinizing undifferentiated npca (47%) followed by non-keratinizing poorly differentiated squamous cell carcinoma (19%). other malignant histopathology results (18.7%) include adenoid cystic carcinoma, non-hodgkins lymphoma, undifferentiated malignancy, round cell malignancy and atypical lymphoid proliferation. among the benign nasopharyngeal histologies, the most common was chronic inflammation (65%). (table 1) table 3 shows the association of age and sex with nasopharyngeal malignancy. there was a significant association of nasopharyngeal malignancy with higher mean age compared to benign biopsy results (p <0.0001). the proportion of males was significantly higher among those with nasopharyngeal malignancy (p <0.03). there was a peak in the incidence of undifferentiated nasopharyngeal carcinoma at age 41-50 years old. (figure 1) the age of patients with nasopharyngeal malignancy was significantly higher/older than those with benign nasopharyngeal mass. the most common reported chief complaint among patients diagnosed with nasopharyngeal carcinoma was a neck mass, followed by decreased hearing. other symptoms include decreased hearing, epistaxis, nasal obstruction, tinnitus, ear pain, facial pain, foreign body sensation on throat, palatal mass & headache. discussion of the 179 cases with nasopharyngeal mass included in the study, 96 cases (54%) had a malignant nasopharyngeal mass. of these, 78 (81.3%) were positive for npca and the most common classification in our study was non-keratinizing undifferentiated npca. in comparison, a 1991 study by uy on the clinical profile of 108 patients diagnosed with nasopharyngeal carcinoma at the university of santo tomas hospital table 2. distribution of nasopharyngeal carcinomas according to stage (ajcc 2010, 7th edition) n % i ii iii iva ivb ivc x no stage total 1 1 8 7 5 3 51 2 78 1 1 10 9 6 4 65 4 100 table 3. association of age and sex with nasopharyngeal malignancy age (in years) mean ± sd sex female male 47.90 ± 13.64 42 (41.6%) 59 (58.4%) 34.28 ± 14.97 47 (57.3%) 35 (42.7%) <0.0001 (s) 0.03 (s) nasopharyngeal malignancy (n=96) non-malignant nasopharyngeal mass (n=83) p value figure 1. distribution of nasopharyngeal carcinomas according to subtypes and age variables was done using the t-test to compare groups with numerical data and chi square test to compare/associate nominal data. results records of 179 patients were included in the study with ages ranging from 18-80 years old (mean age 48 years). of the 179 total cases of nasopharyngeal mass, 96 (54%) were reported as malignant philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 38 philippine journal of otolaryngology-head and neck surgery original articles references 1. chan jkc, pilch bz, kuo tt, wenig bm, lee awm. tumors of the nasopharynx: introduction. in: barnes l, eveson jw, reichart p, sidransky d, editors. pathology and genetics of head and neck tumours (world health organization classification of tumours) lyon, france: iarc press; 2005. pp. 82–84. 2. jemal a, bray f, center mm, fer lay j, ward e, for man d. global cancer statistics. c a ca n ce r j c l i n . 2011 m ar-apr ; 61(2): 69-90.doi: 10.3322/caac.201107. epub 2011 feb 4. 3. chang et, adami ho. the enigmatic epidemiology of nasopharyngeal carcinoma. cancer epidemiol biomarkers prev. 2006 oct; 15 (10): 1765–1777. 4. sarmiento mp, mejia mb (2013) preliminary assessment of nasopharyngeal carcinoma incidence in the philippines: a second look at published data from four centers. chin j cancer. 2014 mar;33(3):159-64. doi: 10.5732/cjc.013.10010. epub 2013 aug 19. 5. uy b. clinical profile of nasopharyngeal carcinoma in filipinos. phillipp j otolaryngol head neck surg. 1991: 55-59. 6. uy dc, chiong cm. predictive value of clinical symptoms in nasopharyngeal carcinoma. phillipp j otolaryngol head neck surg. 1996: 130-133. 7. bray f, haugen m, moger ta, tretli s, aalen oo, grotmol t. age-incidence curves of nasopharyngeal carcinoma worldwide: bimodality in low risk populations & aetiologic implications. cancer epidemiol biomarkers prev.2008 sep; 17(9): 2356-65. 8. tan l, loh t. benign and malignant tumors of the nasopharynx. in flint pw, haughey bh, lund vj, niparko jk, richardson ma, robbins kt. cummings otolaryngology head & neck surgery. 5th edition. philadelphia, pa: mosby, elsevier; 2010: 1351-1357. from 1971-1983 showed that poorly differentiated carcinoma was the most common histopathology diagnosis at that time (44%), and the least common was undifferentiated npca (14%).5 among the cases included in his study, a diagnosis of npca was three times more common among males compared to females.5 also, a 1996 study by uy and chiong at the manila doctors hospital of 98 patients with nasopharyngeal mass seen at their institution from 1989-1993 showed that 52% had positive histopathology of npca while 48% had negative results.6 the significant association noted in our study between age and sex of patients with nasopharyngeal malignancy (p <0.0001 and <0.03 respectively) is consistent with the review of literature which shows that npca incidence increases with increasing age in high and intermediate risk countries, while a consistent pattern of bimodality in npca age incidence was observed in low risk populations (increase in npca risk with an early peak in late adolescence (15-24 years old) and a second peak later in life (65-79 years old)).7 in our study, we note that there was a peak in the incidence of npca at age 41-50 years old. the bimodal distribution of age found in other studies was not seen here. could the peak incidence in a younger age group in our study be explained by differences in circumstances and environments -where variations in dietary intake of food such as dried fish (a nitrosamine rich diet) may be more accessible to the lower socioeconomic group? could more exposure to environmental pollution from occupation and lifestyle have affected the younger aged group with peak prevalence of npca compared to the older population? our results showed a greater proportion of males with histopathology of nasopharyngeal carcinoma, consistent with previous studies done in high-prevalence countries. we note however that compared to most studies with a male to female ratio of 2-3:1, there was a higher ratio of females diagnosed with nasopharyngeal carcinoma among the patients in our study (male to female ratio of 1.4:1). could the increasing incidence of smoking among local females have something to do with this? in our study, non-keratinizing undifferentiated carcinoma (47%) was the most common form of nasopharyngeal carcinoma, consistent with studies done in other high risk countries. poorly differentiated squamous cell carcinoma was the second most common form (19%), in contrast to studies in other high risk countries where this form is rare. keratinizing squamous cell carcinoma is usually found in low risk countries like united states and japan, and is associated with smoking. with our results showing a higher proportion of females diagnosed with npca compared to previous studies on the epidemiology of npca in the philippines, future research on the probable role of smoking and other unique factors among females in the philippines may be useful. npca is curable but is usually diagnosed at a late stage. patients have multiple symptoms and a painless upper cervical lymph node is the most common presenting feature followed closely by nasal symptoms particularly, blood stained post nasal drip.1,6,8 in comparison, the most common chief complaint among patients who were eventually diagnosed with nasopharyngeal carcinoma at our institution was a neck mass followed by decreased hearing. perhaps closer scrutiny of the nasopharynx in patients with conductive hearing problems and otitis media effusion may increase detection of npca in our setting. limitations of our study include our small sample size. due to the retrospective nature of the study, incomplete data in some charts limited the data collection. variability in biopsies performed by different ent doctors may also have affected our results. this paper is only an initial evaluation of the prevalence of npca among patients seen in the clinical (public) division of our institution. it is recommended that future researches include the private division of the hospital as well, and should consider including other hospitals/ health facilities to obtain more accurate data of the prevalence of npca in the philippines. detailed information on the ethnicity, dietary practices, occupational exposures and family history of npca should be obtained for all patients suspected of having nasopharyngeal carcinoma, using an npc screening questionaire. complete and organized patient records may provide better references for future research and answer some of the questions this study raised. philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery original articles philipp j otolaryngol head neck surg 2019; 34 (1): 34-37 c philippine society of otolaryngology – head and neck surgery, inc. maxillary sinus squamous cell carcinoma in a tertiary hospital in the philippines anna kristina m. hernandez, md arsenio claro a. cabungcal, md department of otorhinolaryngology philippine general hospital university of the philippines manila correspondence: dr. arsenio claro a. cabungcal department of otorhinolaryngology philippine general hospital ward 10 university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (+632) 554 8400 loc. 2152 email: aacabungcal@up.edu.ph the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest (3rd place). october 22, 2018, maynila ballroom, the manila hotel, manila. abstract objective: to establish preliminary demographic and clinicopathologic data on maxillary sinus squamous cell carcinoma (scc) in the philippine general hospital methods: design: retrospective case series setting: tertiary national university hospital participants: socio-demographic and clinical data from records of 22 patients admitted at the department of otorhinolaryngology of the philippine general hospital from 2013-2016 and histopathologically confirmed to have maxillary sinus scc were collected and described using means and proportions. results: there were 15 males and 7 females with a mean age of 50 years old (range 24 to 77 years old). maxillary mass/swelling was the most common chief complaint. the mean gap between initial symptoms and consult was 6.77 months. initial biopsies were obtained from the maxillary sinus in 16 patients, with 1 patient noted to have undergone malignant transformation from a prior intranasal squamous papilloma. staging was advanced (stage iva in 16, ivb in 4, and iii in 2) with no patients with stage i or ii disease. sixteen (16) patients underwent surgery and radiotherapy while 6 patients received radiotherapy (rt) with or without chemotherapy. regional and distant metastases were uncommon. conclusion: in this series, maxillary sinus scc occurs more in males with a maxillary mass as the most common chief complaint. delay in treatment is common with a mean gap of 6 months between initial symptoms and consult. neck node metastasis is uncommon and most patients undergo surgery with radiotherapy as treatment. keywords: maxillary sinus cancer; paranasal sinus cancer; squamous cell carcinoma maxillary sinus squamous cell carcinoma (scc) is a rare cancer, comprising about 0.2-0.8% of all malignant neoplasms1,2 and 3% of all head and neck malignancies.1 it is the most common histopathologic type among maxillary cancers.1,3,4 this disease is extremely rare in children with those between the ages of 55 to 65 years old usually affected.1 it usually presents in advanced stages in patients who are often treated for benign conditions before malignancy is diagnosed and the overall 5-year survival is at 42%.1 there have been reports of varying clinical behavior among maxillary scc in various regions worldwide through the years. aggressive presentation and rapid onset of maxillary carcinomas are rarely seen in western europe5 while prevalence of cervical metastasis at initial presentation has been observed in india.3,6 survival has improved through the years but conflicting results depending on the modality of treatment have also been reported.3,7-9 creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery original articles local studies tend to focus more on head and neck malignancies in general and a literature search of medline (pubmed) and herdin using the search terms maxillary sinus cancer (mesh term) and squamous cell carcinoma (mesh term) and philippines (all fields) did not yield specific studies on maxillary sinus scc. the rarity of this disease, along with varying findings in the literature necessitates the establishment of baseline data for maxillary sinus scc. this paper aims to establish preliminary sociodemographic and clinicopathologic data on maxillary sinus scc in our institution. methods with institutional review board approval, this retrospective case series considered for inclusion the records of patients admitted at the philippine general hospital department of otorhinolaryngology public ward from january 1, 2013 – december 31, 2016 who were diagnosed with histopathologically-confirmed maxillary sinus scc. records of patients diagnosed with other cancers of the maxillary sinus, residual or recurrent maxillary sinus scc, and those with incomplete records were excluded. we reviewed the patient database of the department of otorhinolaryngology to determine eligible patients for this study. patient records were coded and de-identified socio-demographic data such as age, sex, location, past medical history, family medical history, personal social history, as well as clinical data including chief complaint, time between symptom onset and initial consult, signs/symptoms, staging (t, n, m), biopsy approach, histopathologic diagnosis/grading, intraoperative anatomic involvement, regional metastasis and distant metastasis were extracted from patient records. data were written in data collection sheets and subsequently encoded in a microsoft excel office 365 database. data were checked for accuracy of encoding. data analysis utilized microsoft excel version 1903 (microsoft corp. redmond, wa, usa) to generate descriptive analysis. means and proportions were used to describe the study variables. results out of 25 patient records identified, 22 patients (15 males, 7 females) with ages 24 to 77 years old (mean age 50 years old) were included. excluded were one record for incompleteness and 2 for non-scc biopsy results. twenty (20) patients were from luzon, 2 from visayas, none from mindanao. nineteen (19) of the 22 patients consulted within 6 months of initial symptoms with a chief complaint of mass or swelling in 21 and nasal obstruction in 1. eleven (11) patients had a history of smoking, 15 had a history of alcohol ingestion and 11 had a history of both. only three (3) patients had a history of schedule 1 (high abuse potential) drug use. nine (9) patients had comorbidities but only one (1) patient had a prior intranasal (not maxillary) mass while two (2) patients had prior intranasal (not maxillary) surgeries. the employment of patients varied, 3 were carpenters/construction workers, 3 were jeepney drivers/dispatchers, 2 each were security guards, fishermen farmers, housewives, or retired, 1 each was a seamstress, animator, cashier, and mechanic, and 2 listed no occupation. initial biopsies were mostly taken from the maxillary sinus (n=16) and resulted in a diagnosis of squamous cell carcinoma for all patients with 1 patient noted to have undergone malignant transformation from a prior intranasal squamous papilloma. staging was advanced in all (stage iva in 16, ivb in 4, and iii in 2) with no patients staged i or ii in this series. sixteen (16) patients underwent surgery with radiotherapy, the rest were advised radiotherapy with or without chemotherapy. eleven (11) patients with advanced staging underwent maxillectomy with orbital exenteration. the most common signs/symptoms are enumerated in figure 1. apart from cheek fullness/maxillary swelling, patients also frequently presented with a palatal bulge (n=20). other pertinent signs/symptoms included are hyposmia (n=3), bleeding mass (n=3), septal deviation (n=3), and skin changes (n=3). areas often grossly involved intraoperatively include the oral cavity (n=19; usually the palate and the gingiva), the nasal cavity (n=17; from an intranasal extension of the maxillary mass), and the orbit (n=13; usually through lysis of the orbital floor). nine (9) patients presented with clinically palpable neck nodes. of the nine (9), only five (5) underwent neck dissection and had available post-operative histopathologic results. three (3) of the five (5) patients figure 1. most common signs/symptoms philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery original articles usa (st. pierre & baker, 1983) origin (authors, year published) usa (st. pierre & baker, 1983) netherlands (tiwari, et al. 1999) brazil (santos, et al. 2014) japan (kondo, et al. 2016) india (qureshi, et al. 2006) philippines (hernandez & cabungcal, 2019)* number of patients gender distribution, age stage distribution percentage of lymph node metastasis treatment outcomes 66 patients (1964-1975) 42 male, 24 female average age at 60 years 1 stage i, 8 stage ii, 21 stage iii, 36 stage iv 10.6% of patients had lymph node metastasis surgery + rt 5-year survival 75% for t2, 28.5% t3, 19.4% t4 43 squamous cell carcinoma patients (1975-1994) 28 male, 15 female age range at 32-90 years 7 stage ii, 20 stage iii, 16 stage iv surgery + rt, chemotherapy + rt 5-year disease-free survival 64% for surgery+rt 2-year survival of 37% for chemo+rt 58 patients (more adenocarcinomas than squamous cell carcinomas) 35 male, 23 female median age of 59 years 5 stage i or ii, 53 stage iii or iv 17.2% of patients had regional metastasis surgery +rt, chemotherapy + rt overall 5-year survival rate of 17.7% 26 patients (20022008) 18 male, 8 female average age at 64.2 years (50-84 years) 4 with t2, 13 with t3, 9 with t4a 8 patients had lymph node metastasis (30.8%) chemotherapy + rt overall 5-year survival rate of 71.3% 73 patients (1994-1999) 39 male, 23 female median age 55 years 61 presented with t3/t4 disease 6 presented with lymph node metastasis surgery + rt, chemotherapy, radiotherapy overall 5-year survival after surgery + rt of 43% 22 patients (20132016) 15 male, 7 female average age at 50 years (24-77 years) 0 stage i/ii, 2 stage iii, 16 stage iva, 4 stage ivb 3 patients had lymph node metastasis surgery + rt, rt +/ chemotherapy table 1. comparison of maxillary sinus cancer data *data from the present series yielded positive regional metastasis to the cervical lymph nodes. diagnostics for distant metastases were normal for most patients including liver ultrasound (n=18), chest x-ray (n=16), aspartate aminotransferase (n=16), alanine aminotransferase (n=12) and alkaline phosphatase (n=14). four (4) patients had remarkable liver ultrasound findings -2 had benign findings (hepatic cyst and parenchymal disease), 1 had a hepatic focus measuring 1.8cm, and another had nonspecific calcifications. biopsy was not obtained from any of the masses identified. four (4) patients had significant x-ray findings suggestive of infection (pneumonia in 1, pulmonary tuberculosis in 3). discussion the general demographic and clinicopathologic profile of patients with maxillary scc in this series is similar with findings in our literature review from the region. (table 1) common symptoms include pain, nasal discharge, epistaxis and obstruction, commonly affecting males more than females at a ratio of 1.5:1.1 other symptoms include: (1) nasal fullness, stuffiness or obstruction, (2) pain, (3) cheek paresthesia, (4) cheek fullness or swelling, (5) palatal bulge, (6) persistent, nonhealing nasal/oral sore or ulcer, (7) nasal mass, (8) proptosis, diplopia or lacrimation.1 similar to existing literature, our study revealed male predominance in this disease – with a male: female ratio of 2.1:1. the presence of a maxillary mass was the most common chief complaint identified. the development of maxillary sinus cancer appears to be influenced by several factors such as: exposure to (1) nickel, (2) chlorophenols, (3) textile dust, (4) thorotrast instillation, (5) smoking, (6) formaldehyde, (7) wood, (8) concurrence of sinonasal (schneiderian) papilloma, and (9) human papilloma virus.1,7 however, due to methodological limitations of this study, we were unable to identify these factors in our sample. smoking and alcohol ingestion were observed in at least half of the patients and were more frequently noted than schedule 1 drug use. employment as a construction worker or jeepney driver was more common among the patients in our series. risk for exposure may be inferred, at best, from the patients’ residence or employment. the dilemma with diagnosing maxillary sinus scc is that tumor growth is usually indolent. delay in consultation may range from a month to even years, with some patients in this series first consulting ophthalmologists for eye symptoms or dentists for dental symptoms, only to discover that the problem was in the maxillary sinus. many patients in our series presented in advanced stages, in contrast to the rarity of aggressively presenting maxillary carcinomas among patients philippine journal of otolaryngology-head and neck surgery vol. 34 no. 1 january – june 2019 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery original articles in western europe.5 since the maxillary sinus is an area surrounded by bone, significant bony involvement usually occurs prior to clinically apparent symptoms such as a cheek bulge which usually prompts medical consult. patients may initially be diagnosed with some areas as unresectable, profoundly affecting prognosis. the usual treatment for maxillary sinus scc in our institution was surgery with radiotherapy. radiotherapy with or without chemotherapy was usually advised for patients who were poor surgical candidates. it has been established in the literature that histopathologic diagnosis is a strong factor for nodal metastasis with a primary scc or undifferentiated carcinoma being the most likely to result in neck node metastasis.11 the grading of differentiation (well-differentiated, moderately-differentiated, and poorly-differentiated) has been found to have no significant difference in the likelihood for nodal metastasis.11 only three (3) patients (2 well-differentiated scc, 1 poorly differentiated scc) out of the 22 patients in our study presented with positive cervical metastasis, relatively low compared to the high (46%) incidence (69 out of 148 patients) noted in india.3,5 this is consistent with findings in literature that nodal metastasis is uncommon in tumors without extensive lymphatic involvement, as is the case for the maxillary sinus.11 studies such as by le et al., found an overall incidence of 15.5% for neck node metastases in patients with maxillary scc.12 due to this low rate of neck node metastasis, elective neck dissection is not routinely done for patients with maxillary sinus scc in our institution. fine needle aspiration biopsy (fnab) is likewise not done for clinically palpable neck nodes among patients with maxillary sinus scc as these patients are treated with an additional neck dissection. our results may underestimate the incidence of neck node metastases in our institution. however, fnab may be explored as an option to determine neck node metastasis among patients who are not good candidates for surgical management. there have been conflicting reports regarding factors influencing nodal metastasis, with some studies citing that extension of tumor outside of the maxillary sinus was closely related to the risk of cervical lymphadenopathy for maxillary sinus scc.12,13 another study reports that staging (t2 in particular) confers a higher risk for nodal metastasis than t3 or t4 tumors.4 a study by ahn et al. found that the increase in risk begins with t2 tumors and progresses to t3 and t4 tumors as well.15 all three patients who presented with positive cervical metastasis were staged as t4a tumors and 2 of the 3 patients were positive for tumor at the area of the pterygoid plates. these findings may be worth investigating in future research. there are several limitations to this study. first, the limited sample size precludes the generalizability of our findings. our series was also limited to the patients of one department (otorhinolaryngology) in our hospital and does not reflect the general surgery census of the same hospital. it is recommended that more patients with maxillary sinus scc be included in future studies to gain more insight from trends observed in the data. the inclusion of imaging findings and post-treatment followreferences 1. pilch b, bouquot j, thompson. squamous cell carcinoma. in: barnes l, eveson j, reichart p, and sidransky d (editors). world health organization classification of tumours: pathology and genetics of head and neck tumours. geneva: iarc press; 2005. p. 15-17. 2. grant rn. cancer statistics 1970. ca cancer j clin 1970, 8: 6-20. as cited in le qt, fu kk, kaplan mj, terris dj, fee we, goffinet dr. lymph node metastasis in maxillary sinus carcinoma. int j radiat oncol biol phys. 2000 feb 1; 46(3): 541-549. pmid: 10701732. 3. santos mr, servato jp, cardoso sv, de faria pr, eisenberg al, dias fl, et al. squamous cell carcinoma at maxillary sinus: clinicopathologic data in a single brazilian institution with review of literature. int j clin exp pathol. 2014 dec 1; 7(12): 8823-8832. pmid: 25674251 pmcid: pmc4313952. 4. cantu g, bimbi g, miceli r, mariani l, colombo s, riccio s, et al. lymph node metastases in malignant tumors of the paranasal sinuses: prognostic value and treatment. arch otolaryngol head neck surg. 2008 feb; 134(2): 170-177. pmid 18283160. 5. tiwari r, hardillo ja, mehta d, slotman b, tobi h, croonenburg e, et al. squamous cell carcinoma of maxillary sinus. head neck. 2000 mar; 22(2): 164-169. pmid: 10679904. 6. sakai s, hohki a, fuchihata h, tanaka y. multidisciplinary treatment of maxillary sinus carcinoma. cancer. 1983 oct 15; 52(8): 1360-1364. pmid: 6193854. 7. sharma s, sharma sc, singhal s, mehra yn, gupta bd, ghoshal s, et al. carcinoma of the maxillary antrum – a 10 year experience. indian j otolaryngol. 1991 dec; 43 (4): 191-194. 8. qureshi ss, chaukar da, talole sd, d’cruz ak. squamous cell carcinoma of the maxillary sinus: a tata memorial hospital experience. indian j cancer. 2006 jan-mar; 43(1): 26-29. pmid: 16763359. 9. kondo a, kurose m, obata k, yamamoto k, murayama k, shirasaki h. a clinical study of maxillary sinus squamous cell carcinoma. in: himi k, takano, k (editors). excellence in otolaryngology: 70 years of the department of otolaryngology of the sapporo medical university. basel: karger, 2016, p. 83-87. 10. st-pierre s, baker s. squamous cell carcinoma of the maxillary sinus: analysis of 66 cases. head neck surg. 1983 jul-aug; 5(6): 508-513. pmid: 6885504. 11. jiang gl, ang kk, peters lj, wendt cd, oswald mj, goepfert h. maxillary sinus carcinomas: natural history and results of postoperative radiotherapy. radiother oncol. 1991 jul; 21(3): 193200. pmid: 1924855. 12. le qt, fu kk, kaplan mj, terris dj, fee we, goffinet dr. lymph node metastasis in maxillary sinus carcinoma. int j radiat oncol biol phys. 2000 feb 1: 46(3): 541-549. pmid 10701732. 13. kim ge, chung ej, lim jj, keum kc, lee sw, cho jh, et al. clinical significance of neck node metastasis in squamous cell carcinoma of the maxillary antrum. am j otolaryngol. 1999 novdec; 20(6): 383-390. pmid: 10609483. 14. jeremic b, nguyen-tan pf, bamberg b. elective neck irradiation in locally advanced squamous cell carcinoma of the maxillary sinus: a review. j cancer res clin oncol. 2002 may; 128(5): 235238. pmid 12029438. 15. ahn ph, mitra n, alonso-basanta m, palmer jn, adappa nd, o’malley bw jr, et al. risk of lymph node metastasis and recommendations for elective nodal treatment in squamous cell carcinoma of the nasal cavity and maxillary sinus: a seer analysis. acta oncol. 2016 sep oct; 55(9-10): 1107-1114. pmid 27685421. up in the analysis will make the data more robust. second, no association between the variables and the diagnosis of maxillary sinus scc may be drawn from this series due to the limited number of patients included. the authors aimed to establish preliminary data for this condition and such associations may better be evaluated using other methods of statistical analysis in future studies with a larger sample size. a longer study period can also allow us to evaluate outcomes. third, review of patient records limits the kind of data available. clinicians usually do not ask about (or write down) technical risk factors such as exposure to substances and these may only be implied based on employment. in retrospect, broader inclusion criteria—including all types of maxillary sinus cancers— might have resulted in more patients and may have provided a more comprehensive understanding of the clinical behavior and outcomes of various maxillary sinus malignancies in our institution. in conclusion, our series found that maxillary sinus scc occurs more in males, with a maxillary mass as the most common chief complaint. delays in treatment are usual, with a mean gap of 6 months between initial symptoms and consult. neck node metastasis is uncommon and most patients undergo surgery with radiotherapy as treatment. philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles abstract objective: to determine the prevalence of diabetes mellitus among patients admitted for head and neck infections and describe their clinicodemographic features. methods: design: retrospective case series setting: tertiary government training hospital participants: forty-two (42) patients results: out of 211 adult patients admitted for head and neck infections during the study period, 42 (20%) were diagnosed to have concomitant diabetes mellitus (dm). only 6 (14%) were known to have dm before admission while 28 (67%) were found to have dm only after admission. the most common site of infection was the neck (11; 26%). more than half of the patients (24; 57.1%) had infections in the head only, 17 (40.5%) had infections in the neck only, and 1 (2.4%) had infections in both the head and neck regions. among these, 26 (61.9%) had infection in one site only, 15 (35.7%) had infections in two sites and one (2.4%) had infections in three sites. the majority (28; 66.7%) had an unknown etiology of infection with spontaneous appearance of redness and swelling in the involved area. six (14.3%) were odontogenic, five (11.9%) were due to skin trauma, and three (7.1%) were due to nasal mucosal trauma. available cultures in 14 patients revealed 12 (86%) with aerobic microorganisms and two (14%) with anaerobic growths. half of the aerobic cultures grew k. pneumoniae. all patients were started on empiric intravenous antibiotics and over half of them (52.4%) needed surgical management. more than half (27; 64.3%) suffered from diabetic head and neck-associated complications, categorized into orbital (56%), organ/systemic (26%), local (11%), and neural (7%). despite these complications, the majority (37, 86%) went home improved while five (12%) expired. conclusion: this study found that 20% of patients admitted for head and neck infections during the study period had concurrent dm. guided by known clinicodemographic characteristics, patients admitted with suspicious head and neck infections must be promptly screened for concomitant dm and properly managed before substantial morbidity and death ensue. otolaryngologists head and neck surgeons, endocrinologists, general practitioners and patients alike must be cognizant of diabetic head and neck infections so that they can be prevented or managed early before complications set in. keywords: diabetes mellitus; head and neck infections; diabetic infections prevalence of diabetes mellitus and clinicodemographic profiles of patients with head and neck infections in a philippine tertiary government hospital jesusa m. santos, md department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center correspondence: dr. jesusa m. santos department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center san lazaro compound, rizal avenue sta. cruz, manila 1003 philippines phone: (632) 8711 9491 local 320 e-mail: zette_jms@yahoo.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest. december 5, 2019. palawan ballroom, edsa shangri la hotel, mandaluyong city. philipp j otolaryngol head neck surg 2020; 35 (2): 27-31 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles over the years, lifestyle-related/non-communicable diseases such as dm have risen to be among the top causes of morbidity and mortality globally and locally.1 in the philippines, there were 3,721,900 cases of diabetes in 2017 with a 6.2% prevalence in the adult population.2 diabetic-related complications include heart attack, stroke, kidney failure, foot and leg gangrene, vision loss, nerve damage and infections all of which bring about substantial financial burden and extended hospital stays.3 diabetes increases susceptibility to various infections that can affect any region of the body including the head and neck. head and neck infections include malignant otitis externa, deep neck space abscesses, parotid abscesses, rhino-cerebral mucormycosis, and others.4 these bring potential serious complications like hearing loss, airway obstruction, facial palsy and even blindness. diabetics are predisposed to greater infection risk primarily due to hyperglycemia and acidemia which exacerbate impairments in humoral immunity and polymorphonuclear leukocyte and lymphocyte functions.5 these may precipitate metabolic derangements, and conversely, the metabolic derangements of diabetes may facilitate infection.6 the treatment of diabetes associated head and neck infections is quite challenging and involves prolonged anti-microbial therapy, glycemic control and even major surgical debridement. to the best of my knowledge based on a search of herdin, medline (pubmed) and google scholar using the search terms “diabetes,” “infections,” “head and neck,” “diabetic head and neck infections,” and “philippines” there are no previous studies on the prevalence of diabetes among patients admitted for head and neck infections in the philippines. thus, this study aims to determine the prevalence of diabetes among patients admitted for head and neck infections in our ward over a 5-year period, and to describe their clinicodemographic characteristics. methods after obtaining approval of the jose r. reyes memorial medical center institutional review board (irb protocol no. 2019-085), this 5-year retrospective series was conducted by reviewing the available ward census of the department of otorhinolaryngology – head and neck surgery for the period between january 2014 to december 2018. the source population were records of all patients admitted for head and neck infections at the department of otorhinolaryngology – head and neck surgery. of these, records of adult patients with dm admitted for head and neck infections were considered for inclusion if they met any of the following criteria: glycosylated hemoglobin test (hba1c) level of 6.5% and higher, or fasting blood sugar of 126mg/dl (7.0mmol/l) or above, or random glucose test of 200 mg/dl or higher, or were listed as a known diabetic with maintenance medications. incomplete records were excluded. the clinicodemographic profile of included patients such as age, gender, site of infection, multiplicity of sites of infection, etiology of infection, culture studies (if available), blood glucose level, treatment modality (antibiotics, other medications, surgery), length of hospital stay, complications and outcomes were extracted from the records. data was recorded and tabulated using microsoft excel® for mac version 16.4 (microsoft corp., redmond wa, usa), while stata version 14 (statacorp llc, college station tx, usa) was used in data analysis. descriptive statistics were employed to determine the mean ± standard deviation for continuous variables and the proportions for categorical variables. results a total of 211 adult patients were admitted for head and neck infections during the study period and 42 (20%) of these patients were identified to have concomitant dm. there were 24 (57%) males and 18 (43%) females, with ages ranging from 25 to 76 years old (mean age 48 years old). there was bimodal distribution with 16 (38%) aged 51 to 60 years old and 11 (26%) aged 31 to 40 years old. eight (19%) were aged between 41-50, four (10%) between 61-70, two (5%) between 21-30, and one (2%) between 71-80 years of age. only six patients (14%) were known to have dm before admission. following admission, 28 patients (67%) were identified to have dm based on elevated hba1c levels, six (14%) based on elevated fbs level while two (5%) had elevated random blood sugar. the mean hba1c level was 10.7%, with the highest level at 18% and lowest at 6.6%. the most common site of infection was the neck (11; 26%) followed by the nose (9; 21%), ear (4; 9.5%), submandibular area (3; 7%), submental area, upper lip, buccal and retropharyngeal areas (2 each; 5% each), and temporal area, epiglottis, tonsil, parotid, frontal area, cheek, and lower lip (1 each; 2% each). among the patients, 26 (61.9%) had infection in one site only, while 15 (35.7%) had infections in two sites. only one (2.4%) had infections in three sites. infections in the head region only were observed in more than half of the patients (24; 57.1%), while infections in the neck region only were observed in 17 (40.5%). only one patient (2.4%) had infections in both the head and neck regions. a majority (28; 66.7%) of the patients had an unknown etiology of infection with spontaneous appearance of redness and swelling in the involved area. six (14.3%) were odontogenic (associated with dental caries) and 5 (11.9%) were due to skin trauma. three (7.1%) were due to nasal mucosal trauma such as plucking of nasal vibrissae. (figure 1) philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles cavernous sinus thrombosis (2), and orbital cellulitis (1). seven (26%) had organ/systemic complications: mediastinitis (1), pleural effusion (1), hypoxemic encephalopathy (1) and sepsis (1), with three having concomitant impending upper airway obstruction. three (11%) had local complications such as skin defect (2) and saddle nose deformity (1). two (7%) had neural complications, facial palsy (1) and hearing loss (1). patients who had pre-septal cellulitis initially had infections of the nose, upper lip, temporal area, buccal and frontal area, respectively. the patient with saddle nose deformity had a nasal septal abscess (and subsequently underwent septorhinoplasty). the two patients who had lateral neck skin defects were allowed to heal by secondary intention. the patient with hypoxemic encephalopathy developed from airway obstruction due to the significant retropharyngeal abscess. the patient with hearing loss had malignant otitis externa that led to external auditory canal stenosis. despite complications, 36 patients (86%) went home improved, one (2%) was readmitted due to recurrence of lateral deep neck abscess, and five patients (12%) expired. the mean duration of hospital stay for diabetic patients with head and neck infections was 14 days, with the longest hospital stay at 32 days and the shortest at less than one day. discussion the prevalence of dm among patients with head and neck infections in our institution during the 5-year study period was 20%. this suggests that one out of five patients admitted for head and neck infections in the hospital has diabetes, although most might only be diagnosed to have dm following admission. only a small proportion of the patients in this present series knew that they had diabetics on admission. patients admitted for head and neck infections must be properly screened for concomitant dm to facilitate appropriate management. smit’s study reported that diabetic patients with poor management of their blood glucose level((hba1c > 7%) show a greater risk for infections which are relatively more serious.7 hyperglycemia has been reported to impair the immune functions of hosts by increasing the virulence of some pathogens, lowering the production of interleukins, immobilization of leukocytes and reduced chemotaxis and phagocytic activity.8 these render the patients at higher risk for severe or invasive infections involving any organ or regions of the body but are also common in the head and neck region.7 in this study, the majority of the patients were in their fifth decade. this can be attributed to the older age group being more predisposed to systemic illness such as dm and a decline in their immune function.9 this is also reflective of the age group 50-59 identified in the global report on diabetes by who.3 synergistically, poorly controlled diabetes and aging subject a person to increased infection risk. figure 1. etiologies of infection. most are from unknown causes (dotted), followed by odontogenic (grid), skin trauma (dashed) and nasal mucosal trauma (solid lines). culture results were available in 14 patients (collected from surgery or needle aspiration). twelve (86%) had growths of aerobic microorganisms while two (14%) had anaerobic microbial growths. among the aerobic cultures, six grew k. pneumoniae, three grew s. aureus and one each grew salmonella, staphylococcus epidermidis and pseudomonas. among the anaerobes there were one sample each of arizona sp. and enterobacter aerogenes. all of the patients were started on empiric intravenous antibiotics until culture studies led to definitive treatment. antibiotics and number of patients were: oxacillin + gentamicin (10; 24%), piperacillin tazobactam (8; 19%), oxacillin (4; 10%), penicillin g + metronidazole (3; 7%), piperacillin tazobactam + clindamycin (3; 7%), ampicillin sulbactam (2; 5%) and one each (2% each), sultamicillin + metronidazole, penicillin g, ceftriaxone + metronidazole, oxacillin + ciprofloxacin, piperacillin tazobactam + metronidazole, piperacillin tazobactam + meropenem, ceftriaxone, vancomycin + ceftazidime, ciprofloxacin, clindamycin, clindamycin + ceftazidime, ceftriaxone + oxacillin + metronidazole. more than half of the patients (27; 64.2%) were on insulin therapy. ten (23.8%) were taking oral hypoglycemic agents and five (12%) were taking combination therapy (insulin sq/iv + oral hypoglycemic agents). of the 42 patients, half (22; 52.4%) required surgical intervention. of these 22, 14 (63%) underwent incision and drainage under local anesthesia while four patients (18%) with deeper abscesses underwent incision and drainage under general anesthesia. one patient underwent direct laryngoscopy for mapping of the extent and drainage of the retropharyngeal abscess. three patients (14%) underwent wound debridement under general anesthesia due to substantial amounts of necrotic tissues in the affected site. more than half (27; 64.3%) of the patients had complications associated with diabetic head and neck infections. of these, 15 (56%) had orbital complications. these were pre-septal cellulitis (12), philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles the most commonly involved site of infection identified in this study was the neck but any part of the head and neck region such as the ear, nose, face, lip, and throat can be primary sites of infection as well. these sites are infrequently identified as potential nidus for diabetic-related complications, with blindness, kidney failure, cardiovascular events and lower limb amputation as the most commonly identified consequences that impact significantly on diabetic patients.3 several studies revealed that diabetes mellitus is the most commonly associated systemic disease in deep neck infections with a unique clinical picture in comparison with those without diabetes mellitus.10,11 in this study, most of the patients were admitted due to unknown etiology of infection followed by odontogenic infections. el-sayed et al. stated that the causes of infections remain obscure in diabetic patients because of possible resolution of the infectious foci or because subclinical infectious foci exist.12 a study by vieira and stocks theorized that poor oral hygiene and low socio-economic status probably accounted for the odontogenic causes.13 caqueiro et al. stated that the hyperglycemic state of patients seems to be central in the initiation of the pathophysiology of diabetic head and neck infections.8 klebsiella pneumoniae was the most common aerobic bacteria isolated from purulent exudates of our patients followed by staphylococcus aureus while anaerobic microbial growth revealed arizona sp. and enterobacter aerogenes. this shows that diabetic patients are prone to infections with various causative organisms. a german study revealed that k. pneumoniae in deep neck infection patients with diabetes is common due to increased oropharyngeal colonization by gram-negative bacilli and defects on host defenses, specifically the phagocytic function which predispose them to invasive type of infections.14 culture and sensitivity is a great tool in giving appropriate antimicrobial therapy in these types of serious bacterial infections. in vitro data show that a wide-range of beta-lactams, aminoglycosides and quinolones are useful treatment for klebsiella infections.15,16,17 because only six (14%) of the patients were known to have dm on admission, screening for the blood glucose level was requested from patients who presented with unconfirmed and more severe forms of infection of the head and neck. the mean hba1c level of the diabetic patients with this specific test was 10.7% with highest level at 18%. hyperglycemia causes protein glycation which can cause impairment of host proteins involved in complement activation, bacterial uptake, phagocytic killing, and scavenging of bio-limiting nutrients and change the binding of host surface receptors for pathogens.18 moreover, glycation of immunoglobulin occurs in patients with diabetes in proportion with the increase in hba1c, and this may harm the biological function of the antibodies.19 hence, confinement of the infection by the host’s immune system is also ineffective leading to morbid complications, extensive infections and even death.6 intravenous antibiotics were started empirically based on site of infection and organism that was most likely to be the causative agent while definitive antibiotics were given for patients with culture studies. blood glucose lowering agents were also needed to optimize treatment. almost half of the diabetic patients in our study suffering from head and neck infections required surgical treatment. holkom et al. documented that diabetic patients with abscess formation with extended space infection underwent surgery more than non-diabetic patients, with the difference being statistically significant.20 this aggressive mode of treatment was expedited since conservative medical treatment failed to completely resolve the deep-seated infections. in developing countries like the philippines, it is common for patients to seek medical consultation in the advanced stages of the clinical spectrum when complications have already set in. the mean hospitalization period among our patients was 14 days. during their hospital stay glycemic control was aimed to maximize the effect of medical and surgical treatment. daily wound care by the surgeon was also necessary since some needed regular debridement and the cases of deep neck infections were left to heal by secondary intention, necessitating prolonged hospital stay. a multitude of complications ranging from local, orbital, nerve and organ/systemic affectation were seen in our patients. huang et al. concluded that diabetic patients tend to have more frequent complications from head and neck infections which may be related to high percentage of extended involvement rendering them less suitable for conservative treatment and prolonged hospital stay.21 within the age range of 2576 years old, five (12%) of our study patients succumbed to death. this rate is higher than the worldwide statistics of 7-8% deaths due to high blood glucose among those aged 20-69 presented by the who. hence, at the individual level, the who suggested that intensive interventions to improve diet and physical activity can prevent or delay the onset of diabetes in people at high risk.3 due to disturbances of their immune system and hyperglycemic state, a high fatal outcome of infectious diseases in diabetic patients was reported in an israeli study by leibovici.22 huang et al. also stated that risk of mortality related to infection in a diabetic adult patient is greater than that of a cardiovascular disease patient.17 however, when managed appropriately, maximal medical and surgical treatment and glycemic control can promote full recovery of patients.17 the major limitation of this study is the small number of patients gathered during the study period. the source population itself was biased as it consisted of admissions for head and neck infections. philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles a future multi-center prospective study can be conducted to increase the study population. the source population could be expanded to include all patients with dm and identify those with head and neck infections in particular (rather than starting with all patients with head and neck infections and identifying those with underlying dm). the glycosylated hemoglobin (hba1c) level was also not available in all patients (particularly those who expired within less than a day of admission). association studies could have been performed if all patients had the same dm indicators such as their hba1c level. an awareness program is needed to increase the knowledge of lay persons, general practitioners and otolaryngologists head and neck surgeons about diabetic head and neck infections, their clinical picture and implications on patients, their families, physicians, hospitals and communities. this study focused on dm as a prevalent disease seen among patients with head and neck infections. the general public and physicians should be made aware of the neglected presentation of beginning erythema or swelling on any part of the head and neck without prior source as a possible diabetic head and neck infection. systemic antibiotics covering k. pneumoniae should be considered since majority of the infections grew these bacteria. primary prevention is still best by observing strict dietary control, regular exercise and secondary prevention by encouraging patient with known dm to have good compliance with anti-diabetic medications and regular screening of the body giving importance to the head and neck region as well. diabetic head and neck infections can lead to significant disability and even premature death. the role of an otolaryngologist may be almost as essential as that of the endocrinologist in handling such cases. the results of the prevalence and clinicodemographic profile of diabetic patients admitted for head and neck infections in this study may be a basis for future studies that can establish the association of hyperglycemic state to the characteristics seen in the infections of the patients which can later on create an awareness program that can educate patients and medical practitioners alike on the alarming consequence of diabetes in general and diabetic head and neck infections in particular. a high index of suspicion is needed to diagnose and properly treat a patient with head and neck infections with concomitant dm. acknowledgements the author acknowledges dr. milabelle b. lingan for providing invaluable contribution, input, encouragement and support in pursuing this research. she served as the clinical consultant to the patients in this study and scientific advisor of this research article. references 1. department of health philippines. lifestyle-related diseases. [cited 2019 july 21]. available from: https://www.doh.gov.ph/lifestyle-related-diseases. 2. international diabetes federation. the philippines. [cited 2019 july 21]. available from: https:// www.idf.org/our-network/regions-members/western-pacific/members/116-the-philippines. html. 3. world health organization. global report on diabetes. [cited 2019 july 21]. available from: https://www.who.int/diabetes/global-report/en/. 4. sathasivam p. head and neck infections in diabetic patients. j assoc physicians india. 2018 sep; 66(9):84-88. pubmed pmid: 31321937. 5. delamaire m, maugendre d, moreno m, le goff mc, allannic h, genetet b. impaired leucocyte functions in diabetic patients. diabet med. 1997 jan; 14(1):29-34. doi: 10.1002/(sici)10969136(199701)14:1<29::aid-dia300>3.0.co;2-v; pubmed pmid: 9017350. 6. gupta s, koirala j, khardori r, khardori n. infections in diabetes mellitus and hyperglycemia. infect dis clin north am. 2007 sep; 21(3):617-38, vii. doi: 10.1016/j.idc.2007.07.003; pubmed pmid: 17826615. 7. smit j, søgaard m, schønheyder hc, nielsen h, frøslev t, thomsen rw. diabetes and risk of community-acquired staphylococcus aureus bacteremia: a population-based case–control study. eur j endocrinol. 2016 may; 174(5):631-9. doi: 10.1530/eje-16-0023; pubmed pmid: 26966175. 8. juliana casqueiro, janine casqueiro, and cresio alves. infections in patients with diabetes mellitus: a review of pathogenesis. indian j endocrinol metab. 2012 mar; 16 suppl 1(suppl1):s27-36. doi: 10.4103/2230-8210.94253; pubmed pmid: 22701840; pubmed central pmcid: pmc3354930. 9. pae m, meydani sn, wu d. the role of nutrition in enhancing immunity in aging. aging dis. 2012 feb; 3(1):91-129. pubmed pmid: 22500273; pubmed central pmcid: pmc3320807. 10. parhiscar a, har-el g. deep neck abscess: a retrospective review of 210 cases. ann otol rhinol laryngol. 2001 nov; 110(11):1051-4. doi: 10.1177/000348940111001111; pubmed pmid: 11713917. 11. chen mk, wen ys, chang cc, lee hs, huang mt, hsiao hc. deep neck infections in diabetic patients. am j otolaryngol. may-jun 2000; 21(3):169-73. doi: 10.1016/s0196-0709(00)85019-x; pubmed pmid: 10834550. 12. el-sayed y, al dousary s. deep-neck space abscesses. j otolaryngol 1996 aug;25(4):227-33. pubmed pmid: 8863209. 13. vieira f, allen sm, stocks rms, thompson jw. deep neck infection. otolaryngol clin north am. 2008 jun; 41(3):459-83, vii. doi: 10.1016/j.otc.2008.01.002; pubmed pmid: 18435993. 14. sahly h, podschun r, ullmann u. klebsiella infections in the immunocompromised host. adv exp med biol. 2000; 479:237-49. doi: 10.1007/0-306-46831-x_21; pubmed pmid: 10897425. 15. weisenberg sa, morgan dj, espinal-witter r, larone dh. clinical outcomes of patients with klebsiella pneumoniae carbapenemase-producing k. pneumoniae after treatment with imipenem or meropenem. diagn microbiol infect dis. 2009 jun;64(2):233-5. doi: 10.1016/j. diagmicrobio.2009.02.004. epub 2009 apr 2. pubmed pmid: 19345034; pubmed central pmcid: pmc2764245. 16. chan yr, liu js, pociask da, zheng m, mietzner ta, berger t, mak tw, clifton mc, strong rk, ray p, kolls jk. lipocalin 2 is required for pulmonary host defense against klebsiella infection. j immunol. 2009 apr 15;182(8):4947-56. doi: 10.4049/jimmunol.0803282. pubmed pmid: 19342674; pubmed central pmcid: pmc2708928. 17. adams-haduch jm, potoski ba, sidjabat he, paterson dl, doi y. activity of temocillin against kpc-producing klebsiella pneumoniae and escherichia coli. antimicrob agents chemother. 2009 jun;53(6):2700-1. doi: 10.1128/aac.00290-09. epub 2009 mar 30. pubmed pmid: 19332667; pubmed central pmcid: pmc2687206. 18. gan yh. host susceptibility factors to bacterial infections in type 2 diabetes. plos pathog. 2013; 9(12):e1003794. doi: 10.1371/journal.ppat.1003794; pubmed pmid: 24385898; pubmed central pmcid: pmc3873456. 19. peleg ay, weerarathna t, mccarthy js, davis tm. common infections in diabetes: pathogenesis, management and relationship to glycaemic control. diabetes metab res rev. 2007 jan; 23(1):313. doi: 10.1002/dmrr.682; pubmed pmid: 16960917. 20. holkom ma, fu-qiang x, alkadasi b, yang l, long mx, mohamed a. analysis of maxillofacial and neck spaces infection in diabetic and non diabetic patients. dentist case rep, 2018; 2(2):30-6. corpus id: 52998664. 21. huang t, tseng f, liu tc et al. deep neck infection in diabetic patients: comparison of clinical picture and outcomes with nondiabetic patients. otolaryngol– head neck surg 2005;132:6 doi:10.1016/j.otohns.2005.01.035 pubmed pmid: 15944569. 22. leibovici l, yehezkelli y, porter a, regev a, krauze i, harell d. influence of diabetes mellitus and glycaemic control on the characteristics and outcome of common infections. diabet med. 1996 may; 13(5):457-63. doi: 10.1002/(sici)1096-9136(199605)13:5<457::aid-dia83>3.0.co;2-t; pubmed pmid: 8737028. president’s page past presidents of the pso-hns especially founding president dr. tierry garcia, president of the pbo-hns dr. rudy nonato, presidents of the chapters and chairs of the subspecialty groups, co-fellows of the society, friends, guests, ladies and gentlemen. at the threshold of the 60th anniversary of this venerable society, i stand here today as the humble recipient of your trust and confidence as your president. as a child i have seen the photos of the heroic founders and had been witness to the lasting friendship between them. i was in high school when my father, dr. armando t. chiong, sr. became the 10th president of the organization. i now follow my brother, president dr. armando chiong, jr. to continue the programs he started. such laudable programs started by the past years’ bot with the advocacy map, public awareness, chapter and institutional initiatives will be continued. with the funding earmarked from the proceeds of the diamond jubilee celebration on april 2016, research and academic programs will be strengthened and the society’s journal the pjo-hns will move for even more international recognition. the breadth and the depth of human capacity to help one another is limitless. the same can be said for our organization whose dedicated fellows strive for excellence in their clinical practice with honor and integrity. make no mistake that it is a privilege being here amongst you my co-dreamers for a society that will be recognized not only for its international standing, its global perspective, its innovations but for its sincere quest for helping raise the quality of lives to heal the sick among our countrymen and render the best ent care possible at an affordable cost and of wider availability. we thank our mentors for the great example they have given us, their wisdom and good counsel so all of us 694 fellows united can champion the cause of the patients we serve. the pso-hns will use all its available resources to move the organization forward to work more closely with partners in industry, government, non-government, academic institutions and each fellow, chapter, and subspecialty group will be supported by your bot in these endeavors. lead, we will. serve with dedication in our best capacity for sure and we trust in your full support of our institution. we stand proud of this prestigious society of the best experts in ent care. the growth of pso-hns from the ‘heroic 9’ to 694 in 60 years is phenomenal. challenges, there will be always be but in the end we will know that more is yet to be done and the future brilliant because the legacy will always remain. see you all in the anniversary ball in february and the jubilee celebration in april, 2016 organized by dr. dan poblete. good evening to you all. charlotte martinez chiong, md, phd president philippine society of otolaryngology-head and neck surgery 2 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 31 no. 1 january – june 2016 presidents’ inaugural address philippine society of otolargyngology head and neck surgery annual congress december 2, 2015 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles abstract objective: to determine the incidence of cerebrospinal fluid (csf) leak after hadadbassagasteguy flap (hbf) reconstruction after endoscopic endonasal transsphenoidal surgery for skull base pathologies from 2016 to 2020 at the university of the east ramon magsaysay memorial medical center. methods: design: case series setting: tertiary private training hospital participants: charts of 35 patients who underwent endoscopic endonasal transsphenoidal surgery with reconstruction using hadad-bassagasteguy flap between january 2016 to february 2020 were reviewed and data on demographics, date of procedure, mass size, final diagnosis, presence of preoperative, intraoperative and postoperative csf leak, placement of lumbar drain and course in the wards were collected. results: there were 23 women and 12 men with ages ranging from 21 to 71 years. four patients (11.4%) had postoperative csf leak after reconstruction with hbf. two of these four patients had episodes of nose blowing and sneezing weeks after surgery, prior to the development of the csf leak. the other two patients experienced csf leak 3 days postoperatively. conclusion: hbf has been a workhorse for reconstruction of skull base defects after transsphenoidal surgery, and based on our experience remains to be so, making it possible for expanded approaches and a wide variety of pathologies to be operated on via the endonasal route. keywords: hadad-bassagasteguy flap, hadad flap, cerebrospinal fluid leak; csf leak, endoscopic endonasal transsphenoidal surgery cerebro-spinal fluid leak in skull base reconstruction using hadad bassagasteguy flap after endoscopic endonasal transsphenoidal surgery: a case series jan paul d. formalejo, md jay pee m. amable, md department of otorhinolaryngology head and neck surgery university of the east ramon magsaysay memorial medical center correspondence: dr. jay pee m. amable department of otorhinolaryngology head and neck surgery university of the east ramon magsaysay memorial medical center 5th floor, ent office, hospital service bldg., 64 aurora blvd., quezon city 1113 philippines phone: (632) 8715 0861 local 257 telefax: (632) 8716 1789 e-mail: jpamablemd@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by the authors, and that each author believes that the manuscript represents honest work. disclosure: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery, 1st virtual descriptive research contest (3rd place) october 21, 2020. philipp j otolaryngol head neck surg 2021; 36 (2): 22-24 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles the transsphenoidal route is the standard approach for pituitary or sellar tumors of the skull base.1 endoscopic endonasal transsphenoidal surgery (eets) is a minimally invasive technique that is the current approach of choice for pituitary and sellar tumors.2,3 expanded endonasal approaches have been developed, making it possible to access the skull base through the nasal cavity, enabling access to the suprasellar, parasellar and retrosellar spaces.4 however, cerebrospinal fluid (csf) leak has been one of the feared complications of endoscopic endonasal transsphenoidal surgery. hadad et al.5 described the hadad-bassagasteguy flap (hbf) to reconstruct skull base defects after endoscopic endonasal expanded approaches. it utilizes a neurovascular pedicle flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, a branch of the posterior septal artery and the terminal branches of the internal maxillary artery.5 this technique has reduced the incidence of cerebrospinal fluid leak after expanded endonasal approaches from >20% to 4-6%. 2,5-7 a number of studies have been published in the success of their eets using hbf.2,5-7 however, after a search of herdin plus, the asean citation index (aci), who global index medicus western pacific region index medicus (wprim), directory of open access journals (doaj), pubmed (medline and pubmed central), and the cochrane database, we found no local published data regarding its utilization and surgical outcomes in the philippines. this study aims to determine the incidence of cerebrospinal fluid leak after hbf reconstruction after endoscopic endonasal transsphenoidal surgery for skull base pathologies from 2016 to 2020 at the university of the east ramon magsaysay memorial medical center. methods with university of the east ramon magsaysay memorial medical center research institute for the health sciences ethics review committee approval (rihs erc code: 0865/h/2020/093), hospital records of all adult patients who underwent eets with reconstruction using hbf between january 2016 and february 2020 were considered for inclusion in this case series. charts with incomplete data were subsequently excluded. the surgical technique for the harvest of the hbf followed the technique of hadad et al.5. we utilized a multilayer technique with the use of abdominal fat graft, septal cartilage graft, hbf, monomeric n-butyl-2-cyanoacrylate glue and a bioresorbable nasal dressing. medical records were individually reviewed, and the patient’s age, sex, date of procedure, size of mass, final diagnosis, presence of preoperative, intraoperative and postoperative csf leak, placement of lumbar drain after eets and course in the wards were recorded by the first author in a data collection form. the presence of intraoperative csf leak was determined based on the intraoperative findings in the operative technique. the occurrence of postoperative csf leak was determined based on the course in the wards of each patient, daily physical examination record, and nasal endoscopy reports in the charts. descriptive statistical evaluation was performed using microsoft excel 2019 version 16.52 (microsoft corp., redmond wa, usa) and data was presented using percentages, means and standard deviations. results a total of 35 hospital records were included in this series. they represented 23 women and 12 men with ages ranging from 21 to 71 years old (mean, 47 years). the different pathologies were 28 (80%) pituitary macroadenomas, two (5.7%) craniopharyngiomas, two (5.7%) squamous cell carcinomas, and 1 each (2.8% each) pituitary cyst, chordoma, and idiopathic csf leak. depending on pathology, the different surgical approaches used were two transplanar, two transclival, and 31 transsellar. four (11.4%) of the 35 patients had postoperative cerebrospinal fluid leak. the first patient had csf leak 1 week after surgery after the patient purposely blew his nose and sneezed despite strict instructions to refrain from such actions. the second patient had csf leak at home 2 weeks postoperatively, also after intentional nose blowing and frequent sneezing. he had been ambulatory on discharge and was able to maintain upright position and flex his head anteriorly without csf rhinorrhea. the third and fourth patients developed csf leak 3 days after surgery with no identified aggravating cause. eleven (31.4%) patients did not have a postoperative lumbar drain, which were the ones with no gross intraoperative csf leak during eets. all patients who had a postoperative lumbar drain (68.6%) had an intraoperative csf leak. the 4 patients who had postoperative csf leak had a postoperative lumbar drain placed after the eets. among the patients who experienced post-operative csf leak, three were diagnosed with pituitary macroadenoma and one was diagnosed with craniopharyngioma. in terms of size, the mean diameter of the mass among the patients was 3.1 ± 1.28 centimeters. the four patients who experienced post-operative csf leak had a mass diameter ranging from 2.5 to 3.8cms. postoperative csf leak of the three patients resolved by repositioning of the previously laden hbf. the postoperative csf leak of the fourth patient was resolved by utilizing a lateral nasal mucosal wall flap to reconstruct the defect. all the csf leaks were identified at the lateral and superior edges of the hbf. no recurrence of csf leak was noted after the repair in all 4 patients. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles discussion in our study 11.4% of patients had a postoperative csf leak which is higher than rates reported internationally. it is of note that of the four patients who had csf leak, two had an aggravating cause purposeful nose blowing and sneezing with most of the force passing through the nasal cavity instead of releasing it through the mouth. it is also noteworthy that the postoperative csf leak in the two patients occurred only after the incident of nose blowing. blowing through the nose and sneezing may lead to increased intracranial pressure, which in turn, may cause a csf leak.8 furthermore, these actions may displace the hbf, thereby causing csf rhinorrhea. carabba et al.9 showed that the incidence of csf leak after expanded endonasal approach without the hbf was 24%.9 since the advent of hbf, reports have shown a decrease in postoperative csf leak after expanded endonasal approaches to 4-6%.2,5-7 if we exclude the two patients who had an external aggravating cause, the rate of spontaneous post-operative csf leak would then be 5.7%, which is within the range of reported complication rates of other published studies.2,5-7 to the best of our knowledge, there are no other reports in the philippines that provide an incidence of postoperative csf leak after reconstruction using hbf. there are various reasons why csf leak can occur postoperatively even with reconstruction and these are: 1) insufficient size of the flap, 2) tucking of flap margins, 3) reverse placement of the flap, 4) pedicle constriction which leads to flap ischemia, 5) incomplete denudation of the bony margin of the reconstructed defect, 6) flap retraction, and 7) ineffective arrangement of the multilayer reconstruction.10,11 in our case, the most likely cause for the other 2 patients who did not have any aggravating cause is incomplete denudation of the bony margin of the reconstructed defect. the csf leak was noted to occur at the edges of the hbf where the incomplete denudation of the bony margin may have occurred. there are numerous limitations in this study. the study sample size is small with only 35 patients. due to the small sample size, no inferential statistical analysis could be done to assess for associations between age, pathology of the mass, size of the mass, presence of intraoperative csf leak and presence of lumbar drain. also, the small sample size may not be representative of the population. the study also lacks a control group. this study is a retrospective study and was based on chart review. a prospective study would be better to evaluate the associations between other factors that may lead to csf leak. indeed, the hbf has become a workhorse for reconstruction of skull base defects after transsphenoidal surgery, and based on our experience remains to be so, making it possible for expanded approaches and a wide variety of pathologies to be operated on via the endonasal route. acknowledgements we would like to acknowledge the uermmmci neurosurgery department headed by dr. alfredo l. tan and dr. christopher o. concepcion for the surgical collaboration and dr. joey francis b. hernandez for his statistical assistance. references 1. de divitiis e, cappabianca p, editors. endoscopic endonasal transsphenoidal surgery. 1st ed. new york: springer; 2003. 2. brunworth j, lin t, keschner db, garg r, lee jt. use of the hadad-bassagasteguy flap for repair of recurrent cerebrospinal fluid leak after prior transsphenoidal surgery. allergy rhinol (providence). 2013 fall;4(3):e155-61. doi: 10.2500/ar.2013.4.0072; pubmed pmid: 24498521; pubmed central pmcid: pmc3911805. 3. cappabianca p, cavallo lm, de divitiis e. endoscopic endonasal transsphenoidal surgery. neurosurgery. 2004 oct;55(4):933-40; discussion 940-1. doi: 10.1227/01. neu.0000137330.02549.0d; pubmed pmid: 15458602. 4. chung yg. advances and technical standards in neurosurgery (volume 33). j korean neurosurg soc. 2008 feb; 143(2): 123. doi: https://doi.org/10.3340/jkns.2008.43.2.123. 5. hadad g, bassagasteguy l, carrau rl, mataza jc, kassam a, snyderman ch, et al. a novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. laryngoscope. 2006 oct;116(10):1882-6. doi: 10.1097/01. mlg.0000234933.37779.e4; pubmed pmid: 17003708. 6. kassam ab, thomas a, carrau rl, snyderman ch, vescan a, prevedello d, et al. endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. neurosurgery. 2008 jul;63(1 suppl 1):ons44-52; discussion ons52-3. doi: 10.1227/01.neu.0000297074.13423.f5; pubmed pmid: 18728603. 7. singh cv, shah nj. hadad-bassagasteguy flap in reconstruction of skull base defects after endonasal skull base surgery. int j otorhinol head neck surg. 2017;3(4):1020. doi:10.18203/ issn.2454-5929.ijohns20174325. 8. deenadayal ds, vidyasagar d, naveen kumar m, sudhakshin p, sharath chandra sv, hameed s. spontaneous csf rhinorrhea: our experience. indian j otolaryngol head neck surg. 2013 aug; 65(suppl 2): 271–275. doi: 10.1007/s12070-011-0431-3; pubmed pmid: 24427660; pubmed central pmcid: pmc3738769. 9. carrabba g, dehdashti ar, gentili f. surgery for clival lesions: open resection versus the expanded endoscopic endonasal approach. neurosurg focus. 2008;25(6):e7. doi: 10.3171/ foc.2008.25.12.e7; pubmed pmid: 19035704. 10. wardas p, tymowski m, piotrowska-seweryn a, markowski j, ładziński p. hadad-bassagasteguy flap in skull base reconstruction – current reconstructive techniques and evaluation of criteria used for qualification for harvesting the flap. wideochir inne tech maloinwazyjne. 2019 apr;14(2):340-347. doi: 10.5114/wiitm.2018.79633 pubmed pmid: 31119003; pubmed central pmcid: pmc6528130. 11. caicedo-granados e, carrau r, snyderman ch, prevedello d, fernandez-miranda j, gardner p, et al. reverse rotation flap for reconstruction of donor site after vascular pedicled nasoseptal flap in skull base surgery. laryngoscope. 2010 aug;120(8):1550-1552. doi:  10.1002/lary.20975 pubmed pmid: 20564666. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery president’s page greetings of peace and good health! i would like to commend the editorial staff of the philippine journal of otolaryngology head and neck surgery for this latest issue of our bi-annual publication headed by its editor-in-chief, dr. jose florencio f. lapeña, jr. the philippine society of otolaryngology head and neck surgery (pso-hns) is grateful for your tireless efforts in making this internationally recognized publication a great repository of research data in our field of specialty. covid-19 has changed the way we do almost everything. this global pandemic has presented a variety of challenges in all aspects of our lives and careers and the effects have lingered on more than a year after it started. the researchers and educators in our training institutions face a multitude of challenges unique to this current situation. the pso-hns is one with them in hoping that we can still come up with information useful in our field of specialty. may we all see opportunities for academic research improvement despite these challenges. enjoy reading these fine articles! john rodolfo d. suan, jr., md, mha, fpso-hns, fpcs president philippine society of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial nagwakas ang araw lupa’t dagat, langit, pumanaw tahan na, humimlay siyanawa — jf lapeña, tahan na, humimlay1 the continuing covid-19 pandemic has directly or indirectly claimed the lives of countless colleagues, friends, and family. i personally thought my tears had run dry as people i knew and loved died throughout the past year, but the wells of grief run deep, even as the plague continues its scourge as of this writing. especially when fellow front-liners fall, the haunting bugle call echoes the finality of death: “day is done, gone the sun, from the lake, from the hills, from the sky.”1 of my original fellow office-bearers in the philippine association of medical journal editors (pamje), two have passed on: dr. gerard “raldy” goco and jose ma. “joey” avila.2 even in our philippine society of otolaryngology head and neck surgery, i do not recall us dedicating so many passages in issues past as we do now, with tributes to dr. elvira colmenar, dr. ruben henson jr., dr. marlon del rosario, and dr. oliverio segura. our philippine medical association central tagalog region (pma-ctr) has lost more than its share of physicians: dr. joseph aniciete, dr. patrocinio dayrit, and dr. rhoderick presas of the caloocan city medical society; dr. mar cruz, dr. mayumi bismarck, and dr. edith zulueta of the marikina valley medical society; dr. kharen abatsenen of the valenzuela city medical society; dr. romy encanto and dr. cosme naval of the san juan medical society; dr. roberto anastacio and dr. encarnacion cabral of the makati medical society; and dr. amy tenedero and dr. neil orteza of the pasay parañaque medical society. the rest of the pma has lost over 145 physicians due to, or during, the pandemic. as healthcare workers, how do we deal with their deaths, the inevitability of more deaths, and the very real prospect of our own deaths during these trying times? how do we continue our work of saving lives in our overcrowded hospitals and community-based clinics while dealing with grief and facing our own fears for ourselves and our families? over 50 years ago, elisabeth kübler-ross formulated a model of dying with five stages of coping with impending loss of life (denial, anger, bargaining, depression and acceptance) correspondence: prof. dr. josé florencio f. lapeña, jr. department of otolaryngology head and neck surgery ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 telefax: (632) 8524 4455 email: lapenajf@upm.edu.ph , jflapena@up.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr. ma, md department of otolaryngology head and neck surgery college of medicine, university of the philippines manila department of otorhinolaryngology head and neck surgery east avenue medical center, diliman, quezon city death and dying during the covid-19 pandemic: tahan na, humimlay c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philipp j otolaryngol head neck surg 2021; 36 (1): 4-5 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery editorial based on her work with dying patients at the university of chicago, and these have become widely considered as phases of grief that people go through when faced with the prospect of their own death (or as a response to any major life change).3 by focusing “on dying, rather than death,” her work “shifted attention of religious thinkers, pastors, and authors of personal testimonies onto the themes and framework she offered” and “her legacy was to offer a fresh way to think and speak about dying, death and grieving.”4 whether, and how we might appropriate her framework in order to cope with our personal and collective experiences during this pandemic, a pandemic that is arguably worse than any worst case scenario ever imagined, is another matter altogether. does the framework even apply? the very nature of the covid-19 pandemic is changing how people die -in ambulances, makeshift tents and long queues outside overflowing hospitals, or en route to distant hospitals with vacancies (with patients from the national capitol region travelling to as far away as central and northern luzon or southern tagalog and bicol), or in their own homes (as people with “mild” symptoms are encouraged to monitor themselves at home, often rushing in vain to be admitted in hospitals with no vacancies when it is already too late) -and “we have to make difficult decisions regarding resuscitation, treatment escalation, and place of care,”5 or of death. the new normal has been for covid-19 patients to die alone, and rapidly so, within days or even hours, with little time to go through any process of preparation. friends and family, including spouses, parents, and children, are separated from the afflicted, and even after death, the departed are quickly cremated, depriving their loved ones of the usual rites and rituals of passage. in most cases, wakes and novenas for the dead can only be held virtually, depriving the grieving loved ones of the support and comfort that face-to-face condolences bring. indeed, the social support systems that helped people cope with death have been “dismantled, and the cultural and religious rituals that help us process grief also stripped away.”5 amidst all this, “we must ensure that humanity, community, and compassion at the end of life are sustained,” and that “new expressions of humanity help dispel fear and protect the mental health of bereaved families.”6 what these expressions might be, and whether they can inspire hope in the way that community pantries7 have done remains to be seen. but develop these expressions we must, for our sakes as for the sake of our patients. the “hand of god” -two disposable latex gloves filled with warm water and tied around the hand of a woman with covid-19 to alleviate her suffering by nurse technician araújo cunha at the vila prado emergency care unit in são paulo is one such poignant expression.8 ultimately, we must develop such expressions for and among ourselves as well. as healthcare workers, our fears for ourselves, our colleagues, and our own loved ones “are often in conflict with professional commitments” and “given the risks of complicated grief,” we “must put every effort into (our) own preparation for these deaths as well as into (our) own healthy grieving.”9 we cannot give up; our profession has never been as needed as it is now. true, we can only do so much, and so much more is beyond our control. but to this end, let us imagine the soothing, shushing “tahan na” (don’t cry) we whisper to hush crying infants, coupled with the calming invitation “humimlay” (lay down; rest; sleep). yes, the final bugle call may echo the finality of death, but it can simultaneously reassure us that “all is well, safety rest, god is nigh!”1 references 1. lapeña jf. tahan na, humimlay. 2020. filipino translation from the lyrics. “taps.” (u.s. army bugle call). ©pennsylvania military college [cited 2021 may 12] available from; https://www. scoutsongs.com/lyrics/taps.html. 2. lapeña jf. seasons and times, reasons and rhymes: di niyo ba naririnig? philipp j otolaryngol head neck surg. 2020 jul-dec;35(2):4-5. doi: 10.32412/pjohns.v35i2.1467. 3. kübler-ross e. on death and dying: what the dying have to teach doctors, nurses, clergy and their own families. 1st edition (40th anniversary edition) london: routledge; 2008. doi: 10.4324/9780203889657. 4. bregman l. kübler-ross and the re-visioning of death as loss: religious appropriation and responses. j pastoral care counsel. 2019 mar;73(1):4-8. doi:  10.1177/1542305019831943 pubmed pmid: 30895849. 5. moore kj, sampson el, kupeli n, davies n. supporting families in end-of-life care and bereavement in the covid-19 era. int psychogeriatr. 2020 oct;32(10):1245-1248. doi: 10.1017/ s1041610220000745 pubmed pmid: 32349850; pubmed central pmcid: pmc7235296. 6. yardley s, rolph m. death and dying during the pandemic. bmj. 2020 apr 15;369:m1472. doi: 10.1136/bmj.m1472 pubmed pmid: 3229575. 7. mongaya k. community pantries inspire hope amid pandemic and economic crisis in the philippines. global voices. 5 may 2021. [cited 2021 may 13] available from: https://globalvoices. org/2021/05/05/community-pantries-inspire-hope-amid-pandemic-and-economic-crisis-inthe-philippines/. 8. from: técnica em enfermagem de são carlos ‘ampara’ mão de paciente intubada com luvas cheias de água morna. g1 globo. 23 march 2021. [cited 2021 may 13] available from: https://g1.globo. com/sp/sao-carlos-regiao/noticia/2021/03/23/tecnica-em-enfermagem-de -sao-carlosampara-mao-de-paciente-intubada-com-luvas-cheias-de-agua-morna.ghtml. 9. rabow mw, huang c-h s, white-hammond ge, tucker ro. witnesses and victims both: healthcare workers and grief in the time of covid-19. j pain symptom manage. 2021 feb 6;s0885-3924(21)00164-0. doi: 10.1016/j.jpainsymman.2021.01.139 pubmed pmid: 33556494; pubmed central pmcid: pmc7864782. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 president’s page soaring high on the heels of our just-concluded jubilee year, the philippine society of otolaryngology-head and neck surgery is very proud of its strides in the fields of service, education, training, and -with the philippine journal of otolaryngology-head and neck surgery (pjohns) as its documentation and publishing arm, it is now a force to reckon with in-research! the pjo-hns is in a continuous journey of improvement and development into an open access journal, which will benefit our trainees, diplomates and fellows, and open our research work to be more accessible on the international scientific stage. we laud the continued efforts of our training institutions in pushing for their respective research agendas. we must also look forward the constitution and operationalization of an irb (for pso-hns to make its own institutional review board) to approve, monitor and review biomedical and behavioral research conducted by our fellows, who may not have any tie-up or affiliation with established training institution. this is one area which the editorial board led by dr. jose florencio lapeña and the board of trustees are seriously looking into. congratulations to the contributing authors of this issue and more power to the pjo-hns! melfred l. hernandez, md, mha president philippine society of otolaryngology-head and neck surgery 2 philippine journal of otolaryngology-head and neck surgery onwards to our 61st year of existence! philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles abstract objective: to determine the effectiveness of levodropropizine in reducing the incidence of post-operative sore throat (post) among ear, nose, throat, head and neck (ent-hns) patients undergoing general endotracheal anesthesia. methods: design: double-blind, randomized, placebo controlled trial setting: tertiary government training hospital participants: sixty (60) ent-hns patients aged between 19 to 60 years old admitted to the southern philippines medical center from january to march 2019 for surgeries on benign thyroid tumors, benign submandibular gland tumors and tonsils requiring orotracheal intubation were randomized into control and treatment groups of 30 patients each. results: there was a statistically significant difference (p=.0016) in the incidence of post 6 hours after surgery between control (25/30; 83%) and treatment (16/30; 53.33%) groups. however, confounders such as length and type of surgery (more females and tonsillectomy cases in the control group) were not fully eliminated by randomization. conclusion: perioperative levodropropizine significantly decreases the incidence of moderate (as well as mild) postoperative sore throat. it was not shown to decrease the incidence of severe sore throat. a larger cohort (adjusted for other confounders) may better describe the benefit of this treatment. keywords: levodropropizine; postoperative complications; post-operative sore throat post-operative sore throat (post) is a common complication following general endotracheal intubation (geta).1 it has an estimated incidence of as low as 14.4-30%2 to as high as 50-90%.3-5 many cases of post resolve spontaneously in a matter of days and only a few require intervention in the form of medications.6,7 although considered a minor complication,8-10 significant physical distress can cause overall patient discomfort postoperatively.11 recent findings on the mechanisms of post prompted the use of zinc,3 nsaids,4 magnesium,4,5 steroids,7 nmda,12,13 and levodropropizine14-16 in reducing its incidence and severity. effectiveness of levodropropizine on post-operative sore throat after endotracheal intubation for head and neck surgery: a double-blind randomized controlled trial ivabelle m. ducto, md joseph e. cachuela, md department of otorhinolaryngology head and neck surgery southern philippines medical center correspondence: dr. joseph e. cachuela department of otorhinolaryngology head and neck surgery southern philippines medical center j.p. laurel ave. bajada, davao city 8000 philippines phone: +63 82 227 2731 local 353 email: j_cachuela_md@yahoo.com the authors declared that this presents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and the author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationship, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. presented at the philippine society of otolaryngology head and neck surgery analytical research contest. december 6, 2019. palawan ballroom, edsa shangri-la hotel, mandaluyong city. philipp j otolaryngol head neck surg 2020; 35 (2): 6-10 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles levodropropizine is a non-opiate agent with peripheral tracheobronchial antitussive effect recently shown to reduce incidence and severity of post.14 it is administered orally in syrup form making it convenient and well tolerated by patients.17 previous studies have associated the coughing reflex in the development of post,18,19 supporting a role for the antitussive effect of levodropropizine in attenuating post, although none of them involved surgical procedures in the head and neck. because head and neck procedures that are more proximate to the throat may impact on post more directly than procedures on the trunk and extremities, studies in this anatomic area are needed. this study aims to determine the effectiveness of levodropropizine on reducing the incidence of post-operative sore throat among ear, nose, throat, head and neck patients undergoing general endotracheal anesthesia. methods with department of health cluster xi ethics review committee approval, 60 adult patients of the southern philippines medical center undergoing geta for a head and neck surgery (thyroidectomy, submandibular gland excision, and tonsillectomy) from january to march 2019 were randomized by an admitting resident physician using fishbowl draw to receive levodropropizine or placebo. the sample size to determine difference between estimated 50% post in placebo and 15% post in the treatment group with an alpha error of 5% and a power of 0.80 was calculated at 25 patients per arm; and set at 30 patients per arm with a dropout rate of 20%. excluded from the study were those with a history of gastroesophageal reflux disease (gerd); history of drug reactions after taking anti-cough or common cold medications; were pregnant; had congenital or acquired abnormalities of the upper airway such as tumor, polyp, trauma, abscess, inflammation, infection, or foreign bodies; had previous airway surgery; had increased risk of aspiration; had coagulation disorders; had previous history of difficult intubation or conditions with expected difficult airway including mallampati classification ≥ 3 or thyromental distance < 6.5 cm; had symptoms of sore throat or upper respiratory tract infection; were expected to need (or who needed) a nasogastric tube during the perioperative period; used other intubation devices beyond direct laryngoscopy such as a lighted stylet or fiberoptic bronchoscopy; and who required nasotracheal intubation. initial data collected included age, gender, and smoking history (as a risk factor for sore throat). the treatment group received 15 ml of levodropropizine syrup one hour prior to induction. the placebo group received an equivalent amount of sucrose solution syrup. the treatment and placebo were administered by a pre-assigned resident physician, keeping the investigators, surgeons, nurses, and patients blinded to treatment allocation. no sedative drugs were given preoperatively. routine anesthesia induction procedures were observed by an anesthesiologist also blinded to treatment allocation. standard cuffed endotracheal tubes (ett) lubricated with k-y® jelly (reckitt benckiser group, slough, england) were used, with the size of endotracheal tube used during each procedure recorded. standard laryngoscopes with 3 or 4 macintosh metal blades were utilized as needed. after intubation, the cuff was inflated until no air leakage was heard, with peak airway (intracuff ) pressure maintained between 20-22 cm h 2 o using the rusch®  endotest™ (teleflex® inc. morrisville, nc, usa) handheld cuff pressure manometer. no nasogastric tube was inserted in any patient. after the surgical procedure, anesthesia administration was terminated. upon emergence from anesthesia, adequate spontaneous ventilation and response to verbal commands were confirmed, gentle oropharyngeal suctioning of oral secretions using a soft rubber catheter was performed to minimize injury to tissues in the oral cavity then tracheal extubation was immediately performed. after extubation, all patients were transferred to the post-anesthesia care unit. intraoperative variables recorded and collected included duration of anesthesia, duration of surgery, asa-ps classification, inhalational anesthetic, number of attempts at laryngoscopy, traumatic laryngoscopy, number of attempts at intubation, presence of blood in the secretions or the tube, size of endotracheal tube, initial cuff pressure, bucking and coughing upon intubation, and extubation. in the wards, post assessment was performed by resident evaluators who were also blinded to treatment allocation at 6 hours, 24 hours, 48 hours and 72 hours. the severity of post was graded on a four-point scale (0 –3) as follows: 0, no sore throat; 1, mild sore throat (complained of sore throat only upon inquiry); 2, moderate sore throat (complained of sore throat on his/her own); and 3, severe sore throat (change of voice or hoarseness, associated with throat pain). continuous variables were summarized as means ± sd and compared using independent sample t-test. categorical variables were summarized using frequencies and percentages and compared using chi-square with yates’ correction and fisher exact tests if the contingency table had a value less than 1. a value of p < .05 was considered significant. absolute and relative risk reduction were determined with an intention to treat analysis. as secondary analysis, we also compared the groups on severity of post at 6, 24, 48 and 72 hours after surgery. in this stratified analysis, the groups were compared separately using presence or absence of mild, moderate, or severe post (binomial) as categorical dependent variable, and study drug (levodropropizine versus placebo) as independent variable. results a total of 60 patients, 30 each in the control and treatment groups, completed the study. their ages ranged between 19 to 60 years old, with a control group mean age of 34.10 (sd ± 8.68) and treatment philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles group mean age of 35.47 (sd ± 10.34). there was no significant difference between both groups in terms of age (p = .5815). there were 24 males and 36 females; with a female to male ratio of 20:10 (66.7%) in the control group, and 16:14 (53.33%) in the treatment group. although there were more females in the placebo group, there was no significant difference in gender ratio between the two groups (p = .1679). there were 8/30 (26.67%) with a history of smoking in the control group, and 4/30 (13.33%) in the treatment group, but there was no statistically significant difference between the two groups (p = .564). a total of 44 underwent thyroidectomy (20 controls, 24 treatment), 6 underwent submandibular gland excision (3 controls, 3 treatment), and 10 underwent bilateral tonsillectomy (7 controls, 3 treatment). having more tonsillectomy cases randomized to the placebo group was statistically significant (p = .0). multiple t-test analyses were performed on intraoperative variables summarized in table 1. there were no significant differences between control (m = 277.79, sd = 115.29) and treatment (m = 272.2, sd = 92.54) groups in terms of duration of anesthesia administration t (n-1) = .85, p = .55. there were no significant differences between control (m = 225.5, sd = 121.37) and treatment (m = 235.84, sd = 90.91) groups in terms of duration of surgical procedures (p = .6). the anesthetic administered to all patients in both groups was sevoflourane and all patients underwent atraumatic laryngoscopy. there were no significant differences between control (m = 1.04, sd = .18) and treatment (m = 1.04, sd = .18) groups in terms of attempts at laryngoscopy t (n-1) = .94, p = .52 and there were no significant differences between control (m = 1, sd = 0) and treatment (m = 1.04, sd = .18) groups in terms of intubation attempts t (n-1) = .33, p = .8 either. there was no significant difference between control (m = 7.16, sd = .4) and treatment group (m = 7, sd = .32) in terms of size of ett inserted t(n-1) =.13, p = .92. there was no significant difference in the initial cuff pressure applied in control group (m = 20.5, sd = .9) and treatment group (m = 20.24, sd = .69) with t (n-1) = .23, p = .86) . there was no bucking or coughing reported on intubation and during extubation among all patients in both groups. no adverse events were noted in both treatment and control groups. most of the patients included in the study were classified as asa i (n = 48), with 25 controls and 23 in the treatment group. there were 12 classified as asa ii; 5 controls and 7 in the treatment group. chi-square test revealed no significant difference between the two groups x2 (1, n=60) 0.42, p = .52). blood in the secretions or in the et tube was only reported in 11 patients (6/30 controls and 5/30 in the treatment group). chi-square test revealed no significant difference between control and treatment groups x2 (1, n=60) 0.11, p = .74). table 2 summarizes the distribution of patients with post at 6, 24, 48, and 72 hours for control and treatment groups. at six hours postoperatively, there was a statistically significant difference (p = .002) in the number of patients who developed moderate post among control (15 patients; 50%) and treatment (4 patients; 13%) groups. table 1. intraoperative variables and frequency distribution control (n= 30) p-valuelevodropropizine (n= 30) duration of anesthesia (min) duration of surgery (min) inhalation anesthetic (des/iso/sevo) number of attempts at laryngoscopy traumatic laryngoscopy number of attempts of intubation size of ett initial cuff pressure (cm h2o) bucking or coughing on intubation bucking or coughing on extubation 277.8 225.5 sevoflourane 1 0 1 7 20.5 0 0 .552167 .600501 1 .520827 1 .798638 .916817 .857274 1 1 272.2 235.8 sevoflourane 1 0 1 7 20.2 0 0 variables there was no significant difference noted in the number of patients who developed mild post, 5 (16.7%) versus 4 (13%) in the control and treatment groups (p = .72). interestingly, the percentage of patients who reported severe post was much higher in the treatment than in the control arm, 8 (26%) versus 5 (16.7%) although this was not statistically significant (p = .36). at 24 hours postoperatively, there was a statistically significant difference (p = .004) in the number of patients who reported moderate post, with 7 (23%) controls and none from the treatment group. more patients from the control group 9 (30%) also reported mild post compared to 5 (16.7%) patients in the treatment group, but this was not statistically significant (p = .23). however, a reverse pattern was noted among patients who reported severe post, with only 5 (16.7%) in the control group compared to 8 (26.7%) in the treatment group, although there was no significant difference (p = .39). at 48-hours postoperatively, significant statistical differences were noted between control and treatment groups for the number of patients who reported mild (p = .01) and moderate (p = .04) post. in the control group, 10 (33%) and 4 (13%) patients reported mild and moderate post respectively, in contrast to only 2 (6.7%) and zero (0) patients in the who reported mild and moderate post, respectively, in the treatment group. while there were more patients (8, 26.7%) who reported severe post in the treatment group after 48 hours, no statistically significant differences were noted when compared with 3 (10%) in the control group (p = .11). at 72-hours postoperatively, there were 8 (26.7%) and 4 (13%) patients who reported mild and moderate post in the control group compared to none (0) in the treatment group; and this difference was statistically significant (p = .002; p = .04). among those who reported philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles severe post, 3 (10%) patients were from the control group while 8 (26.7%) were in the treatment group. however, there was no statistically significant difference (p = .098). these same eight patients (26.7%) in the treatment group consistently reported severe post at 6, 24, 48 and 72 hours. revealed that there was a significant difference between treatment and control groups at 6 hours post-surgery (x2 = 4.929; p = .026; arr = 0.3 [0.064 to 0.496]; nnt = 3 [16 to 2]). however, there was no clear difference between treatments at 24 hours post-surgery (x2 = 3.326; p = .068; arr = 0.267 [0.017 to 0.475]; nnt = 4 [60 to 2]), at 48 hours postsurgery (x2 = 2.424; p = .119; arr = 0.233 [-0.017 to 0.446]; nnt = 4 [-60 to 2]) and at 72 hours post-surgery (x2 = 2.538; p = .111; arr = 0.233 [-0.012 to 0.443]; nnt = 4 [-86 to 2]). (table 3) table 2. frequency distribution of patients with postoperative sore throat at 6 hours, 24 hours, 48 hours and 72 hours control, n (%) (n= 30) levodropropizine, n (%) (n= 30) p-value 6 hours mild moderate severe post 24 hours mild moderate severe post 48 hours mild moderate severe post 72 hours mild moderate severe post 5 (16.7) 15 (50.0) 5 (16.7) 25 (83.3) 9 (30.0) 7 (23.0) 5 (16.7) 21(70.0) 10 (33.0) 4 (13.0) 3 (10.0) 17 (56.7) 8 (26.7) 4 (13.0) 3 (10.0) 15 (50.0) 4 (13.0) 4 (13.0) 8 (26.7) 16 (53.33) 5 (16.7) 0 8 (26.7) 13 (43.0) 2 (6.7) 0 8 (26.7) 10 (33.3) 0 0 8 (26.7) 8 (26.7) .72 (.723235) <.01 (.001835) .36 (.355617) .026 .23 (.229058) <.01 (.004316) .40 (. 391261) .068 <.01 (.009253) .04 (.035528) .11 (.11125) .119) <.01 (.001938) .04 (.038983) .10 (. 098417) .111 time frame in this study, there were a total of 12 patients with a history of tobacco smoking. on post randomization, 8 patients were randomly assigned to the control group while 4 were in the treatment group. post-operative sore throat was present in all 8 control group patients with varying degrees of severity and in 3 of 4 patients in the treatment group. among the non-smokers, 26 patients were randomly assigned to the treatment group while 22, were in the control group. among those in the treatment group, 14 developed post (54%) compared to 19 out of 22 controls (86%). there was no statistically significant relationship between smoking history and the incidence of post (p = .61). of 10 patients who underwent tonsillectomy, seven were randomized to the control group and three to the treatment group. all seven controls developed post, compared to two out of three in the treatment group, although this was not statistically significant (p = .36). stratified comparisons between proportions of post done at 6, 24, 48 and 72 hours with estimates for absolute risk reductions (arr) and numbers needed to treat (nnt) at 95% confidence intervals (ci) table 3. frequency distribution of post between placebo and levodropropizine evaluation time control (n=30) treatment (n=30) relative risk nnt arr p value odds ratio 95% (cl) 6h 24h 48h 72h 25 (83.3%) 21 (70.0%) 17 (56.7%) 15 (50.0%) 16 (53.3%) 13 (43.0%) 10 (33.3%) 8 (26.7%) 1.56 1.62 1.7 1.88 3.3 3.7 4.3 4.3 0.2997 0.27 0.234 0.233 .026 .068 .119 .111 4.38 3.05 2.62 2.75 3 (0.77, 5.27) 2.7 (1.02, 4.31) 2.3 (0.28, 4.39) 2.3 (0.39, 4.28) discussion our study demonstrated that treatment with 15 ml of levodropropizine administered 1 hour before surgery reduced the incidence of moderate post after general anesthesia with orotracheal intubation. at 6 hours post-surgery, the absolute risk reduction is 30% [confidence interval 6 to 50%] and the number needed to treat is 3. the differences for mild post were also evident but less pronounced, being only significant at 48 and 72 hours after surgery. that post generally decreases as time interval from surgery to post reassessment increases may be attributed to post-operative medications, healing and decreased swelling. however, because patients manifesting severe post minimally decreased in number even in the treatment group might suggest that severe post requires supplementary medications and may further suggest that the effect of levodopropizine is clinically and statistically significant in alleviating post mostly during the first 6 hours post-surgery. moreover, the distribution of mild, moderate and severe post between treatment and control groups over time did not show any decrease in severity of post. a previous study by rashwan et al.2 evaluated the efficacy of tramadol gargle in post and concluded that preoperative gargling with tramadol reduced the incidence and severity of post. farhang and grondin3 studied the effectiveness of zinc lozenges in post and found that administration of a single preoperative dose of 40-mg zinc lozenges is effective to reduce post. in another study, borazan et al.5 showed that giving preoperative oral magnesium lozenge is effective in reducing both incidence and severity of post. in all of these studies however, the patients enrolled underwent orthopedic surgeries or urological surgeries and no head and neck surgeries were included. although the average duration of anesthesia exposure was slightly longer in the control group (277 minutes) compared with the treatment group (272 minutes), there was no statistically significant difference. philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles references 1. kalil dm, silvestro ls, austin pn. novel preoperative pharmacologic methods of preventing postoperative sore throat due to tracheal intubation. aana j. 2014 jun; 82(3):188-97. pubmed pmid: 25109156. 2. rashwan s, abdelmawgoud a, badawy aa. effect of tramadol gargle on postoperative sore throat: a double blinded randomized placebo controlled study. egyptian journal of anaesthesia. 2014 jul; 30(1): 235–239. doi: https://doi.org/10.1016/j.egja.2014.01.010. 3. farhang b, grondin l. the effect of zinc lozenge on postoperative sore throat: a prospective randomized, double-blinded, placebo-controlled study. anesth analg. 2018 jan; 126(1):78-83. doi: 10.1213/ane.0000000000002494; pubmed pmid: 28953493. 4. chattopadhyay s, das a, nandy s, roybasunia s, mitra t, halder ps, et al. postoperative sore throat prevention in ambulatory surgery: a comparison between preoperative aspirin and magnesium sulfate gargle – a prospective, randomized, double-blind study. anesth essays res. jan-mar 2017; 11(1):94-100. doi: 10.4103/0259-1162.186602; pubmed pmid: 28298764; pubmed central pmcid: pmc5341650. 5. borazan h, kececioglu a, okesli s, otelcioglu s. oral magnesium lozenge reduces postoperative sore throat; randomized, prospective, placebo-controlled study. anesthesiology 2012 sep; 117(3):512-8. doi: 10.1097/aln.0b013e3182639d5f; pubmed pmid: 22797283. 6. hisham an, roshilla h, amri n, aina en. post-thyroidectomy sore throat following endotracheal intubation. anz j. surg. 2001nov; 71(1) 669–671. doi: 10.1046/j.1445-1433.2001.02230.x; pubmed pmid: 11736830. 7. cho ck, kim je, yang hj, sung ty, kwon hu, kang ps. the effect of combining lidocaine with dexamethasone for attenuating postoperative sore throat, cough, and hoarseness. anesthesia pain med. 2016 jan; 11(1): 42-48. doi: 10.17085/apm.2016.11.1.42. 8. lee jy, sim ws, kim es, lee sm, kim dk, na yr, et al. incidence and risk factors of postoperative sore throat after endotracheal intubation in korean patients. j int med res. 2017 apr; 45(2):744752. doi: 10.1177/0300060516687227; pubmed pmid: 28173712; pubmed central pmcid: pmc5536682. 9. el-boghdadly k, bailey cr, wiles md. postoperative sore throat: a systematic review. anaesthesia. 2016 jun; 71(6):706-17. doi: 10.1111/anae.13438; pubmed pmid: 27158989. 10. biro p, seifert b, pasch t. complaints of sore throat after tracheal intubation: a prospective evaluation. university of zurich: zurich open repository and archive. eur j anaesthesiol. 2005 apr; 22(4):307-11. doi: 10.1017/s0265021505000529; pubmed pmid: 15892411. 11. kadri ia, khanzada tw, samad a, memon w, irfan d, kadri a. post-thyroidectomy sore throat: a common problem. pak j med sci. 2009 jul; 25(3): 408-412. 12. almazan na. benzydamine hc10.15 percent for the oropharyngeal diseases and surgeries: a review of clinical trials. health research and development information network. journal. manila central university-filemon d. tanchoco medical foundation. 2009; 42(1) 37-42. 13. aigbedia so, tobi ku, amadasun fe. a comparative study of ketamine gargle and lidocaine jelly application for the prevention of postoperative throat pain following general anesthesia with endotracheal intubation. niger j clin pract. 2017 jun; 20(6):677-685. doi: 10.4103/11193077.208960; pubmed pmid: 28656921. 14. zanasi a, lanata l, fontana g, saibene f, dicpinigaitis p. de blasio f. levodropropizine for treating cough in adult and children: a meta-analysis of published studies. multidiscip respir med. 2015 may 31; 10(1):19. doi: 10.1186/s40248-015-0014-3; pubmed pmid: 26097707; pubmed central pmcid: pmc4472410. 15. mannini c, lavorini f, zanasi alessandro, saibene f, lanata l, fontana g. a randomized clinical trial of levodropropizine effect on respiratory centre output in patients with intractable chronic cough: preliminary results. chest. 2017 jun; 151(6):1288-1294. doi: 10.1016/j.chest.2017.02.001; pubmed pmid: 28192113. 16. banderali g, riva e, fiocchi a cordaro ci, giovannini m. efficacy and tolerability of levodropropizine and dropropizine in children with non-productive cough. j int med res. mayjun 1995; 23(3):175-83. doi: 10.1177/030006059502300304; pubmed pmid: 7649341. 17. de blasio f, lanata l, fontana g, saibene f, zanasi a. efficacy of levodropropizine in pediatric and adult population: 2 systematic reviews and meta-analysis of published clinical studies, education, teaching, and quality improvement. chest. 2014 oct; 146(4): 526a. doi: 10.1378/ chest.1991481. 18. kallesen m. cough reflex following orotracheal intubation: presence and recovery of the cough reflex after extubation and validity of cough reflex testing. [internet]. the university of canterbury. 2016. available from: http://hdl.handle.net/10092/13001. 19. divatia jv, bhowmick k. complications of endotracheal intubation and other airway management procedures. indian journal of anaesthesia. 2005 jan; 49(4):308-318. 20. song jw, jang ys, jung mc, kim jh, choi jh, park s, et al. levodropropizine-induced anaphylaxis: case series and literature review. the korean academy of asthma, allergy and clinical immunology. allergy asthma immunol res. 2017 may; 9(3):278-280. doi: 10.4168/ aair.2017.9.3.278; pubmed pmid: 28293935; pubmed central pmcid: pmc5352580. likewise, the duration of surgery did not differ significantly between control (225 minutes) in and treatment (235 minutes) groups. the number of attempts at laryngoscopy as well as initial cuff pressures were not significantly different either, and no bucking or coughing were noted for intubation and extubation in all patients. in the previous studies, the researchers suggested that effectiveness of the administered drugs in the reduction of incidence and severity of post was due to the anti-inflammatory effects of the medications. the mode of action of levodropropizine may be related to diminished pharyngeal movement that can trigger pain. levodropropizine is a racemic non-opiate antitussive agent and acts through a mainly peripheral tracheobronchial antitussive effect by inhibition of vagal c-fiber and its sensor neuropeptide.15 the reduction in c fiber activation may dampen coughing reflexes stimulated by ett insertion,18 reducing and perhaps preventing post among the patients in the treatment group. interestingly, all of the 8 patients who scored severe post in the treatment group consistently reported severe post in all time measurements. among these patients (4 females, 4 males), 7 underwent thyroidectomy and 1 underwent tonsillectomy and 2 of the patients claimed to have a history of smoking. however, in this research, these findings are not sufficient to support that gender, smoking and type of surgery are risk factors for development of severe post. although levodropropizine exhibits considerably lower central nervous system (cns) depressant effects than other opiate antitussives and is least likely to cause sedation in treated patients,15 several adverse drug reactions include vomiting, abdominal pain, diarrhea,16 and allergic reactions.20 because these adverse effects are generally similar to other antitussive and anesthetic medications, we were not concerned in using levodropropizine as a treatment. fortunately, none of these effects were seen among our patients. this study has several limitations. first the number of enrolled patients per procedure was relatively small. the head and neck surgical procedures included were not stratified according to type due to the limited number of cases. a study limited to only one type of head and neck surgical procedure may reduce intervening factors affecting post. this may particularly apply to the small number of patients who underwent tonsillectomy. because tonsillectomy inherently causes sore throat, a separate study including only patients for tonsillectomy is recommended. this study succeeded in showing the effectiveness of levodropropizine in decreasing the incidence, but not the severity of post. future studies can address this variable, including extended time measurements to days to further evaluate the progression of post. a larger cohort (adjusted for other confounders) may better describe the benefit of levodropropizine for post. in conclusion, levodropropizine administered an hour before surgery significantly decreases the incidence (but not the severity) of moderate (as well as mild) post-operative sore throat among head and neck surgery patients undergoing general endotracheal anesthesia. it was not shown to decrease the incidence of severe sore throat in this study. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles philippine journal of otolaryngology-head and neck surgery 33 abstract objective: to determine whether the interval from pathological diagnosis to treatment is significantly delayed, and the presence or absence of disease progression occurring in those with, and without treatment delay, among head and neck cancer patients in our institution. methods: design: retrospective chart review setting: tertiary government hospital participants: medical records of 70 patients with newly diagnosed head and neck cancer who underwent primary surgery from january 2011 to december 2015 were retrieved and available data were extracted. results: a total of 28 patients were included in this study. majority of the cancers were in the larynx (42.9%) and oral cavity (42.9%). the mean diagnostic-to-treatment interval (dti) was 54 days but 5 (17.8%) out of the 28 had a dti of more than 60 days. four (80%) with a dti more than 60 days had an upstage during surgery while 4 (17.4%) patients with dti less than or equal to 60 days also had an upstage. 2 (60%) patients with treatment delay had tumor progression compared to 5 (21.7%) of those without treatment delay. only 1 (20%) out of the 5 patients with treatment delay had increased nodal metastasis in contrast to 8 (34.8%) of those who did not have treatment delay. conclusion: a number of patients undergoing surgery in our institution experienced delay to initiate treatment of more than 60 days and majority of these patients were noted to have disease progression. however, even patients with treatment prior to 60 days had increases in tumor stage, which may suggest that the interval aimed for should be shorter than 60 days. keywords: head and neck cancer, treatment delay, diagnostic interval, tumor progression neoplasms, including head and neck cancers, are the third leading of cause of mortality in the philippines.1 establishing diagnoses at an earlier stage and early initiation of treatment are essential to achieve good treatment outcome.2 diagnostic-to-treatment interval (dti) is defined as the interval from which histopathological diagnosis is established until radiotherapy or chemotherapy is commenced or the actual date of surgery.2,3 various factors can cause delay or prolonged dti in the management of patients with head and neck cancer and should be avoided if possible.4 a significant delay that confers a detrimental effect on survival is defined as more diagnostic-to-treatment interval and disease progression among head and neck cancer patients undergoing surgery gerard f. lapiña, md samantha s. castañeda, md department of otorhinolaryngology head and neck surgery rizal medical center correspondence: dr. samantha s. castañeda department of otorhinolaryngology head and neck surgery rizal medical center barangay pineda, shaw boulevard, pasig city 1600 philippines phone: (632) 865 8400 local 197 email: ent.hns_rmc@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest (1st place), october 6, 2016. natrapharm, the patriot bldg. parañaque city. philipp j otolaryngol head neck surg 2017; 32 (1): 33-36 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 34 philippine journal of otolaryngology-head and neck surgery original articles than 60 days from the pathological diagnosis to commencement of treatment.5 in our institution, despite priority given to head and neck cancer patients, there are still patients who worsen from the time they are diagnosed to the actual day of the surgery. this study aimed to determine whether there is treatment delay in head and neck cancer patients operated on in our institution and to determine if there is progression in stage, tumor size and lymph node status occurring in these patients. methods with ethical review board approval, records of all 70 patients with newly diagnosed head and neck cancers that underwent surgery in rizal medical center from january 2011 to december 2015 were identified, and retrieved to extract patient and tumor characteristics such as age, sex, primary site of cancer, date of pathological diagnosis and exact date of surgery. corresponding tnm staging, based on the american joint committee on cancer staging in 2010 (7th edition)6 during the time of diagnosis and eventual surgery were also noted. excluded were patients with thyroid neoplasms (due to their relatively better prognosis compared to other head and neck cancers), those with incomplete records or who were admitted for surgery of tumor recurrence. patients with unresectable tumors and those with metastasis during the time of diagnosis were also not included in this study. the patients were divided into two groups based on dti of ≤ 60 days and > 60 days. data were tabulated in microsoft excel 2016 (v16.0.6769.2017, microsoft corp., redmond, wa, usa) and descriptive statistics were computed. results a total of 31 out of 70 patient records were initially considered for inclusion, with one more excluded due to inadequate data, and two more excluded because they underwent surgery for recurrence, leaving a total of 28 patient records included. the ages of the patients ranged from 26-72 years (mean, 56.9 years), with 46.4% more than 60 years of age and 67.9% were male. the dti ranged from 10 to 363 days with a median of 54 days. out of the 28 patients, 5 (17.9%) had a significant delay in the initiation of treatment. the most common primary sites were the larynx (42.9%) and oral cavity (42.9%). treatment delay (dti > 60 days) was present in 16.67% of patients with laryngeal malignancy in compared to 25% of patients with oral cavity malignancy as shown in figure 1. a minority of patients (14.29%) were diagnosed with malignancies of the parotid and paranasal sinus. no treatment delay was noted in these patients. the majority (75%) of patients were diagnosed at a late stage (stage iii and iv) with a smaller portion (25%) diagnosed at an earlier stage (stage i and ii). across all the stages, there were patients who experienced treatment delay (13.33 33.33%). (figure 2) figure 3 shows that 4 out of 5 patients (80%) with treatment delay had an increased stage at the time of diagnosis either due to increased tumor size, increased nodal metastases or both. despite having been operated on within 60 days from the time of pathological diagnosis, there were still 4 out of 23 patients (17.4%) that had increased stage at the time of surgery. figure 1. diagnostic-to-treatment interval and site of primary lesion n o. o f p at ie nt s figure 3. diagnostic-to-treatment interval and tnm staging *stage according to the 2010 ajcc tnm staging n o. o f p at ie nt s figure 2. diagnostic-to-treatment interval and stage at diagnosis *stage at diagnosis based on the 2010 ajcc tnm staging n o. o f p at ie nt s philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles philippine journal of otolaryngology-head and neck surgery 35 tumor stage increase in tumor stage was noted in 3(60%) of 5 patients with treatment delay, compared to 5(21.7%) of 23 patients without treatment delay as shown in figure 4. among the patients who were operated on or before 60 days, there were still patients who experienced marked tumor growth as documented by an increase in tumor stage. the shortest interval observed in which there was tumor upstage was 25 days. discussion this study aimed to determine if there was treatment delay and the presence or absence of disease progression in patients undergoing surgery for head and neck cancer. the authors found out that the median dti for head and neck cancers in our institution was 54 days. this interval is subpar compared to the findings of lynhe et al. of decreasing median dtis of 47 days in 1992, 31 days in 2002 and 25 days in 2010 among different institutions in denmark, mandated by government to initiate treatment without delay in head and neck cancer patients.7 another study with a shorter median dti of 48 days found out on subgroup analysis, that the median dti of patients with late stage head and neck cancer in their institution was significantly prolonged at 57 days,2 similar to our study. even though the median time in our institution did not exceed 60 days, this is still unfavorable, according to the findings of murphy et al. “a dti of at least 46 days seemed to affect survival, and a dti of more than 60 days persistently had a detrimental effect on survival.”5 the dutch guidelines also proposed that the interval from initial consult to treatment should not be more than 30 days because tumor doubling times of 30 days or less in some of these cancers implies progression of disease.10 however, this is difficult to achieve in our setting where a lot of factors, professional and patient-related, possibly result in prolonged dti. studies have shown that doubling time of tumors occur at an average 87-96 days and or as brief as 30 days for fast growing tumors.10,11 this concept is essential since we could expect to see tumor progression at a similar rate in our study in which the shortest interval was 25 days. we found out that even in patients without treatment delay, 34.8% had an increase in lymph node metastases which translates to poorer outcomes since this is included in the independent factors that affect survival rate negatively.9 the presence of nodal metastases in the neck has been said to decrease 5-year survival by 50% and increase the risk for metastasis two-fold.13 similarly, another study also concluded that an increasing number nodes positive for malignant cells confers a worse outcome for these patients.14 interestingly, one of the patients had clinically positive nodes bilaterally and only those on the ipsilateral side turned out positive for malignant cells resulting in a lower nodal stage. this could be explained by the study of finn et al. in 2002 which concluded that not all clinically positive and suspicious nodes would turn out to have invasion with malignant cells and that 30% of clinically positive nodes are falsely positive.9,15 specific causes for delay were not identified due to the limited data available on the retrieved charts as to why the dti was prolonged in some patients. another limitation is that patients who underwent nonsurgical management were not included in this study. patients who were initially candidates for surgery and rendered non-operable due to disease progression not identified since this study only encompassed nodal metastases increase in nodal metastasis was observed in 8(34.8%) of 23 patients without treatment delay and only 1(20%) of the 5 patients with treatment delay. (figure 5) increased nodal stage was observed in as early as 12 days from the time of histopathological diagnosis. there was one patient with laryngeal squamous cell carcinoma initially diagnosed as n2c but the final histopathologic diagnosis was n2b. figure 4. diagnostic-to-treatment interval and tumor stage *tumor stage according to the 2010 ajcc tnm staging n o. o f p at ie nt s figure 5. diagnostic-to-treatment interval and nodal stage *nodal stage according to the 2010 ajcc tnm staging n o. o f p at ie nt s philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 36 philippine journal of otolaryngology-head and neck surgery original articles references department of health [internet] philippines: statistics; c2016 [updated 2013 april 26; cited 2016 1. aug 1]. leading causes of mortality. available from: http://portal.doh.gov.ph/node/198.html. patel ue, brennan te. disparities in head and neck cancer: assessing delay in treatment initiation. 2. laryngoscope. 2012 aug;122(8):1756-60. doi: 10.1002/lary.23357; pmid: 22570084. stoker sd, wildeman ma, fles r, indrasari sr, herdini c, wildeman pl, et al. a prospective study: 3. current problems in radiotherapy for nasopharyngeal carcinoma in yogyakarta, indonesia. plos one. 2014 jan 23;9(1): e85959. doi: 10.1371/journal.pone.0085959; pmid: 24465811; pmcid: pmc3900459. nash r, hughes j, sandison a, stewart s, clarke p, mace a. factors associated with delays in 4. head and neck cancer treatment: case–control study. j laryngol otol. 2015 apr;129(4):383-5. doi: 10.1017/s0022215115000687; pmid: 25788249. murphy ct, galloway tj, handorf ea, egleston bl, wang ls, mehra r, et al. survival impact of 5. increasing time to treatment initiation for patients with head and neck cancer in the united states. j clin oncol. 2016 jan 10;34(2):169-78. doi: 10.1200/jco.2015.61.5906; pmid: 26628469; pmcid: pmc4858932. edge sb, byrd dr, compton cc, fritz ag, greene fl, trotti a. seventh edition of ajcc cancer 6. staging manual. springer-verlag, new york, ny. 2010. lyhne nm, christensen a, alanin mc, bruun mt, jung th, bruhn ma, et al. waiting times for 7. diagnosis and treatment of head and neck cancer in denmark in 2010 compared to 1992 and 2002. eur j cancer. 2013 may;49(7):1627-33. doi: 10.1016/j.ejca.2012.11.034; pmid: 23274198. hörmann k, sadick h. role of surgery in the management of head and neck cancer: a 8. contemporary view of the data in the era of organ preservation. j laryngol otol. 2013 feb;127(2):121-7. doi: 10.1017/s0022215112002988; pmid: 23298649. tong xj, shan zf, tang zg, guo xc. the impact of clinical prognostic factors on the survival of 9. patients with oral squamous cell carcinoma. j oral maxillofac surg. 2014 dec;72(12):2497.e1-10. doi: 10.1016/j.joms.2014.07.001; pmid: 25454713. van harten mc, de ridder m, hamming-vrieze o, smeele le, balm aj, van den brekel mw. 10. the association of treatment delay and prognosis in head and neck squamous cell carcinoma (hnscc) patients in a dutch comprehensive cancer center. oral oncol. 2014 apr;50(4):282-90. doi: 10.1016/j.oraloncology.2013.12.018; pmid: 24405882. waaijer a, terhaard ch, dehnad h, hordijk gj, van leeuwen ms, raaymakesr cp, et al. waiting 11. times for radiotherapy: consequences of volume increase for the tcp in oropharyngeal carcinoma. radiother oncol. 2003 mar;66(3):271-6. pmid: 12742266. van harten mc, hoebers fj, kross kw, van werkhoven ed, van den brekel mw, van dijk ba. 12. determinants of treatment waiting times for head and neck cancer in the netherlands and their relation to survival. oral oncol. 2015 mar;51(3):272-8. doi: 10.1016/j.oraloncology.2014.12.003; pmid: 25541458. wan xc, egloff am, johnson j. histological assessment of cervical lymph node identifies 13. patients with head and neck squamous cell carcinoma (hnscc): who would benefit from chemoradiation after surgery? laryngoscope. 2012 dec;122(12):2712–2722. doi: 10.1002/ lary.23572; pmid: 23060119; pmcid: pmc3522766. finn s, toner m, timon c. the node-negative neck: accuracy of clinical intraoperative lymph 14. node assessment for metastatic disease in head and neck cancer. laryngoscope. 2002 apr;112(4):630-3. doi: 10.1097/00005537-200204000-00007; pmid: 12150514. coskun hh, medina je, robbins kt, silver ce, strojan p, teymoortash a, et al. current philosophy 15. in the surgical management of neck metastases for head and neck squamous cell carcinoma. head neck. 2015 jun; 37(6):915-26. doi: 10.1002/hed.23689; pmid: 24623715; pmcid: pmc4991629. those who underwent surgery. we recommend that a prospective study be done which would include all patients diagnosed with head and neck cancer, both surgically and non-surgically managed patients, wherein close monitoring and documentation is done from initial consult up until any form of therapeutic intervention is done. in this way, specific and significant causes of delay may be identified and analyzed to recommend preventive measures and expedite health care for these patients. in conclusion, a number of patients undergoing surgery in our institution experience treatment delay. there was also disease progression, in terms of increase in size of the primary tumor or increased nodal metastases, noted in majority of these patients. philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles abstract objective: to determine the validity and reliability of the filipino dizziness handicap inventory (fdhi) questionnaire among geriatric patients with dizziness. methods: design: linguistic validation setting: tertiary government training hospital participants: twenty-five (25) patients results: the dizziness handicap inventory was translated into filipino by a filipino language specialist and an ent specialist who are experts in their field. the translated version was easily understood by the 25 geriatric patients with cronbach α scores of .957 overall [m = 2.16; sd = 1.93]. sub-domain item-total correlation scores (physical m = 2.6, sd = 1.90, cronbach α = .860; emotional m = 1.66, sd = 1.84, cronbach α = .901; and functional m = 2.5, sd = 1.97, cronbach α = .902) demonstrated validity of the respective subdomains. conclusion: the filipino dizziness handicap inventory questionnaire is an internally valid tool for assessment of dizziness among geriatric patients. external validity and reliability can be evaluated in future studies employing corroborative measures and repeated testing. keywords: content validity; filipino dizziness handicap inventory dizziness is the ninth most common complaint that leads patients to visit their primary care physicians, ranking third among those 65 to 75 years of age and first among older patients.1 dizziness is a subjective disorder that causes psychological, functional or social abnormalities rather than simple pathological illness.2 dysequilibrium, unsteadiness, vertigo and lightheadedness are terms that patients may use to describe their sensations.1 the common causes of vertigo may manifest differently in the elderly, with a more confusing constellation of symptoms, as patients tend to report less rotatory vertigo and more non-specific dizziness and instability.3 underlying this phenomenon is the progressive multimodal impairment of balance, including loss of vestibular and proprioceptive functions and impairment of central integration of these and other sensory inputs associated with aging.3 in addition, skeletal muscle strength and mass are also reduced with aging, thereby increasing the risk of fall-related injuries in elderly a linguistic validation study on the filipino dizziness handicap inventory sherwin n. agustin, md celso v. ureta, md natividad a. almazan, md department of otorhinolaryngology head and neck surgery veterans memorial medical center correspondence: dr. celso v. ureta department of otorhinolaryngology head and neck surgery veterans memorial medical center north avenue, diliman, quezon city 1104 philippines phone: (632) 8927 6426 local 1359 email: enthns_vmmc@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest (1st place). december 6, 2019. palawan ballroom, edsa shangri la hotel, mandaluyong city. philipp j otolaryngol head neck surg 2020; 35 (2): 37-40 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles patients.3 these factors contribute to multifactorial causes of dizziness among the elderly which poses great concern, being at heightened risk for other complications brought about by their dizziness. the dizziness handicap inventory (dhi) is a questionnaire used to assess the impact of dizziness on quality of life.4 the self-report questionnaire was originally designed to quantify the handicapping effect of dizziness imposed by vestibular system disease, but it has also been used for persons with dizziness of other origins5 such as autonomic dysfunction as a result of diabetes or cardiovascular disease and even the effects of polypharmacy in the elderly with several comorbidties.6 the 25-item questionnaire is divided in 3 sub-domains of self-perceived handicap and comprises physical, functional and emotional questions.4 it has been translated into different languages such as german,7 brazilian,8 persian9 and italian.10 to the best of our knowledge, there is no validation study of the dhi available in our local setting. hence, this study aims to establish the validity and reliability of the filipino dizziness handicap index (fdhi) among a sample of geriatric patients with dizziness. methods this two-phase validation study was conducted at the veterans memorial medical center (vmmc) with institutional review board approval (vmmc-2017-035). consent for translation was obtained from the original author of the dizziness handicap inventory (dhi).4 the first phase involved joint translation of the dhi into filipino by two persons, a filipino language professor and an ear, nose and throat (ent) specialist fluent in english and filipino. the resulting draft fdhi was back translated into english by another physician. content validity of the translated fdhi was assessed by these experts to ensure that the contents of the questionnaire were appropriate and opine that it could produce reliable results. meetings were conducted to discuss the results of the translation, and then the first version of fdhi was produced. (figure 1) the second phase was validation of the fdhi. the validity of the questionnaire was determined through pretesting among 25 filipino geriatric patients. twenty-five (25) participants aged 65 years old and above who were consulting for dizziness were serially recruited by the ear, nose, throat head and neck surgery (ent-hns) resident doctors from the out-patient department (opd) clinic and emergency ward of the vmmc department of otorhinolaryngology – head and neck surgery from october 2017 – may 2018. prospective participants had to be able to read, write, understand and converse in filipino. excluded were patients with dementia, alzheimer’s disease and other neurological disorders. informed consent was obtained from all participants. filipino dizziness handicap inventory pagsukat sa antas ng pagiging mahiluhin p1. nakadaragdag ba sa iyong pagiging mahiluhin ang pagtingin sa itaas? e2. nakadarama ka ba ng pagkadismaya dahil sa iyong pagiging mahiluhin? f3. nalilimitahan ba ng iyong pagiging mahiluhin ang pagnanais mong maglakbay para sa negosyo o libangan? p4. nakadaragdag ba sa iyong pakamahiluhin ang paglalakad sa pasilyo ng mga pamilihan? f5. nagbubunga ba ng kahirapan sa pagbangon at paghiga sa kama ang iyong pagiging mahiluhin? f6. nalilimitahan ba ng iyong pagiging mahiluhin ang pagnanais mong lumahok sa iba’t ibang gawain gaya ng pagkain sa labas, panonood ng sine, pagsasayaw at/o pagdalo sa mga pagtitipon? f7. nakararanas ka ba ng kahirapan sa pagbabasa dahil sa iyong pagiging mahiluhin? p8. napalalala ba ang iyong iyong pagiging mahiluhin ng pagsasagawa ng mabibigat na mga gawain gaya ng palahok sa iba’t ibang isports, pagsasayaw at mga gawaing-bahay (tulad ng pagwawalis at paghuhugas ng plato)? e9. pinangangambahan mo bang lumabas sa bahay nang walang kasama dahil sa iyong pagiging mahiluhin? e10. naging dahilan ba ng iyong pagkapahiya sa harap ng maraming tao ang iyong pagiging mahiluhin? p11. nakadaragdag ba sa iyong pagiging mahiluhin ang mabilis na paggalaw ng iyong ulo? f12. umiiwas ka ba sa mga matataas na lugar dahil sa iyong pagiging mahiluhin? p13. sa pagbuwelta mo ba sa kama ay nadaragdagan ang iyong pagiging mahiluhin? f14. nahihirapan ka bang isagawa ang mas mabibigat at nakapapagod na mga gawaing bahay (gaya ng paglilinis sa bakuran) dahil sa iyong pagiging mahiluhin? e15. pinangangambahan mo bang isipin ng iba na ika’y lasing sa alak dahil sa iyong pagiging mahiluhin? f16. nahihirapan ka bang lumakad nang mag-isa dahil sa iyong pagiging mahiluhin? p17. nakadaragdag ba sa iyong pagiging mahiluhin ang paglalakad nang pababa sa mga bangketa? e18. nahihirapan ka bang magkaroon ng sapat na konsentrasyon dahil sa iyong pagiging mahiluhin? f19. nahihirapan ka bang maglakad sa paligid ng inyong tahanan kapag madilim dahil sa iyong pagiging mahiluhin? e20. natatakot ka bang manatili nang mag-isa sa inyong tahanan dahil sa iyong pagiging mahiluhin? e21. nakadarama ka ba ng kakulangan sa iyong mga kapasidad dahil sa iyong pagiging mahiluhin? e22. naaapektuhan ba ng iyong pagiging mahiluhin ang iyong relasyon sa pamilya at mga kaibigan? e23. nakadarama ka ba ng pagkalumbay dahil sa iyong pagiging mahiluhin? f24. nakasasagabal ba ang iyong pagiging mahiluhin sa iyong trabaho at mga responsibilidad sa tahanan? p25. nakadaragdag ba sa iyong pagiging mahiluhin ang pagliyad o pagyuko? m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi m oo m minsan m hindi dhi tagubilin sa pagmamarka ang pasyente ay sumagot ng mga katanungan ukol sa pagkahilo o problema sa kawalan ng balanse, partikular na isinasaalang-alang ang kanilang kalagayan sa panahon ng nakaraang buwan. ang mga katanungan ay dinisenyo upang isama ang functional (f), pisikal (p), at emosyonal na (e) epekto sa kapansanan. sa bawat item, ang mga sumusunod na mga marka ay maaaring italaga: hindi = 0 kung minsan = 2 oo = 4 mga marka: scores mas malaki kaysa sa 10 puntos ay dapat na tinutukoy sa balanse espesyalista para sa karagdagang pagsusuri. 0-34 puntos (banayad na kapansanan) 36-52 puntos (katamtamang kapansanan) 54+puntos (malubhang kapansanan) figure 1. the filipino dizziness handicap inventory philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles all eligible patients were asked to accomplish a demographic questionnaire which included basic information such as: name, age, gender, race, marital status, education, and underlying medical condition. technical and medical terms were completed by the interviewing resident from patient medical records. after accomplishing the general information sheet and history taking, each of the 25 selected participants were administered the 25-item fdhi, with a total score ranging from 0-100 points by summing ordinal scale responses and higher scores indicating more severe handicap. the questionnaires were answered by each patient in the presence of their companion or caregiver and a resident physician-incharge in case clarifications were needed. the respondents were given enough time to answer each of the questions and completeness of the data were ensured by the resident-in-charge and finally submitted to the investigator on the same day. the responses were encoded and tallied using microsoft excel for mac 2011 version 14.0 (microsoft corp., redmond wa, usa). nominal data frequencies and percentages were computed and mean ± sd were generated for numerical data. cronbach alpha was used for estimation of internal consistency. statistical analyses were performed using the statistical package for social sciences (spss) statistics version 10 (ibm corp., armonk, ny, usa). results a total of 25 participants with ages ranging from 65 to 75 years old (mean age 70 years old) completed the study. the majority (18; 72%) were male, married (23; 92%), college graduates (19; 76%), and had co-morbidities (20; 80%). all participants were able to understand and answer all the items in the questionnaire. for the functional subdomain of the filipino dhi, majority of the respondents claimed to have difficulty in performing basic activities of daily living like performing household chores (15; 60%), and also difficulty engaging in social activities (14; 56%). for the emotional subdomain, most reported being depressed (20; 80%) and feeling frustrated (18; 72%) because of their dizziness. for the physical subdomain, majority answered that quick head movements increase their dizziness problems (21; 84%). cronbach alpha for internal consistency showed the seven items under the physical sub-domain were reliable (mean = 2.60, sd = 1.90, cronbach α = .860). item analysis showed good item-total correlation, indicating psychometrically-sound items. the nine items under the emotional sub-domain were likewise shown to be reliable (mean = 1.66, sd = 1.84, cronbach α = .901). item analysis showed also good item-total correlation, indicating psychometrically-sound items. finally, the nine items under the functional sub-domain were also shown to be reliable (mean = 2.50, sd = 1.97, cronbach α = .902), with item analysis showing good item-total correlation, indicating psychometricallysound items. overall, the 25-item fdhi was internally valid (mean = 2.16, sd = 1.93, cronbach α = .957). discussion this study established the filipino dizziness handicap inventory questionnaire as an internally valid tool for assessment of dizziness among geriatric patients. however, external validity and reliability were not established in this study. the ability to maintain posture and orientation is one of the most indispensable conditions in daily life and is regulated by vestibular function, somatic sensation and vision.2 a problem with any one of these causes imbalance, which affects everyday life and can disable patients by causing fear, depression or anxiety.2 the dizziness handicap inventory (dhi) is the first self-assessment inventory to evaluate the degree of disability in everyday life associated with any cause of dizziness on patients suffering from dizziness, developed in 1990 by jacobson and newman.4 each item for the questionnaire is divided into 3 subdomains: functional, emotional, and physical area, comprised of 25 questions, and with a total of 100 points. the degree of disability is quantified based on total scores of each item.4 among these, items concerning functional aspects are about occupation or movements related to leisure activity; items on emotional aspects are about anxiety and frustration associated with the occurrence of dizziness; and those on physical aspects cover basic physical movements often experienced in daily life.2 validity of items were verified and reliability was shown to be high (cronbach alpha 0.95) and the reliability of the questionnaire can be sustained when the test is translated into different languages.2 in terms of functional aspects, the majority of our filipino dhi respondents reported having difficulty in performing activities of daily living (such as basic household chores) and engaging in social activities. while respondents in the brazilian dhi study also reported interference of dizziness with such functional aspects as the capacity to perform domestic, social and leisure activities, there was a focus on independence for doing tasks such as walking without help and walking at home in the dark.8 the persian dhi translation study also reported that participants responded having difficulty getting into and out of bed as part of their daily activities.9 on the other hand, for the italian dhi study, the functional aspects were those most affected together with increasing age of the patients, which was probably due to the effects of aging on the vestibular system, which may enhance the functional limitations in these patients.10 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles in terms of emotional aspects, most respondents of our filipino dhi study reported depression, anxiety and feelings of frustration brought about by the handicapping effects of dizziness. the brazilian dhi study found that emotional effects created possible harm on the quality of life of affected individuals, generating frustration, fear of going out without company, or staying home alone, shame of its clinical manifestations, worries about self-image, concentration disorder, incapacity sensation, familiar or relationship alteration and depression.8 the persian dhi study on the other hand showed that their results for the emotional subdomain had the least positive response among patients who answered the following: afraid to leave home without accompany, afraid to stay at home alone and afraid that people may think that they are intoxicated.9 while the emotional aspects evaluated by the italian dhi study were also abnormal in the patients studied, these aspects investigated the possible harm caused by the dizziness on the quality of life, generating frustration, fear of going outside without company or staying home alone, shame regarding the clinical manifestations, worries about concentration disorders, a sensation of incapacity, changes in family or social relationships and depression.10 under physical aspects, most respondents of the filipino dhi reported that quick head movements, bending over, and walking down on sidewalks increase their dizziness problems. the brazilian dhi study similarly found that the manifestation of dizziness in certain positions or head movements is very common and may provoke or worsen the dizziness.8 for the persian dhi study, most also answered that quick head movements increase their dizziness (74%), followed by bending over (72%) and looking up (63%) aggravates their dizziness.9 on the other hand, the physical aspects investigated by the italian dhi study presented the highest scores, wherein the performance of physical functions such as the relationship between the manifestation and/or the severity of the dizziness and the eye and body movements, and the manifestation of dizziness in specific positions or following head movements, were significantly more affected compared to the other aspects evaluated by the dhi.10 the translated fdhi questionnaire yielded a cronbach α score of 0.957 comparable to the original dhi study score of 0.954 the dhigerman score of 0.907 and the dhi-italian score of 0.92.10 the process of translation of the dhi to its filipino version was unproblematic and its internal consistency was investigated in a limited and controlled study population. it is a valid and internally consistent questionnaire and can be used as a baseline tool for future studies. there are several limitations to our study. first and foremost, the fdhi produced after translation and back translation relied on consensus by an expert panel. while linguistic translation may have references 1. hullar te, zee ds, minor lb. evaluation of the patient with dizziness. in: flint pw, haughey bh, lund vj, niparko jk, richardson ma, robbins k (editors). cummings otolaryngology head and neck surgery 6th ed. mosby elsevier, philadelphia, pa: saunders. 2015. pp.2525-2547. 2. han gc, kim mj, kim ks, joo yh, park sy. the dizziness handicap inventory and its relationship with vestibular diseases. j int adv otol. 2012 jan; 8(1): 69-77. 3. fernandez l, breinbauer ha, delano ph. vertigo and dizziness in the elderly. front neurol. 2015 jun 26; 6:144. doi:10.3389/fneur.2015.00144; pubmed pmid: 26167157 pubmed central pmcid: pmc4481149. 4. jacobson gp, newman cw. the development of the dizziness handicap inventory. arch otolaryngol head neck surg. 1990 apr;116(4):424-7. doi: 10.1001/archotol.1990.01870040046011 pubmed pmid: 2317323. 5. tamber al, wilhelmsen kt, strand li. measurement properties of the dizziness handicap inventory by cross-sectional and longitudinal designs. health qual life outcomes. 2009 dec 21; 7:101. doi: 10.1186/1477-7525-7-101; pubmed pmid: 20025754; pubmed central pmcid: pmc2804706. 6. lee ath, diagnosing the cause of vertigo: a practical approach. hong kong med j. 2012 aug; 18:327-32. 7. kurre a, van gool cj, bastiaenen ch, gloor-juzi t, straumann d, de bruin ed. translation, crosscultural adaptation and reliability of the german version of the dizziness handicap inventory. otol neurotol. 2009 apr;30(3):359-67. doi: 10.1097/mao.0b013e3181977e09. pubmed pmid: 19225437. 8. de castro as, gazzola jm, natour j, ganança ff. brazilian version of the dizziness handicap inventory. pró-fono. 2007 jan-apr; 19(1):97-104. doi: 10.1590/s0104-56872007000100011; pubmed pmid: 17461352. 9. jafarzadeh s, bahrami e, pourbakht a, jalaie s, daneshi a. validity and reliability of the persian version of the dizziness handicap inventory. j res med sci. 2014 aug;19(8):769-75. pubmed pmid: 25422664; pubmed central pmcid: pmc4235099. 10. nola g, mostardini c, salvi c, ercolani ap, ralli g. validity of italian adaptation of the dizziness handicap inventory (dhi) and evaluation of the quality of life in patients with acute dizziness. acta otorhinolaryngol ital. 2010 aug;30(4):190. pubmed pmid: 21253284; pubmed central pmcid: pmc3008147. been achieved, this may not have been able to account for difference in cultural context. time constraints limited this study to establishing content validity and internal consistency of the filipino dizziness handicap inventory only. it can still be further evaluated for face validity (for cultural adaptation) and test-retest reliability (for external reliability). second, we had a small sample of participants sourced from an already dizzy geriatric population. discrimination between dizzy and non-dizzy persons (as well as ability to distinguish between degrees or severity of dizziness), or assessment of dizziness in other age groups, cannot be established. future research that includes both dizzy and non-dizzy individuals (either as a case-control study or a randomized trial) as well as other age groups may better establish the validity of the fdhi. third, we only administered the test once at a single point in time to each participant. establishing test retest reliability over time, perhaps in comparison to other measures of dizziness (including corroboration with objective balance tests) would be an important step. in conclusion, this study may have established the filipino dizziness handicap inventory questionnaire as an internally valid tool for assessment of dizziness among geriatric patients. however, external validity and reliability need to be evaluated in future studies with expanded research designs employing corroborative measures and repeated testing. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery practice pearls keywords: polycaprolactone; pcl mesh; structural rhinoplasty; extended spreader graft; septal extension graft; septoplasty surgery as an art in rhinoplasty involves grafting techniques wherein materials (usually autologous) are taken from the septum and supplemented by conchal cartilage. however, not all noses have adequate cartilage material. the quest for materials as possible replacement for human tissue have led to invention of synthetic (e.g. silicone, e-ptfe, porous polyethelene) and non-synthetic products (e.g. processed homograft and xenograft). in this era of advanced medical science, tissue engineering has started the use polycaprolactone (pcl) as a template and scaffold for tissue growth. because of this characteristic feature, pcl as a mesh has a significant role in structural rhinoplasty. what is structural rhinoplasty? the surgical goal of rhinoplasty is to achieve functional improvement in breathing and aesthetic overall look, most notably the tip. the tip is determined by the final shape of the lower cartilage in its proper location but since the lower cartilage is a floating structure supported only by fibrous tissue and ligaments, there is a high incidence of tip drooping post op. so, the idea of structured rhinoplasty was conceptualized in 1997 by dr. byrd and popularized by dr. toriumi.1,2 a piece of central septum is harvested and fashioned as an extension of the caudal margin of the septum. this is called a septal extension graft (seg) and the lower cartilage is sutured to the caudal margin of the seg for better control of the tip. since then, the technique has been the main workhorse support graft for the tip.3 (figure 1) why is structural rhinoplasty needed in east asian noses? east asian noses, particularly southeast asian noses are usually short and small, with low dorsum and upturned bulbous nose. tremendous strength in the design of the structural support with its foundation base at the caudal septum should be achieved in order to elongate the nose, counter rotate and project the tip. (figure 2) this is made possible by using the central harvested cartilage as a seg attached to the residual strong dorsal and caudal strut.4 (figure 3) why is it that seg alone fails in achieving the desired result? it was noted that the septum of asian noses is weak and small. using the harvested septal understanding the use of polycaprolactone in east asian structural rhinoplasty: questions and answers eduardo c. yap, md1,2 1belo medical group 2department of ent metropolitan medical center correspondence: dr. eduardo c. yap unit 3, 28 times st., west triangle, quezon city 1104 philippines phone: (632) 8254 1111 email: edcyap88@gmail.com the author declares that this represents original material that is not being considered for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2021; 36 (1): 57-61 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery practice pearls cartilage as a seg alone may not be strong enough to fix the tip in a new vector of projection. usually, there is a need to spare a smaller piece of the harvested septum as an extended spreader graft (esg) to counteract the bending and collapse of the seg. therefore, the foundation system is a usually a combination of seg and esg fashioned in a new vector for tip counter rotation and projection.5 since the introduction of the concept of extending the caudal margin of the septum, many varieties of seg evolved but are mainly of 2 types: side-to-side seg and end-to-end seg. the side-to-side seg is attachment of the seg to either side of the caudal strut of the septum while the end-to-end seg is attachment of the seg directly at the caudal margin of the caudal strut held by bilateral esg.6 (figure 4 and 5) what should be done if the harvested septum is weak and small? sometimes the septum is small and soft with some inherent deviation leading to a dilemma on to how to design an adequate seg and esg. folded conchal cartilage may be used as extension graft of a seg, however since conchal cartilage is weak, it may droop or deviate. although costal cartilage is the best graft material, it is not popular because of the high cost and morbidity of the procedure, and other non-autologous materials may be used instead e.g. processed homograft, xenograft and synthetic products like the non-absorbable porous polyethylene and absorbable polycaprolactone (pcl). of all the non-autologous materials, pcl seems to be the more favorable material because it has properties similar to septum, and it is resorbable in 2 years. what is polycaprolactone? polycaprolactone (pcl) is a biocompatible and biodegradable synthetic polyester polymer that has been extensively used as 3d scaffold in bone tissue, cartilage and mesenchymal tissue engineering. pcl resorbs in 2-3 years depending on thickness after which new surrounding in-growth tissue structures mature. whatever tissue is placed beside the pcl during the healing process will be the same tissue until total resorption. recent applications include scaffolds for bone defects in craniomaxillofacial surgery and fillers/threads in aesthetic facial rejuvenation.7 polycaprolactone is 3d printed and can be made accordingly to the shape desired. the dimension and strength can be varied as requested. the product commercial availability in the late quarter of 2018 made its role very useful in septoplasty and rhinoplasty because its physical properties are similar to septal cartilage. the usual dimension is 10mm x 40mm x 1mm. (figure 6) the pcl mesh can be cut easily by blade or scissors and sutured to surrounding tissues. the role of pcl figure 1. the septal extension graft (seg). the usual technique to lengthen the nose and counter-rotate the tip is the use of central harvested septum and fashioned into a support graft. commonly used technique is the septal extension graft. figure 2. the aim in asian rhinoplasty is counter rotation and projection of the tip. figure 3. the final concept of counter-rotation and projection of the tip. the lower cartilage is sutured to the caudal edge of the seg. figure 4. side-to-side seg. this requires a strong dorsal and caudal strut. this technique may sometimes lead to deviation at the junction of suture fixation of seg and caudal strut causing obstruction and twisting of the tip. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery practice pearls is initially as a scaffold for strength in support and later as a template for tissue adhesion, migration and proliferation. it is advisable that the surrounding tissues are cartilage so that after 2-3 years when the pcl is totally resorbed it will be replaced with the ingrown cartilage.8 polycaprolactone should not be used for pressure or weight bearing purposes because it may extrude or break during the process of healing. how do you use pcl in structural rhinoplasty? the principle in structural grafting in asian rhinoplasty is to modify the nasal tip to a more counter rotated and projected position. the lower cartilage which determines the tip is sutured to a structure which is firmly fixed to the septum. the usual technique is to make the inherent dorsal and caudal struts (after harvest of central septum) stronger and more extended. the lower cartilage is then sutured and fixed to the caudal margin of the extended strut system for a new projected and counter rotated tip. the approach is an open rhinoplasty with dissection of membranous septum to expose the caudal edge of cartilaginous septum. the septum is approached anteriorly in a subperichondrial plane; the dissection can be unilateral or bilateral. the central cartilage is harvested leaving a 1012mm dorsal and caudal strut. there are some instances that harvested septal cartilage may be inadequate because of inherent small size and weakness, and likewise the remaining dorsal and caudal struts are weak or deviated.9 (figure 7) in these instances, pcl is used as a unilateral or bilateral extended spreader graft (esg) and septal extension graft (seg). why is pcl used as esg and seg in structural rhinoplasty? the esg lengthens, straightens and strengthens the dorsal strut while the seg extends the whole strut system for tip support.10 because of the stiff nature of the pcl mesh, a unilateral placement of esg is good enough to support a seg which is designed as an end-to-end attachment so the vector of healing contraction force is in the midline, minimizing chances of extrusion in mucosa.11,12 (figure 8) any deviation in the caudal strut can be corrected with a batten graft from the harvested septum.13 the rest of the pcl can be covered with remaining septal cartilages and conchal cartilages. finally, a folded conchal cartilage is sutured at the caudal margin of the seg in order to protect against erosion to mucosa and columellar skin. (figure 9 and 10) this type of pcl structural grafting addresses almost all types of deviation and weakness of the septal strut. the end-to-end seg assures a midline structure too. the whole system will not deviate because the seg is held by esg deep from the dorsal septum. (figure 8) figure 5. . end-to-end seg. this technique assures a midline structure. the bilateral extended spreader graft (esg) stabilizes the end-to-end seg. the esg not only straightens, counterrotates and strengthens the dorsal strut but also widens the internal valve. it is also necessary to put spare septal or conchal cartilage at the posterior part of the end-to-end seg for further stabilization. this technique assures a midline support. deviation and obstruction are seldom encountered. figure 6. a sample pcl mesh 10mmx 40mm x 1mm figure 7. weak dorsal strut. in some cases of support grafting, the dorsal strut collapses or is bent because of the pressure and tension of the lower cartilage and skin/soft tissue envelope (sste) during closure thereby causing deviation, obstruction and twisting/drooping of the tip. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery practice pearls can one use pcl solely like a septum? unfortunately, pcl should not be used solely as a graft similar to a septum. in the early phase, pcl should be treated as a scaffold in correction of deviation and strengthening a weak cartilage. in the late phase, pcl acts as a mesh or template for ingrowth of tissue. therefore, it is highly recommended to cover the mesh with cartilages even in patches to allow cartilage cells to integrate. it is advised also to avoid direct contact of pcl to mucosa.8 (figure 11) will the use of pcl shorten the operating time? using pcl in structural rhinoplasty prolongs the operating time because the surgeon has to plan and imagine the fate of the future of the pcl grafts since pcl will be hydrolyzed and resorbed in 2 years. therefore, majority of pcl should be covered with cartilages to allow tissue ingrowth in order to provide strength in the future. this will assure longevity of the support graft system of the nose. (figure 12) figure 9. pcl as unilateral esg and end-to-end seg. a. placement of pcl (stippled green) as esg, right and an end-to-end seg; b. placement of a conchal cartilage (cross-hashed orange) at the posterior area of the seg and caudal strut, right; c. placement of extended caudal batten strut graft (plain yellow), left. its source is from the harvested septum; d. placement of folded conchal cartilage (cross-hashed orange) at the caudal margin of the seg. fixation suture done using pds® 5-0. majority of pcl including the esg should be covered with cartilage for adhesion and migration of cartilage tissue. figure 10. sample intraoperative photo of pcl as end-to-end seg. a. pcl as end-to-end seg and septal cartilage as extended caudal batten graft, left. not shown is the pcl as esg on the right. the pcl-esg and septum-extended caudal batten graft hold the end-to-end seg well; b. folded conchal cartilage is utilized as coverage of the caudal margin of the seg in order to prevent erosion to skin and mucosa. the folded conchal cartilage is where the lower cartilage is fixed for the final nasal framework. figure 11. schematic diagram of pcl covered with cartilages to allow adhesion, migration and proliferation of cartilage tissue. note that sutures are all submucosal. notice too that the mucosa is elevated from pcl because of cartilage placement. since pcl will be totally resorbed in 2-3 years, it is advisable to avoid direct contact of mucosa to pcl. this is to avoid chances of erosion and subsequent extrusion. figure 8. pcl used as unilateral esg (r, stippled green) and end-to-end seg (midline, stippled green). a piece of septal cartilage is used as caudal batten graft (l, plain yellow). a folded conchal cartilage (midline, plain yellow) is attached at the caudal margin of the pcl. note the vector of wound contracture is midline towards the septum. this design of structural grafting will not cause extrusion of the pcl nor cause deviation or collapse of the septal struts. a b c d a b in summary, pcl mesh is a good material for use in structural rhinoplasty where the septum is weak or small. it is absorbable and easy to use because its physical properties are similar to septum. in the early phase, pcl acts as a scaffold to correct deviation and weakness of the septum, while in the late phase, it acts as a template for tissue ingrowth. therefore, cartilage should cover the majority of the pcl especially at key areas where the future extended dorsal and caudal struts will be located. (figure 13) philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery practice pearls figure 12. pre-op (l) and post-op (r) photos. pre-operative and post-operative photos show a remarkable change of the nose. the tip is counter rotated and well projected. the premaxilla is fuller. structural rhinoplasty assures longevity of results. figure 13. pcl role in structural rhinoplasty. a. in its initial phase, pcl acts as a scaffold which provides strength; b. in the late phase, pcl acts as template for tissue ingrowth. therefore, it is essential that the tissue surrounding the pcl should be cartilage in order for the support system to sustain strength. a b references 1. byrd hs, andochick s, copit s, walton kg. septal extension grafts: a method of controlling tip projection shape. plast reconstr surg. 1997 sep;100(4):999-1010. doi: 10.1097/00006534199709001-00026; pubmed pmid: 9290671. 2. toriumi dm. structure approach in rhinoplasty. facial plast surg clin north am. 2005 feb;13(1):93-113. doi: 10.1016/j.fsc.2004.07.004; pubmed pmid: 15519931. 3. rohrich rj, durand pd, dayan e. changing role of septal extension versus columellar grafts in modern rhinoplasty. plast reconstr surg. 2020 may;145(5): 927e-931e. doi: 10.1097/ prs.0000000000006730; pubmed pmid: 32332531. 4. toriumi dm. discussion: septum-based nasal tip plasty: a comparative study between septal extension graft and double-layered conchal cartilage extension graft. plast reconstr surg. 2018 jan;141(1):57-58. doi: 10.1097/prs.0000000000004125; pubmed pmid: 29280861. 5. chen yy, kim sa, jang yj. centering a deviated nose by caudal septal extension graft and unilaterally extended spreader grafts. ann otol rhinol laryngol. 2020 may;129(5):448-455. doi: 10.1177/0003489419894617; pubmed pmid: 31822124. 6. kim mh, choi jh, kim ms, kim sk, lee kc. an introduction to the septal extension graft. arch plast surg.  2014 jan; 41(1): 29–34.  doi: 10.5999/aps.2014.41.1.29; pubmed pmid:  24511491; pubmed central pmcid: pmc3915152. 7. christen mo, vercesi f. polycaprolactone: how a well-known and futuristic polymer has become an innovative collagen-stimulator in esthetics. clin cosmet investig dermatol. 2020 jan 20;13;31-48. doi: 10.2147/ccid.s229054; pubmed pmid: 32161484; pubmed central pmcid: pmc7065466. 8. yap e. techniques in the safe use of polycaprolactone in structural rhinoplasty. philipp j otolaryngol head neck surg. 2020 may;35(1): 66-70. doi: 10.32412/pjohns.v35i1.1267. 9. choi jy, kang ig, javidnia h, sykes jm. complications of septal extension grafts in asian patients. jama facial plast surg. 2014 may-jun; 16(3):169-75 doi: 10.1001/jamafacial.2013.2379; pubmed pmid: 24526131. 10. palacín jm, bravo fg, zeky r, schwarze h. controlling nasal length with extended spreader grafts: a reliable technique in primary rhinoplasty. aesthetic plast surg. 2007 nov-dec;31(6):645-50. doi: 10.1007/s00266-007-0065-8; pubmed pmid: 17876658. 11. kim dh, yun ws, shim jh, park kh, choi d, park m. clinical application of 3-dimensional printing technology for patients with nasal septal deformities: a multicenter study. jama otolaryngol head neck surg. 2018 dec 1;144 (12): 1145-1152. doi: 10.1001/jamaoto.2018.2054; pubmed pmid: 30326042; pubmed central pmcid: pmc6583092. 12. park yj, cha jh, bang si, kim sy. clinical application of three-dimensionally printed biomaterial polycaprolactone (pcl) in augmentation rhinoplasty. aesthetic plat surg. 2019 april; 43(2):437446. doi: 10.1007/200266-018-1280-1; pubmed pmid: 30498936. 13. wee jh, lee je, cho sw, jin hr. septal batten graft to correct cartilaginous deformities in endonasal septoplasty. arch otolaryngol head neck surg. 2012 may; 138(5): 457-461. doi: 10.1001/archoto.2012.650; pubmed pmid: 22652943. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 7776 philippine journal of otolaryngology-head and neck surgery under the microscope philipp j otolaryngol head neck surg 2020; 35 (1): 76-77 c philippine society of otolaryngology – head and neck surgery, inc. botryoid odontogenic cystjose m. carnate, jr., md department of pathology college of medicine university of the philippines manila correspondence: dr. jose m. carnate, jr. department of pathology college of medicine, university of the philippines manila 547 pedro gil st. ermita, manila 1000 philippines phone (632) 8526 4450 telefax (632) 8400 3638 email: jmcjpath@gmail.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. a 70-year-old man consulted for a mass of unspecified duration in the anterior area of the mandible. radiologic information was not provided. an incision biopsy was performed by the dentistry service. the specimen received at the laboratory was labeled “cystic lining” and consisted of two light-gray to dark brown, irregularly shaped tissue fragments measuring 0.3 cm and 0.4 cm in diameters. histological sections show biloculated cyst wall segments composed of fibrocollagenous tissue lined by an epithelial lining of varying thickness. (figure 1) the latter consists of a thin layer of non-keratinizing epithelium with plaque-like thickenings that are composed of cells with a whorled pattern and variably clear cytoplasm. (figures 2 & 3) based on these microscopic features we signed the case out as a botryoid odontogenic cyst. botryoid odontogenic cyst (boc) is a developmental, non-inflammatory odontogenic cyst derived from residual odontogenic epithelium such as the dental lamina.1,2 it occurs between the roots of erupted teeth and is typically multilocular. it represents less than 1% of odontogenic cysts. most cases occur in the sixth and seventh decades of life and a slight preponderance of males has been observed.1 other studies report an equal distribution between sexes.2 it most often occurs in the mandible anterior to the molars, particularly the incisive/canine and premolar regions.1,2 most bocs are asymptomatic and discovered incidentally on radiographs although occasionally bone expansion is observed.1 radiologically, bocs often present with a multilocular radiological appearance.2 this multilocular feature has been likened to a “bunch of grapes” (botryoid: from the greek botrys – bunch of grapes, and oeides – in the shape of ).3 creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. bilocular septated cyst cavity (asterisks) with an epithelial lining of varying thickness (arrow) (hematoxylin-eosin, 40x magnification). (hematoxylin – eosin , 40x) philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 7776 philippine journal of otolaryngology-head and neck surgery under the microscope references 1. speight p, fantasia je, neville bw. lateral periodontal cyst and botryoid odontogenic cyst. in: el-naggar ak, chan jkc, grandis jr, takata t, slootweg pj. who classification of head and neck tumors. iarc: lyon 2017 p.236. 2. chrcanovic br, gomez rs. gingival cyst of the adult, lateral periodontal cyst, and botryoid odontogenic cyst: an updated systematic review. oral dis. 2019 jan; 25(1): 26-33. doi: 10.1111/ odi.12808; pmid: 29156092. 3. goncalves r, ribeiro junior o, borba am, ribeiro anc, sugaya nn, guimaraes junior j. botryoid odontogenic cyst: case report with etiopathogenic, diagnostic and therapeutic considerations. rgo, rev. gaúch. odontol. 2015 july-sept; 63(3). doi: https://doi.org/10.1590/198186372015000300015618. 4. liu c, samani m, kwok j, sproat c. conservative management of botryoid odontogenic cysts using carnoy’s solution. br j oral maxillofac surg. 2020 feb; 58(2): 245-247. doi: 10.1016/j. bjoms.2020.01.014; pmid: 32005498. microscopically, the cyst locules are lined by a one-to-two cell thick non-keratinizing epithelium with plaque-like thickenings of cells in a whorled arrangement and connective tissue septa.1,3 cytoplasmic clearing may be observed because of glycogen.1 the differential diagnosis includes a lateral periodontal cyst (lpc) and a gingival cyst (gc). although their histological features are largely identical, a lpc is unilocular while a gc occurs in the alveolar ridge of infants.1-3 a boc is often considered a multilocular variant of lateral periodontal cyst.2,3 making this distinction however is more than just of morphologic interest but is important as bocs are reported to give rise to recurrences unlike lpcs and gcs.2,3 an ameloblastoma may be considered because of the multilocular appearance although the microscopic features are sufficiently distinct to rule out this entity. an adenomatoid odontogenic tumor (aot) may be considered because of the nodular thickenings with a whorled pattern. however, aot is a solid tumor characterized in addition by the presence of rosetteor duct-like spaces with dentinoid matrix. the recommended treatment is by enucleation.1 successful conservative management with carnoy’s solution has also been described.4 peripheral ostectomy has also been recommended – a more aggressive approach being proposed as appropriate to extirpate any residual lesion.3 recurrence has been stated to be between 15 to 30% which is largely ascribed to the multilocular characteristic of bocs and consequent difficulty of complete removal, or of larger lesions.1-3 thus, appropriate follow-up of cases or adjunctive therapy after enucleation might be warranted.2,3 to the author’s awareness, this is the first locally reported case of boc after a search of local health research databases. figure 2. thin non-keratinizing epithelium (arrows) with plaque-like thickenings that are composed of cells with a whorled pattern (asterisks) (hematoxylin-eosin, 100x magnification). (hematoxylin – eosin , 100x) figure 3. thin non-keratinizing epithelium (arrow) with plaque-like thickenings of cells in a whorled pattern (asterisk) with variably clear cytoplasm (double arrow) (hematoxylin-eosin, 400x magnification). (hematoxylin – eosin , 400x) philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles philippine journal of otolaryngology-head and neck surgery 17 abstract objective: to study various etiologies of traumatic tympanic membrane perforation; evaluate the factors involved in healing of traumatic tympanic membrane perforation; and identify patients with perforations unlikely to benefit from conservative management. methods: design: prospective observational study setting: tertiary government medical college and hospital participants: 64 consecutive cases of traumatic tympanic membrane perforation seen over one year were followed for 3 months. perforations were assessed in terms of size, etiology, condition of edge and other associated factors or combinations of factors with regards to spontaneous healing using descriptive statistics and chi-square tests. results: of the 64 cases, 51 perforations healed while 13 did not. there were significant associations between tympanic membrane condition after 3 months and explosive mode of injury (χ2 = 23.30; p=.00001) as well as with size of perforation ((χ2 = 25.75; p=.00001). the risk of persistence of a tympanic membrane perforation was 34.57 times more among patients with a perforation size >50% compared to those with perforation size ≤50% [or-34.57 (6.28, 190.14); p= .00001]. combined, explosive etiology and perforation size >50% were significantly associated with non-healing ((χ2 = 37.60; p = .00001). there were no significant associations with the condition of the edge of the perforation and upper respiratory tract infection. conclusions: an explosive etiology and tympanic membrane perforation size >50% may be significant risk factors predicting non-healing of the perforation. risk stratification of patients having one or both of these risk factors with early intervention for those with both, and close monitoring for those with any one of these may lessen unnecessary morbidity. bigger multicenter future studies are necessary to confirm these initial findings. keywords: tympanic membrane perforation, tympanic membrane, risk factors, wound healing, early intervention traumatic perforation of the tympanic membrane is a commonly-encountered problem traumatic perforation of the tympanic membrane: etiologies and risk factors for healing and intervention rajarshi sannigrahi, mbbs1 debangshu ghosh, mbbs, ms (ent)1 jayanta saha, mbbs, ms (ent)2 sumit kumar basu, mbbs, ms(ent)1 1department of ear, nose, throat r.g. kar medical college kolkata, west bengal, india 2department of ear, nose, throat burdwan medical college burdwan, west bengal, india correspondence: dr. debangshu ghosh kalyan nagar (near k.g. school) p.o.-kalyan nagar, via-panshila dist.-24 parganas (north) kolkata-700112, west bengal, india phone: +91 903 833 6301 / +91 943 303 8925 email: ghoshdr.d777@ymail.com the authors declared that this represents original material that is not being considered for publication or has not yet been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to conflict of interest. philipp j otolaryngol head neck surg 2017; 32 (1): 17-22 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles 18 philippine journal of otolaryngology-head and neck surgery in our day-to-day ear, nose and throat (ent) practice. traumatic perforation can result from blunt or penetrating injuries. blasts, slaps, rapid airplane descent or deep-water diving can create a column of compressed air within the external auditory canal that can implode the tympanic membrane. penetrating injuries are mostly self-inflicted but may also be due to procedures like removal of wax or foreign bodies. in most studies, spontaneous healing of the tympanic membrane happens in about 80% of cases within 3 months of injury.1 thus, masterly inactivity is the standard mode of treatment for the first 3 months. but in doing so, patients are unnecessarily exposed to disabling symptoms (decreased hearing, discharge from ears) and the need to modify lifestyles for those 3 months. if we can identify the causes of failure of spontaneous tympanic membrane healing after traumatic perforation, we may be able to recommend early intervention and reduce morbidity. this paper aims to study various etiologies of traumatic tympanic membrane perforation; evaluate the factors involved in healing of traumatic tympanic membrane perforation; and identify the patients who are unlikely to benefit from conservative management so that early surgical intervention may be recommended. methods with institutional review board approval, this prospective observational study was conducted in the department of ent of our tertiary medical teaching institution in kolkata from january to december 2015. the inclusion criterion was a traumatic perforation of the tympanic membrane irrespective of time of presentation. patients with history of previous ear discharge or impaired hearing, ear surgery or chronic otitis media in the same ear and patients who were lost to follow up were excluded. a total of 64 patients were enrolled in the study. after obtaining a history in terms of perforation etiology and duration from occurrence to patient presentation, all patients underwent ent and general examinations. these included otoscopy, serial tuning fork tests (256, 512 and 1024 hz) followed by pure tone audiometry (pta) and impedance audiometry and examination under microscope (eum) in the operating theatre. the size, site and margin of the perforation were documented by taking photographs. (figure 1) all the patients were advised to keep their ear dry and follow up regularly every two weeks. all the patients were followed up serially up to three months. the perforation sizes were compared with the tympanic membrane using imagej v.1.47 (open source software, public domain). statistical analysis included descriptive statistics and chi-square test using epi info™ 3.5.3 (centers for diseases control and prevention, cdc, atlanta, ga, usa). figure 2. percentage of patients with perforation size (as percentage ≤50% or >50% of total tm surface area) versus healing of tympanic membrane. figure 3. percentages of patients and etiologies of perforation(explosive or non-explosive) versus condition of tympanic membrane(healed or perforated) after three months. figure 1. representative photographs. a. at presentation, showing a <50% dry, antero-inferior central perforation and b. unhealed after 3 months follow up. a b philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles philippine journal of otolaryngology-head and neck surgery 19 results sixty four (64) participants, 18 (28%) males and 46 (72%) females with a male : female ratio of 1:2.5 completed the study. their mean age was 27.85±12.05 years while the range was 7 – 67 years and median age of 25 years. most (82.8%) were between 15-44 years of age, significantly higher than that of other age groups (z = 9.27, p = .0001). (table 1) most of the perforations (51, 79.7%) healed within three months. among the 13 unhealed perforations, 6 developed ear discharge while the other 7 were dry. (table 2) according to size, 95.7% of the perforations ≤50% healed within 3 months while 84.6% of the perforations >50% remained unhealed at the end of 3 months. (table 3) chi-square test showed that there was a significant association between size of perforation and condition of the tympanic membrane after 3 months (χ2 = 25.75; p = .00001). the risk of persistence of a perforated tympanic membrane was 34.57 times more among patients with a perforation size >50% compared to patients with perforation size ≤50% [or-34.57 (6.28, 190.14); p = .00001]. (figure 3) most of the traumatic injuries were due to either explosive or non-explosive causes and none were iatrogenic or penetrating. in addition, majority (61.5%) of the persistent perforations after 3 months were from explosive followed by non-explosive (38.5%) injuries. (figure 4) the most common explosive injuries were from bomb blasts, and the most common non-explosive injuries were from a slap over the ear arising out of domestic violence. chi-square test showed a significant association between mode of injury and tympanic membrane condition after three months (χ2 = 23.30; p = .00001). ( table 3) there was no significant association between appearance of the perforation edges and healing of tympanic membrane perforation after 3 months (χ2 = 1.48; p = .47). the healed and perforated cases were more or less equally distributed for all types of perforation edges. (table 4) there was no significant association between upper respiratory tract infections (urti) and tympanic membrane healing after 3 months (χ2 = 1.83; p = .17). while 7.4% of cases with clinical evidence of urti did not heal within 3 months, 29.7% of cases with no clinical evidence of urti also did not heal within 3 months. (table 5) combinations of factors were also analyzed and explosive etiology and perforation size >50% were significantly associated with non-healing (χ2 = 37.60; p = .00001). (table 6) most of the persistent perforations after 3 months (53.8%) were those with perforations of >50% and explosive in etiology while 36.4% had perforations of >50% figure 4. bar graph showing distribution of persistently perforated and healed perforations based on combined factors (size of perforation ≤50% or >50% and explosive and non-explosive etiology). figure 5. sample measurement of area of perforation using image j software, where surface area of perforation, 6609/area of tm, 270503= <50%. table 1. age distribution age group (in years) number (n) percentage (%) <15 15-44 >44 total 6 53 5 64 9.4% 82.8% 7.8% 100.0% table 2. distribution of condition of tympanic membrane after 3 months healed persistent perforation with discharge dry perforation total 51 6 7 64 79.7% 9.4% 10.9% 100.0% tympanic membrane condition after 3 months number percentage (%) philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles 20 philippine journal of otolaryngology-head and neck surgery table 3. table showing healing of traumatic perforation of tm as a product of size and mode of injury factors condition of tm after 3 months healed perforated statistically significant (s) or not (ns) x2 value p-valuetotal 2 4.3 15.4 11 61.1 84.6 13 20.3 100.0 8 72.7 61.5 5 11.9 38.5 0 0.0 0.0 0 0.0 0.0 13 20.3 100.0 46 100.0 71.9 18 100.0 28.1 64 100.0 100.0 11 100.0 17.2 42 100.0 65.6 6 100.0 9.4 5 100.0 7.8 64 100.0 100.0 25.75 23.30 .00001 .00001 44 95.7 86.3 7 38.9 13.7 51 79.7 100.0 3 27.3 5.9 37 88.1 72.5 6 100.0 11.8 5 100.0 9.8 51 79.7 100.0 size of perforation ≤50% row% col % >50% row% col % total row% col % mode of injury explosive row% col % nonexplosive row% col % iatrogenic row% col % penetrating row% col % total row% col % s s table 4. table showing healing of traumatic perforation of tm as a product of appearance of its edge factors condition of tm after 3 months healed perforated statistically significant (s) or not (ns) x2 value p-valuetotal 3 12.5 23.1 5 26.3 38.5 5 23.8 38.5 13 20.3 100.0 24 100.0 37.5 19 100.0 29.7 21 100.0 32.8 64 100.0 100.0 1.48 .47 21 87.5 41.2 14 73.7 27.5 16 76.2 31.4 51 79.7 100.0 edges of perforation ragged row% col % everted row% col % inverted row% col % total row% col % ns table 5. table showing healing of traumatic perforation of tm due to effect of upper respiratory tract infection factors condition of tm after 3 months healed perforated statistically significant (s) or not (ns) x2 value p-valuetotal 2 7.4 15.4 11 29.7 84.6 13 20.3 100.0 27 100.0 42.2 37 100.0 57.8 64 100.0 100.0 1.83 .17 25 92.6 49.0 26 70.3 51.0 51 79.7 100.0 clinical evidence of urti yes row% col % no row% col % total row% col % ns and non-explosive etiology. only 7.7% of persistent perforations after 3 months had perforations ≤ 50% and explosive etiology and size of perforation ≤ 50% and non-explosive etiology combined. (figure 5) discussion trauma with its manifold manifestations is on an exponential rise in india given the diversity of political, cultural and social interests of its millions. this could be in form of assault, road traffic injury, domestic violence, industrial and sports injuries. this has significant economic and psychosocial impact at individual as well as national levels most of which is difficult to quantify. trauma to the ear can range from simple to complex cases like blunt trauma, laceration, or avulsion of part or all of the pinna; uncomplicated tympanic membrane perforation; dislocation of the ossicles; and longitudinal and transverse fractures of philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles philippine journal of otolaryngology-head and neck surgery 21 the petrous temporal bone with associated loss of inner ear and facial nerve function.2,3 the current study focused on tympanic membrane perforation as a consequence of trauma. while the management of the otologic complications of trauma are well validated, tympanic membrane perforation has been considered to be mostly a self-healing condition. almost all standard textbooks and previous large scale studies consider a ‘wait and watch’ policy of management for traumatic tympanic membrane perforation.4 however, there is still a subset of patients, albeit small, who will not spontaneously heal and tend to suffer increased morbidity for three months. our study attempts to identify this subset of patients who may benefit from early intervention based on certain risk factors, etiology and characteristics of the perforation. our focus was to propose criteria based on a set of parameters for identification of these patients. in our study the high ratio of females (72%) may likely be due to increased domestic violence, corroborating the findings of other indian studies.5 after 3 months of masterly inactivity, almost 80% (51) of the perforations healed spontaneously. among the 13 unhealed cases, 6 developed discharge, a marker of increased morbidity. other studies show similar rates of spontaneous healing.1 in this study, non-healing perforations had a direct and statistically significant correlation with >50% perforation, suggesting that there a 34.7 times greater chance of persistent perforation after 3 months when the perforation size is greater than 50% of the total tympanic membrane surface area. that larger perforations have less chances to heal spontaneously has also been shown by other studies.6 we used imagej software on photographs obtained during examination under microscope to calculate perforation size as a percentage of the size of whole tympanic membrane. (figure 6) the reliability of imagej software has been validated in a previous quantitative analysis of tympanic membrane perforations compared to blinded data on perforation area obtained independently from assessments by two trained otologists.7 in this study the mode of injury was classified as explosive, iatrogenic, non-explosive (blunt trauma) and penetrating in accordance with a standard textbook.4 of the 11 cases due to explosive injuries, 8 remained unhealed after three months of observation, and this was statistically significant. previous studies show up to 62% non-healing after traumatic perforation from explosive injuries like bomb blasts.8 there was no statistically significant association between the condition of perforated margins or urti and healing of the tympanic membrane in this study. there have been contradictory results regarding these findings in prior studies. whereas inverted or everted edges compared with no curled edges did not significantly affect healing rate9 and edge approximation of inverted edges had little benefit in improving the healing outcome,10 the results of another study showed a definite correlation of non-healing with curled edges.11 the relationship with urti was positively correlated in the study by griffin et al.6 and accelerated healing has been shown table 6. composite table showing healing of tm as a product of size of perforation, mode of injuries and combinations of these factors with their correlation coefficient and statistical significance factors condition of tm after 3 months healed perforated statistically significant (s) or not (ns) x2 value p-valuetotal 7 100.0 53.8 4 36.4 30.8 1 25.0 7.7 1 2.4 7.7 13 20.3 100.0 7 100.0 10.9 11 100.0 17.2 4 100.0 6.3 42 100.0 65.6 64 100.0 100.0 37.60 .00001 0 0.0 0.0 7 63.6 13.7 3 75.0 5.9 41 97.6 80.4 51 79.7 100.0 presence of combination of factors size of perforation >50% +explosive row% col % size of perforation >50% + non explosive row% col % size of perforation ≤50% + explosive row% col % size of perforation ≤50% + non explosive row % col % total row% col % s *s-significant, **ns-non-significant philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 22 philippine journal of otolaryngology-head and neck surgery original articles following treatment with antibiotics and nasal decongestants,12 but urti was found to have no correlation in the study of lou et al.13 our study categorized the non-healed cases into four groups based on combinations of statistically significant risk factors. all of the seven cases with >50% perforation and explosive causes of perforation remained unhealed after three months. in the 11 cases where perforation was >50% but the cause was not explosive, 4 cases remained unhealed. with perforation <50% and explosive cause, 1 out of 4 case remained unhealed. lastly, with perforation <50% and nonexplosive cause, only 1 out of 42 remained unhealed. these results show a statistical significant association of non-healing when a >50% perforation size and explosive cause are combined. this may provide a preliminary basis for stratification of patients into a high-risk group acknowledgement the authors would like to thank the principal, r.g. kar medical college, kolkata, india for allowing us to conduct the study. references 1. kristensen s. spontaneous healing of traumatic tympanic membrane perforations in man: a century of experience. j laryngol otol. 1992 dec; 106(12): 1037-50. pmid: 1487657. 2. ologe fe. traumatic perforation of tympanic membrane in ilorin, nigeria. nig j surg. 2002; 8 (1): 9-12. 3. toner jg, kerr ag. ear trauma. in: booth jb, kerr ag, groves j (editors). scott-brown’s otolaryngology. london: butterworth heinemann; 1997.p. 3/711-3/7/13. 4. sismanis aa. tympanoplasty: tympanic membrane repair. in: gulya aj, minor lb, poe ds (editors). glasscock–shambaugh surgery of the ear 6th edition. new york: pmph-usa; 2010. p 468. 5. sarojamma, raj s, satish hs. a clinical study of traumatic perforation of tympanic membrane. iosr-jdms. 2014 apr; 13(4): 24-28. 6. griffin wl jr. a retrospective study of traumatic tympanic membrane perforations in a clinical practice. laryngoscope. 1979 feb; 89 (2 part 1): 261-282. doi: 10.1288/00005537-19790200000009; pmid: 423665. 7. ibekwe ts, adeosun aa, nwaorgu og. quantitative analysis of tympanic membrane perforation: a simple and reliable method. j laryngol otol. 2009 jan; 123(1): e2. doi:10.1017/ s0022215108003800; pmid: 18940030. 8. miller is, mcgahey d, law k. the otologic consequences of omagh bomb disaster. otolaryngol head neck surg. 2002 feb; 126(2): 127-8. doi: 10.1067/mhn.2002.122186; pmid: 11870341. 9. lou zc, tang ym, yang j. a prospective study evaluating spontaneous healing of aetiology, size and type‐different groups of traumatic tympanic membrane perforation. clin otolaryngol. 2011 oct; 36(5): 450-460. 10. lou zc, wang yb. healing outcomes of large (> 50%) traumatic membrane perforations with inverted edges following no intervention, edge approximation and fibroblast growth factor application; a sequential allocation, three‐armed trial. clin otolaryngol. 2013 aug; 38(4): 289296. doi: 10.1111/coa.12135; pmid: 23731690 pmcid: pmc4234003. 11. shetty h, gangadhar ks. study of conservative treatment in traumatic perforation of tympanic membrane and its clinical outcome. iosr-jdms. 2015 aug; 14(8):21-23. 12. ng l, monagle k, monagle p, newall f, ignjatovic v. topical use of antithrombotics: review of literature. thromb res. 2015 apr; 135(4): 575-581. doi: 10.1016/j.thromres.2015.01.006; pmid:25704903. 13. lou zc, lou zh, zhang qp. traumatic tympanic membrane perforations: a study of etiology and factors affecting outcome. am j otolaryngol. 2012 sep-oct; 33(5): 549-55. doi: 10.1016/j. amjoto.2012.01.010; pmid: 22365389. having a combination of these factors who might benefit from early intervention while groups having any one of these risk factors alone may benefit from close and stringent monitoring. to the best of our knowledge, there have been no prior studies in english proposing a similar risk-stratification for patients. in conclusion, an explosive etiology and tympanic membrane perforation size >50% may be significant risk factors predicting nonhealing of the perforation. risk stratification of patients having one or both of these risk factors with early intervention for those with both and close monitoring for those with any one of these may lessen unnecessary morbidity. bigger multicenter future studies are necessary to confirm these initial findings. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 case reports philipp j otolaryngol head neck surg 2021; 36 (2): 40-43 c philippine society of otolaryngology – head and neck surgery, inc. single stage transoral cordectomy and medialization thyroplasty in early glottic squamous cell carcinoma: a case report joyce anne f. regalado-go, md terrence jason flores, md al e. santiago, md department of otolaryngology-head and neck surgery ‘amang’ rodriguez memorial medical center correspondence: dr. al e. santiago department of otolaryngology-head and neck surgery ‘amang’ rodriguez memorial medical center sumulong highway sto, nino, marikina 1800 philippines fax: (632) 8941 3441 email: e-mail: doc_al_santiago@yahoo.com the authors declared that this presents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationship, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. presented at the 62nd pso-hns annual convention and ifhnos world tour held on october 22, 2018 at the manila hotel, philippines and at the philippine society of otolaryngology head and neck surgery 1st virtual surgical instrumentation contest (3rd place). november 25, 2020. abstract objective: to present the case of a 78-year-old man with glottic scca stage i who underwent single stage transoral cordectomy type iv with medialization thyroplasty under general anesthesia. methods: design: case report setting: tertiary government training hospital patient: one results: postoperatively, patient was able to phonate and gave a vhi score of 12 and grbas score of 4. he was able to resume oral feeding without any signs of aspiration. postoperative flexible laryngoscopy showed fully mobile vocal cords with good approximation in the midline. conclusion: this report suggests that vocal cord medialization via thyroplasty may be performed after cordectomy in a single stage, providing acceptable postoperative voice as well as good swallowing outcome. keywords: thyroplasty; laryngeal cancer; squamous cell carcinoma; glottis; vocal cord; cordectomy laryngeal squamous cell carcinoma (scca) is one of the most common malignancies of the head and neck. in the philippines, it ranked 17th with an incidence rate of 1% in both sexes, the 10th most common among men (3%), and the 21st among women (0.5%).1 with the advent of endoscopy, diagnosis of early (t1-t2) laryngeal scca enabled surgeons to manage these patients early in the course of the disease.2 with deeper knowledge of laryngeal compartmentalization as well as early diagnosis, the management of early glottic scca has shifted from total laryngectomy to larynx-preserving surgery.2 creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 case reports transoral cordectomy is the mainstay of treatment for early glottic scca. it provides excellent local control and laryngeal preservation.3 although it is considered superior compared to other modalities, it has its disadvantages. postoperative complications such as dysphonia and aspiration are correlated with the amount of tissue resected.4 type iii and iv cordectomy, which involve trans muscular approach and total cordectomy respectively, are associated with persistent dysphonia postoperatively.5 one way to address these postoperative complications is by medialization via type i thyroplasty.6 the current practice in applying this technique after cordectomy is to wait for at least 6 -12 months to allow for adequate wound healing as well as postoperative surveillance for tumor recurrence.4 however, during the interval prior to planned phonosurgery, patients may suffer from postoperative dysphonia and aspiration resulting in decreased quality of life and a higher incidence of complications. in this report, we present our case of a 78-year-old man diagnosed with stage i glottic scca (t1n0m0) who underwent transoral cordectomy type iv combined with medialization thyroplasty in a single stage approach. to the best of our knowledge, such procedures done in a single stage setting have not been previously reported. case report a 78-year-old man consulted at our out-patient clinic with a 6-month history of hoarseness and voice handicap index (vhi) of 46 with grbas score of 11 (g3r2b2a2s2) without any signs of dyspnea nor dysphagia. he was a known smoker and alcoholic beverage drinker with no familial history of carcinoma. indirect laryngoscopy revealed a white plaque on his left vocal cord. neck examination was unremarkable. laryngeal computed tomography (ct) showed a soft tissue prominence of the left glottic cord relative to the right with no enlarged lymph node seen. (figure 1) he underwent direct laryngoscopy with biopsy that showed a diffuse whitish plaque extending from the anterior to posterior part of the left true vocal cord and a white plaque at the anterior 1/3 of the right true vocal cord. (figure 2) histopathological report revealed keratinizing squamous cell carcinoma of the left vocal cord and squamous metaplasia on the right. we diagnosed glottic scca stage i (t1a n0 m0). a single stage transoral type iv cordectomy of the left with simultaneous medialization thyroplasty under general anesthesia was planned. our patient underwent cordectomy type iv under direct suspension laryngoscopy. while maintaining direct suspension, we proceeded with vocal cord medialization type i thyroplasty type using gore-tex implant (figure 3, 4) maintaining an intact inner perichondrium. postoperatively, our patient was able to phonate and resume oral feeding. no dyspnea nor aspiration were noted. postoperative flexible laryngoscopy showed figure 1. laryngeal ct scan with contrast, axial view, showing a soft tissue prominence of the left glottic cord relative to the right. figure 2. intraoperative direct laryngoscopy findings showing a diffuse whitish plaque at the anterior 2/3 of the left true vocal cord extending anteriorly, sparing the anterior commissure, and posteriorly, sparing the vocal process of the arytenoid. the white blob on the anterior 1/3 of the right true vocal cord was mucoid material that was easily removed with a cottonoid swab without any underlying mucosal findings. l, left; r, right; a, anterior; p, posterior. fully mobile vocal cords with good approximation in the midline on phonation. the patient was discharged on his 3rd hospital day. he was followed up every month based on the national comprehensive cancer network (nccn) guidelines. flexible endoscopy and fees done after 1 month (figure 5) and 3 months (figure 6) postsurgery yielded no aspiration and no tumor recurrence. on both philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 case reports occasions, a vhi score of 12 and grbas score of 4 (g1r1b0a1s1) was obtained showing significant improvement in dysphonia. discussion based on the nccn 2020 guidelines, the recommended treatment options for patients with early glottic scca (t1) include endoscopic/ open resection, partial laryngectomy, or radiotherapy.7 whereas different studies argue the superiority of one treatment modality over another, the choice depends on the patient’s wishes, anticipated functional outcome, reliability of follow-up, and general medical condition. these options were presented to the patient, and he opted for transoral cold steel cordectomy. transoral microsurgery is associated with several postoperative complications due to the extent of the surgical approach. resulting glottic incompetence causes dysphonia and aspiration.8,9 these complications are especially associated with type iv cordectomy, which includes complete cordectomy that extends from the vocal process to the anterior commissure, and type v cordectomy, which is an extended cordectomy encompassing a contralateral cord (type va) or the arytenoid (type vb).5 the incidence of postoperative aspiration occurs at a rate of 2.1% to 11.5% in various studies.10-14 these resulting complications are usually managed conservatively with voice therapy and speech rehabilitation. however, this only marginally attenuates complications due to the wide glottic gap resulting from the procedure. in these cases, medialization thyroplasty is commonly performed to ameliorate glottal closure.9 historically, type i thyroplasty or medialization thyroplasty which was popularized by isshiki is used in patients with disease causing imperfect closure of the glottis during phonation such as vocal cord paralysis or atrophy.6 recent applications of this procedure include the management of patients who develop postoperative dysphonia after cordectomy for laryngeal carcinoma.14 the timing of thyroplasty after cordectomy is usually 6-12 months to allow for scar maturation and for surveillance of tumor recurrence.9,14,16 moreover, maintaining an intact perichondrium is crucial to preserve laryngeal compartmentalization and intralaryngeal barriers.16,17 performing medialization thyroplasty after cordectomy is widely documented in literature.18,19 however, to the best of our knowledge, these two procedures have not been performed in tandem for early glottic scca, based on a search of herdin plus, the asean citation index (aci), the global index medicus western pacific region index medicus (wprim) and index medicus of the south east asia region (imsear), the directory of open access journals (doaj), pubmed medline, google scholar, and cochrane library using the keywords (“single-stage” and “cordectomy” and [“medialization thyroplasty” or “thyroplasty type i”]). figure 3. a. marking of tracheal window on the left thyroid cartilage; and b. tracheal window created, with intact perichondrium seen in the window. a, anterior; p, posterior; s, superior; i, inferior. a b figure 4. a. goretex implant inserted through the tracheal window allowing medialization of the remaining left glottis; and b. translaryngeal inspection via direct suspension laryngoscopy showing medialization of left glottis. a b figure 5. one-month postoperative flexible laryngoscopy showing mobile true vocal cords with a. good glottic closure; and b. full abduction; note pooling of saliva. a b figure 6. three-month postoperative flexible laryngoscopy showing fully mobile vocal cords with a. good glottic closure; and b. full abduction; no pooling of saliva noted. a b philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 case reports references 1. laudico av, mirasol-lumague mr, medina vm, mapua ca, valenzuela f, pukkala e. philippines cancer facts and estimates. philippine cancer society. available from: http://www.philcancer. org.ph/wp-content/uploads/2017/07/2015-pcs-ca-facts-estimates_can090516.pdf. 2. chawla s, carney as. organ preservation surgery for laryngeal cancer. head neck oncol. 2009 may 15;1:12. doi: 10.1186/1758-3284-1-12; pubmed pmid: 19442314; pubmed central pmcid: pmc2686690. 3. sigston e, de mones e, babin e, hans s, hartl dm, clement p, et al. early-stage glottic cancer: oncological results and margins in laser cordectomy. arch otolaryngol head neck surg. 2006 feb; 132(2):147-152. doi: 10.1001/archotol.132.2.147; pubmed pmid: 16490871. 4. bertelsen c, reder l. efficacy of type i thyroplasty after endoscopic cordectomy for earlystage glottic cancer: literature review. laryngoscope. 2018 mar;128(3):690-696. doi: 10.1002/ lary.26877; pubmed pmid: 29314074. 5. remacle m, eckel he,  antonelli a, brasnu d,  chevalier d,  friedrich g, et al. endoscopic cordectomy. a proposal for a classification by the working committee, european laryngological society. eur arch otorhinolaryngol. 2000; 257(4), 227-231. pubmed pmid: 10867840. 6. isshiki n, okamura h, ishikawa t. thyroplasty type i (lateral compression) for dysphonia due to vocal cord paralysis or atrophy. acta otolaryngol. 1975 nov-dec;80(5-6):465–473. doi: 10.3109/00016487509121353; pubmed pmid: 1202920. 7. national comprehensive cancer network® (nccn®) [homepage on the internet]. nccn guidelines (head and neck cancers) version 2020 cancer of the glottic larynx [cited 21 feb 2020]. available from: https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1437. 8. peretti g, piazza c, del bon f, mora r, grazioli p, barbieri d, et al.  function preservation using transoral laser surgery for t2–t3 glottic cancer: oncologic, vocal, and swallowing outcomes. eur arch otorhinolaryngol. 2013 aug;270(8):2275-81. doi: 10.1007/s00405-013-2461-9; pubmed pubmed pmid: 23568037. 9. piazza c, villaret ab, de zinis lor, cattaneo a, cocco d, peretti g. phonosurgery after endoscopic cordectomies. ii. delayed medialization techniques for major glottic incompetence after total and extended resections. eur arch otorhinolaryngol. 2007 oct;264(10):1185-90.  doi: 10.1007/ s00405-007-0330-0; pubmed pmid: 17534641. 10. galli a, giordano l, sarandria d, di santo d, bussi m. oncological and complication assessment of co2 laser-assisted endoscopic surgery for t1-t2 glottic tumours: clinical experience. acta otorhinolaryngol ital. 2016 jun;36(3):167-73. doi: 10.14639/0392-100x-643; pubmed pmid: 27214828; pubmed central pmcid: pmc4977004. 11. sjögren ev. transoral laser microsurgery in early glottic lesions.  curr otorhinolaryngol rep. 2017;5(1):56‐68. doi: 10.1007/s40136-017-0148-2; pubmed pmid:  28367361; pubmed central pmcid: pmc5357474. 12. estomba cmc, reinoso fab, velasquez ao, fernandez jlr, conde jlf, hidalgo cs. complications in co2 laser transoral microsurgery for larynx carcinomas. int arch otorhinolaryngol. 2016 apr;20(2):151-5. doi: 10.1055/s-0035-1569145; pubmed pmid:  27096020; pubmed central pmcid: pmc4835325. 13. roh jl, kim dh, park ci. voice, swallowing and quality of life in patients after transoral laser surgery for supraglottic carcinoma. j surg oncol. 2008 sep 1;98(3):184-9. doi: 10.1002/ jso.21101; pubmed pmid: 18561157. 14. ford cn, bless dm, prehn rb. thyroplasty as primary and adjunctive treatment of glottic insufficiency. j voice. 1992 jan 1; 6(3):277–285.  doi: https://doi.org/10.1016/s08921997(05)80154-7. 15. demir ul, çevik t, kasapoğlu f. is there a change in the treatment of t1 glottic cancer after co2 laser? a comparative study with cold steel. turk arch otorhinolaryngol. 2018 jun;56(2):64-69. doi:10.5152/tao.2018.3053; pubmed pmid: 30197801; pubmed central pmcid: pmc6123107. 16. sittel c, friedrich g, zorowka p, eckel he. surgical voice rehabilitation after laser surgery for glottic carcinoma. ann otol rhinol laryngol. 2002 jun;111(6):493-9. doi: 10.1177/000348940211100604; pubmed pmid: 12090704. 17. kirchner ja, carter d. intralaryngeal barriers to the spread of cancer. acta otolaryngol. may-jun 1987;103(5-6):503-13. pubmed pmid: 3618179. 18. kirchner jc, kirchner ja, sasaki ct. anatomic foramina in the thyroid cartilage: incidence and implications for the spread of laryngeal cancer. ann otol rhinol laryngol. 1989 jun; 98(6), 421– 425. doi:10.1177/000348948909800604; pubmed pmid: 2729824. 19. zapater e, oishi n, hernandez r, basterra j. medialization thyroplasty under intubation anesthesia to restore the voice after cordectomy. laryngoscope. 2016 jun;126(6):1404-7. doi: 10.1002/lary.25600; pubmed pmid: 26372050. in our case, we performed a single stage transoral cordectomy together with medialization thyroplasty and achieved good postoperative outcome. we believe that this combined technique is an acceptable option for the management of early stage glottic scca especially in patients who cannot tolerate or are unable to undergo a second stage procedure. more importantly, this combined technique may enable the surgeon to improve dysphonia immediately and simultaneously prevent if not eliminate aspiration symptoms post surgery. we hope that more cases will support our experience. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 30 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the patterns of neck node metastases of patients with laryngeal carcinoma in our institution. methods: design: chart review setting: tertiary public hospital participants: records of thirty-eight (38) laryngeal cancer patients who underwent laryngectomy with neck dissection from january 2010 to january 2017 were considered. results: records of 34 laryngeal cancer patients with ages ranging from 45-72 years old were included. the most common subsite was the glottis with 19 (55.88%) patients. the distribution of neck node metastases for all subsites were 0/64 (0%) for level i, 22/64 (34.37%) for level ii, 12/64 (18.75%) for level iii, 7/64 (10.93%) for level iv, 0/64 (0%) for level v, and 1/64 (1.56%) for level vi. distributions of lymph nodes per subsite for supraglottic scca were 0 (0%) for level i, 3/22 (13.63%) for level ii, 2/12 (16.66%) for level iii, 1/7 (14.28%) for level iv, 0 (0%) for level v, and 0/1 (0%) for level vi. for glottic scca, they were 0 (0%) for level i, 12/22 (54.54%) for level ii, 8/12 (66.66%) for level iii, 3/7 (42.85%) for level iv, 0 (0%) for level v, and 1/1 (100%) for level vi; and for transglottic scca, they were 0 (0%) for level i, 7/22 (31.81%) for level ii, 5/12 (41.66%) for level iii, 3/7 (42.85%) for level iv, 0 (0%) for level v, and 0/1 (0%) for level vi. conclusion: our findings show that neck node levels ii, iii and iv are most frequently affected in laryngeal carcinoma patients in our sample and may guide recommendations for neck dissection in our institution. keywords: laryngeal cancer, metastases, neck dissection, supraglottic, subglottic, glottic, transglottic lymph nodes may serve as barriers to the spread of tumor cells, as vehicles for progression of tumor spread within lymphatics, and as vehicles for progression of tumor spread from lymphatics to more remote sites.1 there are predictable pathways of lymphatic drainage within the subsites of the upper aerodigestive tract.2 neck dissection is a surgical procedure in head and neck cancers to either remove or prevent disease progression. the role of elective treatment of the neck in laryngeal cancer continues to be controversial and variations in type and extent of surgical dissection have evolved.3 a complete functional neck laryngeal cancer neck node metastases: patterns of spread mark jansen d. g. austria, md rodante a. roldan, md department of otolaryngology head and neck surgery rizal medical center correspondence: dr. rodante a. roldan department of otolaryngology head and neck surgery rizal medical center pasig blvd., pasig city 1600 philippines phone: (632) 865 8400 local 106 email: raroldan@rmc.doh.gov.ph / raroldanmd@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2017; 32 (1): 30-32 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles philippine journal of otolaryngology-head and neck surgery 31 discussion among the 34 laryngeal cancer patients who underwent total laryngectomy with neck dissection in our study, the most commonly involved lymph node groups were levels ii, iii and iv. the lymph node groups involved per laryngeal subsite in our sample were levels ii, iii, iv for supraglottic; levels ii, iii, iv,vi for glottic; and levels ii,iii,iv for transglottic cancer. supraglottic scca usually metastasizes to levels ii, iii and iv because of its rich lymphatic network and midline location that has a high propensity for bilateral lymph node involvement.5 the lymphatic channels from the supraglottis pass through the thyrohyoid membrane and drain into the jugular chain.5,6 the posterior cervical nodes (level v) are seldom involved, and submandibular (level ib) and submental (level ia) nodes are almost never involved.5 the results of our study are comparable to those of lindberg et al. where the main spread was along levels ii, iii and iv among 2,044 patients including supraglottic scca. our findings also echo those of candela et al.7 that revealed levels ii, iii and iv had the highest risk of nodal metastases from squamous cell carcinoma among 247 patients who underwent 267 neck dissections.7,8 on the other hand, the nodes at risk of metastasis from glottic scca are those in levels ii, iii, iv and vi.6 bilateral or contralateral metastases are rare because the true vocal folds are nearly devoid of lymphatics.5,6 it is interesting to note that patients with glottic scca who were operated on in our institution had multiple lymph node involvement (ii, iii, iv ) at the time of surgery. this may be explained by the fact that majority (52.63%) of glottic scca in our institution presented at stage 4a. on the other hand, our series had only one patient with level vi involvement. this is in contrast to the study of waldfahrer et al.9 that reported an incidence of occult metastases of 18%. though the reasons for this need to be investigated, one possible explanation may involve the diligence of the surgeon and pathologist in identifying and isolating level vi lymph nodes in the specimen, separating them from the primary tumor. dissection has been considered unnecessarily extensive for treatment of the clinically negative neck and therefore selective neck dissection is now routinely employed for elective and some therapeutic neck dissections in patients with laryngeal cancer.4 to guide our recommendations for neck dissection, the objective of this paper was to determine the pattern of neck node metastases of patients with laryngeal carcinoma in our institution. methods with ethical review board (erb) approval, a chart review of all patients with laryngeal carcinoma who underwent laryngectomy and neck dissection in the department of otolaryngology-head and neck surgery of rizal medical center from january 2010 to january 2017 was performed. the neck dissections done were either prophylactic or elective and the type of dissection was selective or modified radical. data was retrieved from the hospital records section and recorded using microsoft excel 2010 version 14.0.4760.1000 (32-bit) (microsoft corp., redwood, ca, usa). only the initials of patients were recorded to maintain confidentiality. records of 38 patients were initially considered but because of inadequate data and chart unavailability, 4 records were excluded. data obtained were gender, age, tnm staging, type and number of neck dissections performed and relative frequency of positive nodes in each nodal group for each subsite. descriptive statistics were generated using the same ms excel program. results the records of 34 patients who underwent total laryngectomy with neck dissection were included in our study (31 males, 3 females) with ages ranging from 45 to 72 years old. table 1 shows the tnm staging of our patients with most cases in stage 4 (58.82%). there were sixtyfour (64) neck dissections performed, sixty (60) selective and four (4) modified radical, thirty-two (32) on the right and thirty-two (32) on the left neck, respectively. the subsites involved were supraglottic in 5 (14.7%), glottic in 19 (55.88%) and transglottic in 10 (29.41%). the relative frequency of positive nodes in each nodal group for each subsite is shown in table 2. table 1. tnm staging tnm stage percentage (%)number of patients (n) i ii iii iva total 2 1 11 20 34 5.88 2.94 32.35 58.82 100.00 table 2. relative frequency of positive nodes in each nodal group for each subsite lymph node levels supraglottic (n/n) % glottic (n/n) % transglottic (n/n) % i ii iii iv v vi 0 (3/22) 13.63 (2/12) 16.66 (1/7) 14.28 0 0 0 (12/22) 54.54 (8/12) 66.66 (3/7) 42.85 0 (1/1) 100 0 (7/22) 31.81 (5/12) 41.66 (3/7) 42.85 0 0 philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 32 philippine journal of otolaryngology-head and neck surgery original articles references 1. aarsvold jn, alazraki np. update on detection of sentinel lymph nodes in patients with breast cancer. semin nucl med. 2005 apr; 35(2):116-28. epub 2005/03/15. doi: 10.1053/j. semnuclmed.2004.11.003; pmid: 15765374. 2. mukherji sk, armao d, joshi vm. cervical nodal metastases in squamous cell carcinoma of the head and neck: what to expect. head neck. 2001 nov; 23(11): 995-1005. epub 2002/01/05. pmid: 11754505. 3. ferlito a, rinaldo a, silver ce, robbins kt, medina je, rodrigo jp, et al. neck dissection for laryngeal cancer. j am coll surg. 2008 oct; 207(4):587-93. epub 2008/10/18. doi: 10.1016/j. jamcollsurg.2008.06.337; pmid: 18926464. 4. genden em, ferlito a, silver ce, jacobson as, werner ja, suarez c, et al. evolution of the management of laryngeal cancer. oral oncol. 2007 may; 43(5):431-9. epub 2006/11/23. doi: 10.1016/j.oraloncology.2006.08.007; pmid: 17112771. 5. cahlon o, lee n, le qt, kaplan mj, colevas ad. cancer of the larynx. in: hoppe r, phillips tl, roach iii m (editors). leibel and phillips textbook of radiation oncology 3rd ed. vol 2. philadelphia, pa; saunders. 2010; 31, 642-665. 6. armstrong wb, vokes de, verma sp. malignant tumor of the larynx. in: flint pw, haughey bh, lund vj, niparko jk, robbins kt, thomas jr, et al (editors). cummings otolaryngology head and neck surgery, 6th ed. vol 2. philadelphia (pa): mosby, c2010. p1613-1614. 7. candela fc, shah j, jaques dp, shah jp. patterns of cervical node metastases from squamous carcinoma of the larynx. arch otolaryngol head neck surg. 1990 apr; 116(4): 432-5. epub 1990/04/01. pmid: 2317325. 8. byers rm, wolf pf, ballantyne aj. rationale for elective modified neck dissection. head neck surg. 1988 jan-feb; 10(3): 160-7. epub 1988/01/01. pmid: 3235344. 9. waldfahrer f, hauptmann b, iro h. [lymph node metastasis of glottic laryngeal carcinoma]. laryngorhinootologie. 2005 feb; 84(2): 96-100. epub 2005/02/16. doi: 10.1055/s-2004-826075; pmid: 15712044. 10. santoro r, turelli m, polli g. primary carcinoma of the subglottic larynx. eur arch otorhinolaryngol. 2000 dec; 257(10): 548-51. epub 2001/02/24. pmid: 11195034. 11. coskun hh, medina je, robbins kt, silver ce, strojan p, teymoortash a, et al. current philosophy in the surgical management of neck metastases for head and neck squamous cell carcinoma. head neck. 2015 jun; 37(6):915-26. epub 2014/03/14. doi: 10.1002/hed.23689; pmid: 24623715 pmcid: pmc4991629. primary subglottic carcinoma is rare, constituting from 1-3.6% of the laryngeal cancers reported in the literature.10 paratracheal node (level vi) metastases are more frequent in patients with primary subglottic carcinoma.11 the rarity of primary subglottic carcinoma and late stage of presentation in our patients may have limited us from obtaining such cases. our study is limited to one type of carcinoma and by a small sample size. hence, we recommend future multi-center studies that include the experience of other institutions. moreover, though not a formal part of the study, we noticed that majority of our patients presented with cancer in later stages. while searching for and addressing underlying reasons for this, we should strengthen our head and neck cancer awareness and education programs for health promotion, disease prevention, and early detection. meanwhile, our findings that neck node levels ii, iii and iv are most frequently affected in laryngeal carcinoma patients in our sample may guide recommendations for neck dissection in our institution. philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 practice pearls during a discussion on temporal bone imaging, a group of resident trainees in otolaryngology were asked to corroborate the finding of a fracture in set of images that were supposed to be representative of a fracture involving the otic capsule.1 (figure 1) on the importance of proper window and level settings in temporal bone ct imaging nathaniel w. yang, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila department of otolaryngology head and neck surgery far eastern university nicanor reyes medical foundation institute of medicine correspondence: dr. nathaniel w. yang department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 8526 4360 fax: (632) 8525 5444 email: nathaniel.w.yang@gmail.com the author declared that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2020; 35 (2): 51-54 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international their comments included the following statements: “the image still does not clearly identify the fracture. it would have been better if the images were set to the optimal bone window configuration…” “the windowing must be of concern as well. the exposure setting for the non-magnified view is different from the magnified ones. one must observe consistent windowing in order to assess the fractures more accurately.” “…the images which demonstrate a closer look on the otic capsule areas are not rendered in the temporal bone window which makes it difficult to assess.” “…aside from lack of standard windowing…” figure 1. “ct image of the patient with otic-involved temporal bone fractures (thin arrows point to the evident fracture lines)” original figure legend from reference one published under a creative commons (cc by-nc-nd 4.0) license; edited to singular form. philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 practice pearls although stated in very general terms, these statements all refer to the concept of windowing, which is an important factor in computerized tomographic (ct ) imaging. the window setting (‘windowing’) impacts on the ability to demonstrate the presence or absence of a lesion. the objective of this article is to present to the otolaryngologist some basic concepts underlying ct imaging. particular emphasis will be placed on ct window and level settings and related concepts for non-radiologists in the interpretation and explanation of technical knowledge in the field of radiology. a reappraisal of the images in question based on the principles elaborated on will cap the discussion. in 1895, roentgen discovered x-rays and recognized its ability to variably penetrate or pass through objects, including parts of the human body, as captured on photographic plates and film.2 since then, man has been able to visualize internal body structures in images rendered in different shades of black and white. how a structure appears on a radiograph depends on how much of the x-ray beam is absorbed or attenuated by the structure in question before it reaches the detector. bones appear white because the calcium it contains absorbs or attenuates x-rays. fat and other soft tissues absorb less and thus look gray. air absorbs the least, so air filled structures like the lungs appear black (air filled normal mastoid air cells or paranasal sinuses appear grey, because these images actually pass through bony layers of the cranium). although the distinction between air and bone are strikingly obvious, conventional x-rays cannot distinguish between soft tissues, because the more subtle variations between structures like the liver and pancreas are not clearly discernible. since the radiograph records the mean absorption by all of the various structures that the x-ray penetrates, quantitative measurements for individual soft tissue structures is not possible.3 this problem was surmounted by the development of computed tomography, a radiologic imaging modality that combines narrow beams of x-rays with computer technology in order to produce a detailed, cross-sectional image of an object of interest. a standard radiograph reflects an image obtained by passing a single, uni-directional x-ray beam through the body. on the other hand, computed tomography measures the attenuation of x-ray beams passing through sections of the body from a multitude of different angles. these measurements are processed by a computer in order to reconstruct an image of the body’s interior and render it for viewing in greyscale on a monitor display.3 structures are depicted on ct images as varying shades of gray, depending on the characteristic absorption or attenuation pattern that each tissue exhibits when exposed to ionizing radiation. the hounsfield unit (hu) is a relative quantitative scale of radio density which is used to display the range of tissue densities when viewing a ct scan.3,4 figure 3. a. axial ct image of the mastoids on a “bone window” setting that extends the range of hu values to 4000. there is very little visually apparent difference in the appearance of the different soft tissue structures, including the brain, csf, orbital muscles, fat and orbital contents; and b. axial ct of the mastoids on a soft tissue window of 400 hu. note the clear delineation between the ocular muscles, periorbital fat, and intraocular soft tissues. the brain parenchyma and the csf cannot be visually distinguished because it requires an even narrower window to achieve sufficient tissue contrast. the scale is based on the density of water, which is arbitrarily defined to be zero hounsfield units. it then ranges from the density of air, which is defined as -1000 hu, to the density of bone at +1000 hu. the denser the tissue, the more positive its value on the hounsfield scale, and the brighter it appears on ct; the less dense the tissue, the more negative the value, and the darker it appears on the ct display.4 it can be seen from the scale of hounsfield units for the most common soft tissues in the human body (figure 2) that they occupy a very small portion of the entire scale, from around +20 to +40 hu for soft tissues and blood, to around -70 to -90 hu for fat. this represents a range of less than 150 hu. figure 2. the scale of hounsfield units (hu) adapted from hounsfield 19803 blood volume measurements bone 1, 00 0 99 0 98 0 60 50 40 30 20 10 -1 0 -2 0 -3 0 -4 0 -5 0 -6 0 -7 0 -8 0 -9 0 -9 80 -9 90 -1 ,0 000 tissue water fat air a standard monitor display like a cathode ray tube (crt) or liquid crystal display (lcd) computer screen can display 256 shades of gray from black to white. since the hounsfield scale contains 2000 units from +1000 hu to -1000 hu, each unit cannot be individually displayed on a monitor display. each of the 256 separate shades of grey would have to represent a range of hounsfield units, with a maximum of 7 hu (approximate value of 2000 divided by 256) represented by a single shade of grey. because of this, soft tissues whose representation in hounsfield units are very close to each other would be nearly indistinguishable when the display depicts the entire range from air to bone. (figure 3a, b) a b philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 practice pearls in order to address this issue, the range of hu values depicted by the greyscale display can be manipulated to represent a much narrower range of numbers along the scale. this involves adjusting the window width (ww), which in standard ct terminology for image reconstruction and display is defined as the range of ct numbers (hu) that are distributed over the viewable grey scale of the display device or film.5 by doing so, each of the 256 shades of grey can represent a much smaller range of hounsfield units, (figure 4) and thus, increase the contrast between structures with very similar hu values (figure 3 b). it does mean, however, that structures whose hu values lie outside of the range can only be depicted by being either very black or very white. appear on the darker side of the grey scale, while those whose hu numbers lie above will appear on the lighter side of the grey scale. thus, the appearance of a structure can appear to be darker or lighter on the monitor display depending on the window level, despite their natural appearance in relation to the entire hounsfield scale. how do these concepts relate to the images in question? they relate to the obvious differences in the visual appearance of the two images. these differences will be highlighted in the following example, where the window settings of a totally different temporal bone imaging study set at approximately the same anatomic level were manipulated to simulate the appearance of the images in question. figure 6a is an image set at the proper bone window setting for temporal bone studies, with a window width (ww) of 4000 and a window level (wl) or window center at 1000. the white arrow is pointing to a thin layer of bone that is clearly present overlying the figure 4. concept of window width. in this case, a range of only 400 hu is depicted by the grey scale display. each of the individual shades of grey represent less than 2 hu, thus increasing the contrast between structures with very close hu values. figure 5. a. axial ct of the temporal bone on a bone window setting (ww 4000 wl 1000). note that the head of the malleus (black dot) can be clearly delineated from the adjacent incus. the central bony island of the lateral semicircular canal (black star) can be clearly delineated from the canal lumen, which has a gray appearance due to its fluid content; and b. axial ct of the temporal bone on a soft tissue window (ww 400, wl 60). note that the head of the malleus (black dot) now appears as a homogenous white structure indistinct from the adjacent incus. the central bony island of the lateral semicircular canal (black star) and the surrounding canal lumen can no longer be distinguished from each other. *the ww and wl parameters are normally included in the information display of the dicom study and is usually found in a corner. depending on the imaging software, however, this information may be absent when viewing images in multiplanar reconstruction (mpr) mode. how does this relate to imaging structures within the temporal bone? it must be recognized that most of the important structures within the temporal bone are made of varying densities of bone surrounded by discrete pockets of air. since these two are on opposite sides of the spectrum, a very wide window is necessary in order to depict them properly. in fact, the ideal window setting for the temporal bone was extended to represent 4000 hu, in order to accommodate the wide range of hounsfield units that were subsequently discovered to represent the variations in bone density, which ranged from +700 for cancellous bone to +3000 hu for dense bone.6,7 an inappropriate window setting could render the fine structures within the temporal bone indistinguishable from each other. (figure 5a, b) another key concept is the window level (wl) or window center. this is defined as the midpoint of the range of ct numbers (hu) displayed.8 whatever lies at this level will appear in the middle of the greyscale, with those structures whose hu numbers lie below will a b philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 practice pearls references 1. lacanilao rc, chua rj. response from the authors. philipp j otolaryngol head neck surg. 2020 may; 35(1):81. doi: 10.32412/pjohns.v35i1.1261. 2. underwood ea. wilhelm conrad röntgen (1845–1923) and the early development of radiology proc r soc med. 1945 oct; 38(12): 697-706. doi: 10.1177/003591574503801214. pubmed pmid: 19993187, pubmed central pmcid: pmc2181457. 3. hounsfield gn. computed medical imaging. nobel lecture, december 8, 1979. j comput assist tomogr. 1980 oct; 4(5): 665-674. doi: 10.1097/00004728-198010000-00017. pubmed pmid: 6997341. 4. osborne t, tang c, sabarwal k, prakash v. how to interpret an unenhanced ct brain scan. part 1: basic principles of computed tomography and relevant neuroanatomy. south sudan med j. 2016 aug; 9(3): 67-69. 5. american association of physicists in medicine (aapm) working group on standardization of ct nomenclature and protocols. aapm ct lexicon version 1.3 04/20/2012. [cited 2020 oct 29] available from: https://www.aapm.org/pubs/ctprotocols/documents/ctterminologylexicon. pdf. 6. shaffer ka, volz dj and haughton vm. manipulation of ct data for temporal-bone imaging. radiology 1980 dec; 137(3): 825-829. doi: 10.1148/radiology.137.3.7444067. pubmed pmid: 7444067 7. bibb r, eggbeer d, paterson a. medical modelling: the application of advanced design and rapid prototyping techniques in medicine. 2nd edition. cambridge: woodhead publishing; 2015. doi: 10.1016/b978-1-78242-300-3.00002-0. 8. murphy a, et al. (co-authors not listed). windowing (ct). radiopaedia. [open-edit radiology resource on the internet] radiopaedia.org [cited 2020 oct 30] available from: https:// radiopaedia.org/articles/windowing-ct. round window niche. this image is similar to the larger, zoomed out view in the original images in question in figure 1. it can be seen that, like the original image, the cochlear lumen appears grey, as it contains fluid. figure 6 b appears to significantly transform the situation. by simply manipulating the window width (ww) to a much lower level close to 1000, but maintaining the window level (wl) or window center at 1000, the thin bone overlying the round window niche appears to have disappeared (white arrow), thus simulating the fracture supposedly identified in the magnified original image in figure 1. how can we be certain that the two images have similar settings? although the original image does not contain the window width and window level settings, two distinct features are obvious: the nearly homogenously white appearance of the bony structures, and the black appearance of the cochlear lumen. this appearance can be understood based on the figure 6. a. axial ct of the temporal bone on a bone window setting (ww 4000, wl 1000) set at approximately the same anatomic level as the original images in question. the white arrow points to a thin layer of bone overlying the round window niche; and b. axial ct of the temporal bone on an unconventional setting (ww near 1000, wl 1000). the white arrow points to the thin bone that appears to have disappeared, simulating the fracture identified in the original images in question. parameter changes. by decreasing the window width but maintaining the window level, a greater degree of contrast can be seen between thick bone and thin bone. as the midpoint did not change, the thin bone and the soft tissues within the cochlear lumen are now shifted to the lower spectrum of the grey scale and appear darker, thus explaining why the thin bone appears to have disappeared and the cochlear lumen appears black. this explains why a fracture can be misdiagnosed as being present when it actually does not exist. in summary, this exercise in image evaluation brings out the importance of evaluating images using the correct window width and window level settings. although computed tomographic imaging can allow visualization of even the tiniest bones in the human body with exquisite detail, these same details can be lost or misinterpreted by applying inappropriate imaging parameters. parameters that can be so easily manipulated by a simple swipe of a mouse or the click of a button. caveat utilitor! a b philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2020; 35 (1): 56-59 c philippine society of otolaryngology – head and neck surgery, inc. primary intraosseous carcinoma of the mandible: a case report gerard aga rafael g. doroy, md nilson l. gelbolingo, md department of otorhinolaryngology head and neck surgery vicente sotto memorial medical center correspondence: dr. gerard aga rafael g. doroy department of otorhinolaryngology vicente sotto memorial medical center b. rodriguez st., cebu city 6000 philippines phone: (032) 253 9174 fax: (032) 253 9174 e-mail address: gerard_dor@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. abstract objective: to present a rare case of primary intraosseous carcinoma arising from the mandible and to discuss the ensuing course and the management of the patient. methods: design: case report setting: general tertiary government training hospital patient: one result: a 56-year-old man consulted for a right mandibular mass of 4 months that started as a small bony swelling which gradually increased to its present size of 8 x 6 cm. incisional biopsy revealed invasive squamous cell carcinoma and the patient underwent segmental mandibulectomy and bilateral selective neck dissection (levels 1 to 3). final histopathologic findings revealed squamous cell carcinoma. conclusion: primary intraosseous carcinoma of the mandible was diagnosed since there was no overlying mucosal ulceration, other types of odontogenic carcinoma were ruled out, and no other distant primary tumor was noted from the time of examination until six months post-treatment. keywords: primary intraosseous carcinoma; squamous cell carcinoma; odontogenic tumor; epithelial rest of malassez; dental lamina primary intraosseous carcinoma (pioc) is a rare tumor of the jaw that is probably derived from the remnants of odontogenic tissue, either the epithelial rests of malassez or the remnants of the dental lamina.1 the world health organization (who) in 1972 suggested the term“ primary intraosseous carcinoma” and classified the lesion as an odontogenic carcinoma.2 this condition may arise in the confines of jaws either from a pre-exisiting epithelial lesion rather than a previous odontogenic cyst or de novo. there are cases of malignant transformation of odontogenic tumors or odontogenic cysts while primary intraosseous carcinoma arising de novo has been infrequently reported.2 the largest series identified 40 cases of de novo pioc between 1970 and 2004 with very few reported cases in asia and none from the philippines.3 to the best of our knowledge based creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery case reports on a search of herdin plus, medline (pubmed) and google scholar using the terms “mandibular primary intraosseous carcinoma” and “intraosseous mandibular carcinoma” there have been no reported cases of pioc in the philippines. we report one such case. case report a 56-year-old man from ormoc city, leyte consulted for a right mandibular mass. (figure 1) five years prior to admission, he noted carious first and second right mandibular molars associated with intermittent, mild to moderate, non-radiating, gnawing pain. he selfmedicated with mefenamic acid, 500 mg per tablet, thrice a day, as needed for pain. four months prior to admission, the patient finally had his carious teeth (nos. 29-30) extracted by a dentist. the surgery was apparently uneventful, with only mild swelling and bleeding of approximately three tablespoons, for which he was advised to apply pressure and take tranexamic acid 500 mg per tablet every eight hours for three days and amoxicillin 500 mg per tablet every 8 hours for one week. two weeks after extraction, the patient noted an enlarging mass over the right mandible just below the tooth extraction sites. the mass was approximately 1-2 cm in diameter, firm, non-tender, non-movable, irregular in shape, and accompanied by throbbing pain, swelling, and mildto moderate-grade fever with chills. the mass rapidly increased in size, prompting him to consult a general practitioner who prescribed clindamycin 300 mg per capsule every six hours for 7 days and celecoxib 200 mg per tablet every 12 hours as needed for pain. there was relief of pain and fever but the mass gradually became larger and more painful. the remaining unextracted teeth over the mass were not loose. there was no history of denture use prior to, or after the appearance of the mass. six weeks prior to admission, alarmed by the rapidly enlarging mandibular mass, the patient consulted another general practitioner who ordered an anteroposterior x-ray of the skull that revealed an extensive radiolucent lesion extending from the right mandibular angle to the left mandibular parasymphysis. (figure 2) a three-dimensional facial computed tomographic (ct) scan showed osteolytic destruction extending from the right mandibular angle to the left mandibular parasymphysis, and teeth 23-28 over the lesion appeared to be floating. (figure 3) the patient was then advised to see an ear, nose and throat (ent) specialist. three weeks prior to admission, the patient consulted our outpatient department and was found to have a firm 8 x 6 cm non-ulcerated, non-bleeding, non-tender, fixed, irregularly shaped mandibular mass, extending from the right mandibular angle to the left mandibular parasymphysis with poor dental hygiene. (figure 4) there were no figure 1. frontal and oblique photos showing right mandibular swelling. figure 4. intraoral 8 x 6 cm non-ulcerated, non-bleeding, non-tender, fixed, irregularly shaped mandibular mass, extending from the right mandibular angle to the left mandibular parasymphysis, with poor dental hygiene. the surrounding buccal mucosa and tongue were uninvolved and there was no trismus or malocclusion. figure 2. skull x-ray, anteroposterior view showing an extensive radiolucent lesion extending from the right mandibular angle to the left mandibular parasymphysis. figure 3. facial 3d reconstruction ct-scan showing osteolytic destruction extending from the right mandibular angle to the left mandibular parasymphysis; teeth no. 23-28 over the lesion appear to be floating. other lesions of the surrounding buccal mucosa and the tongue was uninvolved and fully mobile. no cervical lymph nodes were palpated at all levels on both sides. the patient exhibited neither trismus nor malocclusion. the past medical history, family history and personal and social history were non-contributory. an incision biopsy specimen was diagnosed as invasive squamous cell carcinoma, and the patient underwent segmental mandibulectomy from the right condylar neck to the left body with frozen section of the bony and soft tissue margins, application of steinmann pin, and bilateral philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery case reports figure 5a, b. intraoperative images, segmental mandibulectomy from the right condylar neck to the left body. c. gross specimen measuring 6 x 5 x 4.5 cm excised en bloc with 1.5 cm margins including ten mandibular teeth (nos. 20-28, 31). a b c selective neck dissection (levels 1 to 3) under general anesthesia. intraoperative findings revealed a firm 6 x 5 x 4.5 cm mass with irregular borders extending from the right angle of the mandible to the left parasymphysis. (figure 5 a, b) the mass and mandibular segment was excised en bloc with 1.5 cm margins including ten mandibular teeth (nos. 20-28, 31). (figure 5c) the surgery was uneventful with minimal blood loss and the patient had stable vital signs throughout. histopathological examination showed sections of malignant neoplasm composed of proliferating atypical squamous epithelial cells forming nests and sheets. the malignant cells had hyperchromatic to vesicular nuclei with prominent nucleoli, surrounded by moderate to abundant eosinophilic cytoplasm with defined borders. individual figure 6. histopathologic images, hematoxylin-eosin, a. low-power view (20x) showing island of epithelial cells, note the keratin pearls (arrow); and b. high-power view ( 40x) showing dysplastic features such as cellular and nuclear polymorphism (arrow) a b (hematoxylin – eosin , 20x) (hematoxylin – eosin , 40x) figure 7a. 6-month post-operative follow-up photo; and b. follow-up ap x-ray of mandible showing no signs of tumor recurrence a b keratinization and keratin pearls were observed. mitotic figures were rare. the supporting stroma was infiltrated with lymphocytes and plasma cells. all surgical margins were clear. histologically confirmed lymph nodes were all negative for metastasis and exhibited reactive lymph node hyperplasia. the final histopathological diagnosis was well-differentiated squamous cell carcinoma with all nodes negative for metastasis. (figure 6) the patient was discharged improved after the 7th post-operative day. no recurrence of the mass was been noted at follow-up 6-months post treatment. (figure 7a) there were no sequelae aside from mild difficulty in articulation. the steinmann pin was still in place with no signs of extrusion. (figure 7b) discussion primary intraosseous carcinoma (pioc) is defined as squamous cell carcinoma that originates from the odontogenic epithelium entrapped within the jaw with no connection to the surface oral mucosa.1 first described by loos in 1913, pioc occurs in adults in their sixth to seventh decade with a male to female ratio of 3:1 usually in the ramus of the mandible.1 the most common contributor is a reactive inflammatory stimulus with or without a predisposing genetic cofactor1 and the classic head and neck squamous cell carcinoma risk factors of alcohol, tobacco or betel-quid use are not usually found in pioc patients.2 in our patient, the possible stimulus may have been the recent extraction of his carious teeth. the clinical features in pioc include pain and swelling of the affected area as seen in our patient.2 in a pooled analysis of 33 cases recorded in literature performed by thomas et al., pain was the most common presenting feature in 17 (54.8%) followed by jaw swelling in 16 (51.6%) and sensory disturbances in five (16.1%), while nonspecific clinical findings may mimic inflammatory dental processes.3 thomas et al. also found that piocs have varied radiographic findings such as cup or dish-shaped patterns, well-defined lesions, small radiolucent loculations and poorly-defined moth-eaten appearance. 3 there are previous reports of patients in whom dental procedures (extractions and denture adjustments) were performed in an attempt to resolve the symptoms associated with the neoplasm4 although our patient’s pain and jaw swelling began following extractions. radiographic examination is one of the most effective methods for detecting piocs.5 a ct scan is ideal for diagnosis but panoramic radiography is a simple but effective, low-cost alternative that can be used instead.5 a lesion that is completely surrounded by bone can be regarded as one of intraosseous origin,5 and primary intraosseous carcinomas exhibit radiolucencies with a wide variation in size and shape.6 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery case reports histologically, pioc’s vary from well-differentiated tumors exhibiting significant keratinization to non-keratinizing poorly differentiated carcinomas.5 primary intraosseous carcinoma is currently managed by wide surgical resection.7 aggressive surgical treatment comprising a segmental mandibulectomy with reconstruction is the best therapeutic option, either solely or in combination with radiotherapy or chemotherapy.7 segmental resection or hemi mandibulectomy lead to significant patient morbidity.7 because loss of mandibular support to the teeth, tongue, and lip causes dysfunctions of mastication, swallowing, speech, airway protection, and oral competence, other reconstructive procedures include bridging plates and distraction osteogenesis.8 other options include free autologous bone grafts fixed with miniplates; post-operative radiotherapy is feasible with titanium plates.8 radiotherapy and chemotherapy are never used alone for treatment9 and should be considered only for lesions that cannot be surgically controlled. however, the effectiveness of these modalities is unclear because of a low number of cases and documented follow-up.9 in their series of piocs, huang et al. found that multimodality therapy did not improve the outcome of surgery alone.10 the tumor may metastasize to cervical lymph nodes, with nodal metastasis in pioc reported to be as high as 50% in some series (and even be the first manifestation of the neoplasm).10 a series of 17 pioc patients undergoing elective neck dissection demonstrated occult metastases in levels i (53.3%), ii (40%), and iii (6.7%); hence, prophylactic selective neck dissection is recommended even in an n0 neck11 as performed in our patient. the prognosis of pioc is generally poor. of 12 cases of de novo pioc reported by elzay, a 40% two-year survival rate was noted with a reported survival time of only 13 months after initial diagnosis.12 however, we have yet to document the long-term outcome for our patient. in conclusion, our experience teaches us that in a patient presenting clinically with asymptomatic swelling of jaw of long duration and a radiographically ill-defined osteolytic lesion, pioc should be considered. in our case, primary intraosseous carcinoma of the mandible was diagnosed as there was no overlying mucosal ulceration, other types of odontogenic carcinoma were ruled out, and no other distant primary tumor was noted from the time of examination until six months posttreatment. as physicians, early diagnosis of pioc is a valuable service we can perform. hence, accurate knowledge of this rare entity is must to prevent delayed diagnosis. references 1. punnya a, kumar gs, rekha k, vandana r. primary intraosseous odontogenic carcinoma with osteoid/dentinoid formation. j oral pathol med. 2004 feb;33(2):121–4. doi: 10.1111/j.16000714.2004.00029.x. pubmed pmid: 14720199. 2. chaisuparat r, coletti d, kolokythas a, ord ra, nikitakis ng. primary intraosseous odontogenic carcinoma arising in an odontogenic cyst or de novo: a clinicopathologic study of six new cases. oral surg oral med oral pathol oral radiol endod 2006 feb; 101(2): 194-200. doi: 10.1016/j. tripleo.2005.03.037. pubmed pmid: 1644892. 3. thomas g, pandey m, mathew a, abraham ek, francis a, somanathan t, et al. primary intraosseous carcinoma of the jaw: pooled analysis of world literature and report of two new cases. int j oral maxillofac surg. 2001 aug;30(4):349-55. doi: 10.1054/ijom.2001.0069. pubmed pmid: 11518362. 4. to eh, brown js, avery bs, ward-booth rp. primary intraosseous carcinoma of the jaws. three new cases and a review of the literature. br j oral maxillofac surg. 1991 feb;29(1):19-25. doi: 10.1016/0266-4356(91)90168-5. pubmed pmid: 2004071. 5. suei y, tanimoto k, taguchi a, wada t. primary intraosseous carcinoma: review of the literature and diagnostic criteria. j oral maxillofac surg 1994 jun; 52(6): 580-3. doi: 10.1016/02782391(94)90094-9. pubmed pmid: 8189294. 6. kochaji n, goossens a, bottenberg p. central mucoepidermoid carcinoma: case report, literature review for missing and available guideline proposal for coming case reports. oral oncol extra 2004 sep-oct;40(8-9):95-105. doi: 10.1016/j.ooe.2004.06.001. 7. waldron ca, mustoe ta. primary intraosseous carcinoma of the mandible with probable origin in an odontogenic cyst. oral surg oral med oral pathol. 1989 jun;67(6):716-24. doi: 10.1016/0030-4220(89)90014-5. pubmed pmid: 2662106. 8. gonzález-garcía r, sastre-pérez j, nam-cha sh, muñoz-guerra mf, rodríguez-campo fj, naval-gías l. primary intraosseous carcinomas of the jaws arising within an odontogenic cyst, ameloblastoma, and de novo: report of new cases with reconstruction considerations. oral surg oral med oral pathol oral radiol endod. 2007 feb;103(2):e29-33. doi: 10.1016/j. tripleo.2006.08.007. pubmed pmid: 17095253. 9. wood k, goaz p. differential diagnosis of oral and maxillofacial lesions 5th ed. new york: mosby, 1997. 10. huang jw, luo hy, li q, li tj. primary intraosseous squamous cell carcinoma of the jaws. clinicopathologic presentation and prognostic factors. arch pathol lab med. 2009 nov;133(11):1834-40. doi: 10.1043/1543-2165-133.11.1834. pubmed pmid: 19886720. 11. shear m. primary intra-alveolar epidermoid carcinoma of the jaw. j pathol. 1969 apr;97(4):645– 51. doi: 10.1002/path.1710970409. pubmed pmid: 5354042. 12. anneroth g, hansen ls. variations in keratinizing odontogenic cysts and tumors. oral surg oral med oral pathol. 1982 nov;54(5):530-46. doi: 10.1016/0030-4220(82)90192-x. pubmed pmid: 6184661. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the stage of middle ear cholesteatoma of patients who underwent middle ear surgery at the southern philippines medical center from january to december 2019, based on european academy of otology and neurotology / japan otological society (eaono/ jos) system. methods: design: case series setting: tertiary government training hospital participants: a total of 42 charts were included in the study results: of the 42 cases evaluated, congenital cholesteatoma was seen in 4 while acquired cholesteatoma was noted in 38, (further subdivided into 34 retraction pocket cholesteatoma and 4 non-retraction pocket/traumatic cholesteatoma). a majority (57%) had stage ii cholesteatoma (mass occupying at least two sub-sites in the middle ear) at the time of surgery. eight (19%) had stage i cholesteatoma (confined to one sub-site), five (12%) had stage iii cholesteatoma evidenced by extracranial complications such as subperiosteal abscess and erosion of the semicircular canals. stage iv cholesteatoma was seen in 5 (12%) presenting with intracranial abscess. canal wall down mastoidectomy was the most common surgical approach performed. the sinus tympani (s 2 ) was the most commonly involved difficult to access site across all classifications of middle ear cholesteatoma (60%). conclusion: our study provided an initial profile of the stages and severity of middle ear cholesteatoma in our institution based on actual surgical approaches. such a profile can be the nidus for a database that can help us to understand disease prevalence and compare local surgical practices with those in the international community. keywords: cholesteatoma, aural; cholesteatoma, middle ear; cholesteatoma, middle ear*/ classification; cholesteatoma, middle ear*/diagnosis; cholesteatoma, middle ear*/surgery classification and stages of middle ear cholesteatoma at the southern philippines medical center using the european academy of otology and neurotology / japan otological society (eaono / jos) system dominador b. toral, md chris robinson d. laganao, md department of ear nose throat head and neck surgery southern philippines medical center correspondence: dr. chris robinson d. laganao department of ear, nose, throat head and neck surgery southern philippines medical center bajada, davao city 8000 philippines phone: +63 916 539 5589 / +63 923 835 3675 email: dmc_ent@yahoo.com the authors declared that this presents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and the author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationship, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest 2020 (2nd place), 21 october 2020. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philipp j otolaryngol head neck surg 2021; 36 (1): 24-27 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery original articles cholesteatoma is benign growth of keratin tissue in the middle ear cavity. typically, patients present with chronic ear discharge and sometimes, hearing loss, and imbalance, depending on the anatomical extent of bony erosion by the cholesteatoma.1 the global estimate of the incidence of middle ear cholesteatoma reaches up to approximately 9 to 12.6 cases per 100,000 adults and from 3 to 15 cases per 100,000 children.2 in the philippines, the disease prevalence is estimated at 4.2% but is feared to be much higher though underreported due to health economic reasons.3 attempts have been made in the past to classify or categorize cholesteatoma and propose a clinically acceptable and practical staging system.4 in 2017, the european academy of otology and neurotology and the japan otological society published the eaono/jos joint consensus statements on the definitions, classification and staging of middle ear cholesteatoma in an attempt to finally create a uniform system of staging that would be recognized globally.1 however, to the best of our knowledge, based on a search of herdin plus, the asean citation index, and the global index medicus western pacific region index medicus, the eano/jos definitions, classifications, and staging have not been applied locally in the philippines. this study used the eano/jos classification system to determine the stage of middle ear cholesteatoma of patients who underwent middle ear surgery at the southern philippines medical center from january to december 2019 in order to provide a profile of the severity of cases and the surgical approaches used to address the extent of the disease in our institution. it is hoped that with the uniformity of the classification and staging system, surgical approaches and results can be compared as the disease process is understood even further. methods with department of health xi cluster ethics review committee (doh xi cerc) approval (p20021701), this case series searched the southern philippines medical center hospital information database from january 2019 to december 2019 for cases of cholesteatoma and the respective patient charts were retrieved from the medical records section. records of all patients who underwent middle ear surgery for cholesteatoma during the study period were considered for inclusion. charts of patients who were admitted for reasons other than surgery of the middle ear, or who were re-operated on the ipsilateral side were excluded. completeness of each chart was assessed in terms of history information sheet, diagnostic examinations, surgical memorandum, and intraoperative findings. results of ancillary procedures and diagnostic examinations not present in the chart (such as audiology records) were retrieved from the appropriate department archive. the demographic profile (age, gender, otologic history including the chief complaint and onset of symptoms), relevant diagnostic procedures, surgical memorandum and technique were extracted from each chart and filled into a data gathering tool specifically constructed for this study. the stage of middle ear cholesteatoma was determined on each chart using the eaono/jos system. based on this system, middle ear cholesteatoma was staged i when only one primary site was affected. for pars flaccida cholesteatoma, stage i meant that the cholesteatoma formation was limited only to the attic. for congenital cholesteatoma, the mass should be seen behind an intact tympanic membrane. if cholesteatoma formation was due to pars tensa perforation, stage i denoted presence of cholesteatoma only in the tympanic cavity. stage ii cholesteatoma meant more than 1 primary site was affected. for pars flaccida cholesteatoma, stage ii meant that either the tympanic cavity or mastoid antrum was also filled with keratin. for pars tensa cholesteatoma, stage ii meant involvement of the attic and difficult access sites such as the supratubal recess and sinus tympani. stage iii cholesteatoma meant that extracranial extension was evident intraoperatively, and manifestations of extracranial extension may have been present preoperatively (e.g. ipsilateral facial nerve palsy, dizziness and balance disorders) as well as abscess formation in the parotid, posterior auricular area, and sternocleidomastoid muscle. stage iv cholesteatoma implied associated intracranial complications such as abscess and purulent meningitis, otitic hydrocephalus and lateral sinus thrombosis. (figure 1) the surgical memoranda and operative techniques recorded the extent of cholesteatoma and evaluated important anatomic structures in reference to the eaono/jos classification system which includes the difficult site (s), tympanic cavity (t), attic (a), and mastoid (m). the difficult access sites are further subdivided into s1, supra tubal recess and s2, sinus tympani. (figure 2) these findings were collated in our data gathering tool. data was tabulated and means and frequencies were computed using microsoft excel® for mac version 16.16.27 (microsoft corp. redmond, wa, usa). figure 1. schematic drawing of the clinical classification of middle ear cholesteatoma used in the eaono/jos consensus statement (adapted from reference 1). philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles results our initial hospital database search revealed 96 records of patients with cholesteatoma admitted during the study period. fifty (50) records of those admitted due to a medical reason other than surgery of the middle ear were excluded. of the 46 remaining records of mastoidectomy done in 2019, four more were excluded due to reoperation on the ipsilateral ear. the 42 remaining charts were checked for completeness including the surgical memorandum and intraoperative findings. ancillary and diagnostic procedures not present in the charts were retrieved from the audiology records kept in the department. all 42 records qualified and were included in this study. twenty-nine (69%) were in the 18 to 40-year-old age bracket. there were eight (19%) minors (<18 years old) and five (12%) older than 40. there were 20 males (48%) and 22 females (52%) females. slightly over half were single (22; 52%). the most common chief complaint was ear discharge (20; 48%) followed by hearing problems (18; 43%) and ear pain (4; 10%). twenty five (60%) reported symptoms for more than 5 years, 14 (33%) had symptoms for more than one year, and three (7%) had symptoms for less than a year. none of the patients had normal hearing thresholds. most (15; 36%) had moderate conductive hearing loss, nine (21%) had severe conductive hearing loss, and three (7%) had mild conductive hearing loss. twelve (29%) had profound sensorineural hearing loss, with no cases of mild, moderate or severe sensorineural hearing loss. there were two (5%) cases of moderate mixed hearing loss and one (2%) case of severe mixed hearing loss. thirty-eight (90%) had flat (type b) tympanometry results, three (7%) had “type a” tympanograms, and one (2%) had a “type as” tympanogram. there were four (9%) congenital cholesteatomas (based on preoperative description of intact tympanic membrane with no history of trauma or ear discharge) and 38 (90%) acquired cholesteatomas. of these, retraction pocket cholesteatoma was seen in 34 (81%), while non-retraction pocket cholesteatoma was noted in the remaining four (9%). in terms of the type and approach of middle ear surgery, two out of four cases (50%) of congenital cholesteatoma were managed thru canal wall down mastoidectomy, while two other cases were through transcanal approach. all four cases of congenital cholesteatoma were stage iii, of which three (75%) presented with post auricular subperiosteal abscess formation. among the 34 cases of retraction pocket cholesteatoma, canal wall down mastoidectomy was the most common surgical approach (22 out of 34 cases). canal wall up mastoidectomy was performed in 5 cases of stage i and in 4 cases of stage ii retraction pocket cholesteatoma. transcanal approach was also performed in 2 cases of stage i and 1 case of stage ii retraction pocket cholesteatoma. for the four non-retraction pocket cholesteatomas, a trans-canal approach was performed for one stage i and one stage ii case each, a canal wall up procedure for the other stage ii case, and a canal wall down approach for the single stage iv case. the sinus tympani (s 2 ) was the most commonly involved difficult to access site across all the classifications of middle ear cholesteatoma. it was noted to be involved in 25 cases (60%) overall. the supra-tubal recess (s 1 ) was involved in 14 cases (33%). overall, 24 cases (57%) were stage ii (cholesteatoma occupying at least two subsites in the middle ear cleft). stage i cholesteatoma (confined to one subsite only) was seen in 8 patients (19%), and stage iii (extracranial complications) and iv (intracranial complications) cholesteatomas were seen in 5 patients (12%) each. discussion a cholesteatoma is a benign mass in the middle ear cavity composed of keratin debris capable of erosion of adjacent bony structures. the extent of cholesteatoma dictates the morbidity it can cause and may range from hearing loss, ear discharge, and ear pain to intracranial extension. in 2017, the european academy of otology and neurotology (eaono) and the committee on nomenclature of the japan otological society (jos) agreed on a practical system of classification generally accepted by otogists/neurotologists internationally.1 even so, the application of such a classification is still in its early stages. the majority of patients (69%) in this present study were in the 18 to 40-year-old range. this finding parallels the finding that most patients (60%) had long-standing ear complaints. their age on admission may be indicative of the period when they finally gave significance to their ear complaints or achieved sufficient economic means to seek medical consult.2,5 the nature of cholesteatoma is often insidious. in most cases, the ear complaints start as a minimal ear discomfort associated with upper respiratory tract infections that often resolve spontaneously. over figure 2. schematic drawing of the clinical classification of middle ear cholesteatoma used in the eaono/jos consensus statement (adapted from reference 1). philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles references 1. yung m, tono t, olszewska e, yamamoto y, sudhoff h, sakagami m, et al. eaono/jos joint consensus statements on the definitions, classification and staging of middle ear cholesteatoma. j int adv otol. 2017 apr;13(1):1-8. doi: 10.5152/iao.2017.3363 pubmed pmid: 28059056. 2. kuo c-l, shiao a-s, yung m, sakagami m, sudhoff h, wang c-h, et al. updates and knowledge gaps in cholesteatoma research. biomed res int. 2015;2015:854024. doi: 10.1155/2015/854024 pubmed pmid: 25866816 pubmed central pmcid: pmc4381684. 3. chan kh, dreith s, uhler km, tallo v, lucero m, de jesus j, simões e. large-scale otoscopic and audiometric population assessment: a pilot study. int j pediatr otorhinolaryngol. 2019 feb;117:148-152. doi: 10.1016/j.ijporl.2018.11.033 pubmed pmid: 30579070 pubmed central pmcid: pmc6338678. 4. linder te, shah s, martha as, röösli c, emmett sd. introducing the “chole” classification and its comparison to the eaono/jos consensus classification for cholesteatoma staging. otol neurotol. 2019 jan; 40(1):63-72. doi: 10.1097/mao.0000000000002039 pubmed pmid: 30339650. 5. tono t, sakagami m, kojima h, yamamoto y, matsuda k, komori m, et al. staging and classification criteria for middle ear cholesteatoma proposed by the japan otological society. auris nasus larynx. 2016;44(135-140). doi: 10.1016/j.anl.2016.06.012 pubmed pmid: 27616746. 6. chole r. chronic otitis media, mastoiditis, and petrositis. in: flint pw, haughey b, lund v, niparko k, lesperance m, thomas robbins k, regan thomas j, editors. cummings otolaryngology head and neck surgery. 6th ed. philadelphia: elsevier inc; 2015.p.2139-2155. 7. lee kj. audiology. in: lee kj, chan y, das s, editors. essential otolaryngology head and neck surgery. 10th ed. new york: mcgraw-hill; 2012. p.24-67. succeeding episodes of recurrent nasal congestion, infection may set in and discharge from the ear can be a harbinger of a more chronic otologic pathology. repetitive infection can cause mucosal inflammation in the middle ear mucosa that favors the formation of cholesteatoma.6,7 ear discharge (48%) followed by hearing problems (43%) were common chief complaints of patients coming to the hospital. although ear pain may comprise only 10% as chief complaint overall, the presence of ear pain was more often associated with more advanced staged middle ear cholesteatoma. patients with extracranial and intracranial complications of cholesteatoma present symptoms such as posterior auricular abscess (stage iii), or neck pain from meningitis (stage iv). hearing difficulty on the background of cholesteatoma is an important predictor of the prognosis of the patient. when cholesteatoma has eroded the middle ear ossicles, mechanical conduction of sound would be affected. this can be seen as a conductive hearing loss on the pure tone audiogram (pta) and varies depending on the severity i.e. mild, moderate, severe. when the cholesteatoma is large enough to erode even the bony cochlea, the pta would reflect a profound hearing loss.7 in this study, most patients (36%) had a moderate conductive hearing loss, while profound hearing loss was found in 29%. theoretically, profound hearing loss can be difficult to reverse and the indication of surgery is geared towards disease elimination and not necessarily hearing conservation. meanwhile, mixed hearing loss is a combination of both conductive and sensorineural causes. mixed hearing loss was documented in 3 patients in this study, 2 (5%) moderate and 1 (2%) severe. an organic sensorineural hearing loss seen especially among individuals above 40 years old coupled with the formation of cholesteatoma produces a mixed-type hearing loss on pta. 6,7 furthermore, tympanometry studies showed fairly predictable results. tympanometry is a test that determines the mobility of the tympanic membrane in response to pressure changes. it is designated as “a” when the tympanic membrane is mobile, “as” when it is stiff, “ad” when it is lax, “b” when it is flat/fixed, and “c” when it is retracted.7 a type b tympanogram is more consistent with cholesteatoma because it implies that the tympanic membrane does not move because of the space-occupying lesion behind it. in this study, an overwhelming 90% of the ears had type b tympanograms. although not found in our sample, a type c tympanogram suggests eustachian tube dysfunction, an important early pathophysiologic culprit of cholesteatoma formation.6,7 the participants in our study had more advanced disease than the earlier-stage eustachian tube dysfunction that would have been reflected by a type c tympanogram. findings of this study support our experience that patients with cholesteatoma seek consult only when symptoms become troublesome, which coincides clinically with stage ii disease. symptom tolerance is a significant factor that may explain why early stage disease is uncommonly seen in our department. indeed, stage iii and stage iv diseases often present with sequela of long standing ear disease such as meningitis or abscesses in the posterior auricular area and neck. our results may vary from those of other institutions should they replicate the methods used in our series. factors such as the general economic status of their sample population may alter the frequency distribution of cholesteatoma stages. when ear complaints are not given priority until symptoms of intracranial symptoms are evident, then stage i and ii diseases may not even be documented. nevertheless, this study needs to be continued so that future cases of cholesteatoma are appropriately documented. a more appropriate study design would be a prospective multicenter study, using a uniform comprehensive case report form. even if an international database is not yet available, we highly recommend that the eano/jos definition, classification, and staging system be used in all otorhinolaryngology residency training institutions in the country to provide comparative data on disease stages, surgical approaches and outcomes. in conclusion, our study provided an initial general profile of the stages and severity of cholesteatoma in our institution based on actual surgical approaches. such a classification and staging of middle ear cholesteatoma can serve as the nidus for a database of cholesteatoma classification and staging in our institution that can help us to understand the disease prevalence and compare local surgical practices with those in the international community. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2021; 36 (1): 41-44 c philippine society of otolaryngology – head and neck surgery, inc. self-inflicted craniofacial impalement injury with a screwdriver during the covid-19 pandemic: a case report jl jane g. gatela, md department of otorhinolaryngology head and neck surgery east avenue medical center correspondence: dr. jl jane g. gatela department of otorhinolaryngology head and neck surgery 6th floor, east avenue medical center east avenue, diliman, quezon city 1100 philippines phone: (632) 8928 0611 local 324/ (632) 906 230 4704 email: eamc_enthns@yahoo.com jljane.gatela@gmail.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believe that the manuscript represents honest work. disclosures: the author signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery 1st virtual covid-19 research forum. november 18, 2020. abstract objective: to present a case of a 37-year-old man presenting with craniofacial impalement injury from a screwdriver that happened during the early stages of the covid-19 pandemic. methods: design: case report setting: tertiary government training hospital patient: one results: during the early stages of covid-19 pandemic a 37-year-old man was brought to the emergency room with a screwdriver embedded in his right eye. a multidisciplinary team observing available recommendations (level iv ppe, carefully planned operative directives) successfully performed endoscopic endonasal transsphenoidal surgery with application of a nasoseptal hadad flap and abdominal fat obliteration. aside from medial gaze limitations of the right eye, there was no csf leak or rhinorrhea and no neurologic sequelae on follow up. conclusion: endoscopic skull base surgery for such an impalement injury as this is a formidable multidisciplinary challenge, even in normal times. the early stages of the covid-19 pandemic presented additional challenges. observing evolving guidelines minimized the high risk of exposure for health care workers while maximizing care for the patient. keywords: craniofacial impalement injuries; endoscopic sinus surgery; covid-19 pandemic craniofacial impalement injuries are uncommon, and when encountered are a cause for conversation because of their eccentric location and strange objects involved.1 skull base involvement makes cases even more complex, potentially causing such complications as csf leak, meningitis, hydrocephalus, nerve or vessel injury, and even death.2 even in the best of times, the skull base surgery required for such an impalement injury poses a formidable multidisciplinary challenge. however, this case presented in april 2020, during the early surge of the covid-19 pandemic. we present our experience in managing this case while trying to observe evolving guidelines to minimize risks of exposure for health care workers while maximizing care for the patient. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery case reports case report a 37-year-old man who was found lying unconscious at home with a screwdriver embedded in his right eye was brought to the emergency room by a relative. the patient had been observed to be in a depressed mood over the previous weeks, self-inflicting wounds on his wrist. on later review of history, the patient claimed to have no recall of events preceding the incident. he also claimed to have been hearing voices accusing him of doing something he did not do and forcing him to harm himself. he arrived at the emergency room with glasgow coma score (gcs) 13 (e3v4m6), was awake, ambulatory, opened eyes on verbal command, and was conversant but disoriented to time and place, confused, and had an object impaled in the medial canthus of the right eye. (figure 1a, b) ophthalmologic evaluation revealed an intact globe with visual acuity of counting fingers on the right and 6/6 on the left, right extraocular muscle movement limitation (unable to move horizontally), with retinal edema but no papilledema on fundoscopy. the right upper and lower canaliculi were transected. psychiatric assessment highly considered schizophrenia and risperidone 2mg/ tablet, ½ tablet was started once daily. a plain cranial ct scan with orbital cuts showed a high attenuation metallic density traversing the medial aspect of the right orbit apparently in the intra orbital compartment with suspicious discontinuity of the right medial rectus muscle, through the sphenoid sinus, pons and probably cerebellar tonsils also. there were subtle hyperdensities (suggestive of intraparenchymal hemorrhage) in the pons and anterior aspect of the right cerebellum. there were fractures of the right lamina papyracea and anterior and posterior walls of the right sphenoid sinus. (figure 2a, b) prophylactic intravenous antibiotics (ceftriaxone 2grams once a day, metronidazole 500mg every 8 hours and oxacillin 500mg every 6 hours) were started and removal of the foreign object through a combined direct and endonasal transsphenoidal approach with abdominal fat obliteration and a hadad bassagasteguy flap, and lacrimal probing and medial canthal repair under general anesthesia were planned. because there were no clear surgical guidelines during the early stages of the covid-19 pandemic, the procedure was delayed for 5 days to achieve adequate planning and to ensure the safety of the surgical team, staff and patient. throughout this time, the patient was ambulatory, with stable vital signs, no sensorial changes and no progression of symptoms. he had no symptoms or signs of covid-19 infection, and was cleared for the procedure by the infectious disease service without requiring an rt-pcr swab test. our patient was transported to the operating room (or) theater through a dedicated path for non-covid patients. the or air conditioning had been turned off to lessen the chance of aerosol circulation (a negative pressure environment was not yet available in our institution during this time), and the theater had been sanitized. all instruments and equipment were prepared inside the or, sanitized figure 1. preoperative photos a. lateral view; and b. frontal view showing embedded screwdriver in right medial canthus (photos published in full, with permission). figure 2. plain cranial ct scans a. axial view; and b. sagittal view showing a high attenuation metallic density (400 hu) traversing the medial aspect of the right orbit, sphenoid sinus, pons, and probably cerebellar tonsils. note subtle hyperdensities (intraparenchymal hemorrhage) in the pons and anterior aspect of the right cerebellum, and fractures in the right lamina papyracea, and anterior and posterior walls of the right sphenoid sinus. a b a b and well covered, eliminating the need to transit in and out of the room. personnel were equipped with complete personal protective equipment (ppes) including respiratory masks, head caps, double gloves, shoe covers and face shields. proper donning and doffing areas were provided with designated containers for disposal of ppes, linen and other materials. all nonessential staff left the room during intubation, returning only after the airway was secured (they later also left the room during extubation). otherwise, the or door was closed, with no ingress or egress during the entire surgery. the operative procedure started with harvesting of a nasoseptal hadad flap that was tucked into the nasopharynx. (figure 3a, b) a 2x2 cm abdominal fat graft was harvested from the left lower abdominal quadrant. the anterior sphenoid ostium was widened and the metal shaft of the impaled object was visualized. (figure 3c) the shaft was 2mm below the sella turcica, using the vidian canal as a landmark. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery case reports figure 3. operative procedure showing a. incision of nasoseptal flap; b. tucking in of nasoseptal flap into nasopharynx; c. visualization of foreign body through anterior sphenoid ostium; and d. abdominal fat graft laid over the post-extraction defect. a b c d figure 4. post-extraction photo of 13 cm penetrating object (screwdriver) under endoscopic visualization of the sphenoid, the screwdriver was extracted externally, measuring 13 cm in length. (figure 4) an abrupt cerebro-spinal fluid (csf) leak from the 5mm defect after the screwdriver extracted was controlled with an abdominal fat graft plug over which a composite middle turbinate graft composed of bone and mucosa was laid. (figure 3d) lastly, the nasoseptal flap was placed over the middle turbinate graft with the mucoperichondrial side facing the skull base, and a nonabsorbable nasal pack was placed. ophthalmologic exploration with lacrimal probing in the right eye revealed transected upper and lower canaliculi, and primary closure was just done using pga 6-0. the entire procedure was completed in three hours, and ppes were doffed and disposed in designated containers. all involved personnel showered after the procedure before donning outside clothes. all equipment and instruments were left in theater to be cleaned together. there were no postoperative complications. the postoperative ct scan confirmed complete extraction of the foreign body. (figure 5a, b) the patient was discharged 2 weeks later after completion of antibiotics, and the patient and all personnel involved in this surgery were symptom-free of covid-19 infection. there was no csf leak or rhinorrhea following nasal pack removal on the 14th postoperative day. risperidone was discontinued after unremarkable psychiatric evaluation, but the right medial gaze limitation and episodes of uncontrolled tearing of the right eye persisted at four months’ follow-up. after 6 months, full extraocular movements were already appreciated. (figure 6) endoscopy showed a healed posterior sphenoid wall with a remnant of fat that was used to obliterate the defect. (figure 7) discussion craniofacial impalement injuries encountered in the emergency department are more often than not challenging, but they become even more challenging in the context of a surging covid 19 pandemic. craniofacial impalement injury seldom occurs and usually only a few survive when it happens because of its fatal complications.3 pavlidis et al. discussed 21 incidents of perforating screwdriver craniocerebral injuries reported from 1950 to 2016, of which only 2 out of 21 were suicide attempts.4 impalement in the orbital area is uncommon, accounting only for 2 out of the 21 cases, although the mortality rate for overall screwdriver impalement was high (9 out of 21 cases; 47.6%).4 fortunately, our patient was able to survive and recover. intracranial foreign body penetration (such as from a screwdriver) can cause such sudden complications as subarachnoidal or intraparenchymal cerebral hemorrhages, csf rhinorrhea, and pneumocephalus as well as delayed severe complications like meningitis and cerebral abscess.5 increased intracranial pressure from edema or cerebral hemorrhage can also crush sensitive cerebral tissue.4 most deaths due to penetrating trauma are induced by the figure 5. postoperative ct scan images, axial views a. bone window; and b. cranial window. the previously noted metallic foreign body (screwdriver) is no longer seen. a b philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery case reports experiences and expertise were being shared on social media and other channels of information. we had to decide how to manage our patient during the pandemic and minimize the risk of exposure for healthcare workers. there was only one operating room that was made available to all cutting services resulting in a long queue of emergency procedures. moreover, endoscopic surgery and endotracheal intubation for general anesthesia were classified as high-risk aerosol generating procedures.9,10 other factors of concern at the time were extended duration of exposure, proximity to the airway, manipulation of high viral load tissue and aerosolization through the use of energy devices such as drills. careful planning and coordination between the services involved (neurosurgery, otorhinolaryngology head and neck surgery, ophthalmology, anesthesiology, nursing) was needed to facilitate a smooth and quick operative procedure, minimize movement in and out of the room, and minimize duration of exposure. fortunately, we succeeded in achieving all these. indeed, craniofacial impalement injuries such as our case should be managed through a multidisciplinary approach. we succeeded in successful endoscopic endonasal removal of a 13 cm screwdriver that pierced through the medial canthus of right eye and penetrated through the sphenoid sinus into the cranium. the procedure was planned and executed in a careful manner, observing protective protocols against covid-19 while maintaining the best possible level of care we could give our patient in our particular context. we hope our report encourages our colleagues and the healthcare community to continue striving and adapting to the new norm. let us not lose hope in our continued pursuit of combating covid-19. figure 6. a-f. gaze evaluation after 6 months showing full extraocular muscle movement: a. elevation; b. dextrodepression; c. dextreversion; d. depression; e. levodepression; and f. levoversion. figure 7. endoscopic view of sphenoid sinus posterior wall after 6 months showing healed surface and fat remnant used to obliterate the defect site (arrow). a d b e c f laceration of blood vessels.4 resuscitation and stabilization of the patient are still the initial management of any craniofacial impalement injury.5 according to kazim et al., surgical treatment should be performed within 12 hours of injury to decrease the risk of infectious complications such as meningitis or brain abscess.6 delays greater than 48 hours from the time of injury increase the incidence of infection dramatically from 4.6% to 36.5% making antibiotic coverage necessary.6 it is recommended that broad spectrum antibiotics be instituted in all cases of penetrating brain injury, started as soon as possible and maintained for at least 7–14 days.6 in our case, prophylactic antibiotics were started while preparing for the surgery that took place 5 days after injury. our case took place on april 4, 2020 during the early days of the covid-19 global pandemic.7 we knew then that the virus primarily infected the mucosa of the upper and lower airways with the highest viral load present in nasal tissue, placing otolaryngologists in particularly high risk situations for covid-19 infection.8 because covid-19 was relatively new in the philippines, there was no established protocol on handling trauma patients during this time when recommendations, references 1. eppley bl. craniofacial impalement injury: a rake in the face. j craniofac surg. 2002 jan;13(1):357. doi: 10.1097/00001665-200201000-00006; pubmed pmid: 11886989. 2. samuelson mb, chandra rk, russell pt, weaver kd. sinonasal metallic foreign body penetration of the anterior cranial fossa. otolaryngology case reports. 2017 feb 1;2:10-2. doi: 10.1016/j. xocr.2017.02.002. 3. nadeau ds, hazzi c. self-inflicted crossbow injury in an adult: challenges of surgical management with skull base disruption and airway precariousness. journal of otolaryngology head and neck diseases. 2020 july 11;2(1). [cited 2020 july 11]; available from: https:// escientificpublishers.com/self-inflicted-crossbow-injury-in-an-adult-challenges-of-surgicalmanagement-with-skull-base-disruption-and-airway-precariousness-johnd-02-0012. 4. pavlidis p, karakasi mv, birbilis ta. traumatic brain injury due to screwdriver assaults: literature review and case report. am j forensic med pathol. 2016 dec;37(4):291-298. doi:  10.1097/ paf.0000000000000267 pubmed pmid: 27571172. 5. as y, mahmud mr, alfin jd, adeleke na. clinical presentation and outcome of impalement craniocerebral injuries– a case series. j west afr coll surg. 2017 apr-jun;7(2):112-123. pubmed pmid: 29951469; pubmed central pmcid: pmc6016750. 6. kazim sf, shamim ms, tahir mz, enam sa, waheed s. management of penetrating brain injury. j emerg trauma shock. 2011 jul-sep;4(3):395-402. doi: 10.4103/0974-2700.83871; pubmed pmid: 21887033; pubmed central pmcid: pmc3162712. 7. mohan bs, nambiar v. covid-19: an insight into sars-cov-2 pandemic originated at wuhan city in hubei province of china. j infect dis epidemiol. 2020;6(4):146. doi: 10.23937/24743658/1510146. 8. lammers mjw, lea j, westerberg bd. guidance for otolaryngology health care workers performing aerosol generating medical procedures during the covid-19 pandemic. j otolaryngol head neck surg. 2020 jun 3;49(1):36 doi: 10.1186/s40463-020-00429-2. pubmed. 9. givi b, schiff ba, chinn sb, clayburgh d, iyer ng, jalisi s, et al. safety recommendations for evaluation and surgery of the head and neck during the covid-19 pandemic. jama otolaryngol head neck surg. 2020 jun 1;146:579-584. doi:10.1001/jamaoto.2020.0780 pubmed pmid: 32232423. 10. howard be. high-risk aerosol-generating procedures in covid-19: respiratory protective equipment considerations. otolaryngol head neck surg. 2020 jul;163(1):98-103. doi: 10.1177/0194599820927335; pubmed pmid: 32396451. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to evaluate the efficacy and safety of posterior nasal neurectomy on the treatment of nasal congestion, rhinorrhea, sneezing and post-nasal discharge in intractable rhinitis patients. methods: design: preliminary case series setting: tertiary university medical center participants: ten (10) patients with intractable rhinitis underwent endoscopic posterior nasal neurectomy in both sides. symptoms were compared preand post-operatively one month and one year after surgery using visual analog scale (vas) scores. endoscopic pre and one-month post-operative lund-mackay scores were also compared. results: all four mean nasal symptom scores were reduced significantly at 1-month follow-up for nasal congestion (1.5 ± 1.08 vs 4.1 ± 0.5687, p = .00001), rhinorrhea (0.7 ± 0.823 vs 3.4 ± 0.966, p = .00001) post-nasal discharge (0.9 ± 0.994 vs 2.4 ± 1.5, p = .03), and sneezing (1.1 ± 0.738 vs 3 ± 0.943, p = .02). mean endoscopic scores were also reduced significantly at one month, from 12.9 ± 2.55 to 4.2 ± 3, p = 0.0001.in the 6 patients that followed up at 1-year, post-operative mean nasal symptoms were still significantly better for congestion (0.6667 ± 0.8165 vs 4 ± 0.632, p = 0.00001), rhinorrhea (0.6667 ± 0.5164 vs 3.67 ± 1.033, p = .001), post-nasal discharge (0.1667 ± 0.40825 vs 2.17 ± 1.835, p = .033), sneezing (0.5 ± 0.54772 vs 3.17 ± 0.983, p = 0.0001). mean postoperative vas nasal scores and endoscopic scores were well associated (correlation coefficient -.648, p = .048). conclusion: posterior nasal neurectomy could be considered as a safety and effective way to treat intractable rhinitis patients in vietnam. keywords: posterior nasal neurectomy, vasomotor rhinitis, allergic rhinitis, vidian neurectomy rhinitis is an inflammatory condition of the nasal mucosa that concerns 10 to 20% of the population and is characterized by four nasal symptoms: rhinorrhea, nasal congestion, sneezing and post-nasal discharge.1 while current medical treatment may be helpful in most patients, posterior nasal neurectomy in treatment of intractable rhinitis: a preliminary series minh cong vo, md1 huu kien pham, md1 minh hien nguyen, md2 1department of otolaryngology head and neck surgery university medical center, ho chi minh city, vietnam 2department of immunology and pathophysiology university of medicine and pharmacy ho chi minh city, vietnam correspondence: dr. minh cong vo department of otolaryngology – head and neck surgery university medical center at ho chi minh city, vietnam 215 hong bang st. ward 11 district 5, ho chi minh city 700000 vietnam phone: +842838554269; +842839525355 fax number: +842839506126 email: minh.vc@umc.edu.vn the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology – head and neck surgery 61st annual convention and 10th international symposium on recent advances in rhinosinusitis and nasal polyposis, december 1, 2017. manila hotel, one rizal park, philippines. philipp j otolaryngol head neck surg 2018; 33 (1): 12-16 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery original articles there are still those whose symptoms are not resolved and who are not satisfied with medications. in such patients, surgical management may be needed and many procedures have been used including vidian neurectomy, inferior turbinate reduction and posterior nasal neurectomy.2 posterior nasal neurectomy, first performed by kikawada3 in 1997, has become an alternative to vidian neurectomy in japan because it is safe, quick to perform, has less bleeding and almost no complications. however, this procedure has not been applied in vietnam. we decided to try this procedure to assess the efficacy and safety of endoscopic posterior nasal neurectomy in the treatment of intractable rhinitis patients. the aim of this study was to evaluate the efficacy of the procedure by evaluating the four nasal symptoms (nasal discharge, nasal congestion, sneezing and post-nasal drip) as well as its safety by noting possible complications, preand post-operatively. methods with approval of the ethics review board of the university of medicine and pharmacy at ho chi minh city, vietnam, patients between 18 – 60 years of age, presenting with four mentioned nasal symptoms of rhinitis lasting more than 2 consecutive years with unsatisfactory relief from conventional medical treatments for rhinitis (including antihistamines, decongestants, oral and topical steroids), were selected for posterior nasal neurectomy at the university medical center at hcmc from december 2015 to august 2017 and informed consent was obtained. all of the patients had continuously followed up at the ent clinics of the university hospital of medicine in ho chi minh city for at least one month and agreed to do so one year after the surgery. patients with any serious basal medical disease, and those with bacterial sinusitis were excluded, the latter corroborated on routine pre-operative screening nasal endoscopy using a 4.0 mm 0° and 30° nasal endoscope (karl storz, tuttlingen, germany) and computed tomography (ct) of the paranasal sinuses using a siemens somotom sensation 64 ct scanner (siemens ag, berlin, germany). pre-operative endoscopic findings were staged according to lund-mackay.4 pre-operatively, patients scored each of their nasal symptoms (nasal congestion, nasal discharge, sneezing and postnasal discharge) using a 5-point visual analog scale (vas) pre-operatively. choices were “no problem” (0), “very mild problem” (1), “mild or slight problem” (2), “moderate problem” (3), “severe problem” (4), and “problem as bad as it can be” (5). surgical procedure under general endotracheal anesthesia, transnasal posterior nasal nerve resection was performed on both sides. after topical nasal decongestion with 0.1% xylometazoline hydrochloride (otrivin®, novartis, nyon, switzerland) and submucosal infiltration with 2% lidocaine and 1:100,000 epinephrine (astrazeneca, cambridge, uk) a one centimeter vertical incision was made with a no. 15 scalpel blade (feather®, japan) behind the uncinate process inferiorly and posteriorly. the mucosa was undermined to look for the ethmoidal crest. (figure 1) to find the pterygopalatine bundle more easily, we used a 2 mm kerrison rongeur punch (karl storz, tuttlingen, germany) to open the ethmoidal crest and see the full view of the bundle. after exposing the bundle, we looked for and isolated the posterior nerve away from the pterygopalatine artery. (figure 2) in order to resect the nerve, a 5 mm curved blade sickle knife (karl storz, tuttlingen, figure 1. ethmoidal crest beneath undermined mucosa. dotted line shows the native border of the ethmoidal crest covering the pterygopalatine bundle and pterygopalatine fossa. figure 2. pterygopalatine bundle; note the posterior nasal nerve (black arrow). dotted line shows remnants of the native border of the ethmoidal crest which was partially removed by ronguer to expose the pterygopalatine bundle and pterygopalatine fossa. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery original articles germany) or bipolar forceps (valleylab® medtronic, mn, usa) cautery was used carefully. bleeding that could occur occasionally was also controlled using surgicel® original absorbable hemostat (ethicon, somerville, nj, usa) or bipolar cautery. normal saline irrigation and post-operative merocel® standard nasal dressing (medtronic, mn, usa) was applied bilaterally and patients were monitored for 24 hours and nasal dressing was removed before discharge. home care instructions were given for nasal saline irrigation with premixed sachets (sinusrinse™ neilmed® pharmaceuticals, santa rosa, ca, usa) twice a day and follow-up was scheduled for one week, one month and one year. on follow-ups, post-operative results were noted using both subjective and objective assessments. subjectively, the patients scored their four most common nasal symptoms (nasal congestion, nasal discharge, sneezing, and postnasal discharge) using the same vas at 1-month and at 1-year follow-up. objectively, nasal endoscopy was performed to assess the nose and perform any needed debridement of crusts, from one week to one month after the procedure, and postoperative endoscopic findings were staged according to the lundmackay system.4 all follow-ups were conducted in our ent clinic at university medical center at hcmc. the patients were requested to follow up again in 1 year with repeat subjective (vas) assessment. data was tabulated by the first author using microsoftò excel 2016 mso (16.0.9226.2114) (microsoft corporation redmond, wa, usa). statistical analysis was performed using spss® statistics version 20.0 (ibm corporation, armonk ny, usa). descriptive data were presented as mean ±sd. all the collected symptoms were explored for normality by shapiro-wilk test. the paired t-test was used to compare preand post-operative subjective (vas) scores and objective (endoscopic) scores. the spearman correlation coefficient was used to explore the correlation between subjective (vas) scores and objective (endoscopic) scores. differences were considered significant when p-value was <.05. results ten patients, 7 males and 3 females aged 27 to 50 years old (mean age, 33.8 ± 9.05) met inclusion criteria and completed this series between december 2015 to august 2017. among these, five patients had undergone at least one previous surgery (for nasal septum deviation, inferior turbinate hypertrophy or fess) and one patient had two separate surgeries (for septum deviation reconstruction and fess). the 5 other patients had never undergone any nasal surgeries. routine pre-operative rhinomanometry showed no signs of physical nasal obstruction and routine pre-operative ct scans displayed no signs of the bacterial sinusitis in these 10 patients. the nasal symptom scores were normally distributed: preoperative vas scores (shapiro-wilk statistic .917, df = 10, p = .329) and post-operative vas scores (shapiro-wilk statistic .910, df = 10, p = .281). all of the four nasal symptom scores were reduced significantly at 1-month follow-up. in particular, the mean nasal congestion vas score was 1.5 ± 1.08 post-operatively compared to 4.1 ± 0.5687 pre-operatively, t (7.005), df = 9, p = .00001. the mean rhinorrhea post-operative vas score was 0.7 ± 0.823 compared to 3.4 ± 0.966 pre-operatively, t (7.364), df = 9, p = .00001. the mean post-nasal discharge vas score was 0.9 ± 0.994 post-operatively compared to 2.4 ± 1.5 pre-operatively, t (4.025), df = 9, p = .03. the mean sneezing vas score was 1.1 ± 0.738 post-operatively compared to 3 ± 0.943 pre-operatively, t (4.385), df = 9, p = .02. (figure 3) the endoscopic scores were also normally distributed: pre-operative (shapiro-wilk statistic .873, df = 10, p = .108) and post-operative (shapiro-wilk statistic .890, df = 10, p = .172). the endoscopic scores were also reduced significantly at one month, from a mean of 12.9 ± 2.55 pre-operatively, to 4.2 ± 3 post-operatively, t (7,727), df = 9, p = 0.0001. (figure 4) the mucosal incisions were all well healed at one month. (figure 5) only six patients returned to our clinic after one year. most of them (5 of 6 patients) were still very satisfied and happy with their nose. however, one patient complained that the nasal congestion had returned. despite this, we still found significant improvement of all four nasal symptoms for these patients. their mean 1-year post-operative nasal congestion vas score was 0.6667 ± 0.8165 compared to 4 ± 0.632 pre-operatively, t (10), df = 5, p = 0.00001. their mean 1-year postoperative rhinorrhea vas score was 0.6667 ± 0.5164 compared to 3.67 ± 1.033 before the procedure, t (6.708), df = 5, p = .001. their mean 1-year figure 3. preand 1-month post-operative mean scores of 4 nasal symptoms philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery original articles post-operative post-nasal discharge vas score was 0.1667 ± 0.40825 compared to 2.17 ± 1.835 pre-operatively, t (2.928), df = 5, p = .033. their mean 1-year post-operative sneezing vas score was 0.5 ± 0.54772 compared to 3.17 ± 0.983 pre-operatively, t (8), df = 5, p = 0.0001. the incisions healed very well and were hardly seen under endoscopic examination 1 year after surgery and no further endoscopic staging was performed for the six patients. the mean post-operative vas nasal scores were well associated with the mean post-operative endoscopic scores (correlation coefficient -.648, p = .048), showing that the subjective and objective variables had decreased monotonic relationship. there were no complications in the 24-hour post-operative period. on longer follow-up, no patients had dry eyes, dry nose, nasal crust or facial/ gum pain, between 1 and 12 months after surgery. overall, all the patients were satisfied with the results of surgery. figure 4. preand post-operative mean endoscopic scores at 1 month figure 5. endoscopic view at one month showing well-healed mucosal incision (arrow). ms, maxillary sinus. discussion this study found that endoscopic posterior nasal neurectomy significantly improved all four symptoms (nasal congestion, nasal discharge, sneezing, post-nasal discharge) of intractable rhinitis in our patients with no untoward adverse effects or complications. our results confirm the desired efficacy of over 90% of cases for a follow-up period of 6 months to 2 years reported by kikawada3 particularly in reducing nasal symptoms of rhinitis such as nasal discharge, nasal congestion, sneezing and post-nasal discharge significantly. kikawada3 also reported more than 80% efficacy in 94 patients after 2 years of surgery which are similar to our findings. our most significant findings at 1 month were for nasal discharge and nasal congestion with p<.001 although symptoms of postnasal discharge and sneezing also improved significantly with p<.05. these findings are similar to previously published papers.3,5,6 of the 6 out of 10 remaining patients at 1 year (60%), 5 out of 6 (83%) had satisfactory vas scores. however, one patient was still suffering from nasal congestion. even though he believed that the procedure obviously helped him with sneezing, postnasal discharge and nasal discharge symptoms, he was still feeling a little bit congestion in one side of the nose occasionally, although it was better than before the operation. to explain this situation, we believe that the main purpose of posterior nasal neurectomy is to disrupt the imbalance between the parasympathetic and sympathetic innervation of the nasal cavity and reduce the nasal secretions.1,7 as a result, this surgery may help to reduce nasal obstruction as well as nasal discharge and postnasal discharge however, if the patient had severe nasal congestion, we would suggest inferior turbinate reduction along with posterior nasal neurectomy.8 our results also showed significantly improvements in lund-mackay endoscopic scores in all patients. perhaps it can be suggested that not only could the procedure help reduce mucosal discharge and edema seen endoscopically but it also results in good healing post-operatively. the relationship between the post-operative vas scores and endoscopic scores may imply that the procedure might be more helpful to patients with higher pre-operative vas scores. we had no peri-operative complications or adverse events in our study. intra-operative bleeding was adequately controlled with surgicel® or bipolar cautery. there was no case of dry eyes, mouth or nasal mucosa, or facial or gingival pain reported between 1 and 12 months after surgery. in all 10 cases, the nasal mucosa healed very well in the medial meatus and did not produce nasal crusts at one-month followup. these findings are not very different from those of other authors. as reported by kikawada3 among 1056 patients operated on from 1997 to 2005, seven suffered from bleeding (from the back of the nasal septum philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery original articles or pterygopalatine fossa) in 1 to 4 weeks after surgery. however, this complication can be avoided by intra-operative endoscopic hemostasis with careful endoscopic bipolar cautery.9 in addition, there was no case of tear duct disorder which cause dry eyes or pain in the upper gum region. in a previous study by lee et al.,10 26 of 85 patients (30.6%) that underwent bilateral vidian neurectomy ended with dry eyes for a short period of time (1 to 2 months) and had to use artificial tears while seven female patients reported no tears when crying (8.2%).9 in addition, eight patients (9.4%) had lip numbness within one year and 13 patients (15.3%) had mild nasal dryness.9 jang et al.11 reported that among 6 patients that underwent bilateral vidian neurectomy, similar symptoms disappeared in 2-6 months although one patient still suffered dry eyes for up to seven years. thus, the literature seems to support posterior nasal neurectomy as safer and causing less complications than vidian neurectomy. in particular, posterior nasal neurectomy apparently does not result in dry eyes which is the most common and annoying complication of vidian neurectomy.11 our study is limited by the small sample size and lack of a control group. we also did not randomize participants into medication treatment arms nor did we blind the observers performing follow-up assessments. future studies may correct these limitations to achieve more generalizable results and evidence that might be used for clinical practice decisions. meanwhile, our preliminary experience suggests that endoscopic posterior nasal neurectomy through nasal cavity is a simple and safe procedure. it can be done well by an experienced endoscopic surgeon. the surgeon only needs to know precisely the anatomy of this area including the ethmoidal crest and pterygopalatine bundle to prevent injury to the artery which may cause bleeding. fortunately, bleeding is usually not severe and can be controlled with bipolar cautery. besides negligible intra-operative hemorrhage, our study resulted in no other complication postoperatively especially dry eyes which are a major drawback of vidian neurectomy. at the same time, the procedure also shows good potential to help diminish nasal symptoms significantly in the short and longer period in patients with intractable rhinitis. we believe that posterior nasal neurectomy is a viable option to treat intractable rhinitis in vietnam. acknowledgements we thank brent a. senior md, facs, fars, nat and sheila harris distinguished professor, vice chair of clinical affairs, otolaryngology/head and neck surgery, chief of rhinology, allergy, and endoscopic skull base surgery, university of north carolina for giving us valuable advice during the process of researching. references 1. dykewicz ms, hamilos dl. rhinitis and sinusitis. j allergy clin immunol. 2010 feb; 125(2 suppl 2): s103–s115. doi: 10.1016/j.jaci.2009.12.989. pmid: 20176255. 2. okubo k, kurono y, ichimura k, enomoto t, okamoto y, kawauchi h, et al. japanese guidelines for allergic rhinitis 2017. allergol int. 2017 apr; 66(2): 205-219. doi: 10.1016/j.alit.2016.11.001; pmid: 28214137. 3. kikawada t. endoscopic posterior nasal neurectomy: an alternative to vidian neurectomy. oper tech otolaryngol. 2007 dec; 18(4): 297–301. doi: 10.1016/j.otot.2007.05.010. 4. lund vj, mackay is. staging in rhinosinusitis. rhinology. 1993 dec; 31(4): 183-184. pmid: 8140385. 5. kanaya t, kohno n. endoscopic posterior nasal neurectomy with continuous-suction irrigation method. j otolaryngol res. 2017 sep; 1(1):113. 6. kobayashi t, hyodo m, nakamura k, komobuchi h, honda n. resection of peripheral branches of the posterior nasal nerve compared to conventional posterior neurectomy in severe allergic rhinitis. auris nasus larynx. 2012 dec; 39(6): 593-596. doi: 10.1016/j.anl.2011.11.006. pmid: 22341334 7. betul s, alkis t. pathophysiology of allergic and non-allergic rhinitis. proc am thorac soc. 2011 mar; 8(1):106–114. doi: 0.1513/pats.201008-057rn. pmid: 21364228 8. ikeda k, oshima t, suzuki m, suzuki h, shimomura a. functional inferior turbinosurgery (fits) for the treatment of resistant chronic rhinitis. acta otolaryngol. 2006 jul; 126(7): 739–45. doi: 10.1080/00016480500472853; pmid: 16803714. 9. seno s, arikata m, sakurai h, owaki s, fukui j, suzuki m, et al. endoscopic ligation of the sphenopalatine artery and the maxillary artery for the treatment of intractable posterior epistaxis. am j rhinol allergy. 2009 mar-apr; 23(2):197–199. doi: 10.2500/ajra.2009.23.3294; pmid: 19401049. 10. lee jc, kao ch, hsu ch, lin ys. endoscopic transsphenoidal vidian neurectomy. eur arch otorhinolaryngol. 2011 jun; 268(6): 851–856. doi: 10.1007/s00405-010-1482-x; pmid: 21221616. 11. jang ty, kim yh, shin sh. long-term effectiveness and safety of endoscopic vidian neurectomy for the treatment of intractable rhinitis. clin exp otorhinolaryngol. 2010 dec; 3(4): 212-216. doi: 10.3342/ceo.2010.3.4.212; pmid: 21217963 pmcid: pmc3010541. philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the effect of a single intravenous dose of tranexamic acid on intraoperative bleeding, duration of surgery and surgical field visualization during endoscopic sinus surgery. methods: design: double-blind, randomized, placebo-controlled trial setting: tertiary government hospital participants: 10 patients aged 18-75 years old diagnosed with chronic rhinosinusitis with or without nasal polyposis and unresponsive to medical treatment, who underwent endoscopic sinus surgery from september 2016 to august 2017, were randomly allocated to treatment group and control group, respectively. the “odd” numbers were assigned to the treatment group (intravenous tranexamic acid) given 1 dose of 100mg/ml (500mg tranexamic acid per 5 ml) tranexamic acid slow intravenous drip 1 hour prior to the procedure, while the “even” numbers assigned to the control group received the same amount of normal saline solution. results: the mean duration of surgery of the tranexamic group was 185 minutes (standard deviation, sd 55.23) and the control group was 122.6 minutes (sd 42.03) showing no significant difference (p=.08). the mean blood loss of the tranexamic group was less at 240ml (sd 108.39) compared with the control group at 290ml (sd 74.16), although there was no statistically significant difference (p=.42). intra-operative surgical field assessed by the surgeon based on the boezart grading scale showed that 2 (40%) of the tranexamic group had higher bleeding score compared with the placebo group. however, this was not found to be statistically significant (p=.460). due to the small sample size, a type ii error occurred with alpha level of 0.05 and estimated power of 0.0885, with not enough basis to refute that a single dose of intravenous tranexamic acid has no effect in improving surgical field visualization during endoscopic sinus surgery. no drug side effects were noted after administration until after surgery. conclusion: single dose intravenous tranexamic acid in functional endoscopic sinus surgery decreased mean intraoperative blood loss (but this was statistically insignificant) but its effect on surgical field visualization cannot totally be assessed due to small sample size. there was also no change in the observed duration of surgery. no untoward side effects associated were noted from administration of the drug until after the surgery finished. endoscopic sinus surgery perioperative outcomes after intravenous tranexamic acid: a double blind randomized controlled trial jenna marie c. quiroga, md peter simon r. jarin, md department of otorhinolaryngology head and neck surgery quirino memorial medical center quezon city, philippines correspondence: dr. jenna marie c. quiroga chief resident, department of otorhinolaryngology head and neck surgery quirino memorial medical center katipunan road, project 4, quezon city 1108 philippines phone: (632) 422 2250 local 117 email address: jennamarie_quiroga@yahoo.com the authors declared that this represents original material that is not being considered for publication, or has not been published or accepted for publication elsewhere in full or in part in in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual, passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology-head and neck surgery, analytical research contest, november 9, 2017, menarini office, bonifacio high street, taguig city. philipp j otolaryngol head neck surg 2018; 33 (1): 6-11 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery original articles keywords: functional endoscopic sinus surgery, intravenous tranexamic acid, chronic rhinosinusitis endoscopic sinus surgery (ess) aims to restore mucociliary function by reestablishing physiologic sinus ventilation and drainage by relieving obstruction in the osteomeatal complex.1 the most common intraoperative problem encountered in ess is bleeding in the surgical field making visualization and identification of landmarks difficult.2 it may also prolong operative time, increase the risk of complications and create difficulty in completing the surgery.3 it will be beneficial for the surgeon to determine if the use of intravenous tranexamic acid alone would be enough to lessen bleeding and improve surgical field visualization in endoscopic sinus surgery with no known increase in any adverse events thus lessening surgical morbidities. this paper aims to determine the effect of a single intravenous dose of tranexamic acid on intraoperative bleeding and duration of surgery during endoscopic sinus surgery and determine whether the effect of single intravenous dose of tranexamic acid could improve surgical field visualization or would offer no benefit at all during endoscopic sinus surgery. methods this double-blind, randomized, placebo-controlled trial was performed at a tertiary government hospital from september 2016 to august 2017 with institutional review board and ethics committee approval (study protocol code qmmc hec gcs 2016-022). all patients were voluntarily enrolled and signed a written informed consent. all patients seen at the otorhinolaryngology-head and neck surgery outpatient department were considered for inclusion in the study if they were between 18-75 years old and had chronic rhinosinusitis with or without nasal polyposis unresponsive to treatment. excluded were those with cardiovascular disease, renal disease, bleeding diathesis and anemia, history of previous endoscopic sinus surgery and those receiving anticoagulants. a target population of 12 patients, 6 each in the treatment and control group was computed based on the study of nuhi s., et al.4 using the result of x 1 107.7 and x 2 189.3 with standard deviation of s 1 45.1 and s 2 51 with 5% margin of error and power of 80%. (figure 1) a total of 14 patients diagnosed with chronic rhinosinusitis with nasal polyposis were enrolled in the study, however 4 from the 14 patients enrolled were discovered to have history of previous ess hence were excluded. the 10 remaining patients were randomized using simple random sampling. they were asked to pick a folded paper with written number from a bowl. those who picked the paper with “odd” numbers were assigned to the treatment group (intravenous tranexamic acid) who would receive 1 dose of 100mg/ml (500mg tranexamic acid per 5 ml) tranexamic acid thru slow intravenous (i.v.) drip 1 hour prior to the procedure, while the “even” numbers were assigned to the control where: z α ,z β = corresponds to α and β errors s 1, s 2 = estimate of the variance or standard deviations from previous study for group 1 and group 2 μ 1 ,μ 2 = means for groups 1 and 2 n = (z α +z β )2 (s 1 2+s 2 2) (μ 1 -μ 2 )2 n = (0.05+0.2)2 (45.12+512) (107.7-189.3)2 n = 0.25 (4095.01) 81.6 n = 12 n 1 = 6 n 2 = 6 figure 1. sample size computation (based on two sample comparison of means) figure 2. flow diagram of the progress through the phases of the randomized trial of the two groups. consort 2010 flow 14 assessed for eligibility randomized (10) 5 allocated to iv tranexamic acid 5 allocated to placebo 0 lost to follow-up 0 discontinued intervention 0 lost to follow-up 0 discontinued intervention 5 analysed • 0 excluded from analysis 5 analysed • 0 excluded from analysis allocation follow-up analysis 4 excluded • 4 did not meet inclusion criteria • 0 declined to participate enrollment group receiving the same amount of normal saline solution, resulting in a total of 5 patients each in the treatment and control group. (figure 2) intervention a complete history and physical examination were obtained from all participants. vital signs (blood pressure, respiratory rate and cardiac rate) were recorded after admission and patients > 35-yearsold underwent cardiopulmonary clearance. a complete blood count, philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery original articles prothrombin time and partial thromboplastin time were obtained prior to surgery. the tranexamic group received 1 dose of 100mg/ml (500mg of tranexamic acid per 5 ml) tranexamic acid i.v. through slow drip 1 hour prior to the procedure, while the control group received the same amount of normal saline solution prepared by only 1 person. the surgeons and anesthesiologists were blinded to treatment allocation. all surgeries were performed under general endotracheal anesthesia using sevoflurane and venoclysed with lactated ringer solution. nasal mucosa was decongested with nasal strips soaked in 1:100,000 epinephrine after induction of anesthesia, prior to surgery. only 1 surgeon and 1 assist performed all the procedures with different anesthesiologists using the same anesthesia drugs. vital signs were continually monitored during the surgery and recorded. duration of the surgery was recorded by the circulating nurse, blood loss was estimated by the anesthesiologist after surgery and the surgeon answered the boezart grading scale5 in assessing and grading the surgical field. complete blood count, prothrombin time and partial thromboplastin time were repeated 6 hours after surgery. only one person who was not included in the surgery prepared the medications, collated and tabulated all data. data analysis demographic variables were assessed using the pearson chi-square test and 2 sample t-test and described using means and standard deviation. differences between preand post-operative analysis of the treatment and control group were assessed using paired t-test with 95% confidence interval and <0.05 level of significance and wilcoxon rank sum test and bleeding score was assessed using fischer exact test. stata 10.1 (statacorp., texas, usa) was used for statistics and data analysis. testing of null hypothesis was done using the two-tailed test with alpha value of 0.05. results a total of 10 patients, 2 females and 8 males aged 30-62 years old (median age 52.5 years old and mean age of 51.6 years old) participated in the study, with 5 patients (1 female and 4 males each) randomly allocated to the tranexamic group and to the control group, respectively. (figure 2) the mean (sd) age of the tranexamic group aged 44 62 years old and control group aged 30-62 years old was 53.8 (8.01) and 49.4 (13.37) respectively, with no significant age difference between groups (p>.05). (table 1) there were no significant differences between the tranexamic acid and control groups in preoperative and postoperative vital signs (blood pressure, cardiac rate and respiratory rate) (table 2) as well as in preand post-operative hemoglobin, hematocrit, platelet count, prothrombin time and partial thromboplastin time. (table 3) there was no significant difference in mean duration of surgery for the tranexamic group at 185 minutes (sd 55.23) compared to 122.6 minutes (sd 42.03) for the control group (p=.08). (table 4) there was less mean blood loss in the tranexamic group at 240ml (sd 108.39) compared with the control group at 290ml (sd 74.16), but there was no statistically significant difference (p=.42). (table 4) intra-operative surgical field grading noted slight bleeding requiring occasional suctioning in 40% of the tranexamic acid group and control group, slight bleeding requiring frequent suctioning in 20% of the tranexamic group and 60% of the control group, and moderate bleeding requiring frequent suctioning in 40% of the tranexamic group and none of the control group (table 5). two or 40% of the tranexamic group had higher bleeding scores compared with the placebo group but this was not statistically significant (fischer exact test p-value = .46). based on the boezaart grading scale grades 1 to 3, only 60% (p 1 =.60) of the tranexamic group showed less bleeding in the intraoperative surgical field while 100% (p 2 =1) of the control group showed the same effect in improving the surgical field. due to the small sample size gathered, a type ii error was obtained with an alpha level of 0.05 and an estimated power of 0.0885 suggesting that there is not enough basis to reject the null hypothesis that a single dose of intravenous tranexamic acid has no effect in improving surgical field visualization during endoscopic sinus surgery. no adverse effects such as vomiting, diarrhea, malaise, dizziness, convulsion, hypotension or any signs of thromboembolic events were noted from administration of the drug until after surgery. discussion our findings suggest that single dose intravenous tranexamic acid in functional endoscopic sinus surgery may decrease mean intraoperative blood loss (though statistically insignificant), but its effect on surgical table 1. demographic data measurements in the two groups variable tranexamic acid group n=5 placebo group n=5 p-value gender: male n;(sd) female n;sd) age (years) 4(80) 1(20) 53.8(8.01) 4(80) 1(20) 49.4(13.37) .78 .55 data is presented as mean (standard deviation) philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery original articles table 3. difference between preoperative and postoperative coagulation factors in the two groups t value p value* z score pvalue# dfiqrmedian n sdmeannovariable hematocrit (vol%) tranexamic acid group placebo group hemoglobin (g/l) tranexamic acid group placebo group platelet count(x109/l) tranexamic acid group placebo group prothrombin time (secs) tranexamic acid group placebo group partial thromboplastin time (secs) tranexamic acid group placebo group -1.04 -3.03 -1.47 -2.98 -1.13 -3.58 -0.29 1.79 -4.52 -1.82 .36 .04 .22 .04 .32 .02 .79 .15 .01 .14 1.89 1.57 1.36 -0.84 -1.57 .06 .11 .17 .40 .12 4 4 4 4 4 4 4 4 4 4 0.06 0.01 10 5 31 32 1.1 0.7 1.4 2.3 -0.04 -0.07 -14 -21 -23 -37 0.5 1.2 -3.8 -2.3 0.04 0.05 12.19 13.97 21.71 22.52 2.35 1.20 1.95 2.14 -0.02 -0.07 -8 -18.6 -11 -36 -0.30 0.96 -3.94 -1.74 5 5 5 5 5 5 5 5 5 5 *paired t-test used in determining difference between two groups #wilcoxon rank sum test used in determining difference between two groups table 2. difference between preoperative and postoperative hemodynamic measurements in the two groups pvalue*t valuedfiqrmedian sdmeanno systolic blood pressure (mmhg) tranexamic acid group placebo group diastolic blood pressure (mmhg) tranexamic acid group placebo group respiratory rate (cycles/min) tranexamic acid group placebo group cardiac rate (beats/min) tranexamic acid group placebo group .62 .18 .62 1 .90 .07 .92 .48 -0.53 -1.63 0.53 0 .13 -2.78 -0.10 .77 4 4 4 4 4 3 4 4 10 0 10 10 2 4 11 16 0 -10 0 0 -1 -3 -2 14 8.37 10.95 8.37 12.25 3.35 7.83 12.30 18.56 -2 -8 2 0 0.2 -6.4 -0.6 6.4 5 5 5 5 5 5 5 5 *paired t-test used in determining difference between two groups variable philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery original articles t value p value* z score pvalue# dfiqrmedian n sdmeannovariable duration of bleeding (mins) tranexamic acid group placebo group blood loss (ml) tranexamic acid group placebo group 2.01 -0.85 .08 .42 .67 -0.96 .50 .34 8 8 90 55 150 50 150 120 200 300 55.23 42.03 108.39 74.16 185 122.6 240 290 5 5 5 5 table 4. outcome measurements in the two groups *paired t-test used in determining difference between two groups #wilcoxon rank sum test used in determining difference between two groups field visualization cannot totally be assessed due to small sample size. there was also no change in the observed duration of surgery. according to alimian et al., “several techniques have been suggested to improve the surgical field in sinus surgery however none of them consistently provided a desirable bloodless field for surgeons and unwanted side effects were also noted such as local tissue damage and subsequent bleeding due to the use of bipolar diathermy, hemodynamic instability especially in patients with hypertension or ischemic heart disease due to the use of topical vasoconstrictors and exposing patients to more anesthetic drugs in inducing hypotension leading to more side effects.”4 according to a meta-analysis that reviewed different articles in assessing the effectiveness of intravenous tranexamic acid in endoscopic sinus surgery, intravenous tranexamic acid reduced blood loss and shortened surgical time in endoscopic sinus surgery among patients with chronic rhinosinusitis.2 however, the additional benefit of tranexamic acid for better field visualization was not clear.2 this study was undertaken to determine the effect of single iv dose of tranexamic acid in optimizing surgical field visualization without producing any unwanted side effects. in this study, the use of single dose of iv tranexamic dose in endoscopic sinus surgery decreased mean intraoperative blood loss however insignificantly but its effect on surgical field visualization could not be assessed due to the small sample size. there was also no effect observed on shortening the duration of surgery. the findings were independent from demographic factors or hemodynamic variables. all surgeries were performed by only 1 surgeon and 1 assist and only one person, not included in the surgery, was in charge of the medications and data to be collated to prevent biases. tranexamic acid is “a synthetic antifibrinolytic agent that blocks the lysine-binding site of plasminogen, plasmin and tissue plasminogen activator which prevents their association with fibrin hence reducing bleeding.”6 previous studies6,7 have already confirmed the favorable effect of tranexamic acid on bleeding tendency in major operations such as patients undergoing cardiac, major orthopaedic transplantation, and prostate surgeries as well as the efficacy of topical and oral forms of tranexamic acid in achieving hemostasis and improving the surgical field in functional endoscopic sinus surgery. two previous studies to determine the efficacy of intravenous tranexamic acid in functional endoscopic sinus surgery showed favorable effects.7,8 adverse effects of tranexamic acid are rare and include nausea, vomiting, diarrhea, allergic dermatitis, dizziness, hypotension, seizures, impaired vision and achromatopsia (impaired color vision) which are also usually elicited by rapid intravenous infusion.7 although the drug might theoretically increase the risk of thromboembolism, a systematic review conducted by shakur et al. regarding the use of tranexamic acid in surgery did not show any statistically significant increase in the risks of any of the thromboembolic events nor kidney failure assessed.9 during the course of this study, there were no untoward adverse effects associated with the use of the drug noted from administration until the surgery finished. this study is limited by the small sample size obtained due to the short time span allotted. we recommend that this study be continued table 5. bleeding score between the two groups bleeding score (n;%) tranexamic group n;(%) placebo group n;(%) 1 2 3 4 5 0 2 (40) 1 (20) 2 (40) 0 0 2 (40) 3 (60) 0 0 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery original articles for a longer time frame to be able to produce a larger sample size and validate the preliminary results reported in this study, as well as reflect the overall population of patients undergoing endoscopic sinus surgery. we also recommend that the sizes and grading of nasal polyps be considered as they can also affect bleeding and intraoperative visualization of the surgical field. in conclusion, without achieving statistical significance, single dose intravenous tranexamic acid in functional endoscopic sinus surgery may decrease mean intraoperative blood loss but not duration of surgery. however, its effect on surgical field visualization cannot totally be assessed due to small sample size. acknowledgements we would like to thank the residents of the department of orl-hns and anesthesiologists of the quirino memorial medical center for helping in screening, surgery and data gathering and ms. marilyn crisostomo for helping in evaluating and analyzing statistical results of the study. references 1. lai d, stankiewicz ja. primary sinus surgery. in flint pw, haughey bh, lund vj, niparko jk, robbins kt, thomas rj, et al (editors). cummings otolaryngology: head and neck surgery. 6th edition. philadelphia: elsevier, saunders. 2015. pp. 752-782. 2. ligon jm, almazan n. the effectiveness of intravenous tranexamic acid on blood loss and surgical time during endoscopic sinus surgery: a systematic review. philipp j otolaryngol head neck surg. 2016; 31(2): 8-12. 3. langille ma, chiarella a, cote dw, mulholland g, sowerby lj, dziegielewski pt, et al. intravenous tranexamic acid and intraoperative visualization during functional endoscopic sinus surgery: a double-blind randomized controlled trial. int forum allergy rhinol. 2012 apr; 3(4): 315-8. doi: 10.1002/alr.21100; pmid: 23044919. 4. nuhi s, goljaniantabrizi a, zarkah l, rashedi ashrafi b. impact of intravenous tranexamic acid on hemorrhage during endoscopic sinus surgery. iran j otorhinolaryngol. 2015 sep; 27(82): 349354. pmid: 26568938 pmcid: pmc4639687. 5. boezaart ap, van der merwe j., coetzee a. comparison of sodium nitroprussideand esmololinduced controlled hypotension for functional endoscopic sinus surgery. can j anaesth. 1995 jan; 42(5): 373-6. 6. das a, chattopadhyay s, mandal d, chhaule s, mitra t, mukherjee a, et al. does the preoperative administration of tranexamic acid reduce perioperative blood loss and transfusion requirements after head and neck cancer surgery? a randomized, controlled trial. anesth essays res. 2015 sepdec; 9(3): 384-90. doi: 10.4103/0259-1162.161806; pmid: 26712979 pmcid: pmc4683496. 7. jahanshani j, hashemian f, pazira s, bakhshaei mh, farahani f, abasi r, et al. effect of topical tranexamic acid on bleeding and quality of surgical field during functional endoscopic sinus surgery in patients with chronic rhinosinusitis: a triple blind randomized clinical trial. plos one. 2014 aug 18; 9(8): e104477. doi: 10.1371/journal.pone.0104477; pmid: 25133491 pmcid: pmc4136784. 8. alimian m, mohseni m. the effect of intravenous tranexamic acid on blood loss and surgical field quality during endoscopic sinus surgery: a placebo-controlled clinical trial. j clin anesth. 2011 dec; 23(8): 611-615. doi: 10.1016/j.jclinane.2011.03.004; pmid: 22137511. 9. shakur h, elbourne d, gülmezoglu m, alfirevic z, ronsmans c, allen e, et al. the woman trial (world maternal antifibrinolytic trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. trials. 2010 apr; 11:40. doi: 10.1186/1745-6215-11-40; pmid: 20398351 pmcid: pmc2864262. 10. soler zm, smith tl. quality-of-life outcomes after endoscopic sinus surgery: how long is long enough. otolaryngol head neck surg. 2010 nov; 143(5): 621-625. doi: 10.1016/j. otohns.2010.07.014; pmid: 20974329 pmcid: pmc2965172. 11. cote dw, wright ed. objective outcomes in endoscopic sinus surgery. in: iancu c (editor). advances in endoscopic sinus surgrery. 2011. intech europe: publisher intech. pp. 57-70. doi: 10.5772/22191. 12. ker k, edwards p, perel p, shakur h, roberts i. effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. bmj. 2012 may 17; 344: e3054. doi:10.1136/ bmj. e3054; pmid: 22611164 pmcid: pmc3356857. 13. eldaba aa, amr ym, albirmawy oa. effects of tranexamic acid during endoscopic sinus surgery in children. saudi j anaesth. 2013 jul;7(3): 229-33. doi: 10.4103/1658-354x.115314; pmid: 24015121 pmcid: pmc3757791. 14. horrow jc, van riper df, strong md, grunewald ke, parmet jl. the dose-response relationship of tranexamic acid. anesthesiology.1995 feb; 82(2): 383-92. pmid: 7856897. 15. prentice cr. basis of antifibrinolytic therapy. j clin pathol suppl (r coll pathol). 1980; 14:35-40. pmid: 6159375 pmcid: pmc1347103. 16. gruen rl, jacobs ig, reade mc. trauma and tranexamic acid. med j aust. 2013 sep; 199 (5): 310311. pmid: 23992173. 17. roberts i, prieto-merino d, manno d. mechanism of action of tranexamic acid in bleeding trauma patients: an exploratory analysis of data from the crash-2 trial. crit care. 2014 dec; 18(6):685. doi: 10.1186/s13054-014-0685-8; pmid: 25498484 pmcid: pmc4277654. 18. viswanath o, santhosh s, goldman h. the evolving role of prophylactic use of tranexamic acid before cesarean section: balance between maternal benefits and unknown neonatal effects. j anesthesiol clin sci. 2015;4:4. doi: 10.7243/2049-9752-4-4. 19. goncalves fd, novaes fr, maia, ma. influence of tranexamic acid in postoperative bleeding of cardiac surgery with cardiopulmonary bypass. rev bras cir cardiovasc. 2002; 17(4): 331-338. 20. morrison jj, dubose jj, rasmussen te, midwinter mj. military application of tranexamic acid in trauma emergency resuscitation (matters) study. arch surg. 2012 feb;147(2):113-119. doi: 10.1001/archsurg.2011.287; pmid: 22006852. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to present the perioperative data of patients with solitary or multinodular goiter and/ or papillary thyroid carcinoma who underwent transoral endoscopic thyroidectomy vestibular approach (toetva) in a single tertiary medical center. methods: design: case series setting: tertiary government hospital participants: records of 10 patients who underwent toetva from june 2018 to july 2019 (9 thyroid lobectomies, 1 total thyroidectomy) were reviewed. outcomes and measures included conversion to open surgery, operative time, intraoperative blood loss, size of the thyroid gland, postoperative hospital stay, visual analogue pain scores (vas), and postoperative complications. results: none of the 10 patients were converted to an open procedure. the average preoperative thyroid size was 4.73 cm in widest diameter using thyroid ultrasound (±1.88 cm, range 3.6 to 6.5 cm). mean operative time for thyroid lobectomy and total thyroidectomy was 4 hours and 29 minutes and 4 hours and 15 minutes, respectively. mean intraoperative blood loss was 140 ml (±47.96 ml, range 80 to 200 ml) for thyroid lobectomy and 100 ml for total thyroidectomy. the average intraoperative size of the thyroid gland measured in widest diameter (larger lobe for total thyroidectomy) was 4.48 cm (±0.919 cm, range 3 to 5.5 cm). median postoperative hospital stay was 2 days (±1.55 days, range 2 to 12 days). mean vas pain scores for postoperative days 1, 2, 3, and 7 were 5, 3, 2, and 0, respectively. transient recurrent laryngeal nerve injury (of 3 months duration) occurred in 1 patient. two cases had surgical site infection, 2 had wound dehiscence, 1 had seroma and 1 had skin burn as a complication. none had hypocalcemia or mental nerve injury in the series. conclusions: toetva was replicated in the local setting and a presentation of the perioperative data of all the patients who underwent this novel technique, the indications, as well as surgical and patient outcomes, were described. keywords: toetva; thyroidectomy; transoral; endoscopic; minimally invasive transoral endoscopic thyroidectomy vestibular approach (toetva) for thyroid nodules: a series of the first 10 patients in a single institution lawrence y. maliwat, md1,2 rowald rey g. malahito, md1,3 erasmo gonzalo d.v. llanes, md1 1department of otorhinolaryngology head and neck surgery quirino memorial medical center 2section of otorhinolaryngology head and neck surgery bataan general hospital and medical center 3department of otorhinolaryngology head and neck surgery amang rodriguez memorial medical center correspondence: rowald rey g. malahito, md department of otorhinolaryngology head and neck surgery quirino memorial medical center katipunan road ext., project 4, quezon city 1108 philippines phone ((0916) 326 2906 email: reymalahito@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at: the 10th singapore allergy and rhinology conference, grand copthorne hotel, singapore (oral presentation), and the world congress on thyroid cancer 3.5, parco dei principi, rome, italy (e-poster presentation, 3rd place) presented at the philippine society of otolaryngology head and neck surgery descriptive research contest (3rd place). december 6, 2019. palawan ballroom, edsa shangri la hotel, mandaluyong city. philipp j otolaryngol head neck surg 2020; 35 (1): 39-45 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery original articles thyroidectomy is a surgical procedure that has become the universally accepted technique for selected tumors of the thyroid gland and is one of the most common surgeries performed worldwide.1,2 the standard technique involves a curvilinear incision over the anterior neck, leaving a noticeable scar that is considered disturbing by a majority of patients.1-4 natural orifice transluminal endoscopic surgery (notes) was developed as a minimally invasive technique where procedures done through natural body orifices leave no scar, producing superior cosmetic results, greatly decreased postoperative pain, as well as decreased hospital stay and decreased intraoperative bleeding compared to conventional open surgeries.4 thyroid surgery has applied notes via a transoral approach and transoral endoscopic thyroidectomy vestibular approach (toetva) was developed in 2015, utilizing conventional laparoscopic instruments via the oral vestibule.3 this technique has largely replaced other notes for thyroid surgery and is a relatively new procedure that could be a promising alternative to standard thyroidectomy.1-5 however, data on this technique is still accumulating, and further reports on surgical and patient outcomes of toetva in the local setting may prove to be a significant contribution to the global literature with regards to future developments of this novel procedure.4 moreover, a search of herdin plus using the keywords “transoral,” “endoscopic,” and “thyroidectomy” yielded no local studies on toetva. the objective of this paper is to present the perioperative data of patients with solitary or multinodular non-toxic goiter and/or papillary thyroid carcinoma who underwent toetva in a single tertiary medical center. surgical technique, indications, and outcomes will be described. methods with institutional review board approval, this case series reviewed records of all patients who underwent toetva by a consultant and resident surgeon from the department of otorhinolaryngology – head and neck surgery at the quirino memorial medical center in quezon city, philippines, from june 2018 to july 2019. charts of patients were retrieved from the records section and were considered for inclusion in the study. informed consent for inclusion in this series and publication of clinical photographs was obtained from all patients. the only exclusion criterion was incomplete data. indications and operative technique were adopted from the revised pilot study done by anuwong et al.3 (figures 1 and 2) indications for toetva included those who had a thyroid gland diameter not larger than 10 cm that was (1) a benign tumor, such as a thyroid cyst, single nodular goiter, or a multinodular goiter, (2) a follicular neoplasm, or (3) a papillary carcinoma of the thyroid without evidence of metastasis. the following were considered as contraindications: patients who (1) were not cardiopulmonary cleared for surgery and (2) had a previously irradiated neck. all operations in this series were performed by a consultant and resident surgeon who had undergone and obtained training certificates for toetva. preoperative preparation was identical to that of open thyroidectomy. all patients underwent routine investigation including thyroid function tests, thyroid ultrasonography and fine needle aspiration biopsy. cardiopulmonary clearances were obtained for patients above 40 years old. all patients were informed of the possibility to convert to open surgery should there be difficulties during the surgery such as excessive bleeding or technical issues with the laparoscopic equipment. bedside assessment for hypocalcemia included the presence of perioral numbness and by eliciting a positive chvostek’s sign, and if any were present, serum corrected calcium was obtained (serum parathyroid hormone levels were not obtained routinely due to assay unavailability in the institution). sensation of the lower lip and mentum were examined via light touch sensation and assessed by the presence or absence of numbness. for antibacterial prophylaxis, hexetidine gargle was prescribed for all patients at 10 cc every 4 hours and intravenous clindamycin 300 mg was given every 6 hours for 24 hours and then switched to oral form at the same dosage until 7 days postoperatively. the vas pain score was assessed daily until postoperative day 3 and obtained via phone call or short message service (sms) if discharged. another vas assessment was obtained on the first opd follow-up on postoperative day 7. all of the patients had the same pain medication regimen: 3 doses of intravenous ketorolac 30 mg every 8 hours, followed by celecoxib 200 mg per os around the clock twice daily until 1 week postop. assessment of rln function was determined by the presence of postoperative hoarseness, and if present, a video laryngoscopy was performed to assess vocal cord mobility. recurrent laryngeal nerve injury was noted if there was impaired mobility of the ipsilateral true vocal cord. follow-up plans were 1 week, 1 month, 3 months, 6 months, and 1 year post-operatively with a postoperative thyroid ultrasound requested at 3 months follow-up to determine adequacy of removal. data analysis study variables (age, sex, specific thyroid condition, preoperative size of the thyroid gland, surgical technique as either thyroid lobectomy or total thyroidectomy, conversion to open technique, operative time, intraoperative blood loss, intraoperative size of the thyroid gland, postoperative hospital stay, vas pain score, postoperative complications such as rln injury, hypocalcemia, mental nerve philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery original articles figure 1. patient positioning, incision markings, and port placement. a. supine position with neck hyperextension under nasotracheal intubation. aseptic and antiseptic technique as in open thyroidectomy, extended to upper lip. b. placement of vestibular incision markings. a horizontal 10-mm line was drawn at the center of the lower lip vestibule between the inferior labial frenulum and vermilion border. two 5-mm vertical lines were drawn lateral to the horizontal markings drawn at a line anterior to the junction between the lower canine and first premolar teeth. c. insertion of a 10-mm port in the horizontal 10-mm incision. a 10-mm 30° laparoscope was used. two 5-mm ports inserted at the lateral incisions. laparoscopic instruments were used in the lateral ports. figure 2. surgical technique a. top-down view using 10-mm 30° laparoscope. (triangle: superficial cervical fascia, circle: midline, diamond: l-hook monopolar cautery) b. left strap muscles retracted laterally using an external hanging 2/0 silk suture exposing the trachea. (triangle: strap muscles, circle: silk 2/0 suture needle, diamond: thyroid nodule) c. right strap muscles retracted laterally via external hanging suture. the right thyroid lobe and the inferiorly located mass was exposed. (triangle: trachea, circle: thyroid nodule, square: superior portion of right thyroid lobe, diamond: retracted strap muscles) d. isthmusectomy done using an ultrasonic device. (triangle: trachea, circle: ultrasonic device, square: right thyroid lobe retracted anterolaterally, diamond: posterior suspensory ligament of berry) e. isthmusectomy completed. (triangle: trachea, circle: right thyroid lobe retracted laterally, diamond: posterior suspensory ligament of berry) f. right thyroid lobe retracted medially exposing its lateral attachments and the superior parathyroid gland. both were dissected away from the thyroid using an ultrasonic device. (triangle: right thyroid lobe retracted medially, circle: superior parathyroid gland, diamond: lateral attachments) g. exposure of the superior pole of the right thyroid lobe via dissection through an avascular space. (triangle: right thyroid lobe retracted anteriorly, circle: superior pole vessels, diamond: avascular space of joll) h. ultrasonic device used to ligate the superior pole vessels. (triangle: right thyroid lobe retracted anteriorly, circle: superior pole vessels, diamond: ultrasonic device) i. exposure of the right rln. (triangle: right thyroid lobe, circle: thyroid nodule, diamond: cricothyroid muscle, square: right rln) j. exposure of the right inferior parathyroid gland. (triangle: right thyroid lobe retracted medially, diamond: right inferior parathyroid gland) k. ligation of inferior pole vessels using an ultrasonic device. (triangle: right thyroid lobe, circle: inferior pole of the right thyroid gland, diamond: ultrasonic device, square: cricothyroid muscle) l. specimen held inside endobag and ready for extraction (triangle: right thyroid lobe and mass, circle: endobag) m. approximation of strap muscles using vicryl 4/0 sutures. n. two-layer closure of lower lip vestibule using vicryl 4/0 sutures injury, surgical site infection, wound dehiscence, seroma, and other complications) were abstracted from the hospital charts and frequency distributions and measures of central tendency were computed. data was summarized and processed using ibm spss version 24.0 released 2016. (ibm corporation, armonk, ny, usa). results a total of 10 patients (one male and nine females) underwent toetva from june 2018 to july 2019. the mean age was 37 years (± 9.74, range 27 to 56). patient characteristics and outcomes are summarized in table 1. of the 10 patients, 7 had single thyroid nodules, 4 of which a b c a e i b f j c g k d h l m n philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery original articles were benign colloid nodules (57%), 1 was a follicular neoplasm (14%), and 2 were papillary carcinomas (29%), while 3 of the patients had multinodular goiters, 2 of which were unilateral benign colloid nodules (67%) and 1 case was a unilateral papillary carcinoma with contralateral benign colloid nodules (33%). the average preoperative thyroid size was 4.73 cm in widest diameter using thyroid ultrasound (±1.88 cm, range 3.6 to 6.5 cm). nine patients underwent thyroid lobectomy and one patient underwent total thyroidectomy. no patients were converted to open thyroidectomy. mean operative time for thyroid lobectomy and total thyroidectomy was 4 hours and 29 minutes and 4 hours and 15 minutes, respectively (± 1 hour and 14 minutes, range 3 to 7 hours). the overall average blood loss was 121.5 ml (± 44.54 ml, range 80 to 200 ml), with 140 ml (±47.95 ml, range 80 to 200 ml) for those who underwent thyroid lobectomy, and 100 ml for the patient who underwent total thyroidectomy. the average intraoperative size of the thyroid gland was measured in widest diameter (in total thyroidectomy cases, the larger lobe was measured) which was 4.48 cm (±0.919 cm, range 3 to 5.5 cm). median postoperative hospital stay was 2 days (range 2 to 12 days). there were no cases of hypocalcemia in this series. in this series, none were noted to have a mental nerve injury. a total of 2 table 1. summary of patient characteristics and outcomes who underwent toetva at qmmc (n=10) 1 2 3 4 5 6 7 8 9 10 3.6 6 4 6.5 5.96 3.96 5.31 5.07 3 3.9 5.2 5 4 5.5 3 5 5.1 5 3 4 3:00 5:40 3:55 7:00 6:00 4:00 4:15 3:50 3:40 3:20 120 200 80 200 140 120 100 100 100 200 3 2 2 2 2 2 12 3 2 2 30 26 27 37 51 36 56 30 25 44 f m f f f f f f f f papillary ca follicular neoplasm nodular goiter nodular goiter nodular goiter multinodular goiter papillary ca nodular goiter papillary ca multinodular goiter papillary ca nodular colloid goiter adenomatoid colloid goiter adenomatoid colloid goiter adenomatoid colloid goiter adenomatoid colloid goiter papillary ca adenomatoid colloid goiter papillary ca adenomatoid colloid goiter unilateral unilateral unilateral unilateral unilateral unilateral bilateral unilateral unilateral unilateral lobectomy lobectomy lobectomy lobectomy lobectomy lobectomy total lobectomy lobectomy lobectomy none none none ssi, wound dehiscence skin burn rln injury, seroma ssi, wound dehiscence none none none patient # preoperative diagnosis (fnab) histopathologic diagnosis unilateral vs bilateral nodules operative time (hr:min) index nodule size by us (cm) index nodule gross size (cm) postoperative length of hospital stay (days) blood loss (ml) complications extent of surgery (lobectomy vs total) age sex patients developed anterior neck abscesses with purulent discharge, necessitating an incision and drainage procedure in one of the cases, while the other had delayed removal of post-operative neck drain. (figures 3 to 6) failure of wound closure of the horizontal midline vestibular incision was noted 1 week postoperatively in both cases. a seroma was found in 1 case, which was treated with syringe aspiration using a gauge-23 needle. one of the cases sustained a skin burn secondary to electrocauterization. the mean postoperative vas measurements were 5, 3, 2, and no pain or 0, on the first, second, third, and seventh postoperative days, respectively. recurrent laryngeal nerve injury was noted in 1 patient, confirmed by video laryngoscopy through postoperative days 1, 2, 3, 7, and 1-month postoperatively. there was complete resolution of hoarseness and true vocal cord paresis after 3 months. all of the patients were able to complete follow-ups up to 3 months, 7 patients were able to follow-up at 6 months, and 3 patients were seen after 1 year. (figure 7) only 5 of the patients came back with requested thyroid ultrasound results at three months, 4 of which showed adequate removal with 1 patient who had thyroid lobectomy noted to have a new thyroid nodule on the contralateral side that was managed accordingly via a completion toetva which is not included in this case series. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery original articles figure 3. abscess formation over the sternal area noted 8 days postoperatively figure 6. postoperative day 15. wound dehiscence over the site of the penrose drain. figure 7. follow-up photos of patients taken 6 months post-toetva figure 4. incision and drainage done with noted progressive resolution of persistently draining abscess over the substernal incision site over 4 weeks post-toetva. (a. 8 days post-toetva, b. 2 weeks post-toetva, c. 4 weeks post-toetva) figure 5. patient who underwent total thyroidectomy via toetva presenting with a surgical site infection on postoperative day 4 (a. marked hyperemia, erythema, and tenderness over the anterior neck. b. purulent material soaking the 24-hour gauze dressing) discussion our data suggest that toetva may be a viable alternative for patients with a solitary thyroid nodule who are motivated by its advantages and need to undergo a thyroid lobectomy. complications seen in the series include transient rln injury (managed via observation) and surgical site infection (managed through medical and surgical means). according to anuwong et al., nodules included in the selection criteria were defined as those not exceeding 10 cm.4 thyroid gland size was initially thought to be directly proportional to the operative time for each case, but our experience shows that operative time still varied regardless of thyroid gland size. as previously mentioned in the literature, toetva comes with a steep learning curve, producing a longer operative time during the first few surgeries and noted to stabilize after 20 procedures.1,4 such a learning curve was noted in our experience. for the initial 6 cases, a thyroid lobectomy was indicated and pursued, afterwhich a total thyroidectomy via toetva was also done. however, 6 cases may not be enough to plateau the learning curve of toetva. outcomes in terms of total thyroidectomy and lobectomy in this series were comparable in terms of blood loss and duration; however, the total thyroidectomy case had surgical site infection which necessitated prolonged hospital stay for resolution of the neck abscess. the incidence of infection may be multifactorial, and the experience of the surgeon in terms of the overall management of toetva cases is important. the operative time of 4 hours and 15 minutes for total thyroidectomy ranked fourth out of the 10 in the series in terms of speed of completing the operation. this may be attributed to the learning curve rather than the type of procedure as either lobectomy or total thyroidectomy. factors such as size of the nodule and pathology may have a bearing on duration, although it is important to note that in this series, the total thyroidectomy case was the seventh surgery done by the surgeons and the succeeding cases are noted to have a decreasing trend. a b a b c philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery original articles in this series, there were no noted complications from technique, and intraoperative bleeding was addressed with monopolar cauterization and ultrasonic device. hence, conversion to open surgery was not necessary in all of the cases. our results are comparable to those of anuwong et al. who recorded zero conversion rates among 200 patients who underwent toetva in 2017.4 the mean operative blood loss in this case series was considered low and below the computed allowable blood loss based from the preoperative complete blood count of each patient. however, this was not validated postoperatively. although this result was considered minimal by computation of allowable volume loss per patient, the result was still slightly high compared to the literature, where an excellent profile for intraoperative blood loss was recorded at 11.1 to 97 ml for both lobectomy and total thyroidectomy cases.1 the 2-day median length of hospital stay postoperatively is comparable to literature with average length of hospital days ranging from 2 to 7 days.1-6 factors affecting length of stay in this series include delay in the submission of requirements for the purpose of government reimbursement such as official personal documents and community clearances. one patient was discharged 12 days postoperatively due to surgical site infection, which was considered a factor that extended hospital stay in this series. however, another patient with both wound dehiscence and surgical site infection showed no signs of these complications on postoperative days 1, 2, and 3 and these were not considered factors delaying discharge in this case. pain was not considered a cause of delay in discharge because a significant decrease in pain was noted for all patients by postoperative day 3. perhaps the decrease in postoperative pain may also be because toetva creates less flap dissection compared with open thyroidectomy.6 recurrent laryngeal nerve injury was recorded in one case (10%) with spontaneous resolution of hoarseness and vocal cord paralysis noted on the third month postoperatively. thus, this was considered as a transient rln injury. nevertheless, this complication rate is still high compared to the literature wherein a complication rate for rln injury of 2.67% was reported.1,4 the main difference in locating the rln in toetva is that the nerve is initially located in its insertion to the cricothyroid muscle, and dissection proceeds caudally. this is in contrast to open thyroidectomy where various landmarks are used to locate the rln in its inferior portion and then the dissection proceeds cephalad. injury to the rln in toetva may be attributed to mechanical injury via trauma or stretch injury during dissection using laparoscopic instruments and/or thermal injury from use of an energy device and electrocauterization. there were no cases of hypocalcemia reported in this case series, which is comparable to the literature (0-11%).1,4 because the magnified endoscopic view afforded by toetva allows excellent identification of the parathyroid glands, it is considered beneficial in preventing hypoparathyroidism3,4 although it is important to note that this also limits depth perception due to the 2-dimensional view through a video monitor. previous approaches for transoral thyroidectomy documented a higher complication rate for mental nerve injury (1.5 to 4.3%)1 which has decreased since 2017 due to some modifications to the technique.4 none of the cases in the series had mental nerve injury which is lower compared to recent literature with rates ranging from 1.5 to 4.3%.1,4 surgical site infection was recorded in 2 cases (20%), with both cases having a wound dehiscence on the oral vestibule as well (20%). one of the possible reasons for this occurrence is the concern for infection due to the clean-contaminated nature of the procedure. this data is in contrast to the literature with reports of very low incidences of postoperative infection and wound dehiscence for toetva.1,3-6 most studies have mentioned zero rates of postoperative infection3-6, with a systematic review reporting surgical site infection in 2 out of 211 cases which was also attributed to the clean-contaminated nature of the procedure, hence prophylactic antibiotics were given to all the succeeding cases as what was done initially in this series.1 wound dehiscence for both cases occurred in the gingivobuccal sulcus of the lower lip, which appears to happen because of the collision of laparoscopic instruments in the oral vestibule during surgery, inadvertently extending the initial incisions and forming unwanted lacerations directed posteriorly to the gingivobuccal sulcus, an area which is more difficult to appose due to the lack of deep soft tissue available for closure. factors to lessen collision may include surgeon experience, camera handling, as well as having smaller ports. changes and possible standardization in suturing techniques may be reviewed in the future. seroma formation was treated with aspiration using a 10-cc syringe with a gauge-23 needle. varying rates of seroma formation were reported (4.7 – 5%) which were noted to be lower compared to the percentage seen in this series (10%). it is recognized that seroma formation is a minor complication of toetva and a higher incidence was expected due to the larger flap elevation necessary to create a working space.4 for other complications of toetva, skin burn was noted in 1 case which has a reported rate of 2.4% in a literature review.4 for this series, this complication was attributed to the usage of monopolar cauterization during the creation of the workspace. the plan for this case was to do excision and primary closure; however, the patient did not consent for further corrective surgery and was satisfied with the current cosmetic results. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery original articles references 1. shan l, liu j. a systemic review of transoral thyroidectomy. surg laparosc endosc percutan tech. 2018 jun: 28(3) :135-138. doi: https://doi.org/10.1097/sle.0000000000000512. pmid: 29389814. 2. fabic aj, bisquera ob, macalindong s, dofitas rb. trans-oral endoscopic thyroidectomy – vestibular approach: a case series of operations done in the philippine general hospital. unpublished manuscript 2017. 3. anuwong a. transoral endoscopic thyroidectomy vestibular approach: a series of the first 60 human cases. world j surg. 2016 mar; 40(3):491–7. doi: 10.1007/s00268-015-3320-1; pmid: 26546193. 4. anuwong a, sasanakietkul t, jitpratoom p, ketwong k, kim hy, dionigi g, et al. transoral endoscopic thyroidectomy vestibular approach: indications, techniques, and results. surg endosc. 2018 jan; 32(1):456-465. doi: 10.1007/s00464-017-5705-8; pmid: 28717869. 5. anuwong a, kim hy, dionigi g. transoral endoscopic thyroidectomy using vestibular approach: updates and evidences. gland surg. 2017 jun; 6(3): 277-284. doi: 10.21037/gs.2017.03.16; pmid: 28713700; pmcid: pmc5503927. 6. anuwong a, ketwong k, jipratoom p, sasanakietkul t, duh qy. safety and outcomes of the transoral endoscopic thyroidectomy yestibular approach. jama surg. 2018 jan 1;153(1):21-27. doi: 10.1001/jamasurg.2017.3366; pmid: 28877292; pmcid: pmc5833624. limitations of this study include the cost in performing toetva in the local setting, as this may affect replicability of the study in some institutions. this was not considered a limitation in this series because our institution shouldered the hospital expenses of patients who underwent the surgical procedure, provided these patients were able to submit all the needed requirements. establishing efficacy and safety of the procedure compared with existing effective, standard operative procedures with controlled and standardized processes, in a setting of a randomized controlled trial would be ideal and should be the next step after this study. in summary, toetva was replicated in the local setting and a presentation of the perioperative data of all the patients who underwent this novel technique, the indications, as well as surgical and patient outcomes, have been described. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 captoons assistant professor william u. billones, md de la salle health sciences institute creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international doknet’s world philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 6564 philippine journal of otolaryngology-head and neck surgery from the viewbox philipp j otolaryngol head neck surg 2021; 36 (1): 65-66 c philippine society of otolaryngology – head and neck surgery, inc. fenestral otosclerosis: a subtle lesion easily missed nathaniel w. yang, md department of otolaryngology-head and neck surgery college of medicine philippine general hospital university of the philippines manila department of otolaryngology -head and neck surgery far eastern university nicanor reyes medical foundation institute of medicine correspondence: dr. nathaniel w. yang department of otolaryngology head and neck surgery ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 8526 4360 fax: (632) 8525 5444 email: nwyang@up.edu.ph the author declared that this represents original material, that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. a 29-year-old filipina of chinese descent presented with progressive bilateral conductive hearing loss of several years’ duration. while working overseas, she consulted with an otolaryngologist and underwent computerized tomographic (ct) imaging of the temporal bone as part of her evaluation. she was informed that no abnormalities were identified in the imaging exam, and she was offered exploratory middle ear surgery with possible stapes surgery. she then sought a second opinion, with the intention of obtaining a more definitive diagnosis prior to any invasive medical intervention. a review of the ct imaging study, with particular emphasis on looking for radiologic evidence of otosclerosis, revealed the presence of a focal region of bone demineralization in the region of the fissula ante fenestram. (figure 1) this finding is consistent with a diagnosis of fenestral otosclerosis. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. axial ct image at the level of the stapes footplate / oval window, using a bone window setting for temporal bone imaging (ww 4000, wl 1000). a focal area of demineralization can be identified in the area where the fissula ante fenestram (faf) is located. the landmarks for this area include the cochleariform process (cp), from which the tensor tympani tendon arises to attach to the malleus (mh); and the oval window, where the thin bone of the stapes footplate is located (fp/ow). philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 6766 philippine journal of otolaryngology-head and neck surgery from the viewbox otosclerosis is one of the main differential diagnoses for a patient presenting with bilateral conductive hearing loss and no other visible evidence of otologic disease. although it is more common in the caucasian population,1 it must remain as one of the considerations in the asiatic population, including filipinos. high-resolution ct is the imaging technique of choice in the evaluation of conductive hearing loss.2 when evaluating a scan for evidence of otosclerosis, it must be remembered that the most common location of involvement is the bone just anterior to the oval window, in a small cleft known as the fissula ante fenestram. it is this relationship that gives rise to the term fenestral otosclerosis. the fissula is a thin fold of connective tissue figure 2. axial ct image of a normal temporal bone at the same level and bone window setting for comparison, showing the dense bone in the region of the fissula ante fenestram (faf). the density of this region normally matches that of the otic capsule that surrounds the cochlea. extending through the endochondral layer, located in the region between the oval window and the cochleariform process, where the tensor tympani tendon turns laterally toward the malleus.3 (figure 2) since the average length of the stapes footplate along its short axis is around 1.5 mm, it is highly recommended that submillimeter image slice thickness be routinely ordered for the ct imaging study, in order to maximize the opportunity to identify the oftentimes small and subtle areas of focal demineralization. at a slice thickness of 0.5 mm, such a lesion might only be identified by an astute clinician in 2-3 sequential axial imaging slices. references 1. altmann f, glasgold a, macduff jp. the incidence of otosclerosis as related to race and sex. ann otol rhinol laryngol. 1967 jun;76(2):377-392. doi:10.1177/000348946707600207. pubmed pmid: 6028664. 2. curtin hd. imaging of conductive hearing loss with a normal tympanic membrane. ajr am j roentgenol. 2016 jan;206(1):49-56. doi: 10.2214/ajr.15.15060. pubmed pmid: 26491893. 3. lee tc, aviv ri, chen jm, nedzelski jm, fox aj, symons sp. ct grading of otosclerosis. ajnr am j neuroradiol. 2009 aug;30(7):1435-9. doi: 10.3174/ajnr.a1558. pubmed pmid: 19321627 pubmed central pmcid: pmc7051554 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles abstract objective: to compare subjective nasal airflow and overall pain score (as well as safety and added cost of ) using an improvised nasal airway tube (nasogastric tube) versus nasal packing after endoscopic sinus surgery (ess) for chronic rhinosinusitis with nasal polyposis (crswnp). methods: design: quasi experimental prospective cohort study setting: tertiary government training hospital participants: twenty-six (26) consecutive patients aged 18 to 77 years old diagnosed with crswnp who underwent ess were alternately assigned to an experimental group (a) of 13, where an improvised nasal airway (nasogastric) tube was placed in addition to the nasal pack or a control group (b) of 13 with nasal packing alone. results: there was a significant difference in subjective nasal airflow between experimental (a) and control (b) groups during the immediate postoperative period where the mean subjective airflow was 8.07 and 0.00 over 10.00, respectively. no significant difference was noted between the groups in terms of age, gender, severity of polyposis and overall pain score. no complications such as bleeding, toxic shock syndrome, vestibular or alar injury and septal necrosis were noted immediately post-op and after one week follow-up in both groups. an approximate cost of php 25 was added to group a. conclusion: an improvised nasal airway using a nasogastric tube provides adequate airflow without additional pain in the immediate postoperative period. it is safe to use and an affordable option for patients in need of nasal airway stents residing in areas where a preformed nasal packing with incorporated tube stent is not available. keywords: endoscopic sinus surgery; chronic sinusitis; nasal polyps; nasal obstruction; subjective nasal airflow; nasal stents chronic rhinosinusitis (crs) is an inflammatory disorder of the nasal and paranasal sinuses that lasts for more than 12 consecutive weeks, with the precise pathophysiology still remaining unclear.1 despite multifactorial etiology and classifications, and whether allergic or non-allergic, a common denominator is inflammation.2 inflammation is the common pathway explaining assessment of nasal airflow and pain, safety and cost of an improvised nasal airway (nasogastric) tube after endoscopic sinus surgery josephine grace c. rojo, md rachel zita h. ramos, md department of otorhinolaryngology head and neck surgery corazon locsin montelibano memorial regional hospital correspondence: dr. rachel zita h. ramos department of otorhinolaryngology head and neck surgery corazon locsin montelibano memorial regional hospital lacson cor. burgos sts., bacolod city, negros occidental 6100 philippines phone: (632) 917 722 9704, (632) 917 310 8694/ +63 34 703 1350 e-mail: gratcheia@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery analytical research contest. december 7, 2019. palawan ballroom, edsa shangri la hotel, mandaluyong city. philipp j otolaryngol head neck surg 2020; 35 (2): 22-26 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles signs and symptoms of chronic sinusitis. these include facial pain or pressure, nasal congestion or blockade, nasal discharge, and anosmia or hyposmia as common symptoms prompting consult.1 the more severe forms of crs are those with nasal polyposis (crswnp) making the previously mentioned symptoms even worse. standard surgical management for cases refractory to medical management is endoscopic sinus surgery (ess) that may involve polypectomy, antrostomy, turbinectomy, ethmoidectomy and opening or enlargement of various sinus ostia, as indicated.3 nasal packing is frequently applied postoperatively to aid hemostasis and provide structural support to the recently operated sinonasal cavity especially for those with severe nasal polyposis and advanced sinonasal disease where post-operative bleeding is expected. commercially prepared nasal dressings are widely avaliable, but many do not allow nasal respiration while the pack is in place. there are preformed nasal packs with incorporated stents, but they are in scarce supply and costly especially for indigent populations (such as in the area where this study was conducted). we postulate that an alternative, low-cost and safe improvised nasal stent can provide immediate relief and a nasal airway that are otherwise sacrificed by nasal packing alone in areas where the preformed nasal pack with stent is not available or too costly. we aim to compare the immediate overall pain score and subjective nasal airflow among patients following ess for crswnp using an improvised nasal airway tube (nasogastric tube) versus nasal packing alone. we further aim to evaluate safety as defined by absence of complications (like intractable bleeding, vestibular or alar injury and septal necrosis) and added cost of this innovation. methods with approval of the corazon locsin montelibano memorial regional hospital research ethical review committee (clmmrhrerc-2018-18), all patients aged 18 years and above that were diagnosed with crswnp and consented to undergo ess and participate in this study between january and august 2019 were serially considered for inclusion. primary recruitment and screening of study participants were done in the outpatient department (opd). excluded were those who were pregnant, of foreign nationality and ethnicity, or had bilateral grade 0 to grade ii polyposis not requiring nasal packing for hemostasis and structural support and on whom small non-absorbable or absorbable middle meatal spacers would be applied post-operatively without packs. a quasi-experimental comparative design with alternate assignment to two groups, experimental (a) and control (b) was employed. consecutive participants were alternately assigned to each group to ensure equal distribution of numbers. since this was a procedural study, no blinding was done. both groups underwent a pretest for the two dependent variables, (1) pain score and (2) subjective nasal airflow. a 2-item survey questionnaire with established visual analog scale (vas) were used to collect the data. the items were written in both english and in the vernacular. the vas comprised a 10-cm line with the extremes in pain for item 1 and degree of nasal obstruction-airflow on item 2. (figure 1) the same questionnaire was used on three occasions: 1. one day before surgery when the patient was admitted to the ward; 2. the morning after surgery while the patient was still admitted prior to discharge; and 3. approximately 5-7 days post-operatively during the first outpain and airflow visual analog scale assessment form code: control number: diagnosis: age/sex: date of surgery date survey taken: 1. in a scale of 0-10, zero as no pain and 10 as worst pain, what is the degree of discomfort on nasal area that you feel right now? sa iskala sang 0-10, 0 bilang wala gid sang nga sakit kag 10 bilang inidi maagwantahan nga sakit, ano ang imo ginabatyag nga kasakit? no pain moderate pain worst possible pain tawhay/wala gid sang sakit medyo may sakit inidi maagwanta nga kasakit 0 1 2 3 4 5 6 7 8 9 10 2. after a maximum nasal inhalation with mouth closed, in a scale of 0-10, zero as nose feels completely blocked with no air entry and 10 as nose feels clear with full air entry, how is the air entry in your nose? pagkatapos magginhawa sang todo paagi sa ilong samtang sarado ang baba, sa iskala sang 0-10, 0 bilang wala hangin nga makalusot kag 10 bilang ang tanan nga hangin makalusot sa ilong nga wala sang ga-bara, ano ang pamatyag sang pagsulod sang hangin sa imo nga ilong? no nasal airflow full nasal airflow wala hangin nga makalusot sa ilong makalusot ang hangin sa ilong nga wala sang ga-bara 0 1 2 3 4 5 6 7 8 9 10 figure 1. pain and airflow assessment using modified visual analog scale philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles patient follow-up for removal of the nasal pack at the opd. the survey questionnaire was administered first by first and second year residents on duty and confirmed by accompanying third and fourth year residents excluding the primary investigator. the residents were oriented by the primary investigator prior to initiation of the study. standard operating procedures were observed for all patients. surgeons varied but the same pre-operative preparation, surgical technique and anesthesia care were used. the groups only differed in the application of improvised nasal airway tube after ess. standard commercially available polyvinyl alcohol (pva) coated nasal packs (merocel® medtronic inc., minneapolis, mn, usa) were placed as a middle meatal spacer. in the experimental group, the improvised nasal airway was placed in the nasal floor just below the nasal pack. the improvised airway was constructed from a french 18 nasogastric tube cut according to the length of the nasal airway up to the posterior choanal arch for patients with at least 8mm to 9mm nasal vestibule width. for those with nasal vestibule 5-7mm in size, a 6mm diameter nasogastric tube french 16 was used. the tubes were secured to each other anterior to the columella using silk-0 suture with a cutting needle, tied over gauze. (figure 2) the control group (b) had only the standard nasal pack inserted. subjective airflow and pain, and complications were recorded. data was encoded and processed using spss statistics version 22 (ibm corp. armonk, ny, usa). descriptive statistics (mean and standard deviation) were used for demographic data. independent t-tests were used to compare the means between two groups. analysis of variance was computed at 95% confidence interval; p values < .05 were considered significant. results a total of 26 participants completed the study, 18 males and 8 females, with age range from 18 to 77 years old with a mean age of 45 (sd 3.5). there were 13 in the experimental group (a) with improvised nasal airway tube and nasal packing and 13 in the control group (b) with nasal packing alone without an airway tube. twenty-three (88.5%) had intranasal polyposis while three (12%) had compounding antrochoanal polyposis. on the right nostril, the degrees of polyposis follow: grade iii in 23 (88.5%), grade ii in 2 (7.7%) and none in 1 (3.8%). on the left nostril, the degrees of polyposis were as follows: grade iii in 23 (88.8%), grade ii in 1 (3.8%), and grade i in 2 (7.7%). the procedures performed were: functional endoscopic sinus surgery (fess) only for 17 (65.4%), fess with caldwell-luc (c-l) procedure in 5 (19.2%), fess, c-l and submucous resection (smr) in 3 (11.5%) and revision ess in 1 (3.8%). for the treatment group (a), subjective nasal airflow scores were 3.69, 8.07 and 9.8 out of 10.00, respectively assessed preoperatively, on postoperative day 1 and postoperative follow-up after removal of the improvised airway tube and nasal pack. mean pain scores measured on the same days were 0.15, 0.53, and 0.30 out of 10.00, respectively. mean follow-up and subsequent removal was done in 6.5 days. for the control group (b), subjective nasal airflow scores were 4.15, 0.00, and 9.76 out of 10.00, respectively assessed preoperatively, on postoperative day 1 and postoperative follow-up after removal of the nasal pack. mean pain scores measured on the same days were 0.00, 0.00, and 0.76 out of 10.00 respectively. mean follow-up and subsequent removal was done in 6.23 days. (table 1) at 95% confidence interval, analysis of variance showed no significant difference between groups in terms of age, sex, degree of polyposis, procedure performed, pre-operative and postoperative follow-up pain and subjective nasal airflow scores. the only significant difference (0.5 level of significance) between groups was for subjective nasal airflow assessed immediately the day after the procedure. ( table 1) this was still statistically significant at 99% level of confidence (group a n=13, m = 8.0769, sd 1.60528, sem .44522; group b n = 13, m = .0000, sd .00000, sem .00000). within the treatment group a, 10 (77%) used a french 18 ngt while only 3 (23%) used a french 16 ngt. there is no significant difference noted for size of ngt, postoperative day 1 pain and subjective nasal airflow scores. of the 13 patients in this group, 11 (84.6%) had increased subjective airflow from the preoperative period and immediately post-operatively, 2 patients remained the same and none had lower figure 2. cut-ngt nasal airways in place, secured with silk-0 sutures post-tests were administered the morning after the procedure. another assessment was made during the first postoperative followup period after removal of the nasal pack (including removal of airway tube for group a). data including age, gender, pre-operative diagnosis, grading of nasal polyps for each nostril, surgical procedure, group assignment, improvised airway nasogastric tube size, serial scores for philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles table 1. anova at 95% level of confidence sum of squares df f sig.mean square age between groups within groups total sex between groups within groups total polyposis between groups within groups total right between groups within groups total left between groups within groups total procedure between groups within groups total preopairflow between groups within groups total preoppain between groups within groups total postop1airflow between groups within groups total postop1pain between groups within groups total followupairflow between groups within groups total followuppain between groups within groups total daysremoved between groups within groups total 240.038 7886.000 8126.038 .154 5.385 5.538 .346 2.308 2.654 .346 9.692 10.038 .038 8.000 8.038 .154 18.308 18.462 1.385 194.462 195.846 .154 3.692 3.846 424.038 30.923 454.962 1.885 15.231 17.115 .038 6.000 6.038 1.385 101.077 102.462 .615 29.538 30.154 1 24 25 1 24 25 1 24 25 1 24 25 1 24 25 1 24 25 1 24 25 1 24 25 1 24 25 1 24 25 1 24 25 1 24 25 1 24 25 .731 .686 3.600 .857 .115 .202 .171 1.000 329.104 2.970 .154 .329 .500 .401 .416 .070 .364 .737 .657 .683 .327 .000 .098 .698 .572 .486 240.038 328.583 .154 .224 .346 .096 .346 .404 .038 .333 .154 .763 1.385 8.103 .154 .154 424.038 1.288 1.885 .635 .038 .250 1.385 4.212 .615 1.231 table 2. subgroup analysis of variance for tube size and postoperative day 1 pain and subjective nasal airflow sum of squares df f sig.mean square postop1airflow between groups within groups total postop1pain between groups within groups total 4.523 26.400 30.923 1.131 14.100 15.231 1 11 12 1 11 12 1.885 .882 .197 .368 4.523 2.400 1.131 1.282 postoperative subjective airflow results. (table 2) overall, no complications were noted in both groups. all patients were fit for discharge the day following the surgery. there was no accidental dislodgement, aspiration, ingestion, or bleeding reported during application of the tube, while the tube was in place and on tube removal during follow-up. discussion an improvised nasal airway using a nasogastric tube provides adequate airflow without additional pain in the immediate postoperative period following ess for crswnp. it is safe to use and affordable. chronic rhinosinusitis (crs) is defined as inflammation of the nasal cavity and paranasal sinuses and/or the underlying bone that has been present for at least 12 weeks. it is divided into two subgroups, crs without nasal polyposis (crs w/o np) and crs with nasal polyposis (crs w np). nasal polyps are pedunculated masses of edematous inflamed mucosa usually described as smooth, semi-translucent, pearly white to pinkish in color and sometimes resembling a peeled grape appearance and is a major determinant of debilitating symptoms experienced by patients with crs w np.1 the prevalence rate of nasal polyposis in adults in asia is 1-4% with no predilection in sex, and is noted to occur even less in children.2 in this study, only adults were assessed and majority of the subjects were males. endoscopic sinus surgery (ess) is the standard of surgical management for crs refractory to medical management especially for those with crs w np. various other medical management regimes are available to address the many facets of crs, but nasal obstruction is considered to be one of the most important aspects of the patient’s quality of life (qol) making it a part of many types of qol assessment forms. post-operative improvement of nasal obstruction and qol has been extensively studied, but there is limited data available in the literature as to the degree of nasal airflow assessed immediately postop especially for patients with massive polyposis requiring nasal packing. the degree of relief from nasal obstruction immediately postoperatively was significantly different between groups. all patients in the treatment group a had moderate to high subjective nasal airflow with an average score of 8 over 10 in contrast to those in group b where there was no amount of subjective airflow. although the absence of nasal airflow may not matter much for patients with long-standing preoperative subjective airflow close to zero, those who had some degree philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles acknowledgements the authors acknowledge the valuable general concept applied in this study as practiced and suggested by dr. jose l. montilla iii. references 1. rimmer j, fokkens wj, chong ly, hopkins c. surgical versus medical interventions for chronic rhinusinusitis with nasal polyps. cochrane database syst rev. 2014 dec; (12): cd0006991. doi: 10.1002/14651858.cd006991.pub2; pubmed pmid: 25437000. 2. tikaram a, prepageran n. asian nasal polyps: a separate entity.  med j malaysia.  2013 dec; 68(6):445-7. pubmed pmid: 24632910. 3. stölzel k, bandelier m, szczepek a, olze h, dommerich s. effects of surgical treatment of hypertrophic turbinates on the nasal obstruction and the quality of life in patients with chronic rhinosinusitis. am j otolaryngol.  2017 nov-dec;38(6):668-672. doi: 10.1016/j. amjoto.2017.08.009. pubmed pmid: 28877858. 4. ciprandi g, mora f, cassano m, gallina am, mora r. visual analog scale (vas) and nasal obstruction in persistent allergic rhinitis.  otolaryngol head neck surg. 2009 oct; 141(4):527-9. doi: 10.1016/j.otohns.2009.06.083; pubmed pmid: 19786224. 5. hsu hc, tan cd, chang cw, chu cw, chiu yc, pan cj, et al. evaluation of nasal patency by visual analogue scale/nasal obstruction symptom evaluation questionnaires and anterior active rhinomanometry after septoplasty: a retrospective one‐year follow‐up cohort study. clin otolaryngol. 2017 feb; 42(1):53-59. doi: 10.1111/coa.12662; pubmed pmid: 27102375. 6. yaniv e, hadar t, shvero j, raveh e. objective and subjective nasal airflow.  am j otolaryngol. jan-feb 1997;18(1):29-32. doi: 10.1016/s0196-0709(97)90045-4; pubmed pmid: 9006674. 7. weber rk. nasal packing and stenting. gms curr top otorhinolaryngol head neck surg. 2009;8:doc02. doi: 10.3205/cto000054; pubmed pmid: 22073095; pubmed central pmcid: pmc3199821. 8. akbari e, philpott cm, ostry aj, clark a, javer a. a double-blind randomised controlled trial of gloved versus ungloved merocel middle meatal spacers for endoscopic sinus surgery. rhinology 50: 306-310, 2012. doi: 10.4193/rhino11.215. 9. von schoenberg m, robinson p, ryan r. nasal packing after routine nasal surgery—is it justified?   j laryngol otol.  1993 oct; 107(10): 902-905. doi: https://doi.org/10.1017/ s0022215100124740. pubmed pmid: 8263386. 10. rbgm medical express sales, inc. [website]. product costs. [cited 2018] available from: https:// rbgm-medical.com/ of airflow during the preoperative period would be forced to mouthbreathe postoperatively after nasal packing alone fully obstructs the nasal airway. on the other hand, the greater positive difference was marked among patients who had no or limited airflow preoperatively, comparatively experiencing significant improvement during the immediate postoperative period. the majority of patients reporting improved subjective airflow with none reporting worsened airflow after tube placement supports the importance of providing a nasal airway for patients requiring packing after ess.1, 3 a visual analog scale (vas) used in assessing subjective nasal obstruction or airflow appears to be clinically relevant and may be used in lieu of standard rhinomanometry when the latter is not available. subjective evaluation of nasal obstruction symptoms significantly correlated with rhinomanometry results in many studies.4, 5 although more comprehensive quality of life (qol) forms can better assess the overall postoperative improvement brought about by placement of an improvised nasal airway tube, the importance of vas as an assessment has been previously described in patients who underwent uncinectomy where preand post-operative nasal airflow and resistance using rhinomanometry as an objective tool and vas as a subjective tool were compared.6 there was no significant difference in preand post-uncinectomy rhinomanometry results whereas patients reported significant subjective improvement in nasal airflow, showing that objective rhinomanometric measurements of nasal airflow and resistance may not have direct correlation to subjective sensation of airflow.6 because quality of life and subjective perception of comfortable breathing is more important, rhinomanometry has little clinical value, and subjective vas assessment may be a better option in certain conditions as utilized in this study. various nasal packs available include expandable nasal packs made from polyvinyl alcohol (pva) derived from viscose and cellulose, like netcell® and merocel® with the latter utilized in this study. risks in using nasal packs include pain, discomfort and very rarely, toxic shock syndrome (tss). however, the probable benefit of reducing hemorrhage justifies the possible risks. the addition of a nasal tube could theoretically increase these risks. however, none of these complications were noted in both groups, supporting the safety of the use of nasal packing with or without addition of an airway tube.7, 8,9 excluding concerns with logistics and stock availability, medical grade preformed nasal packs with built-in airway tubes already exist with an average price of php 1,750 per piece or php 3,500 for both nostrils.10 this price was compared with the no-thread merocel® used in this study costing php 250 per piece or php 500 for both nostrils plus php125 for the silk suture used to anchor and tie the nasal pack and php 25 for the ngt, for a maximum total of php 650 and a difference of php 2,850 per patient utilizing these postoperatively.10 this savings, together with the marked improvement in subjective nasal airflow and safety profile are positive factors that can be considered for patients with limited resources or residing in areas where the preformed nasal pack with built-in tube is not available. there are several limitations to this study. first, the limited number of respondents. second, the absence of another comparative group using the commercially available nasal pack with built-in tube and lastly, the absence of an objective nasal airway assessment tool. future studies may improve the process of randomization, utilize a validated questionnaire, or previously-translated and validated qol questionnaires such as snot -22, to assess other facets of postoperative patients’ outcome. other measures like total operative time can be included in the overall analysis of cost and device utility can be studied in other diseases requiring postoperative nasal packing such as obstructive sleep apnea of sinonasal etiology. in conclusion, the use of an improvised nasal airway tube during the immediate postoperative period markedly improves subjective nasal airflow in patients requiring bilateral nasal packing for structural and hemostatic support after endoscopic sinus surgery for crswnp. application of this tube does not cause any added pain compared to those who only have nasal packing alone. furthermore, using a standard ngt as an improvised nasal airway tube is safe and affordable and may be considered for patients with limited resources and in areas where a preformed nasal airway with built-in tube is not available. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles abstract objective: to describe our clinical experience with, and functional outcomes of the nasolabial flap for reconstruction of orofacial defects. methods: design: retrospective case series setting: tertiary national university hospital participants: records of 11 patients on whom a nasolabial flap was performed for reconstruction of head and neck defects between january 2013 and december 2018 were analyzed. results: all patients underwent wide excision with or without frozen section, with or without neck dissection, and nasolabial flap closure was performed by a single surgeon. there were no major complications. in two cases, the nasolabial flap was used as an adjunct for abbé and deltopectoral flap reconstruction. one had poor oral competence due to the bulk of the deltopectoral flap. acceptable aesthetics and functional outcomes were achieved. conclusion: the nasolabial flap is a viable alternative for reconstruction of orofacial defects following head and neck surgeries. additional cases can help validate our initial experience. keywords: nasolabial flap; nasolabial fold; orofacial defects; oral and facial carcinoma; mouth; skin; surgical flaps with expanded applications of microvascular free tissue transfer techniques for oral cavity reconstruction, the routine need for a variety of local and regional flaps has decreased. however, several such flaps remain quite useful and should be considered as an option for the reconstructive surgeon.1 among these is the nasolabial flap (nlf), an arterialized local flap in the head and neck region with an axial blood supply provided either by the angular artery branch of the facial artery (inferiorly based) or by the superficial temporal artery through its transverse facial branch and the infraorbital artery (superiorly based). it is a reliable, versatile, and an easy to raise flap for a variety nasolabial flap reconstruction for orofacial defects: a case series robert zaid dlr diaz, md arsenio claro a. cabungcal, md department of otolaryngology head and neck surgery philippine general hospital university of the philippines manila correspondence: dr. arsenio claro a. cabungcal department of otolaryngology head and neck surgery philippine general hospital taft ave, ermita, manila 1000 philippines phone: +63 920 921 1081 email: aacabungcal@up.edu.ph the authors declared that this presents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by both authors, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationship, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. presented at the philippine society of otolaryngology head and neck surgery 1st virtual descriptive research contest (3rd place) october 21, 2020 philipp j otolaryngol head neck surg 2021; 36 (2): 25-29 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles of small to intermediate defects in the orofacial region. the first nlf for intraoral reconstruction was reported at the end of the 19th century.2 superiorly-based nasolabial flaps can be used for reconstruction of nasal defects, lower eyelid, and the cheek, whereas the inferiorly based flaps are considered useful in reconstruction of defects of the lip, oral commissure, and the anterior oral cavity.2 a retrospective analysis of 26 cases of oral cancer treated with primary excision and nlf reconstruction concluded that the flap is versatile for covering or reconstructing small or medium-sized defects of the oral cavity in selected patients after excision of primary tumors and results in good overall cosmetic and functional outcome.3 however, to the best of our knowledge, there is a dearth of local publications on reconstruction with this flap. using the search terms “nasolabial flap” in combination with “facial reconstruction”, “orofacial defects”, “oral” and “facial” defects, a search on pubmed medline yielded no studies of nasolabial flap from the philippines. similar search terms used at herdin plus, the asean citation index and the global index medicus yielded four local studies.4-7 we present our five-year clinical experience with nasolabial flaps for orofacial reconstruction and the functional outcomes associated with the use of nasolabial flaps as a primary or an adjunct option for reconstruction of head and neck defects in our institution. methods with upmreb exemption (rgao-2019-0375), the records of all patients who had undergone nlf reconstruction of head and neck defects under the department of otolaryngology head and neck surgery of the philippine general hospital between january 2013 and december 2018 were retrieved for possible inclusion in this case series. included were records of patients that were staged using tnm classifications, who underwent wide excision with or with frozen section, with or without neck dissection and closure of the defect carried out by the same surgeon (acac) under general anesthesia. incomplete records were excluded. the following data was extracted from the charts and recorded by the first author (rzdd): age, sex, diagnosis, tnm classification, stage, tumor size, tumor location, surgical procedure performed, operative time, and complications. preoperative contrast enhanced computed tomography and a tissue biopsy were performed in all patients. radiotherapy was administered for patients who had advanced-stage tumors or adverse features on final histopathology. surgical technique standard inferiorly-based nasolabial flap reconstruction was performed in all cases as follows: following en bloc tumor resection with at least 1.5 cm. margins, a fusiform flap was designed and marked, ensuring that the medial border of the flap was in the nasofacial sulcus. the superior border of the flap was placed inferior to the medial canthus along the nasofacial junction. placement of the inferior border depended on the nature of the defect. for floor of mouth reconstruction, the inferior border of the flap was at the superior border of the mandible. the skin incision was carried through the dermis and subcutaneous fat up to the layer just above the underlying musculature. the facial artery lay in a plane deep to the facial mimetic musculature and in a medial position along the nasofacial sulcus. the flap was elevated in a superior-to-inferior fashion along a plane just above the facial musculature, and the artery with the facial muscles were preserved at the pedicle inferiorly. the flap was then tunneled through the buccal space to repair an intraoral defect primarily or as an adjunct flap, or placed on defects of the face and lips. the donor site was closed with minimal tension as much as possible using 4‐0 vicryl sutures for the deep dermal closure and 5-0 fast absorbing catgut sutures to approximate the skin edges. the closure was done in a superomedial direction to avoid distortion of the lower eyelid.8 (figure 1) data analysis data was presented in simple frequencies and percentages and measures of central tendency of sex (mean and standard deviation) were computed where applicable. type of surgery, tnm staging, post-operative functional status as well as adjuvant treatment done and follow up period, and the means and standard deviations was presented for continuous data (age). results a total of 11 patients were included in this series, 7 males and 4 females with a 2:1 ratio of male to female. their ages ranged from 41 to 75 years old (mean age 57, sd = 9). the tumor sizes ranged from 8 x 7 mm to 130 x 25 mm. according to histological type and localization of the tumor, american joint committee on cancer (ajcc) tnm classification, four patients were in stage iva, three in stage iii, two in stage ii and two in stage i. hospitalization ranged from 5 days to a maximum of 18 days with average hospital stay of 8.2 days. final histopathology showed 8 squamous cell carcinomas (scca), 1 basal cell carcinoma, 1 adenocarcinoma and 1 leiomyosarcoma. wide excision of the tumors created defects ranging from the smallest at 18 x 24 mm to the largest at 55 x 65 mm. in 9 cases, a nasolabial flap was used as the primary reconstruction for the defects; philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles figure 1.surgical technique and development of nasolabial flap a. marking and design of the flap along the nasofacial sulcus; b. incision and development of the flap; c. donor site defect; d. tunneling and positioning on the floor of mouth defect; e. suturing and closing of the flap and defect; and f. skin closure. figure 2. intraoperative photos of buccal squamous carcinoma a. extent of the mass on the lip commissure with planned wide excision margin; b. lip and buccal defect; c. nasolabial flap after amputation of deltopectoral flap. a b c a d b e c f 8 intraoral (3 buccal, 2 floor of mouth, 2 gingival, and 1 tongue) and 1 upper lip. in two cases, the nasolabial flap was used as an adjunct to another reconstruction flap: an abbé flap for the lip scca and a deltopectoral flap for a through and through buccal scca. (figure 2) lymphadenopathies were present in 4 of the 11 cases. all those with positive lymph nodes underwent elective neck dissection while 2 lymph node negative cases underwent prophylactic neck dissection. four stage iva and three stage iii patients underwent radiotherapy as adjuvant treatment. the mean operation time was 6.88 hours, with the fastest at 3 hours and longest at 13 hours. follow up ranged from 4 to 8 weeks. the complication rate was 18% with 2 flap dehiscences, 1 flap discoloration, and 1 with poor oral competence. there were no other complications like flap loss, total or partial necrosis or infection. the 2 dehiscences philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles developed after 1 week but these did not progress and resolved through secondary intention healing after around 4 weeks. none of the patients had any complaints about their scars, and were deemed aesthetically acceptable. (figure 3). facial movements such as smiling were not affected by the flap. discussion our five-year clinical experience with nasolabial flaps for orofacial reconstruction involved 11 patients (eight squamous cell carcinomas and one each basal cell carcinoma, leiomyosarcoma, adenocarcinoma) with tumor sizes ranging 8 x 7 mm to 130 x 25 mm. post excision defect sizes ranging from 18 x 24 mm to 55 x 65 mm were reconstructed with 9 nlf alone, and 2 nlf in combination with other flaps. the functional outcomes associated with the use of nlf as primary or adjunct option for reconstruction of head and neck defects was satisfactory, with an 18 % complication rate (2 flap dehiscences, 1 flap discoloration, and 1 oral incompetence as the most bothersome complication). head and neck cancer surgery is often complicated by location, anatomy, complex reconstructions, and long surgical procedures. reconstruction of head and neck defects may be achieved in a variety of ways.9 reconstructive options for defects of the orofacial region include primary closure, secondary healing from mucosalization, covering the defect site with split thickness skin grafts, and various pedicled and free flaps. although reconstruction of orofacial defects using microvascular free flap improves functional and cosmetic outcomes,10 it requires a dedicated team composed of a head and neck surgeon, microvascular surgeon, specialized anesthetist and dedicated nursing and allied medical staff. it also adds more hours to the operating time and even longer hospital stays.11 in low resource areas, pedicled flaps can be the best option. the versatility and usefulness of the nasolabial flap is well established, with good vascular supply that results in higher flap survival.12–14 the vascular supply of the nasolabial flap may come from the anterior facial artery, the infra-orbital artery, the transverse facial artery and the infratrochlear artery (depending on whether it is superiorly or inferiorly based). the nasolabial flap can still be used following extensive neck dissection specially in levels i-iii neck dissection. even if the facial artery is ligated, the flap can be used as random based vascular supply.15 in our present study, all 6 patients who underwent neck dissection did not have any complication of dehiscence or flap failure, supporting the reliability of the nasolabial flap even when neck dissection is performed. the largest defect solely reconstructed with nasolabial flaps was a case of lower lip squamous carcinoma involving 90% of the lower lip for which bilateral nasolabial flaps were used.6 our current study found the nasolabial flap adequate to cover orofacial defects when used solely, although the extent of our defects was mostly intraoral and the largest defect covered was 60 mm x 60 mm in area. despite its good reliability and robust vascular supply, the nlf has its limitations. the size of the defect and redundancy of tissues from the defect as well as the possibility of primarily closing the donor site limits the use of the nlf.16 two cases used nasolabial flap as an adjunct to larger reconstructive option for better coverage. kallapa and shah17 reported 24 cases of oral cancers of which 18 were reconstructed with a unilateral nasolabial flap and 3 with a bilateral flap after radical resection. the largest defect size measured 5 x 2 cm and used a 7 x 3 cm unilateral nlf. three lower lip malignancies were reconstructed with bilateral nlf with the largest defect 6 x 4 cm and reportedly good aesthetic and functional outcomes. lazaridis et al.18 reported nine patients that underwent reconstruction of intraoral defects with nasolabial flaps, five with an inferiorly based nlf. speech and oral continence, including mastication, were preserved. wound healing complications were reported in 18% of our patients, 2 of which were flap dehiscence that eventually resolved thru secondary intention and one with oral incontinence due to the bulk of the deltopectoral flap. our complication rate is higher than previously reported rates which ranged from 4-11%.15 figure 3. post-operative clinical photograph of nasolabial flap donor site philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles references 1. ducic y, burye m. nasolabial flap reconstruction of oral cavity defects: a report of 18 cases. j oral maxillofac surg. 2000 oct;58(10):1104-1108. doi:10.1053/joms.2000.9564 pubmed pmid 11021703. 2. eckardt am, kokemüller h, tavassol f, gellrich nc. reconstruction of oral mucosal defects using the nasolabial flap: clinical experience with 22 patients. head neck oncol. 2011 may 23;3(1):28. doi:10.1186/1758-3284-3-28. pubmed pmid: 21605443; pubmed central pmcid: pmc3121716 3. singh s, singh rk, pandey m. nasolabial flap reconstruction in oral cancer. world j surg oncol. 2012 oct 30;10(1):227. doi:10.1186/1477-7819-10-227 pubmed pmid: 23110587; pubmed central pmcid: pmc3544680. 4. ardena ma, hawson fy, guevarra es. modified nasolabial flap to the anterior floor of the mouth. philipp j otolaryngol head neck surg. 1992;19-22. doi: https://doi.org/10.32412/pjohns. v35i2.1521. 5. the versatility of the nasolabial flap in nasal reconstruction. philipp j otolaryngol head neck surg. 1999; 14(2):31-35. 6. dy es, alfanta em, chiong am. complications of head and neck reconstructive surgery using axial pedicled flap. philipp j otolaryngol head neck surg. 2015; 30 (2): 19-24. doi: https://doi. org/10.32412/pjohns.v30i2.341. 7. cordero jc. reconstruction of large nasal alar squamous cell carcinoma defect using a superiorly based nasolabial flap. philipp j otolaryngol head neck surg 2020; 35 (2): 55-58. doi: https://doi.org/10.32412/pjohns.v35i2.1521. 8. wright h, stephan s, netterville j. open access atlas of otolaryngology, head & neck operative surgery. in: atlas of otolaryngology, head & neck operative surgery. ; 2008:1-12. available from: www.entdev.uct.ac.za. 9. copcu e, metin k, aktas a, sivrioglu ns, öztan y. cervicopectoral flap in head and neck cancer surgery. world j surg oncol. 2003 dec;1:1-8. doi:10.1186/1477-7819-1-29 pubmed pmid: 14690542; pubmed central pmcid: pmc317373. 10. wong ch, wei f-c. microsurgical free flap in head and neck reconstruction. head neck. 2010 sep;32(9):1236-45. doi:10.1002/hed. pubmed pmid: 20014446. 11. trivedi np, trivedi p, trivedi h, trivedi s, trivedi n. microvascular free flap reconstruction for head and neck cancer in a resource constrained environment in rural india. indian j plast surg. 2013 jan;46(1):82-6. doi: 10.4103/0970-0358.113715; pubmed pmid: 23960310; pubmed central pmcid: pmc3745127. 12. mitra gv, bajaj ss, rajmohan s, motiwale t. versatility of modified nasolabial flap in oral and maxillofacial surgery. arch craniofacial surg. 2017 dec;18(4):243-248. doi:10.7181/ acfs.2017.18.4.243. pubmed pmid: 29349048; pubmed central pmcid: pmc5759666. 13. alonso-rodríguez e, cebrián-carretero jl, morán-soto mj, burgueño-garcía m. versatility of nasolabial flaps in oral cavity reconstructions. med oral patol oral cir bucal. 2014 sep 1;19(5):e525-30. doi:10.4317/medoral.19376. pubmed pmid: 24880439. 14. rahpeyma a, khajehahmadi s. the place of nasolabial flap in orofacial reconstruction: a review. ann med surg. 2016 nov;12:79-87. doi:10.1016/j.amsu.2016.11.008. pubmed pmid: 27942380; pubmed central pmcid: pmc513409. 15. el-marakby hh, fouad fa, ali ah. one stage reconstruction of the floor of the mouth with a subcutaneous pedicled nasolabial flap. j egypt natl canc inst. 2012 jun;24(2):71-6. doi:10.1016/j. jnci.2012.02.002. pubmed pmid: 23582598. 16. kaluzinski e, crasson f, alix t, labbé d. the nasolabial flap in reconstruction of the columella. rev stomatol chir maxillofac. 2004 jun;105(3):171-176. doi:10.1016/s0035-1768(04)72298-6 pubmed pmid: 15211216. 17. kallappa s, shah n. outcome of nasolabial flap in the reconstruction of head and neck defects. indian j surg oncol. 2019 dec;10(4):577-581.doi:10.1007/s13193-019-00948-z. pubmed pmid: 31857747; pubmed central pmcid: pmc6895328. 18. lazaridis n, tilaveridis i, karakasis d. superiorly or inferiorly based “islanded” nasolabial flap for buccal mucosa defects reconstruction. j oral maxillofac surg. 2008 jan;66(1):7-15. doi:10.1016/j. joms.2006.06.285; pubmed pmid: 18083409. our study has several limitations. first, our sample size only included 11 patients over five years. we also lack a comparator group. expanding the use of nlf and comparing it to other reconstructive options based on similar indications (such as tumor stage and histopathology, and defect size) may yield more valuable insights. moreover, as a singlesurgeon experience involving a learning curve, the outcomes and complications may not apply to other surgeons. a more systematic documentation of variables may also provide better quality data for analysis that can be generalized to similar cases beyond the study. despite these limitations, our initial experience demonstrates that the nasolabial flap is a viable alternative for reconstruction of intraoral and lip defects. even as other reconstructive options become available, the nlf is useful in resource-challenged settings where microvascular reconstruction is not as accessible. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 editorial to dream the impossible dream, to fight the unbeatable foe to bear with unbearable sorrow, to run where the brave dare not go to right the unrightable wrong, to love pure and chaste from afar to try when your arms are too weary, to reach the unreachable star — mitch leigh and joe darion, the impossible dream1 the brewing storm clouds of prevailing local and global situations are swirling ominously about, threatening to blanket us in a darkness so dismal that no light can dispel it. in the words of the collective expression of indignation and call to action from the members of the medical profession and the health sector, “no other phenomenon in history than this covid-19 global pandemic has … left free and unrestrained politicians and people with absolutely no competence in running the country, much less this catastrophic health debacle, to abuse power with impunity, misuse and steal taxpayers’ money and insult their intelligence, feed on the filipinos’ desperation and helplessness at the time when their plea for true leadership is loudest but has remained unheeded.”2 this document, signed by over 300 leaders of medical societies including five former health secretaries, echoed the earlier expression of outrage and call to action on alleged corruption amid the covid-19 pandemic “over alleged corruption related to the purchase of personal protective equipment (ppe)… and attempts to cover-up what really happened” that was signed by 45 health professional organizations, including the philippine association of medical journal editors (pamje).3 this initial multi-organizational “call for transparency, exigency and accountability” on “the president, all government officials, the senate, the department of justice, the ombudsman, and all filipinos” respectively, in turn… “not to obstruct the testimony of material witnesses to any investigation;” … “to support the call for truth, ensure that the wheels of justice grind swiftly and surely, and provide testimony when sought;” … “to complete the inquiry swiftly and with utmost diligence, to get to the truth behind the alleged corruption, then file a case before the department of justice or ombudsman at the soonest possible time;” … “to conduct an immediate impartial and thorough investigation of the case;” … “to file the appropriate cases against all those responsible for any corruption” and “to join hands and support the search for the truth.”3 this call was accompanied by the collective expression of indignation and call to action signed by hundreds of individual members of the medical profession and health sector, myself included.2 we expressed indignation over “our precarious situation” and the “folly of passivity” in its face; where our battered and “broken health systems” suffer from the “incompetence, insensitivity and corruption” and “shameless greed” of “no less than those who are supposed correspondence: prof. dr. josé florencio f. lapeña, jr. department of otolaryngology head and neck surgery ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 telefax: (632) 8524 4455 email: lapenajf@upm.edu.ph , jflapena@up.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. josé florencio f. lapeña, jr. ma, md department of otolaryngology head and neck surgery college of medicine, university of the philippines manila department of otorhinolaryngology head and neck surgery east avenue medical center, diliman, quezon city covid-19 and climate change: signing up for our impossible dream c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philipp j otolaryngol head neck surg 2021; 36 (2): 4-5 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 editorial to lead;” but do so with no “shame brazen, avaricious, sugapa, with no regard for how the nation would survive;” as “impunity has become the norm.” thus, we affixed our signatures to “shout out our indignation and intolerance,” declaring that “we will no longer compromise the truth for what we have been conditioned to believe to be true but clearly isn’t, we shall not go down the slippery slope of decay as a nation.”2 but there were those who did not sign; nay, who absolutely refused to sign, hiding behind the cloak of neutrality.4 in response, i quote the south african anglican archbishop and 1984 nobel peace laureate desmond tutu, who is attributed with saying “if you are neutral in situations of injustice, you have chosen the side of the oppressor.”5 the act of signing such a document under the current circumstances, may seem quixotic; even foolhardy. etymologically, the verb “sign” circa 1300 (as “to make the sign of the cross”) comes from the old french signier, “to make a sign; to mark,” from the latin signare “to set a mark upon, mark out, designate; mark with a stamp; distinguish, adorn;” figuratively “to point out, signify, indicate,” from signum “identifying mark, sign.”6 for us physicians, writing a prescription ends with the subscription signa (abbreviated sig.), which contains our specific directions to the patient, followed by our signature. instructing the patient how much drug to take, how to take it, how often to take it, and for how long, are very specific signs of our belief in the effectivity of our prescription and we seal it with our signature. for christians, it is interesting that the sign of the cross is a signum fidei, a “sign of faith.” indeed, affixing one’s name or putting one’s mark or stamp on such a document as this is a saltus, a leap of faith that smacks of an impossible dream or quest. our impossible dream, our quest, may not be so farfetched. our october 6 call to action was followed by two very significant events: vice president leni robredo’s filing her certificate of candidacy for president on october 7,7 and maria ressa’s and dmitry muratov’s being awarded the nobel peace prize on october 8 “for their efforts to safeguard freedom of expression, which is a precondition for democracy and lasting  peace.”8 for catholics, october 7 and 8 are the feasts of our lady of the rosary and our lady of good remedy, respectively. seen through the eyes of faith, leni’s commitment to respond to public clamor and maria’s laurels for her persistence in the face of persecution occurring on these feasts of our lady are no coincidence. that two ladies who embody our collective call for justice in the face of tyranny and oppression mark these days under the signs of our lady may yet be the portent of things to come, of hope that darkness and despair will not prevail. radical love will bloom as surely as the pink revolution will triumph. -----------------------------------as though the alleged corruption concerning pandemic funds were not enough, even bigger allegations surrounding the palawan natural gas fields have come to light. while both these issues have devastating effects on our economy and our people, they also have even more far-reaching effects on our environment and health. they respectively represent the massive mismanagement of covid-19 funds and pollution from covid-19 related disposables, and the wanton exploitation of our natural resources and potential misuse and gross mismanagement of fossil fuels. these take place locally just as world leaders meeting for historic climate talks in glasgow continue their empty pledges without real action. our governments’ failure to cut carbon emissions draws us further away from the crucial 2015 paris agreement target of limiting average global temperature rise to 1.5°c, halving global emissions by 2030, and millions will die as our planet is devastated unless we address the climate crisis effectively and avert the “biggest health threat facing humanity.”9 poor countries are holding out, while the rich countries hedge. how can poor countries hard hit by climate disasters expect the money and support promised (but not delivered) by industrialized nations that fueled the crisis, when these rich nations have not done their part in helping poor countries survive the current pandemic and prevent future ones?10 perhaps like perennial climate talks before it, cop26 will fail. but we nevertheless affixed our signatures to the open letter,9 hoping against hope that world leaders will come to their senses and act before it is too late. on the global stage as in the national arena, we dream the impossible dream. references 1. leigh m (music), darion j (lyrics). the impossible dream [music]: (the quest) from man of la mancha [broadway musical]. new york: sam fox pub. co. 1965. [cited 2021 october 31] available from https://catalogue.nla.gov.au/record/3621621. 2. past presidents and leaders of medical societies. a collective expression of indignation and a call to action  from the members of the medical profession and the health sector. [open letter on the internet] 2021 october 11. [cited 2021 october 31] available from: https://www. scribd.com/document/531529382/a-collective-expression-of-indignation-and-a-call-toaction#download&from_embed. 3. health professional organizations alliance against covid-19. health professional organizations join the expression of outrage and philippine college of physicians’ call to action on alleged corruption amid the covid-19 pandemic. 2021 october 6. [cited 2021 november 1] available from: https://www.facebook.com/102929668215367/posts/411756143999383/. 4. pma national officers and board of governors. pma position statement on current issues. october 12, 2021. [cited 2021 november 1] available from: https://www. philippinemedicalassociation.org/13822-2/. 5. ratcliffe s, editor. “desmond tutu 1931 south african anglican clergyman.” oxford essential quotations. 5th edition. oxford: oxford university press; 2017. [cited 2021 november 1] available from: https://www.oxfordreference.com/view/10.1093/acref/9780191843730.001.0001/q-oroed5-00016497. 6. harper d. online etymology dictionary. ©2001-2021 [cited 2021 november 1] available from https://www.etymonline.com/word/signature cf. https://www.etymonline.com/word/ sign?ref=etymonline_crossreference#etymonline_v_24110. 7. cepeda m. leni robredo files candidacy for president. rappler. oct 7, 2021 03:31 pm pht. [cited 2021 november 1] available from: https://www.rappler.com/nation/elections/leni-robredofiles-certificate-candidacy-president-2022. 8. the nobel prize outreach ab 2021. prize announcement. nobelprize.org. [cited 2021 november 1} available from: https://www.nobelprize.org/prizes/peace/2021/prize-announcement/. 9. healthy climate prescription signatories. healthy climate prescription. [open letter on the internet] 2021 october 11. [cited 2021 october 31] available from: https://healthyclimateletter. net (see special announcement: global health community calls for climate action ahead of cop26 to avert “biggest health threat facing humanity” in this issue). 10. tumin r. weekend briefing. october 31, 2021. “leaders are gathering in glasgow for a climate summit. the new york times. [personal email from messaging-custom-newsletters.nytimes. com ny: the new york times, nytdirect@nytimes.com]. philippine journal of otolaryngology-head and neck surgery 5958 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 under the microscope philipp j otolaryngol head neck surg 2020; 35 (2): 59-60 c philippine society of otolaryngology – head and neck surgery, inc. odontogenic keratocyst jose m. carnate, jr., md1 1department of pathology college of medicine university of the philippines manila correspondence: dr. jose m. carnate, jr. department of pathology college of medicine university of the philippines manila 547 pedro gil st. ermita, manila 1000 philippines phone (632) 8526 4450 telefax (632) 8400 3638 email: jmcjpath@gmail.com the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. a 37-year-old woman consulted for a slow-growing mass of one-year duration on the left side of the mandible with associated tooth mobility. clinical examination showed buccal expansion along the left hemi-mandible from the mid-body to the molar-ramus region with associated mobility and displacement of the pre-molar and molar teeth. radiographs showed a well-defined unilocular radiolucency with root resorption of the overlying teeth. decompression and unroofing of the cystic lesion was performed. received in the surgical pathology laboratory were several gray-white rubbery to focally gritty tissue fragments with an aggregate diameter of 1 cm. histopathologic examination shows a fibrocollagenous cyst wall lined by a fairly thin and flat stratified squamous epithelium without rete ridges. (figure 1) the epithelium is parakeratinized with a wavy, corrugated surface while the basal layer is cuboidal and quite distinct with hyperchromatic nuclei. (figure 2) based on these features, we signed the case out as odontogenic keratocyst (okc). creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international figure 1. this section shows a fibrocollagenous cyst wall lined by a fairly thin and flat stratified squamous epithelium without rete ridges (arrows). (hematoxylin-eosin, 100x magnification). (hematoxylin – eosin , 100x) philippine journal of otolaryngology-head and neck surgery 6160 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 under the microscope references 1. speight p, devilliers p, li t-j, odell ew, wright jm. odontogenic keratocyst. in: el-naggar ak, chan jkc, grandis jr, takata t, slootweg pj. who classification of head and neck tumors. lyon: iarc; 2017. p. 235. 2. neville bw, damm dd, allen cm. odontogenic cysts and tumors. in: gnepp dr (editor). diagnostic surgical pathology of the head and neck. philadelphia: saunders/elsevier; 2009. p. 790. 3. sekhar mc, thabusum da, charitha m, chandrasekhar g, shalini m. a review of the odontogenic keratocyst and report of a case. journal of advances in medicine and medical research. 2019 apr;29(8):1-7. doi:10.9734/jammr/2019/v29i830107. 4. philipsen hp. keratocystic odontogenic tumor. in: barnes l, eveson jw, reichart p, sidransky d. world health organization classification of tumours. pathology and genetics of head and neck tumors. lyon: iarc; 2005. p.284. 5. vallejo-rosero ka, camolesi gv, duarte de sá pl, bernaola-paredes we. conservative management of odontogenic keratocyst with long-term 5-year follow-up: case report and literature review. int j surg case rep. 2020;66:8-15. doi: 10.1016/j.ijscr.2019.11.023; pubmed pmid: 31785568; pubmed central pmcid: pmc6889737. figure 2. the epithelium is parakeratinized with a wavy, corrugated surface (asterisks) while the basal layer is cuboidal with hyperchromatic nuclei (arrows). (hematoxylin-eosin, 400x magnification). odontogenic keratocysts are the third most common cysts of the gnathic bones, comprising up to 11% of all odontogenic cysts, and most frequently occurring in the second to third decades of life.1,2 the vast majority of cases occur in the mandible particularly in the posterior segments of the body and the ramus. they typically present as fairly large unilocular radiolucencies with displacement of adjacent or overlying teeth.1 if associated with an impacted tooth the radiograph may mimic that of a dentigerous cyst.2 microscopically, the parakeratinized epithelium without rete ridges, and with a corrugated luminal surface and a prominent cuboidal basal layer are distinctive features that enable recognition and diagnosis.1,2,3 occasionally, smaller “satellite” or “daughter” cysts may be seen within the underlying supporting stroma, sometimes budding off from the basal layer. most are unilocular although multilocular examples are encountered occasionally.1 secondary inflammation may render these diagnostic features unrecognizable and non-specific.2 morphologic differential diagnoses include other odontogenic cysts and unicystic ameloblastoma. the corrugated and parakeratinized epithelial surface is sufficiently consistent to allow recognition of an okc over other odontogenic cysts, while the absence of a stellate reticulum and reverse nuclear polarization will not favor the latter diagnosis.2,3 odontogenic keratocysts are developmental in origin arising from remnants of the dental lamina. mutations in the ptch1 gene have been identified in cases associated with the naevoid basal cell carcinoma syndrome as well as in non-syndromic or sporadic cases.1,3 these genetic alterations were once the basis for proposing a neoplastic nature for okcs and thus the nomenclature “keratocystic odontogenic tumor” was for a time adopted as the preferred name for the lesion.3,4 presently, it is felt there is not yet enough evidence to support a neoplastic origin and hence the latest who classification reverts back to okc as the appropriate term.1 sekhar et al. gives a good review of the evolution of the nomenclature for this lesion.3 treatments range from conservative enucleation to surgical resection via peripheral osteotomy.5 reported recurrences vary in the literature ranging from less than 2% of resected cases up to 28% for conservatively managed cases.1,5 these are either ascribed to incomplete removal or to the previously mentioned satellite cysts the latter being a feature associated with okcs that are in the setting of the naevoid basal cell carcinoma syndrome.1,2,3 thus, long term follow-up is recommended.5 malignant transformation, though reported, is distinctly rare.2 (hematoxylin – eosin , 400x) philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 32 philippine journal of otolaryngology-head and neck surgery contents cover images editorial 4 death and dying during the covid-19 pandemic: tahan na, humimlay lapeña jff review article 6 prevalence of olfactory dysfunction among covid-19 patients with self-reported smell loss versus objective olfactory tests: a systematic review and meta-analysis regalado jaf, tayam mmh, santos ra, gelera je original articles 15 self-reported assessment of outcome-based education in philippine otolaryngology head and neck surgery residency training programs by consultants and residents almazan mna 24 classification and stages of middle ear cholesteatoma at the southern philippines medical center using the european academy of otology and neurotology / japan otological society (eaono / jos) system toral db, laganao crd 28 predominant endotype of nasal polyps in a sample of filipinos following endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis nable-llanes kv, roldan ra 33 association of anosmia and positive sars-cov-2 (covid-19) rt-pcr test results among patients in the quezon city general hospital alega jjp, cruz ets case reports 37 smell training in prolonged covid-19 post-infectious olfactory dysfunction: a case report villar pmac, chua ru, robles rp 41 self-inflicted craniofacial impalement injury with a screwdriver during the covid-19 pandemic: a case report gatela jljg 45 to the lip and beyond: a case report of a midline tessier 30 cleft suarez jdc, perez gcc surgical innovations and instrumentation 50 the use of commercially available non-medical grade usb cameras for physician guided ent out-patient self-examination during the covid-19 pandemic cafino ry practice pearls 57 understanding the use of polycaprolactone in east asian structural rhinoplasty: questions and answers yap ec featured grand rounds 62 delayed sudden blindness from unilateral ophthalmic artery vasospasm following endoscopic sinus surgery? chua rj, regalado jaf, gelera je from the viewbox 65 fenestral otosclerosis: a subtle lesion easily missed yang nw under the microscope 67 inverted ductal papilloma of the salivary gland carnate jm captoons 69 doknet’s world billones wu passages 70 elvira i. colmenar, md colmenar mti 71 ruben g. henson, jr., md henson rd 72 marlon v. del rosario, md calderon af 73 oliverio o. segura, md segura ppr “maxillary fibrous dyslapsia in a 7-year-old” iphone 11 pro max by ricardo l. ramirez jr., md “watching and listening to singing birds, remind me what a blessing it is to be alive” fujifilm xe2s 250mm by adrian f. fernando, md “covid surgery” iphone 11 pro max by ricardo l. ramirez jr., md “make compex things simple then celebrate” samsung galaxy note 10 by adrian f. fernando, md “the hopeful masked lady” 10x14 watercolor and pen by tteresa paz g. pascual, md death and dying during the covid-19 pandemic: tahan na, humimlay prevalence of olfactory dysfunction among covid-19 patients with self-reported smell loss versus objective olfactory tests: a systematic review and meta-analysis self-reported assessment of outcome-based education in philippine otolaryngology head and neck surgery residency training programs by consultants and residents classification and stages of middle ear cholesteatoma at the southern philippines medical center using the european academy of otology and neurotology / japan otological society (eaono / jos) system predominant endotype of nasal polyps in a sample of filipinos following endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis association of anosmia and positive sars-cov-2 (covid-19) rt-pcr test results among patients in the quezon city general hospital smell training in prolonged covid-19 post-infectious olfactory dysfunction: a case report self-inflicted craniofacial impalement injury with a screwdriver during the covid-19 pandemic: a case report to the lip and beyond: a case report of a midline tessier 30 cleft the use of commercially available non-medical grade usb cameras for physician guided ent out-patient self-examination during the covid-19 pandemic understanding the use of polycaprolactone in east asian structural rhinoplasty: questions and answers delayed sudden blindness from unilateral ophthalmic artery vasospasm following endoscopic sinus surgery? fenestral otosclerosis: a subtle lesion easily missed inverted ductal papilloma of the salivary gland doknet’s world elvira i. colmenar, md ruben g. henson, jr., md marlon v. del rosario, md oliverio o. segura, md philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery review article abstract objective: the purpose of this study was to determine the efficacy of proton pump inhibitor (ppi) therapy over placebo in treating the symptoms and laryngeal findings among adult patients with laryngopharyngeal reflux (lpr) using the reflux symptom index (rsi) or reflux finding score (rfs). methods: placebo-controlled, randomized clinical trials published after june 2001 to january 2021 which used ppi as the sole intervention and the rsi or rfs as outcome measures were eligible for inclusion. studies that were published prior to june 2001, those which only made use of questionnaires other than the rsi or rfs, those which used ppi in combination with other treatments, or those with unavailable full-text manuscripts were excluded. these studies were identified from medline, scopus, cochrane library, embase, and herdin plus databases which were searched from may 21 to 26, 2020. the primary outcome was the mean difference between baseline/pre-treatment and post-treatment rsi scores for both ppi and placebo groups. the secondary outcome was the mean difference between pre-treatment and post-treatment rfs scores for ppi and placebo groups. aggregate results of these outcomes were analyzed using forest plots. heterogeneity was determined through prediction intervals. risk of bias of individual studies was assessed using the cochrane collaboration’s tool in assessing risk of bias. results: nine randomized control trials were included with a total of 737 patients randomized and 595 patients analyzed – 294 from the ppi group and 301 from the placebo group. there were notable variations among the studies in terms of choice of ppi, dosage and frequency. out of nine studies, four used both rsi and rfs in their analysis. two studies used rsi alone and three used the rfs in combination with symptom questionnaires other than the rsi. there was a significant decrease in the rsi of the ppi group versus the placebo group with a mean difference of -2.83 (95% ci, -5.13 to -0.53, p = .02). however, there was no significant decrease in the rfs between ppi and placebo groups with a mean difference of -0.84 (95% ci, -2.66 to 0.98, p = .37). for two clinical trials which only reported post-treatment rfs, there was also no significant difference between the two treatment groups with a mean difference of 1.27 (95% ci, -0.22 to 2.76, p = .10). conclusion: this meta-analysis found that, although a statistically significant benefit in rsi was noted with ppi therapy, this difference may not translate to a clinically significant change in symptoms; therefore, there is insufficient evidence to recommend for or against the treatment of lpr with ppis. keywords: laryngopharyngeal reflux; proton pump inhibitors; laryngitis; hoarseness effect of proton pump inhibitors on reflux symptom index (rsi) and reflux finding score (rfs) in patients with laryngopharyngeal reflux: a systematic review and meta-analysis patricia ann u. soriano, md1 erasmo gonzalo d.v. llanes, md1,2,3 anna pamela c. dela cruz, md1 kevin michael l. mendoza, md1 1department of otolaryngology – head and neck surgery philippine general hospital university of the philippines manila 2department of otolaryngology head and neck surgery college of medicine university of the philippines manila 3philippine national ear institute national institutes of health university of the philippines manila correspondence: dr. anna pamela c. dela cruz department of otolaryngology head and neck surgery ward 10, philippine general hospital taft avenue, ermita manila, 1000 philippines phone: (632) 8554 8467 email: acdelacruz14@up.edu.ph the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. this study was not funded or given financial support by any grant or agency. philipp j otolaryngol head neck surg 2022; 37 (2): 6-14 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery review article laryngopharyngeal reflux is a commonly diagnosed condition in the out-patient department.1 several problems, however, are encountered with respect to diagnosing and treating lpr. the true prevalence of gastroesophageal reflux among those with laryngeal symptoms varies widely which leads to a question of whether lpr has indeed been accurately diagnosed.2 to date, there is no ideal test to clinch the diagnosis of lpr.3 twenty-four hour ph monitoring, although considered the gold standard for lpr, has not been shown to be a reliable test for diagnosing lpr given its low sensitivity.1-3 the two validated instruments – the reflux symptom index (rsi) and reflux finding score (rfs) – were developed from patients diagnosed with lpr confirmed by 24-hour dual probe ph monitoring.4-5 the rsi and rfs have been used to diagnose lpr among those who obtain scores greater than 13 and 7, respectively although belafsky noted that rsi scores greater than or equal to 10 and rfs greater than or equal to 5 are clinically significant.6 the empiric use of ppis has been suggested as initial management for patients presenting with laryngeal symptoms in the background of gastroesopheageal reflux (ger).1 although there has been no consensus regarding the optimum diagnosis and a precise treatment protocol, the current recommendation states that twicedaily dosing of ppis may be given for three to six months but with no consensus on the specific ppi or dosage.1,3,7 there have been nine previous systematic reviews and metaanalyses to date studying the effect of ppis on lpr management.2,8-15 all of them measured successful lpr treatment as a 50% reduction in symptoms. these studies showed conflicting results since six of them concluded that the use of proton pump inhibitors did not yield differences that were statistically significant when compared with placebo with an overall risk ratio ranging from 1.18-1.21 but with lower and upper values of the confidence interval less than and greater than 1, respectively.2,8-12 the three remaining systematic reviews and metaanalyses concluded that the use of ppis could improve reflux symptoms although with varying clinical significance.13-15 the limitations of all these previous studies were in the various sources of heterogeneity – the inclusion criteria, the specific ppi chosen, the dosing, the duration, and the outcomes measured. the individual trials included in the systematic reviews and meta-analyses chose different laryngeal symptoms to assess with some studies creating their own questionnaires which may have contributed to differences in results among studies. among the meta-analyses listed, 2 of them conducted subgroup analyses using changes in rsi and rfs as the measured outcome; however, on close inspection, both included studies which did not actually make use of the rsi or rfs, thus making their conclusions questionable.13,14 with the introduction of the validated rsi and the endoscopy-based rfs, a more standardized manner of assessing relief may be used which may also lead to more comparable studies and definitive conclusions. the main objective of this study was to determine the effectiveness of ppi over placebo in the treatment of lpr among adult patients, defined as a statistically significant change in the rsi and rfs from pretreatment to post-treatment after a treatment period of at least one month. a minor objective was to validate conclusions from previous systematic reviews or meta-analyses by specifically selecting rsi and rfs as the outcome measures. because these two instruments were used to assess efficacy of treatment outcome, one source of variation was eliminated. findings of this meta-analysis aimed to assess if the conclusions drawn would support majority of the previous reviews which did not find that ppis were effective in treating lpr versus placebo. methods this systematic review and meta-analysis was conducted from may 21, 2020, to april 22, 2021 with university of the philippines manila research ethics board exemption number 2020-714-ex. this review was registered in the research grants administration office, university of the philippines, manila (rgao-2020-0048). eligibility criteria studies eligible for inclusion were randomized, placebo-controlled trials involving adult patients with lpr which used the rsi and/ or the rfs as outcome measurements. studies which used proton pump inhibitors as the sole intervention for at least one month were included. randomized controlled trials conducted after june 2001 to january 2021 were eligible as the rfs was published first in june 2001. studies that compared ppis with other drugs or in combination with other non-pharmacologic interventions were excluded. studies which used acid reflux measurement or gastroesophageal symptom relief as the sole outcomes were excluded. studies which only made use of questionnaires other than the standardized rsi or rfs were excluded. studies that used the rfs or rsi but did not report mean scores, standard deviations, or standard error were excluded. studies which were published prior to 2001 were excluded. abstracts, reports, and unpublished manuscripts were eligible for inclusion if personal correspondence with the studies’ primary authors yielded full-text manuscripts for analysis; otherwise, these were excluded. included studies were later divided into ppi and placebo groups for synthesis based on either rsi or rfs measurements. information sources a search of randomized control studies using ppis and placebo was done independently by the principal investigator (paus) and a philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery review article co-investigator (kmlm) using medline (through pubmed), scopus, cochrane library, embase (through ovid@journal), herdin plus, and reference lists of existing systematic reviews and meta-analyses from may 21-26, 2020. a final search of each database was done from december 18-20, 2020 to assess if new articles had been added that might be eligible for the meta-analysis. search strategy to create a thorough search, different keywords using laryngopharyngeal reflux and proton pump inhibitors such as “laryngopharyngeal reflux,” “reflux laryngitis,” “laryngitis,” “chronic cough,” “hoarseness,” “proton pump inhibitors,” “omeprazole,” “rabeprazole,” “esomeprazole,” “lansoprazole,” “pantoprazole,” and “dexlansoprazole” were used. a sample search included a line search of the mesh term “proton pump inhibitors” and each specific type of ppi under the filter of title/abstract using the conjunction “or.” the next line search included the mesh term “laryngopharyngeal reflux” and the chosen specific symptom phrases aforementioned under the filter of title/abstract using the conjunction “or.” these two lines were joined together in one search combined by the conjunction “and” to obtain all possible articles with this intersection of search terms. other studies were sought by searching for previous or ongoing trials registered in clinicaltrials.gov to determine if there were any unpublished but relevant studies. the final database search for each was conducted in december 18 to 21, 2020. only studies after june 2001 until january 2021 were included in the search. among all the studies included in the final analysis, the two most recently published rcts were obtained by contacting the author of the published protocol through e-mail. studies were not strictly limited to those written in english; however, no potential study published in another language fit the eligibility criteria. data extraction all studies regarding lpr and ppi treatment independently found by two researchers (paus and kmlm) were listed with duplicate studies combined using the mendeley desktop program version 1.19.4 for windows (mendeley ltd., elsevier, amsterdam, netherlands). each study’s abstract was then analyzed for eligibility. the full text of each seemingly relevant study was read thereafter to assess if it could be included in the meta-analysis. disagreements between the two researchers regarding the inclusion of a study were settled by consensus. data from each study such as number of participants, specific drug choice and dosing, treatment duration, outcomes measured, and methodology were extracted independently. risk of bias was carried out by the primary author using the cochrane collaboration’s tool in assessing risk of bias and the review manager (revman) version 5.3, 2014 (the nordic cochrane centre, the cochrane collaboration, copenhagen, denmark).16 statistical analysis all articles gathered from databases and other sources were screened through reading their respective abstracts. those with information that appeared to fit the eligibility criteria were retained, and available full-text articles of each were obtained. study characteristics such as participant characteristics, specific treatment regimen, treatment duration, control variable, mean differences and sd of rsi, mean differences and sd of rfs were then summarized and tabulated to ensure that eligibility criteria were met prior to inclusion in further analysis. the primary outcome identified in each study was the mean difference between baseline/pre-treatment and post-treatment rsi scores for both treatment (ppi) and placebo groups. the secondary outcome was the mean difference in rfs from preto post-treatment between the 2 treatment groups. duration of treatment was dependent on what was stated in each study as the timeframe prior to primary outcome measurement. standard deviations (sd) of the mean differences were also reported. in the event that mean differences and standard deviations were not reported, the authors were contacted via e-mail to obtain the missing data. two studies reported standard error of the mean instead of standard deviation. 3,7 standard deviation was then calculated from the data provided using the following formula: sd = se √n se = standard error of the mean n = sample size the authors of two studies were unable to supply the mean differences, so a separate analysis was conducted using the posttreatment mean scores and sd as advised by the consultant statistician.17,18 one study reported a median score and range instead of mean scores and sd.18 the median score was reported as the mean score. the sd was derived from the range and was computed as: sd = ¼ (max – min) we used forest plots to depict the summary of findings of the studies using a 95% confidence interval (ci) using review manager (revman) version 5.3, 2014 (the nordic cochrane centre, the cochrane collaboration, copenhagen, denmark). to assess for heterogeneity, higgins i2 coefficient and prediction intervals were identified. random effects modelling was applied for the analysis based on the assumption that the mean and effect size likely varied across studies. publication philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery identification of studies via databases and registers id en ti fic at io n in cl ud ed sc re en in g records identified from: databases (n = 523) registers (n = 2) records screened (n = 441) reports sought for retrieval (n = 21) reports assessed for eligibility (n = 20) studies included in review (n = 9) † reports of included studies (n = 9) records excluded (n = 420) reports not retrieved* (n = 1) records removed before screening: duplicate records removed (n=84) records marked as ineligible by automation tools (n = 0) records removed for other reasons (n = 0) reports excluded: not placebo-controlled (n = 6) not rsi/rfs used (n = 4) no sd reported (n = 1) review article bias was also assessed through the generation of funnel plots using the comprehensive meta-analysis program version 3.3.070, 2014 (biostat, englewood, nj, usa). results literature search the literature search process yielded nine articles that were included in the analysis. (figure 1) the initial search among databases and other sources resulted in a total of 525 articles. after adjusting for duplicates, 441 articles remained. a further 421 articles were excluded since these were mostly reviews, observational studies, uncontrolled studies, or studies which did not make use of the rsi or rfs. the full-text of the remaining 20 articles were read for eligibility resulting in nine articles fitting all the criteria for inclusion and exclusion. figure 1 also shows more detailed descriptions regarding reasons for excluding the other 11 articles. although nine articles were included in this meta-analysis, two of the articles were published using the exact same protocol and participant data in two different journals but under different primary authors.19,20 this duplication of published data ultimately resulted in only eight independent data sets being included in the meta-analysis. study characteristics among the nine rcts included in the analysis, there was a total of 737 patients randomized but only 595 analyzed – 294 of whom were part of the treatment (ppi) group and 301 of whom belonged to the control (placebo) group. characteristics of each individual study were summarized and tabulated. (table 1) out of the nine included studies, four studies made use of both the rsi and rfs and were included in both analyses – primary and secondary outcome. two studies used only the rsi; however, as previously stated, these two studies used a single data set. the remaining three studies analyzed the rfs but used symptom questionnaires other than the rsi in their methodology and analysis. it is notable that there were variations among studies in terms of choice of ppi, dosage, and frequency although majority of the studies (6 out of 8 data sets) used a twice daily regimen. treatment duration for primary outcome measurement also varied among studies ranging from 6 weeks to 16 weeks. most of the studies reported low drop-out rates except for the study of wilson21/o’hara22 which reported 22.8% (79 out of 346) lost to follow up at the time of primary outcome measurement. primary outcome the primary outcome measured was the mean difference of the rsi per treatment group at baseline and post-treatment which included six studies (five data sets). there was a significant decrease in rsi score in the ppi group versus the placebo group with a mean difference of -2.83 (95% ci, -5.13 to -0.53, p = .02) as noted in the forest plot. (figure 2) most studies’ mean differences lay on the side favoring ppis except for the data set with the largest sample size which showed contrary findings regarding the efficacy of ppis in reducing rsi scores. random effects modeling was employed; however, it can be noted that fixed effects modeling resulted in a similar overall effect with a mean difference of 2.94 (95% ci, 2.02 to 3.8, p<.00001). the resulting i2 coefficient showed that 81% of the variance would have remained if sampling error could be removed.24 this high i2 value was contributed solely by the outlier study of wilson21 and o’hara22 since removal of these articles brought the i2 coefficient down to zero. to show the heterogeneity more accurately between studies, a prediction interval was computed showing that the true effect size for 95% of all populations would lie somewhere from -10.973 to 5.313.24 this wide range shows that there is significant heterogeneity among studies. figure 1. prisma preferred reporting items for systematic reviews and meta-analyses for literature search process *full-text article could not be retrieved online or by contacting the primary author through e-mail † 9 full-text articles included in meta-analysis with 2 studies sharing the same data rsi reflux symptom index; rfs reflux finding score; sd standard deviation philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery review article secondary outcome the secondary outcome measured was the mean difference of the rfs preand post-treatment between the ppi and placebo groups. the objective changes in laryngopharyngeal reflux showed the same tendency for benefit of ppi treatment as in symptomatic relief; however, this was not significant with a mean difference of -0.84 (95% ci, -2.66 to 0.98, p = .37) which can be seen in the forest plot. (figure 3) there was once again significant heterogeneity seen. it was estimated that 85% of the observed variance would remain if variance due to sampling error could be removed (i2 = 85%). on analysis of the five studies included, the two studies reporting a significant mean difference in rfs favoring ppi contributed greatly to this as removal of these studies decreased the i2 coefficient to 24%. the prediction interval was computed which showed that the true effect size for 95% of all populations would be found within the range of means from -7.5927 to 5.9127, once again showing significant heterogeneity evidenced by the wide range of dispersion. as stated previously, two studies included in the meta-analysis did not provide mean differences between pre-treatment and posttreatment rfs. a separate analysis was conducted using the posttreatment rfs mean of the ppi and placebo groups. (figure 4) in contrast, there was a tendency for the placebo to cause a reduction in rfs; however, this was again not significant with a mean difference of 1.27 (95% ci, -0.22 to 2.76, p = .10). risk of bias the risk of bias of individual studies was assessed by the primary author. anzić’s study was identified as the study with the highest risk of bias with issues in selection bias, incomplete outcome data, and selective reporting.23 the authors of the study stated a limitation of their study being the lack of stratification of baseline characteristics of study participants. it was revealed that, although random allocation was done, more patients with higher baseline rsi scores were assigned to the ppi group. another bias of this particular study was the apparent incomplete outcome reporting. the study stated in their methodology that other objective measurements were taken, such as ph probe measurements and microbiopsy of inferior turbinates, none of which were reported in the results. the study also chose to only report the mean scores of each group at baseline and at the end of treatment, as well as a corresponding p-value with no mention of mean differences preand post-treatment. however, this was remedied by e-mailing the author who provided the missing data. still, analysis was repeated after removing this study with the highest risk of bias which resulted in an overall rsi mean difference of -2.56 (-5.74, 0.62), resulting in a result that was no longer statistically significant. it was noted that significant figure 2. forest plot showing the mean difference in reflux symptom index between ppi and placebo figure 3. forest plot showing the mean difference in reflux finding score between ppi and placebo figure 4. forest plot showing the post-treatment reflux finding score mean between ppi and placebo table 1. study characteristics source location patients randomized positive ph probe test required* patients analyzed (ppi/ placebo) rsi/ rfs treat ment dura tion‡ dropouts/ lost to follow up ppi dosage and frequency wo, 200620 pawar, 200723 reichel, 20087 lam, 20103 faruqi, 201119 shaheen, 201124 anzić, 201825 wilson, 202121/ o’hara, 202122 university of louisville, usa medical college of wisconsin ludwig maximilians university, munich university of hong kong, queen mary hospital hull cough clinic, cottingham, uk chapel hill, north carolina university of zagreb, croatia eight uk nhs sites 39 53 62 86 51 40 60 346 6 4 4 2 0 0 79|| yes no¶ no no¶ no no¶ no¶ no 20/19 21/26 30/28 42/40 24/25 22/18 33/27 102/118§ rfs† rsi, rfs rsi, rfs rsi, rfs rfs† rfs† rsi, rfs rsi 12 weeks 90 days 3 months 12 weeks 8 weeks 12 weeks 8 weeks 16 weeks pantoprazole 40mg, once in the morning rabeprazole 20mg, twice daily esomeprazole 20 mg, twice daily rabeprazole 20mg, twice daily esomeprazole 20mg, twice daily esomeprazole 40mg, twice daily omeprazole 20mg, once daily lansoprazole 30mg, twice daily * ph probe value <4 required for inclusion † symptom questionnaires other than rsi used ‡ primary outcome measurement as stated in each study ¶ ph probe testing done and participants divided into positive or negative §compliant intention to treat analysis (pragmatic intention to treat sample size was 127/140) ||missing data at time of primary outcome measurement: 63 (37 for ppi and 26 for placebo) did not attend at 16 weeks; 16 (8 for each intervention group) attended but no rsi recorded philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery review article heterogeneity remained despite removal of this study. (figure 5) two studies with unclear but potentially significant bias came from the most recent rct due to the high dropout rate where only 267 out of 346 participants had data from the initial end-of-treatment assessment.19,20 additionally, only 220 participants were included in the main statistical tests of analysis. however, the same statistical tests were done for the pragmatic-intention-to-treat sample, and their data was reported in the appendices which showed similar findings. all other studies included in the meta-analysis were generally deemed to have low risk of bias. (figure 6) in order to assess publication bias, funnel plots were created and analyzed. visual inspection showed asymmetry of findings for both sets of studies which assessed the rsi and the rfs. both funnel plots showed outlier studies which did not lie within the funnel (figures 7 and 8). for studies which assessed the effect of ppis on rsi, there is a gap at the bottom of the funnel which shows a paucity of data from smaller studies with non-significant effects. this points to the possible existence of publication bias. on the other hand, the funnel plot for the studies assessing ppi effect on rfs seems to show some symmetry; however, it can be concluded that more precise studies are lacking as shown by the gap in the upper half of the triangle. two studies are also shown to lie outside of the funnel plot due to the extreme value of the mean difference found in these studies.21,23 a funnel plot for the second analysis involving the remaining studies was not generated due to there being only two studies in the analysis. ideally, more tests to quantify and assess funnel plot asymmetry would have been done. however, these tests are not used in the event of fewer than ten studies since conclusions from these results cannot be drawn or relied upon.25 discussion the use of twice-daily dosing of ppi in the empiric treatment for lpr has been advocated for years; however, this recommendation has been drawn mostly from non-randomized and uncontrolled studies.26 there are no current clinical practice guidelines (cpg) from societies of otolaryngology that specifically or extensively discuss the disease entity lpr. the only available cpg regarding dysphonia/hoarseness by the american academy of otolaryngology-head and neck surgery (aaohns) recommends against the use of ppis for isolated dysphonia without evidence of laryngeal changes or symptoms of gastroesophageal reflux disease (gerd).27 a separate position statement from the aao-hns simply states that empirical medical treatment may be diagnostic of lpr.28 there was no mention regarding the application of belafsky’s validated instruments (rsi or rfs) in the cpg or position statement, figure 5. forest plot showing the mean difference in rsi with anzić’s study removed figure 7. funnel plot of studies assessing the effect on rsi figure 6. risk of bias summary: judgements about each risk of bias item for each included study. figure 8. funnel plot of studies assessing the effect on rfs philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery review article and the position statement did not specify medication as the explicit prescription of ppis. several prospective studies that do report the effectiveness of ppis on significantly reducing rsi and/or rfs are either not placebocontrolled studies or do not have control groups for comparison.29-33 extensive search for placebo-controlled rcts only yielded eight independent data sets (nine articles) that met the eligibility criteria for our meta-analysis, most of which had relatively small sample sizes. this clearly shows the need for the conduction of rcts with larger samples to create a more precise analysis of the true effect of ppis in reducing symptoms and laryngeal findings of lpr. it is also notable that even with the publication of validated instruments for lpr (i.e. rsi and rfs), several placebo-controlled rcts published after 2002 continued to make use of other symptom questionnaires (such as cough or gerd questionnaires) and did not apply the rfs.34-37 three of the rcts included in this meta-analysis applied the rfs but not the rsi despite being published after the creation of the rsi.17,18,22 this is contrary to the range of observational studies that did make use of both the rsi and rfs.29-33 instead of creating a larger pool of studies which could have resulted in a potentially more homogenous set of data and a more precise and powerful meta-analysis, those studies decreased the number of rcts that could have been included. the primary outcome showed that ppi therapy is effective in symptomatic relief of lpr as shown by the overall mean effect among studies. it must be stated that, although the overall mean difference showed a benefit for ppi therapy, the point estimate and corresponding confidence interval may not necessarily translate to a clinically significant change. severe reflux disease was defined as an rsi > 13 and rfs > 7.4,5 if the mean difference of -2.83 were applied, the change would result in an rsi > 10, which would still be deemed clinically significant.6 this lack of efficacy was further highlighted when the study with the highest risk of bias was removed resulting in an overall mean difference in rsi that was not statistically significant. the same inference may be said for the rfs. if an overall mean difference of -0.84 were applied, this would not result in a change that would be clinically significant (rfs > 5).6 the greatest source of heterogeneity was contributed by the most recently conduct rct which was also the largest trial to date and the only published study that did not find ppis to be effective in the treatment of lpr.19-20 this may be due to the smaller studies having poorer methodological quality resulting in larger or inflated effect sizes.25 it is also possible that studies with similar sample sizes which did not yield significant effects were not published and, thus, did not contribute to the pool of known data regarding ppi efficacy. this is evidenced by the funnel plot generated. (figure 7) this possible list of unpublished studies, however, was not found during the literature search of the reviewers. contrary to the popular usage of higgins i2 as the marker for between-study heterogeneity, borenstein et al. clarify that it is a proportion between the variance of the true effect versus the variance in the observed effect, and that it is not automatically used as a surrogate for heterogeneity.24 hence, the use of prediction intervals has been suggested to illustrate the range of variance of true effects instead of the i2 value as the former would lead to a more accurate depiction of dispersion of effects between studies.24,38 due to the presence of the outlier articles,19-20 heterogeneity was found to be significant as evidenced by the wide range of the prediction interval which showed that the true effect size could actually lie on the side of no benefit (upper limit value of 5.313). the outlier articles prove the need for future rcts with larger sample sizes and more rigorous methodology to determine whether the consistent positive findings of the smaller studies might, in fact, be due to inherent bias rather than the true effectiveness of ppis. the secondary outcome of the effectiveness of ppi therapy on laryngeal findings (rfs) showed the same tendency for benefit albeit very small. however, the confidence interval of the overall mean difference for the two analyses of rfs showed that the benefit was not significant. this translates to a difference which is also not clinically significant. heterogeneity was also noted to be significant as shown by the wide range of the prediction interval. this heterogeneity may be due to the differences in the protocols used per study. although four out five studies in the first rfs analysis made use of both rsi and rfs, only two studies7,23 applied cut-off values for both the rsi and rfs (rsi >13 and rfs > 7) as part of their inclusion criteria while one study only applied the cutoff value of rfs > 7 but did not take into account the rsi score in the inclusion criteria.3 although pawar et al. used both instruments in their analysis, the inclusion criteria was not stringent as no cut-off values were used in the recruitment process.21 the study of shaheen et al. made use of entirely different questionnaires and did not factor in the rfs in its inclusion criteria.22 the exclusion criteria among studies also varied widely with one study21 excluding all patients with signs of acute or chronic sinus disease while two studies specifically included patients with signs of postnasal drip or chronic sinus disease.22,23 all of these variations in inclusion and exclusion criteria may have contributed to the heterogeneity. it is interesting to note that this heterogeneity is absent in the analysis of rsi for the four studies which analyzed both rsi and rfs.3,7,21,23 if prediction intervals were to be computed for these four common studies alone, the range for the rsi is narrow with a lower limit of -6.0872 and an upper limit of -1.6528 suggesting a narrow dispersion or variation between studies. in contrast, the prediction interval for the rfs of the four same studies is quite wide with a lower limit of -11.7547 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery review article and an upper limit of 9.9147 suggesting a very wide between-study variation. in this case, it is most probable that the low number of studies (n=4) actually causes the falsely narrow and falsely wide prediction interval values for the rsi and rfs, respectively.38 in assessing the possibility of publication bias for studies assessing rfs, the funnel plot generated suggested that there was little publication bias since most studies were found on the bottom of the funnel and on both sides of the mean difference. (figure 8) this was in contrast to the funnel plot generated for the rsi which suggested possible publication bias. it is possible that the apparent absence of publication bias for rfs is because the rfs as an outcome measure is usually a secondary outcome while any symptom questionnaire was reported as the primary outcome. given this, a small study which reports significant findings with respect to symptomatic relief would still have to report findings of the rfs even in the event of non-significant findings.3 however, it was noted that among the seven studies that made use of the rfs, four studies actually did not find that ppi therapy resulted in a significant effect in their primary outcome measurement whether it was the rsi or another questionnaire.17,18,21,22 it was noted that none of the rcts included applied the cut-off values for the rsi or rfs suggested by belafsky et al.4,5 in assessing response or resolution of lpr; rather, all studies computed for the overall mean score per treatment group with or without the mean difference from baseline to post-treatment. after contacting the authors of the studies, only data from anzić’s study were obtained regarding the proportion of patients with final rfs and rsi scores less than the cut-off. surprisingly, only two participants (6.06%) in the ppi group had a post-treatment rsi less than 13, and eight (24.24%) had an rfs less than 7. it was noted that zero (0%) and four participants (14.81%) in the placebo group had an rsi less than 13 and rfs less than 7, respectively. since only one out of nine studies has data on proportions of patients’ scores, no further subgroup analysis can be carried out. it may be suggested then for future researchers to apply these cut-off values as published by belafsky et al.4,5 a further recommendation would be for future researchers to stratify patients into those with severe disease with rsi greater than 13 and rfs greater than 7 from those with clinically significant disease with rsi greater than 10 and rfs greater than 5.4-6 it is clear that larger, stringent, placebo-controlled, rcts studying the effectiveness of ppi therapy in lpr are still lacking. more so, it is recommended that future researchers make use of the rsi and rfs which are validated instruments specifically for lpr instead of other questionnaires. although this meta-analysis found that there was a statistically significant difference in post-treatment rsi scores favoring ppis over placebo, this does not necessarily translate to a clinically significant effect among patients. given the presence of great heterogeneity among studies, possible risk of bias in at least one rct, and a lack of reporting using cut-off values suggested by belafsky for the rsi and rfs, there is currently insufficient evidence to recommend for or against the use of ppis in the treatment of lpr.6 the conduction of larger rcts with rigorous methodology should address these current issues in order to create a more scientifically sound recommendation regarding the treatment of lpr. these future trials can possibly address the question of ppi efficacy by stratifying patients based on cut-off values for severe disease (rsi>13 and rfs>7) and for clinically significant disease (rsi>10 and rfs>5) in their inclusion criteria and outcome measurements instead of purely reporting mean scores and mean differences. other areas of variability that should be addressed by future trials are the exact type of ppi, dosage, frequency, and minimum duration of therapy. with regard to side effects, only one rct reported a single serious adverse effect possibly related to the treatment.19,20 all others reported no serious adverse events related to the intake of ppis. still, prescribing ppis is not without risk, not to mention the potential financial strain of prolonged treatment. these factors must also be taken into consideration when weighing the benefit of empiric treatment given the lack of robust evidence to support it. as stated, the aao-hns recommends against prescribing ppis for isolated dysphonia without documenting laryngeal findings suggestive of reflux disease.27 in this age of new out-patient consultation procedures with the advent of virtual consultations or telemedicine/ telehealth, new layers to the decision-making process for practitioners are added. one must not only decide whether to prescribe ppis at all if a diagnosis of lpr is being considered but, if so, when – during a virtual consult without the aid of a physical examination or after? we expect that recommendations that will guide these decisions will continue to evolve as more studies are developed and published. registration and protocol a protocol was created and exempted from the authors’ institution ethical board of review (up manila research ethics board (upmreb 2020-714-ex). this review was registered in the research grants administration office, university of the philippines, manila on january 15, 2020 (rgao-2020-0048). philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery review article acknowledgements we thank dr. louella patricia carpio for answering clarifications on statistical computations and approaches for this meta-analysis and professor davor plavec and mr. james o’hara for responding to queries and providing any additional information requested regarding their respective studies. references 1. kavitt rt, vaezi mf. diseases of the esophagus. in: flint pw, haughey bh, lund v, niparko jk, robbins kt, thomas jr, et al., editors. cummings otolaryngology head and neck surgery. 6th ed. philadelphia: saunders elsevier; 2014. p. 1009-1010. 2. karkos pd, wilson ja. empiric treatment of laryngopharyngeal reflux with proton pump inhibitors: a systematic review. laryngoscope. 2006 jan;116(1):144-148. doi:10.1097/01. mlg.0000191463.67692.36 pubmed pmid: 16481828. 3. lam pky, manwa ln, cheung tk, wong byh, tan vpy, fong dyt, et al. rabeprazole is effective in treating laryngopharyngeal reflux in a randomized placebo-controlled trial. clin gastroenterol hepatol. 2010 sep;8(9):770-776. doi:10.1016/j.cgh.2010.03.009 pubmed pmid: 20303417. 4. belafsky pc, postma gn, koufman ja. validity and reliability of the reflux symptom index (rsi). j voice. 2002 jun;16(2):274-277. doi:10.1016/s0892-1997(02)00097-8. pubmed pmid: 12150380. 5. belafsky pc, postma gn, koufman ja. the validity and reliability of the reflux finding score (rfs). laryngoscope. 2001 aug;111(8):1313-1317. doi:10.1097/00005537-200108000-00001 pubmed pmid: 11568561. 6. belafsky pc, postma gn, koufman ja. laryngopharyngeal reflux symptoms improve before changes in physical findings. laryngoscope. 2001 jun;111(6):979-981. doi:10.1097/00005537200106000-00009 pubmed pmid: 11404607. 7. reichel o, dressel h, wiederänders k, issing wj. double-blind, placebo-controlled trial with esomeprazole for symptoms and signs associated with laryngopharyngeal reflux. otolaryngol head neck surg. 2008 sep;139(3):414-420. doi:10.1016/j.otohns.2008.06.003 pubmed pmid: 18722223. 8. liu c, wang h, liu k. meta-analysis of the efficacy of proton pump inhibitors for the symptoms of laryngopharyngeal reflux. braz j med biol res. 2016 jul;49(7):e5149. doi:10.1590/1414431x20165149 pubmed pmid: 27383119 pubmed central pmcid: pmc4942224. 9. megwalu uc. a systematic review of proton pump inhibitor therapy for laryngopharyngeal reflux. ear nose throat j. 2013 aug;92(8):364-371. doi:10.1177/014556131309200811 pubmed pmid: 23975490. 10. spantideas n, drosou e, bougea a, alabdulwahed r. proton pump inhibitors for the treatment of laryngopharyngeal reflux. a systematic review. j voice. 2020 nov;34(6):918-929. doi:10.1016/j.jvoice.2019.05.005 pubmed pmid: 31160182. 11. sen p, georgalas c, bhattacharyya ak. a systematic review of the role of proton pump inhibitors for symptoms of laryngopharyngeal reflux. clin otolaryngol. 2006 feb;31(1):20-24. doi:10.1111/j.1749-4486.2006.01134.x. pubmed pmid: 16441796. 12. gatta l, vaira d, sorrenti g, zucchini s, sama c, vakil n. meta-analysis: the efficacy of proton pump inhibitors for laryngeal symptoms attributed to gastro-oesophageal reflux disease. aliment pharmacol ther. 2007 feb;25(4):385-392. doi:10.1111/j.1365-2036.2006.03213.x. pubmed pmid: 17269993. 13. guo h, ma h, wang j. proton pump inhibitor therapy for the treatment of laryngopharyngeal reflux: a meta-analysis of randomized controlled trials. j clin gastroenterol. 2016 apr;50(4):295300. doi:10.1097/mcg.0000000000000324. pubmed pmid: 25906028. 14. wei c. a meta-analysis for the role of proton pump inhibitor therapy in patients with laryngopharyngeal reflux. eur arch otorhinolaryngol. 2016 nov;273(11):3795-3801. doi:10.1007/s00405-016-4142-y pubmed pmid: 27312992. 15. lechien jr, saussez s, schindler a, karkos pd, hamdan al, harmegnies b, et al. clinical outcomes of laryngopharyngeal reflux treatment: a systematic review and meta-analysis. laryngoscope. 2019 may;129(5):1174-1187. doi:10.1002/lary.27591 pubmed pmid: 30597577. 16. higgins jp, altman dg, gøtzsche pc, jüni p, moher d, oxman ad, et al. the cochrane collaboration’s tool for assessing risk of bias in randomised trials. bmj. 2011;343:d5928. doi:10.1136/bmj.d5928 pubmed pmid: 22008217 pubmed central pmcid: pmc3196245. 17. faruqi s, molyneux id, fathi h, wright c, thompson r, morice ah. chronic cough and esomeprazole: a double-blind placebo-controlled parallel study. respirology. 2011 oct;16(7):1150-1156. doi:10.1111/j.1440-1843.2011.02014.x pubmed pmid: 21707852. 18. wo jm, koopman j, harrell sp, parker k, winstead w, lentsch e. double-blind, placebocontrolled trial with single-dose pantoprazole for laryngopharyngeal reflux. am j gastroenterol. 2006 sep;101(9):1972-2169. doi:10.1111/j.1572-0241.2006.00693.x pubmed pmid: 16968502. 19. wilson ja, stocken dd, watson gc, fouweather t, mcglashan j, mackenzie k, et al. lansoprazole for persistent throat symptoms in secondary care: the toppits rct. health technol assess. 2021 jan;25(3):1-118. doi:10.3310/hta25030 pubmed pmid:  33492208 pubmed central pmcid: pmc7869007. 20. o’hara j, stocken dd, watson gc, fouweather t, mcglashan j, mackenzie k, et al. use of proton pump inhibitors to treat persistent throat symptoms: multicentre, double blind, randomised, placebo controlled trial. bmj. 2021;372:m4903. doi: 10.1136/bmj.m4903 pubmed pmid: 33414239 pubmed central pmcid: pmc7789994. 21. pawar s, lim hj, gill m, smith tl, merati a, toohill rj, et al. treatment of postnasal drip with proton pump inhibitors: a prospective, randomized, placebo-controlled study. am j rhinol. 2007 nov-dec;21(6):695-701. doi:10.2500/ajr.2007.21.3098 pubmed pmid: 18201449. 22. shaheen nj, crockett sd, bright sd, madanick rd, buckmire r, couch m, et al. randomised clinical trial: high-dose acid suppression for chronic cough a double-blind, placebo-controlled study. aliment pharmacol ther. 2011 jan;33(2):225-234. doi:10.1111/j.1365-2036.2010.04511.x. pubmed pmid: 21083673. 23. anzić sa, turkalj m, župan a, labor m, plavec d, baudoin t. eight weeks of omeprazole 20 mg significantly reduces both laryngopharyngeal reflux and comorbid chronic rhinosinusitis signs and symptoms: randomised, double-blind, placebo-controlled trial. clin otolaryngol. 2018 apr;43(2):496-501. doi:10.1111/coa.13005 pubmed pmid: 29024410. 24. borenstein m, higgins jp, hedges lv, rothstein hr. basics of meta-analysis: i2 is not an absolute measure of heterogeneity. res synth methods. 2017 mar;8(1):5-18. doi:10.1002/jrsm.1230. pubmed pmid: 28058794. 25. page mj, higgins jpt, sterne jac. chapter 13: assessing risk of bias due to missing results in a synthesis. in: higgins jpt, thomas j, chandler j, cumpston m, li t, page mj, et al., editors. cochrane handbook for systematic reviews of interventions version 6.2 [internet] [updated 2021 feb; cited 2021 apr 2]. available from www.training.cochrane.org/handbook/current/ chapter-13. 26. altman kw, prufer n, vaezi mf. a review of clinical practice guidelines for reflux disease: toward creating a clinical protocol for the otolaryngologist. laryngoscope. 2011 apr;121(4):717-723. doi:10.1002/lary.21429. pubmed pmid: 21298646. 27. stachler rj, francis do, schwartz sr, damask cc, digoy gp, krouse hj, et al. clinical practice guideline: hoarseness (dysphonia) (update). otolaryngol head neck surg. 2018 mar;158(1_ suppl):s1-s42. doi:10.1177/0194599817751030. pubmed pmid: 29494321. erratum in: otolaryngol head neck surg. 2018 aug;159(2):403. doi: 10.1177/0194599818766900. pubmed pmid: 29494321. 28. american academy of otolaryngology-head and neck surgery. position statement: laryngopharyngeal reflux [internet]. virginia, usa: aao-hns/f; 2006 [updated 2020 aug 11; cited 2021 apr 2]. available from: https://www.entnet.org/content/laryngopharyngeal-reflux. 29. lee js, lee yc, kim sw, kwon kh, eun yg. changes in the quality of life of patients with laryngopharyngeal reflux after treatment. j voice. 2014 jul;28(4):487-491. doi:10.1016/j. jvoice.2013.12.015. pubmed pmid: 24598356. 30. yoon yh, park kw, lee sh, park hs, chang jw, koo bs. efficacy of three proton-pump inhibitor therapeutic strategies on laryngopharyngeal reflux disease; a prospective randomized doubleblind study. clin otolaryngol. 2019 jul;44(4):612-618. doi:10.1111/coa.13345. pubmed pmid: 31002475. 31. doshi k, varghese a, badyal dk. evaluation of omeprazole in the treatment of laryngopharyngeal reflux disease: a single center, prospective and randomized study. int j otorhinolaryngol clin. 2015 jan-apr;7(2):45-50. doi:10.5005/jp-journals-10003-1186 corpus id: 36862984. 32. bhargava a, faiz sm, srivastava mr, shakeel m, singh nj. role of proton pump inhibitors in laryngopharyngeal reflux: clinical evaluation in a north indian population. indian j otolaryngol head neck surg. 2019 sep;71(3):371-377. doi:10.1007/s12070-018-1493-2. pubmed pmid: 31559206 pubmed central pmcid: pmc6737127. 33. chugh r. the role of empirical treatment with proton pump inhibitor as a diagnostic tool in laryngopharyngeal reflux. indian j otolaryngol head neck surg. 2019 oct:1-8. doi:10.1007/ s12070-019-01750-7. 34. eherer aj, habermann w, hammer hf, kiesler k, friedrich g, krejs gj. effect of pantoprazole on the course of reflux-associated laryngitis: a placebo-controlled double-blind crossover study. scand j gastroenterol. 2003 may;38:462–467. doi:10.1080/00365520310001860 pubmed pmid: 12795454. 35. steward dl, wilson km, kelly dh, patil ms, schwartzbauer hr, long jd, et al. proton pump inhibitor therapy for chronic laryngo-pharyngitis: a randomized placebo-control trial. otolaryngol head neck surg. 2004 oct;131:342–350. doi:10.1016/j.otohns.2004.03.037 pubmed pmid: 15467597. 36. vaezi mf, richter je, stasney cr, spiegel jr, iannuzzi ra, crawley ja, et al. treatment of chronic posterior laryngitis with esomeprazole. laryngoscope. 2006 feb;116:254–260. doi:10.1097/01. mlg.0000192173.00498.ba pubmed pmid: 16467715. 37. ezzat wf, fawaz sa, fathey h, el demerdash a. virtue of adding prokinetics to proton pump inhibitors in the treatment of laryngopharyngeal reflux disease: prospective study. j otolaryngol head neck surg. 2011 aug;40: 350–356. pubmed pmid: 21777555. 38. page mj, higgins jpt, sterne jac. chapter 10: analysing data and undertaking meta-analyses. in: higgins jpt, thomas j, chandler j, cumpston m, li t, page mj, et al., editors. cochrane handbook for systematic reviews of interventions version 6.2 [internet] [updated 2021 feb; cited 2021 apr 2]. available from www.training.cochrane.org/handbook/current/chapter-10. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 surgical innovations and instrumentation philipp j otolaryngol head neck surg 2021; 36 (2): 44-48 c philippine society of otolaryngology – head and neck surgery, inc. aerosol and droplet particles contained by inexpensive barrier tent during mastoidectomy: a covid-19 innovation andylou d. mangubat, md patrick john p. labra, md department of otorhinolaryngology head and neck surgery corazon locsin montelibano memorial regional hospital correspondence: dr. patrick john p. labra department of otorhinolaryngology head and neck surgery corazon locsin montelibano memorial regional hospital bacolod city 6100 philippines phone: +63 932 862 6738 email: patrick.labra@gmail.com the authors declared that this presents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by both authors, and the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationship, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. presented at the philippine society of otolaryngology head and neck surgery 1st virtual surgical innovation contest (1st place) november 25, 2020. abstract objective: to investigate the distribution and aerosolized particle counts generated during mastoidectomy, we utilized low-cost and locally available material and developed a plastic tent creating a barrier between the health care workers (hcw) and patient. methods: the barrier tent is a clear plastic bag attached to the microscope lens. the tent is draped and tucked underneath the patient’s head and upper torso with surgeon’s arms also passed underneath and secured with clamps. we demonstrated the area of greater contamination by spread of droplet particles and bone dust after drilling using fluorescent dye. particle counts inside and outside the barrier was determined and then comparison with and without the tent after drilling of cadaveric temporal bone were also done. results: the area with highest concentration of contamination (“hot zone”) was noted opposite the surgeon’s hand drill which is dependent on the operator’s handedness. other hot zones noted were opposite the operator and on the operator’s side.  particle determination of aerosol size 0.3 and 2.5µm inside the barrier tent were at peak levels after bone drilling procedure. then a significant drop of particle counts was noted at 2 minutes after drilling was stopped with flattening observed at 8 minutes. conclusion: our experimental results suggest that the improvised barrier tent can be effective in mitigating aerosols generated during mastoid surgery and may serve as an added protection for the operating room team. keywords: sars-cov-2; otologic surgery, barrier tent, aerosol generating procedure; mastoid; covid-19 the recent report of isolated sars-cov-2 virus from the mastoid and middle ear by a team of experts from johns hopkins school of medicine has significant implications on otolaryngologic practice including heightened precautions during otologic surgery; viral colonization in these two otologic structures confirmed previous knowledge on the theoretical risk on which management decisions and protocols against sars-cov-2 are grounded.1 creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 surgical innovations and instrumentation during otologic surgery, high-speed drilling of bone coupled with continuous irrigation generates aerosols and bone dust increasing exposure risk of the surgical team.2,3 the high rate of asymptomatic and pre-symptomatic covid-19 cases warrants precautions which include personal protective equipment (ppe) including eye protection and fit-tested n95 level mask at a minimum.4 with the critical shortage of ppe, clinicians are compelled to seek alternative solutions to protect themselves. a recent review of best available evidence for covid-19 practice of ents recommends the use of barrier methods to reduce risk of droplet transmission and infection.5 mitigation strategies and methods during otologic surgery utilize a steri-drape™ 2,3,6 and a second microscope cover that act as a physical barrier for containment of droplets generated by irrigated high-speed drilling of bone.7 however, due to limited resources and availability of these materials in our setting, we resorted to alternatives found in the local market. we describe our locally-developed version of protection barrier tent utilizing a low-cost, accessible, and easy to install plastic material which functions both as a physical barrier and a containment system to isolate the surgical field. our objective is for the barrier to contain the droplet particles and aerosols during otologic surgery. methods protection barrier tent assembly the protection barrier tent used an inexpensive 40 x 60 inch clear plastic bag (pe 002, sun ace polymer manufacturing corp, valenzuela, metro manila) which costs only p20 per piece and is available from local plastic suppliers. a 12cm diameter hole was cut at the middle of the base of the plastic bag which served as a port for attachment of the drape to the outer perimeter of the microscope lens secured by a rubber band. the prepared barrier plastic was sterilized using pure 50 low temperature h2o2 plasma sterilizer (zeronitec co. ltd, gyeonggido, korea). during the procedure, the barrier tent was draped over the surgical field and secured by sterile clamps. (figure 1) the surgeon’s hands including those of the assistant were inserted underneath the tent through controlled access ports, and these were made airtight by securing the edges of the plastic barrier and the plastic edge around the surgeon’s wrists with sterile clamps. instruments were passed under the barrier to access the surgical field. (figure 2) simulated mastoid surgery, particle dispersion and clearance using an s100 opmi® pico operating microscope (carl zeiss meditec ag, jena, germany) with an objective focal distance of 250 mm, surgical simulation was performed on cadaveric temporal bone specimens, thawed in fluorescent dye. two surgeons with separate dominant handedness (left and right-handedness) performed the drilling of the mastoid cavity independently. with the specimen in standard otologic position they performed the mastoid cavity drilling using 6 mm cutting burr and a volvere i7 drill (nsk-nakanishi, tochigi, japan) at 70,000 rpm. after the surgical procedure, the spread of droplet particles, bone dust and splatter were evaluated using uv light illumination in a darkened room. the fluorescent dye fluoresces bright yellow if illuminated with uv light. this is used to visualize the contamination in four (4) cardinal directions (surgeon side, opposite the surgeon, left side and right side of the surgeon) generated by high-speed drilling. two ht-9600 high sensitivity pm2.5 detector particle counters (dongguan xintai instrument co. ltd, guangdong, china) with flow rate of 1.0 liters/minute were used to measure changes in particle number in the 0.3 µm and 2.5 µm size distribution. particle counts were determined inside and outside the barrier tent prior to high-speed drilling which served as baseline particle count. measurement of particle counts after high-speed drilling was performed across three scenarios. the total particle counts for particles sizes 0.3 µm and 2.5 µm were collected after one minute of continuous irrigated high-speed drilling of mastoid bone, then at two-minute intervals until baseline was reached. for the first scenario, one particle counter was placed inside and another was placed outside the plastic barrier. for the second drill scenario, both particle counters were placed beside each other inside the plastic barrier tent. for the third drill scenario, the plastic barrier tent was removed and drilling was performed with the particle counter in the same position as the first two scenarios. data analysis electronic photographs were taken to record the data from the particle counter at specific time of measurement. data was tabulated in ms excel 2019 (microsoft corporation, redmond, wa, usa) to generate descriptive statistics. results protection barrier tent assembly the protection barrier tent was easy to set up once the temporal bone was positioned on the operating table with the operating microscope. the application and assembly of the tent took less than 5 minutes. there was no difficulty encountered in positioning the tent, in inserting the hands of the surgeon and assist underneath the tent through access ports, or in securing the edges of the plastic barrier around their wrists with clamps. there was also no difficulty encountered in passing instruments under the barrier to access the surgical field. fluorescein distribution greater fluorescein concentration was observed during simulated cortical mastoidectomy on the surgeon’s non dominant hand which held the suction tip during mastoid drilling. less fluorescein was noted philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 surgical innovations and instrumentation on the surgeon’s dominant hand which was holding the drill handpiece. (figure 3a, b) fluorescein was also demonstrated in greater concentration on the internal surface of the barrier tent opposite of the hand holding the mastoid drill. (figure 4a, b) the internal surface of the tent on the same side of the hand holding the drill had minimal fluorescein staining. (figure 4c, d) minimal fluorescein staining was also found on the internal surface of the barrier tent on the surgeon’s side and the side opposite of the surgeon. particle counts the particle counts for sizes of 0.3 µm and 2.5 µm across time were recorded across three set-ups. figure 5 shows the comparison of particle counts inside and outside the barrier tent after a 1-minute drill. the peak particle counts were detected one minute after the drilling procedure. this was followed by a significant drop after 2 minutes in both particle sizes 0.3 µm and 2.5 µm. at the eight-minute mark, particle counts reached baseline and were stable with no significant changes in the succeeding two-minute mark recordings. figure 6 shows comparison of particle counts of two counters (pc1 and pc2) inside the barrier tent. particle counts with barrier tent removed are depicted in figure 7. discussion during this covid-19 pandemic, there is a general belief that all health care workers in the operating theatre during mastoidectomy are at risk.8 the landmark findings by frazier et al.1 on the presence of sarscov-2 virus in the mastoid and middle ear demonstrated the risk for exposure in the manipulation of these anatomic sites. these findings demonstrate empiric evidence on the need for precautions to mitigate risks for droplet and aerosol viral transmission during otologic surgery where several aerosol-generating steps are needed such as high-speed drilling with irrigation and diathermy. for this aerosol generating procedure (similar to procedures on the nose, mouth and airway), the appropriate ppe includes an n95 mask, googles, and face shield with strong preference for a powered air-purifying respirator (papr). furthermore, a negative pressure atmosphere is also recommended.4 the results of the mastoid surgery simulation emphasized the crucial role of physical barriers in protecting the surgeon and the surgical team. in our simulation, the direction where the drill head is pointing is an important factor in identifying areas of greater contamination during high-speed, irrigated drilling of bone as demonstrated by degree of fluorescein concentration. our results demonstrate greater fluorescein concentration in the surgeon’s non-dominant hand (figure 3a, b) as well as the inner surface of the barrier tent opposite the drill head (figure 4a, b) which were the areas the drill head was directly pointing at. these areas of high contamination corresponds to the “hot zone” (term coined by matava et al.9 ) where most of the particulates are deposited and concentrated during the drilling procedure. by contrast, the least contamination was observed in the surgeon’s dominant hand holding the drill (figure 3a, b) and inner surface of the barrier tent on the same side (figure 4c, d) which were away from direction the drill head was pointing. these patterns of distribution are explained by the direction of the rotation of the drill head according to the study by sharma et al.10 on otologic simulation using cadaver heads. these findings that map out the “hot zones” of droplet contamination show the utility of the barrier tent in minimizing exposure of the surgical team who are in close proximity to the surgeon. the sars-cov-2 particle size identified in hospitalized patients in wuhan, china varied from about 0.06 to 0.14 µm11 and studies have shown that most viral particles are carried by infectious aerosols measuring <5 µm, while droplet spread is transmitted by particles >510 µm in size.12 using high powered instrumentation in mastoidectomy is a highly aerosol generating procedure with the potential to disperse particles smaller than 10µm.3 we investigated the particle size and counts generated during mastoid bone drilling using a particle counter with detection size 0.3 and 2.5µm. our findings showed that within the barrier tent, large quantities of particle size 0.3 µm and 2.5 µm were generated after 1 minute of high-speed drilling on cadaveric mastoid bone. a significant decrease in particle counts in both 0.3 µm and 2.5 µm was noted at 2 minutes after drilling was stopped with flattening of the particle counts at 8 minutes. (figure 5, 6) this was also observed in previous studies by chari et al.3 and sharma et al.10 on cadaveric simulations. our results suggest a period of 8 minutes for the aerosolized particles to significantly decrease inside the barrier tent, which serves as the basis for the timing of safe removal of the barrier tent after mastoid drilling. the comparison of particle counts inside and outside the barrier tent (figure 5) and those with or without the barrier tent (figure 7) demonstrated the efficacy of the barrier strategy in mitigating or trapping aerosols. particle counts detected outside the barrier tent and without using the barrier tent showed no increase in the number of particles generated during the drilling which may suggest the rapid dispersion of aerosolized particles during high-speed drilling. the study of rohit et al.13 on the mechanics of respiratory droplet size, dispersion, and displacement explained that the small particles move according to the law of brownian motion wherein the diffusive forces transport particles in random motion. they showed that smaller particles spread throughout the room faster and remain suspended longer than larger particles. our experience demonstrates that the inexpensive locally acquired clear plastic barrier is practical for clinical use and is effective in philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 surgical innovations and instrumentation figure 1. barrier tent assembly: a. barrier tent mounted on operating microscope; b. elastic band used to secure plastic barrier on microscope lens; and c. surgical clamps used to keep plastic barrier in place. figure 5. particle counts inside and outside the plastic barrier tent: a. 0.3 µm; and b. 2.5 µm. figure 6. comparison of two particle counters (pc1 and pc2) inside the barrier tent over 10 minutes: a. 0.3µm and b. 2.5µm. figure 4. uv fluorescence of barrier tent after simulated mastoid surgery: a. and b. showing opposite side of the hand holding the high-speed drill; c. and d. showing the same side of the hand holding the high-speed drill. a b c figure 2. arm access of surgeon secured with the use of blunt surgical clamps (bold arrows) to maintain an air-tight environment. figure 3. uv fluorescence of surgeons’ hands after simulated mastoid surgery: a. right-handed surgeon; b. left-handed surgeon. a b a c b d a a b b philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 surgical innovations and instrumentation acknowledgements we acknowledge dr. erie imperial for her participation in the simulation of mastoid surgeries. references 1. frazier km, hooper je, mostafa hh, stewart cm. sars-cov-2 virus isolated from the mastoid and middle ear: implications for covid-19 precautions during ear surgery. jama otolaryngol head neck surg. 2020 oct 1;146(10):964-966. doi: 10.1001/jamaoto.2020.1922; pubmed pmid: 32701126. pubmed central pmcid: pmc7378866. 2. carron jd, buck ls, harbager cf, eby tl. a simple technique for droplet control during mastoid surgery. jama otolaryngol head neck surg. 2020 jul 1;146(7):671-672. doi: 10.1001/ jamaoto.2020.1064; pubmed pmid: pmid: 32343347; pubmed central pmcid: pmc7189332. 3. chari da, workman ad, chen jx, jung dh, abdul-aziz d, kozin ed, et al. aerosol dispersion during mastoidectomy and custom mitigation strategies for otologic surgery in the covid-19 era. otolaryngol head neck surg. 2021 jan;164(1):67-73. doi: 10.1177/0194599820941835; pubmed pmid: 32660367; pubmed central pmcid: pmc7361126. 4. george m, alexander a, mathew j, iyer a, waterval j, simon c, et al. proposal of a timing strategy for cholesteatoma surgery during the covid-19 pandemic. eur arch otorhinolaryngol. 2020 sep;277(9):2619-2623. doi: 10.1007/s00405-020-06037-0; pubmed pmid: 32415348; pubmed central pmcid: pmc7225247. 5. lapeña jf, abes fl, gomez ma, villafuerte cv, roldan r, fullante p, et al. otorhinolaryngology out-patient practice in the “post”-covid-19 era: ensuring a balance between service and safety. philipp j otolaryngol head neck surg. 2020 may 15;35(1):6-29. doi: 10.32412/pjohns.v35i1.1249. 6. gordon sa, deep nl, jethanamest d. exoscope and personal protective equipment use for otologic surgery in the era of covid-19. otolaryngol head neck surg. 2020 jul;163(1):179-181. doi: 10.1177/0194599820928975; pubmed pmid: 32423361. 7. hellier w, mitchell t, thomas s. mastoidectomy in the covid era: the 2-microscope drape method to reduce aerosolization. the royal college of surgeons, london: ent-uk groups; 2020. available from: https://www.entuk.org/sites/default/files/mastoidectomy%20in%20 the%20covid%20era%20%e2%80%93%20the%202.pdf. 8. topsakal v, rompaey vv, kuhweidi r, garin p, barbara m, li y, et al. prioritizing otological surgery during the covid-19 pandemic. b-ent. 2020 april;16(1):55-58. doi:10.5152/b-ent.2020.20126. 9. matava ct, yu j, denning s. clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for covid-19. can j anaesth. 2020 jul;67(7):902904. doi: 10.1007/s12630-020-01649-w; pubmed pmid: 32246431; pubmed central pmcid: pmc7124129. 10. sharma d, rubel ke, ye mj, campiti vj, carroll ae, ting jy, et al. cadaveric simulation of otologic procedures: an analysis of droplet splatter patterns during the covid-19 pandemic. otolaryngol head neck surg. 2020 aug;163(2):320-324. doi: 10.1177/0194599820930245; pubmed pmid: 32423287; pubmed central pmcid: pmc7240315. 11. zhu n, zhang d, wang w, li x, yang b, song j, et al. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med. 2020 feb 20;382(8):727-733. doi: 10.1056/ nejmoa2001017; pubmed pmid: 31978945; pubmed central pmcid: pmc7092803. 12. fennelly kp. particle sizes of infectious aerosols: implications for infection control. lancet respir med. 2020 sep; 8(9):914–24. doi: 10.1016/s2213-2600(20)30323-4; pubmed pmid: 32717211; pubmed central pmcid: pmc7380927. 13. rohit a, rajasekaran s, karunasagar i, karanusagar i. fate of respiratory droplets in tropical vs temperate environments and implications for sars-cov-2 transmission. med hypotheses. 2020 nov;144:109958. doi: 10.1016/j.mehy.2020.109958; pubmed pmid: 32575016; pubmed central pmcid: pmc7282739. mitigating droplet spread during mastoid bone drilling. this plastic barrier method is akin to that described and used as an aerosol barrier for intubation/extubation which is effective in limiting aerosolization and droplet spray.8 in our experience, the barrier tent is easy to install on a microscope using clips or clamps, allowing maneuverability of both operator’s and assist’s hands through the port access without impeding surgery especially during movement and adjustment of the microscope. our simulation model using fluorescence raises important concerns that the use of minimum ppe alone will not provide adequate protection against bone particle droplets and aerosols generated by drilling. however, our protection barrier plastic bag does not replace adequate ppe use. there are several limitations of our study. first, we only tested the barrier tent on a mastoidectomy model, and can only infer its use in mastoidectomy and similar otologic procedures. future studies may model more complicated neurotologic procedures. we also did not formally assess the ease of setting up by nurses, or ease of use by surgeons, and these should be evaluated appropriately from the perspective of end-users. second, the cortical mastoidectomies performed in this study utilized cadaveric temporal bones which are incomparable to live patients; future studies involving actual patients may confirm our initial findings. third, the method of particle count determination in this study is limited to optoelectronic particle size measurement during simulation otologic surgery; we therefore recommend the use of aerosol spectrometers (aerodynamic measurement or optical aerosol spectrometers) and condensation particle counters for further studies. our study did not evaluate aerosol dispersion at access ports during passing of instruments, and further studies may consider addressing this. future innovations can also explore other means to secure the plastic tent to the microscope lens and avoid collapse of the plastic tent that may hamper the surgeon’s visual field, and the addition of a high-volume suction system for evacuation of aerosol-generated particles. meanwhile, extra precautions should be observed in properly removing and discarding the plastic barrier to contain particles that adhere to the internal surface of the barrier tent during the aerosol generating procedure. in conclusion, our experimental results suggest that the improvised barrier tent can be effective in mitigating aerosol and droplet particles generated during selected mastoid surgeries and may serve as an added protection for the operating room team. figure 7. comparison of particle count with and without barrier tent over 10 minutes: a. 0.3µm; and b. 2.5µm. a b philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles abstract objective: this study aims to investigate which, if any head and neck symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) might be good predictors of outcomes (mortality, tracheostomy, discharged, decannulated) and prognosis of tetanus patients. methods: design: retrospective cohort study setting: tertiary national university hospital patients: seventy-three (73) pediatric and adult patients diagnosed with tetanus and admitted at the emergency room of the philippine general hospital between january 1, 2013 and december 31, 2017. demographic characteristics, incubation periods, periods of onset, routes of entry, head and neck symptoms, stage, and outcomes were retrieved from medical records and analyzed. results: of the 73 patients included, 53 (73%) were adults, while the remaining 20 (27%) were pediatric. the three most common head and neck symptoms were trismus (48; 66%), neck pain/ rigidity (35; 48%), and dysphagia to solids (31; 42%). results of multivariate logistic regression analysis showed that only trismus (or = 3.742, p = .015) and neck pain/ rigidity (or = 4.135, p = .015) were significant predictors of decannulation. no dependent variable/symptoms had a significant effect in predicting discharge and mortality. conclusion: clinically diagnosed tetanus can be easily recognized and immediately treated. most of the early complaints are head and neck symptoms that can help in early diagnosis and treatment resulting in better prognosis. in particular, trismus and neck pain/rigidity may predict the outcome of decannulation after early tracheotomy, but not of discharge and mortality. keywords: tetanus; head and neck symptoms; outcome; predictors of outcome; trismus; neck pain/ rigidity; tracheotomy tetanus remains a persistent global health problem despite its inclusion in the expanded program on immunization (epi) by the world health organization. its high morbidity and mortality especially in developing countries is unjustified by its preventable nature and course. one million cases are reported annually with a case fatality ratio ranging from 6% to head and neck symptoms as predictors of outcome in tetanus patients angeli c. carlos-hiceta, md,1 ryner jose d. carrillo, md, msc,2,3 jose florencio f. lapeña, jr., ma, md3 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2department of anatomy, college of medicine, university of the philippines manila 3department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 telefax: (632) 8524 4455 email: lapenajf@upm.edu.ph, jflapena@up.edu.ph the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that all the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery analytical research contest. december 7, 2019. palawan ballroom, edsa shangri la hotel, mandaluyong city. philipp j otolaryngol head neck surg 2020; 35 (2): 32-36 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles 72% depending on the availability of a well-equipped intensive care unit.1 the diagnosis of tetanus is clinical, and the primary complaints and history are important in determining the course of the disease.2 most of these early complaints and presenting symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) concern the head and neck region, making otolaryngologic evaluation indispensable.3 however, there is lack of local protocols that focuses on the prognosis and outcome of tetanus in association with head and neck symptoms. the cole staging system is currently used in determining prognosis.4 existing severity scores such as philips, dakar and tetanus severity score (tss) are utilized as predictors of outcome.5 only the dakar score includes spasm as one of its variables; none have taken into account head and neck symptoms as prognostic parameters despite their being the most common early presentation. although preventable through immunization, this disease remains an important threat worldwide. if not recognized early, it may progress to disability and worse, death. this study aims to investigate which, if any head and neck symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) might be good predictors of outcomes (mortality, tracheostomy, discharged, decannulated) and prognosis of tetanus patients. methods this retrospective cohort study included all pediatric and adult patients diagnosed with tetanus and admitted at the emergency room of the philippine general hospital between january 1, 2013 and december 31, 2017. the patient lists were retrieved from the yearly census of the departments of neurosciences, pediatrics and otorhinolaryngology. this study was approved by the university of the philippines manila research ethics board (upmreb 2018-391-01). informed consent was waived by the board. all in-patient and out-patient records of identified patients were considered for inclusion and retrieved from the hospital records section. patients that were diagnosed with tetanus at the out-patient department but not subsequently admitted and those with incomplete records were excluded. data was collected as specified in the case report form. only head and neck symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) were considered, and all other symptoms like abdominal rigidity, fever, generalized rigidity or stiffening were not included. outcomes of the disease listed included: mortality, tracheostomy, discharged, decannulated. deidentified data was tabulated, encoded, and summarized into frequencies/rates (mortality, case fatality rate) and percentages using the ms excel for mac v.15.13.3 (microsoft corp. 2015, redmond, wa, usa). multivariate logistic regression analysis was performed using stata 14 (stata corp. 2015, college station, tx, usa) to determine the predictors of the three dependent variables. a stepwise selection approach was applied in model building. the independent variables were the presence or absence of trismus, dysphagia to solids, dysphagia to liquids, dysarthria, chvostek sign, dyspnea, and neck pain/ rigidity, while the dependent variables were discharge, mortality, and decannulation. a p-value of less than or equal to .05 was considered statistically significant. results a total of 78 patients from all age groups and genders who were clinically diagnosed with tetanus between january 1, 2013 and december 31, 2017 were included in the initial list. five were subsequently excluded; two males with incomplete records and three (1 female, 2 males) who were only seen in the out-patient department but not admitted to the emergency room. a total of 73 patients were finally included in this study. their ages ranged from 3 to 79 years old, with 53 (73%) adults and 20 (27%) pediatric. there were 50 (68%) males and 23 (32%) females. the three most common head and neck symptoms were trismus (48; 66%), neck pain/rigidity (35; 48%) and dysphagia to solids (31; 42%). the incubation period ranged from 1 to 30 days, while the period of onset was one to nine days. the specific route or source of disease in the majority were wounds or burns (47; 64%), followed by dental caries (15; 21%) and animal bites (11; 15%). of the 73 patients, only 19 (26%) had a history of immunization for tetanus, although there was no mention if a complete dose or booster was administered. sixty seven patients (92%) already presented with moderate to severe disease: 23 (32%) were stage ii and 44 (60%) were already stage iii. only six patients (8%) were diagnosed as stage i. all patients, despite the severity of the disease, underwent tracheostomy. of these, 35 (48%) were decannulated, 59 (81%) were discharged from the hospital, while 14 (19%) expired in hospital. thirty four out of fifty males (68%) presented with wound/burns possibly sustained during work (occupational accidents). majority of patients had incubation periods of less than 7 days (45/73; 62%) and 58% of those patients had severe disease (stage iii). sixty two percent (31/50) of those with period of onset of less than 3 days had stage iii disease. sixty one percent (33/54) of those who did not receive any vaccination for tetanus were staged iii tetanus patients. more severe cases of tetanus or those stage iii patients (22/37 patients; 59%) stayed longer than 26 days in the hospital. twenty-seven percent (12/45) of those patients with incubation periods of less than 7 days expired philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles and 18% (9/50) of those patients with periods of onset of less than 3 days expired. causes of death were sepsis and cardiopulmonary complications. the case fatality rate increased with age from 18% for those < 40 years old, to 20% for those 40 to 59 years old, and 22% for those > 60 years old. predictors versus outcomes for multivariate logistic regression analysis are presented in table 1. chvostek sign was omitted in all analysis due to collinearity. the remaining independent variables were not found to be significant predictors of discharge and mortality (table 2 and 3, respectively). on the other hand, results of the analysis showed that only trismus (or = 3.742, p = .015) and neck pain/ rigidity (or = 4.135, p = .015) were significant predictors of decannulation (table 4). the final model used was: decannulation = 0.151 + 2.93 (trismus) + 3.43 (neck pain/rigidity) discussion our present study found that trismus, neck pain/rigidity, and dysphagia to solids were the most common head and neck symptoms. trismus is a common initial symptom in tetanus that may be unilateral early in the course of disease, but usually progresses to bilateral table 1. predictors vs outcome for multivariate logistic regression analysis y yy yn nn n tracheostomy n (%) decannulated n (%) mortality n (%) discharged n (%) trismus with opening slight opening no opening dysphagia to solid yes no dysphagia to liquid yes no dysarthria yes no chvostek yes no dyspnea yes no neck pain/ rigidity yes no 9 (100) 48 (100) 16 (100) 31 (100) 42 (100) 29 (100) 44 (100) 18 (100) 55 (100) 0 0 20 (100) 53 (100) 35 (100) 38 (100) 5 (56) 40 (83) 14 (88) 27 (87) 32 (76) 25 (86) 34 (77) 17 (94) 42 (76) 0 0 15 (75) 44 (83) 27 (77) 32 (84) 4 (44) 8 (14) 2 (12) 4 (13) 10 (24) 4 (14) 10 (23) 1 (6) 13 (24) 0 0 5 (25) 9 (17) 8 (23) 6 (16) 4 (44) 8 (14) 2 (12) 4 (13) 10 (24) 4 (14) 10 (23) 1 (6) 13 (24) 0 0 5 (25) 9 (17) 8 (23) 6 (16) 5 (56) 40 (83) 14 (88) 27 (87) 32 (76) 25 (86) 34 (77) 17 (94) 42 (76) 0 0 15 (75) 44 (83) 27 (77) 32 (84) 0 27 (56) 8 (50) 14 (45) 21 (50) 15 (52) 20 (45) 8 (44) 27 (49) 0 0 8 (40) 27 (51) 21 (60) 14 (37) 9 (100) 21 (44) 8 (50) 17 (55) 21 (50) 14 (48) 24 (55) 10 (56) 28 (51) 0 0 12 (60) 26 (49) í14 (40) 24 (63) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 table 2. multivariate logistic regression analysis for outcome discharge odds ratio p value coefficient estimate std error 95% confidence interval trismus dysphagia to solid dysphagia to liquid dysarthria dyspnea neck pain/rigidity 1.957483 1.057708 1.322432 4.041451 0.71226 0.6248123 .5830814 1.377268 1.350769 1.169684 .6801732 .6356587 .249 .968 .836 .232 .618 .459 .6716595 .0561042 .2794724 1.396604 -.3393123 -.470304 .6242783 6.137872 .0711268 15.72889 .0936691 18.67025 .4082257 40.01053 .1877907 2.701488 .1797529 2.171817 table 3. multivariate logistic regression analysis for outcome mortality odds ratio p value coefficient estimate std error 95% confidence interval trismus dysphagia to solid dysphagia to liquid dysarthria dyspnea neck pain/rigidity .5108601 .9454406 .7561826 .2474359 1.403982 1.600481 .5830814 1.377268 1.350769 1.169684 .6801732 .6356587 .249 .968 .836 .232 .618 .459 -.6716595 -.0561042 -.2794724 -1.396604 .3393123 .470304 .1629229 1.60185 .0635773 14.05939 .0535611 10.67588 .0249934 2.449625 .3701664 5.325077 .4604439 5.563193 table 4. multivariate logistic regression analysis for outcome decannulation odds ratio p value coefficient estimate std error 95% confidence interval trismus dysphagia to solid dysphagia to liquid dysarthria dyspnea neck pain/rigidity 3.74158 .2944081 3.833531 .5039372 .569629 4.135222 .015 .314 .259 .313 .380 .015 1.319508 -1.222789 1.343786 -.6853035 -.56277 1.419541 .5428817 1.214637 1.190193 .6793768 .6413111 .5822732 1.291081 10.84318 .0272301 3.183099 .3719673 39.50874 .133073 1.908372 .1620717 2.00206 1.320891 12.94585 involvement.5 similar to our findings, other head and neck symptoms that present as the chief complaint aside from trismus are stiffness of the neck and dysphagia.3,6 our findings suggest that tetanus patients with trismus or neck pain/rigidity are more likely to be decannulated. thus, patients presenting with either of these head and neck symptoms that undergo immediate tracheostomy and management may have a higher chance of resolution of symptoms and decannulation. although philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles the decannulation time was not recorded in the study, future research may include this variable for further comparison and analysis. as mukherjee highlighted, the efficacy of tracheostomy in the treatment of tetanus cannot be overemphasized.7 he also stated that the sooner tracheostomy is done, the better for the patient.7 fasunla recommended that patients diagnosed as stage ii must undergo tracheostomy sooner for better chances of survival, and that tetanus patients in general must not be allowed to reach stage iii before the procedure is commenced, since prognosis becomes poor.8 the reason for this is if tracheostomy was not initiated earlier, these patients would have died of asphyxia or cardiorespiratory failure.8 this correlates well with our findings that most of our patients (92%) already had stage ii and iii or moderate to severe disease, which is mostly determined by the severity of the trismus. the decision for tracheostomy is made right away when trismus is observed. if trismus becomes more severe, the feasibility of orotracheal intubation for temporary airway protection becomes more difficult, hence tracheostomy is administered as a definitive airway protection measure. the key component is early detection of symptoms, specifically trismus and neck pain/rigidity, for immediate initiation of intervention to attain a favorable prognosis and outcome. referring to cole staging, it is noted that even during stage i, there is already trismus of mild severity, which raises the suspicion of tetanus. thus, the importance of trismus as a symptom cannot be overemphasized in tetanus infection. its presence leads to early detection and management to achieve a good outcome, survival, and in our case, decannulation. aydin et al. found a direct correlation between the clinical stage and the requirement of tracheostomy.3 sun et al. stated that the mainstays of treatment were early ventilatory support and tracheostomy.9 orotracheal intubation may be an initial intervention, but to ensure long term ventilatory support, tracheostomy may be performed early.10 although some did not advocate routine tracheostomy in tetanus cases, there were still those who considered it a lifesaving procedure, especially in moderate and severe stages.2,8 smith and drew emphasized that all tetanus patients should at least be considered candidates for tracheostomy.2 as part of the course of the disease, laryngeal and respiratory muscle spasm may ensue without prior notice and cause sudden death. early tracheostomy is preferred over endotracheal intubation because the latter can provoke laryngospasm and thus exacerbate airway distress.11 other reasons for tracheostomy include difficulty in intubation and reintubation in patients with severe hypertonic state, and prolonged intubation and mechanical ventilator support of more than 7 days in adults and greater than 30-60 days in pediatric patients.8 a study by espinosa and vinco looked into the relationship between the timing of tracheostomy and outcomes of tetanus, such as length of hospital stay, length of mechanical ventilation, morbidity, and mortality rate.12 they defined early tracheostomy as performed within 24 hours from time of admission while those performed beyond 24 hours were classified as late tracheostomy. results of this study showed that early tracheostomy in moderate and severe stage tetanus led to shorter length of hospital stay and length of mechanical ventilation than late tracheostomy.12 with that in mind, early tracheostomy becomes a justifiable step in patients with moderate to severe tetanus.8 once tracheostomy is immediately initiated and management is early administered especially in moderate to severe cases such as stage ii and iii, good prognosis, which can be manifested by decannulation, becomes more likely. in our study, the case fatality rate increased with age, consistent with findings of the research institute for tropical medicine (ritm) report.4 sixty two percent (62%) of our patients had incubation periods of less than 7 days, and 58% of those patients were already assessed as stage iii or severe disease. moreover, 62% of those with periods of onset of less than 3 days already had stage iii disease. fasunla identified a short incubation period as one of the factors associated with more severe disease.8 miranda-filho et al. identified a cut-off incubation period of <10 days and period of onset of <48 hours that indicate worse prognosis; those with incubation period of >10 days and period of onset of >48 hours are associated with better prognosis.13 sixty one percent (61%) of those who did not receive any vaccination for tetanus were staged iii during admission. although a complete dose has not been proven to give lifelong protection against tetanus, it is still recommended that a complete dose be accomplished before 6 years of age followed by booster shots between ages 11 and 18 years and every 10 years in adults.8 according to the centers for disease control and prevention, the antitoxin levels of most persons approach the minimal protective level by 10 years after the last dose. therefore, routine boosters are recommended every 10 years.14 unfortunately, there was no mention of booster shots in the chart entries of our patients. dyspnea can be considered a deadly predictor of negative outcome. another important parameter derived from logistic regression analysis is the coefficient estimate. the sign of the coefficient estimate tells the direction of the relationship between the dependent variable and outcome. a positive coefficient indicates an increased likelihood of an outcome from happening, while a negative one decreases its likelihood. with a negative coefficient estimate for outcomes “discharge” and “decannulation,” tetanus patients are less likely to be discharged and decannulated due to such possible reasons as: “need for/connected to a mechanical ventilator,” “infection,” “complications (ventilator-associated pneumonia, comorbidities),” or more severe disease since they “already progressed to spasms of muscles of respiration.”7 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles acknowledgements we would like to acknowledge ruby anne king, md, phd and john robert c. medina, rmt, md, mhs for helping with the statistics. references 1. chalya pl, mabula jb, dass rm, mbelenge n, mshana se, gilyoma jm. ten-year experiences with tetanus at a tertiary hospital in northwestern tanzania: a retrospective review of 102 cases. world j emerg surg. 2011 jul 8;6(20):1-8. doi: 10.1186/1749-7922-6-20. pubmed pmid: 21740539; pubmed central pmcid: pmc3159100. 2. smith at, drew sj. tetanus: a case report and review. j oral maxillofac surg. 1995 jan;53(1):7780. doi: 10.1016/0278-2391(95)90509-x. pubmed pmid: 7799128. 3. aydin k, caylan r, caylan r, bektas d, koksal i. otolaryngologic aspects of tetanus. eur arch otorhinolaryngol. 2003 jan;260(1):52–6. doi: 10.1007/s00405-002-0508-4. pubmed pmid: 12520358. 4. research institute for tropical medicine. management of tetanus. in: management protocols of infectious and tropical diseases, volume 2. manila: research institute for tropical medicine; 2013. p. 1-28. 5. thwaites cl, yen lm, glover c, tuan pq, nga ntn, parry j et al. predicting the clinical outcome of tetanus: the tetanus severity score. trop med int health. 2006 mar;11(3):279-287. doi: 10.1111/j.1365-3156.2006.01562.x. pubmed pmid: 16553907. 6. hetzer dc, hilsinger rl. the otolaryngologist and tetanus. otolaryngol head neck surg. 1986 nov;95(4):511-5. doi: 10.1177/019459988609500416. pubmed pmid: 3106917. 7. mukherjee dk. tetanus and tracheostomy. ann otol rhinol laryngol. 1977 jan-feb;86(1 pt 1):6772. doi: 10.1177/000348947708600110. pubmed pmid: 835974. 8. fasunla aj. challenges of tracheostomy in patients managed for severe tetanus in a developing country. int j prev med. 2010;1(3):176–181. pubmed pmid: 21566788; pubmed central pmcid: pmc3075528. 9. sun ko, chan yw, cheung rt, so pc, yu yl, li pc. management of tetanus: a review of 18 cases. j r soc med. 1994 mar;87(3):135-7. pubmed pmid: 8158589; pubmed central pmcid: pmc1294391. 10. hsu ss, groleau g. tetanus in the emergency department: a current review. j emerg med. 2001 may;20(4):357–365. doi: 10.1016/s0736-4679(01)00312-2. pubmed pmid: 11348815. 11. world health organization. current recommendations for treatment of tetanus during humanitarian emergencies. [internet]. who technical note. 2010 jan;1-6. [cited 2019 feb 1] available from https://www.who.int/diseasecontrol_emergencies/who_hse_gar_dce_2010_ en.pdf. 12. espinosa wz, vinco vv. timing of tracheostomy and outcomes in moderate and severe tetanus: a cross-sectional study. philipp j otolaryngol head neck surg. 2019 dec 2;34(2):20-23. doi: https://doi.org/10.32412/pjohns.v34i2.915. 13. miranda-filho db, ximenes raa, barone aa, vias vl, vieira ag, albuquerque vmg. clinical classification of tetanus patients. braz j med biol res. 2006 oct;39(10): 1329-1337. doi: 10.1590/ s0100-879x2006001000009. pubmed pmid: 17053841. 14. centers for disease control and prevention. epidemiology and prevention of vaccinepreventable diseases. chapter 21: tetanus. hamborsky j, kroger a, wolfe s, eds. 13th ed. washington d.c. public health foundation, 2015. p. 341-351. [cited 2019 feb 15] available from https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html. “dyspnea” and “neck pain rigidity” showed a positive coefficient estimate in mortality outcome. this is consistent with the literature.4,14 tetanus follows a descending pattern from trismus or lockjaw to neck stiffness, dysphagia, rigid abdomen, progressing to laryngospasm and spasm of muscle of respiration.11,14 as the course of the disease progresses, mortality becomes more likely.4 one limitation of this study is our small sample size. a larger sample size may provide more data and possibly include more patients in stage i that did not undergo tracheostomy. tracheostomy as a surgical procedure comes with various complications that is why some authors only recommend tracheostomy for moderate to severe stages of tetanus.2,8 another limitation of our study is that we did not further investigate the cause of death of some patients, and whether there were complications from tracheostomy. we recommend further studies to evaluate the complications of the procedure and perform a costbenefit analysis in tetanus patients. future studies may employ a larger sample size to explore and describe not only trends, but significant results and associations. moreover, the inclusion of all presenting (head and neck, and non-head and neck) symptoms in the comparison and analysis may provide a more holistic approach to tetanus. in conclusion, trismus and neck pain/rigidity are the most common initial head and neck symptoms of tetanus, with a significant relationship to decannulation. a patient with such symptoms should raise a high index of suspicion for tetanus so that early diagnosis and expeditious intervention (including tracheostomy) can be initiated. to secure the airway via tracheostomy among tetanus patients manifesting with potential difficult airway access heralded by trismus and neck rigidity may allow decannulation but not necessarily favor discharge or decrease in mortality. nevertheless, early tracheostomy should decrease morbidity attributed to frequent or recurrent intubation. securing the airway and initiating medical management improves prognosis, making survival and decannulation more likely. philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 4342 philippine journal of otolaryngology-head and neck surgery case reports abstract objective: to present the case of a patient with left facial swelling as the primary manifestation of multiple myeloma and discuss the surgical management, diagnostic dilemma and subsequent medical management done for this unusual presentation. methods: design: case report setting: tertiary government hospital patient: one results: a 55-year-old man with an enlarging left pre-auricular mass of one (1) year duration underwent superficial parotidectomy with facial nerve preservation and selective lymphadenectomy for pleomorphic adenoma based on initial clinical and cytologic findings. histopathologic examination showed plasmacytoid proliferation and subsequent work-ups finally revealed multiple myeloma. conclusion: emphasized in this case report is the thorough work-up and targeted therapy needed for the timely diagnosis and treatment of a patient with multiple myeloma. keywords: multiple myeloma, plasmacytoma, parotid gland, pleomorphic adenoma myeloma is a neoplasm of plasma cells that usually causes bony lesions, blood abnormalities, and other potentially fatal complications. it may present as a solitary intramedullary lesion (plasmacytoma) or may involve multiple sites (multiple myeloma).1 extramedullary myeloma is an unusual presentation; its occurrence in the salivary glands is rare with only 24 published cases as of 2017.2-6 we report a case of multiple myeloma with unilateral pre-auricular swelling as the initial presentation of disease, its diagnostic work-up and the eventual approach and management done to treat the patient. case report a 55-year-old widower from taguig city, philippines consulted at our ear, nose, throat (ent) out-patient department for a 1-year history of slowly enlarging left pre-auricular mass. on physical examination, a 7 cm x 7 cm mass on the left side of his face extended anteroposteriorly from the left tragal area to the left malar area and superoinferiorly from the left zygomatic arch to the left mandible. the mass was firm, non-tender, movable and non-erythematous with no intra-oral multiple myeloma presenting as a parotid massbenedick b. borbe, md samantha s. castañeda, md department of otolaryngology head and neck surgery rizal medical center, pasig city correspondence: dr. samantha s. castaneda department of otolaryngology – head and neck surgery rizal medical center pasig boulevard, pasig city 1600 philippines phone: (632) 671 9740 (to 43) local 186 or 207 email: scastaneda@ateneo.edu the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the rizal medical center interesting case competition (1st place). october 12, 2016. rizal medical center, pasig city. philipp j otolaryngol head neck surg 2018; 33 (1): 43-46 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery case reports involvement on bimanual palpation. several teeth were missing with some dental caries. no cervical lymphadenopathies were palpated. the rest of the ent examination was unremarkable. (figure 1) a fine-needle aspiration biopsy (fnab) of the pre-auricular mass revealed pleomorphic adenoma confirming the primary consideration of a benign parotid disease. (figure 2) on performing superficial parotidectomy with facial nerve preservation & selective neck dissection, the parotid gland was noted to be almost normal in size with several adherent slightly enlarged lymph nodes. histopathology of the excised specimens revealed atypical plasmacytoid cell proliferation. (figure 3) with a strong suspicion of a plasma cell pathology (mainly due to the findings from the periparotid lymph nodes), work-up became specific into ruling-out the possibility of a plasmacytoma or myeloma. a histopathologic slide review showed plasmacytic proliferation – considerations were plasmacytoma or myeloma. immunohistochemical stain with cd138 was strongly positive for cells of interest. complete blood count, electrolytes, liver and kidney function tests, fasting blood figure 1. facial photographs of the patient (published with permission) showing the left facial swelling. figure 2. fine-needle aspiration biopsy (hematoxylin-eosin). a. low-power view (100x), interpreted as negative for malignant cells, cytomorphologically suggestive of pleomorphic adenoma; b. high-power view (400x), showing several spindle-shaped myoepithelial cells amidst a bloody chondromyxoid stromal background. sugar and metabolic panel were within normal limits as were the total urine and blood protein. although urine protein electrophoresis showed no detectable immunoglobulins, serum protein electrophoresis was consistent with a monoclonal gammopathy (monoclonal peak concentration of 20.3% or 17.9 g/l at the beta 1 region). while these examinations were being conducted, an enlarging mass was noted in the previous surgical site. a facial ct scan revealed a left hemi-mandibular expansile lytic mass with some aggressive features. (figure 4) a chest ct scan showed lytic lesions at vertebral bodies t7, t11 and t12 suggesting probable metastasis although this was not corroborated by bone scintigraphy (that did not show any evidence of a bony metastatic process). bone marrow aspirate biopsy yielded histologic and immunohistochemical findings consistent with a plasma cell neoplasm. focal large aggregates of plasma cells, comprising 10%-20% of cell population with abnormally large and binucleated forms were present. the entire clinical picture and diagnostic exams satisfied the a (hematoxylin – eosin , low-power view 100x) b (hematoxylin – eosin , high-power view 400x) philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 4544 philippine journal of otolaryngology-head and neck surgery case reports figure 3. histopathologic slides (hematoxylin-eosin). a. high-power view, 400x showing lymph nodes diffusely infiltrated with increased number of uniform-sized plasmacytoid cells with eccentric nuclei; b. scanner view (40x) showing parotid tissue with scattered mature adipocytes within unremarkable salivary gland acini, parenchyma and stroma. (hematoxylin – eosin , high-power view 400x) a (hematoxylin – eosin , scanner view 40x) b figure 4. contrast ct scans. a. coronal sections b. axial sections (bottom), showing a large well-marginated expansile lytic enhancing solid mass appearing to arise from the anterior segment of the left mandibular ramus (7.3 x 4.7 x 5.9 cm). anteriorly, the mass partially erodes the posterolateral wall of the left maxillary sinus. superiorly, it is difficult to delineate from the insertion of the temporalis muscle. laterally, the masseter is displaced outward but appears uninvolved. medially, the lateral pterygoid shows no signs of invasion. figure 5. post-chemotherapy photos (published with permission); the previous facial swelling is no longer appreciable. international myeloma working group (imwg) criteria7 for a diagnosis of multiple myeloma. the patient underwent a treatment protocol consisting of eight (8) cycles of bortezomib-melphalan-prednisone with good tolerance and no adverse side effects. the previous left facial swelling was no longer palpable on post-treatment out-patient follow up. (figure 5) a b philippine journal of otolaryngology-head and neck surgery vol. 33 no. 1 january– june 2018 philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery 4746 philippine journal of otolaryngology-head and neck surgery case reports discussion plasmacytoma, a tumor of plasma cells within soft tissue is traditionally divided into medullary and extramedullary types which in turn could either be solitary or multiple; the most common form is the generalized medullary also known as multiple myeloma.1 with a male predilection, the average age of multiple myeloma at diagnosis is around 60 years old.5 normally, plasma cells become b-cells when exposed to pathogens and produce antibodies. however in multiple myeloma, plasma cells generate clones of itself and form tumors eventually interfering with normal cell production and function.8 since the malignant cells come from a common precursor, the antibodies produced are identical monoclonal immunoglobulins (m-proteins) are then released into the blood and urine giving the symptoms and becoming targets for diagnostic examinations.5 multiple myeloma usually present with bony or intramedullary lesions. extramedullary plasmacytoma is an uncommon presentation with predilection for the upper respiratory tract; if ever it occurs in the head and neck region, soft tissue plasmacytomas tend to involve the nasal cavity or nasopharynx.1 its occurrence in the salivary glands is singularly rare9 with only 24 published cases since it was first reported in 1965 up until 2017.2-6 the patient presented with a one (1) year history of a slowly enlarging left pre-auricular mass, with no other accompanying symptoms and no intra-oral involvement – the common presentation of pleomorphic adenoma which is a benign parotid tumor. routine imaging in patients with well-defined superficial lobe masses is not warranted because the result will not change the treatment plan. excision of the parotid was performed after fnab. in the same institution, fnab has a sensitivity of 46% and a specificity of 100%.10 this relatively low sensitivity may explain why the initial benign finding of the pre-auricular mass fnab turned out to be malignant. it could also be that the parotid gland was biopsied even if the tumor was in the mandible. intraoperatively, the parotid was noted to be almost normal in size with several adherent lymph nodes. the parotid together with 5 nodes were excised and sent to the laboratory for further investigation. histopathologic findings of atypical plasmacytoid cell proliferation then warranted further investigation of a plasma cell pathology. the diagnosis of multiple myeloma was confirmed after satisfying the imwg criteria.7 for our patient, this includes 1: clonal bone marrow plasma cells >10% and 2: >1 lytic lesion on the vertebral body; other diagnostics which point to multiple myeloma include the confirmed monoclonal gammopathy on protein serum electrophoresis and the plasma cell morphology on histopathology. the negative bone scan is attributed to the fact that scintigraphy is of acknowledgements we would like to thank dr. mark jansen d.g. austria for the intraoperative details of the case, and drs. carasharyl c. young and jose inigo m. remulla for interpreting the histopathology slides. references 1. kanthan r, torkian b. solitary plasmacytoma of the parotid gland with crystalline inclusions: a case report. world j surg oncol. 2003 aug 1; 1(1): 12. doi: 10.1186/1477-7819-1-12; pmid: 12921538; pmcid: pmc184446. 2. gonzales-perez lm, infante-cossio p, borrero-martin, jj. primary extraosseous plasmacytoma of the parotid gland: a case report and literature review. mol clin oncol. 2017 nov; 7(5): 751–754. doi: 10.3892/mco.2017.1417; pmid: 29181165; pmcid: pmc5700262. 3. obuekwe on, nwizu nn, ojo ma, ugbodaga pi. extramedullary presentation of multiple myeloma in the parotid gland as first evidence of the disease – a review with case report. niger postgrad med j. 2005 mar;12(1):45-8. pmid: 15827597. 4. goyal h, sawhney h, abdu a. clinical progression of multiple myeloma presenting as parotid gland plasmacytoma. int j hematol. 2013; 97:297–298. doi 10.1007/s12185-013-1274-3. 5. thomas ae, kurup s, jose r, soman c. facial swelling as a primary manifestation of multiple myeloma. case rep dent. 2015; 2015: 319231. doi 10.1155/2015/319231; pmid: 26229694; pmcid: pmc4502313. 6. abrar s, ali n, qureshi bm, abbasi an. extramedullary plasmacytoma: rare neoplasm of parotid gland. bmj case reports 2018; doi: 10.1136/bcr-2017-222367. 7. international myeloma working group (imwg) criteria for the diagnosis of multiple myeloma. international myeloma working group. september 2015. [updated 2015 oct 29; accessed 2016 sep 14]. available from: http://imwg.myeloma.org/international-myeloma-working-groupimwg-criteria-for-the-diagnosis-of-multiple-myeloma. 8. multiple myeloma. american association for clinical chemistry. [accessed 2018 may 3]. available from: https://labtestsonline.org/conditions/multiple-myeloma. 9. rothfield re, johnson jt. extramedullary plasmacytoma of the parotid. head neck. 1990 julaug; 12(4):352-4. pmid: 2193906. 10. santiago kj, roldan ra, castañeda ss. accuracy of fine needle aspiration biopsy in diagnosing parotid gland malignancies. philipp j otolaryngol head neck surg. 2016 jul-dec; 31(2): 24-26. 11. healy cf, murray jg, eustace sj, madewell j, o’gorman pj, o’sullivan p. multiple myeloma: a review of imaging features and radiological techniques. bone marrow res. 2011; 2011: 583439. doi: 10.1155/2011/583439; pmid: 22046568; pmcid: pmc3200072. 12. mateos mv, richardson pg, schlag r, khuageva nk, dimopoulos ma, shpilberg o, et al. bortezomib plus melphalan and prednisone compared with melphalan and prednisone in previously untreated multiple myeloma: updated follow-up and impact of subsequent therapy in the phase iii vista (velcade as initial standard therapy in multiple myeloma) trial. j clin oncol. 2010 may 1; 28(13): 2259-2266. doi: 10.1200/jco.2009.26.0638; pmid: 20368561. 13. gagnier jj, kienle g, altman dg, moher d, sox h, riley d, et al. the care guidelines: consensusbased clinical case reporting guideline development. j med case rep. october 2013 sep 10: 7; 223. doi 10.1186/1752-1947-7-223; pmid: 24228906; pmcid: pmc3844611. limited use in multiple myeloma. detection of bone involvement using technetium 99-m relies on the osteoblastic response and activity of the skeletal system for uptake. multiple myeloma, however, is primarily an osteolytic neoplasm.11 the patient’s lytic lesions on the vertebra, therefore, would have been more identified in mri or ct scan. for therapy, the standard treatment for multiple myeloma has been melphalan and prednisone. the patient’s chemotherapy protocol included these plus bortezomib – a new proteasome inhibitor which prevents protein breakdown in multiple myeloma. this protocol significantly prolongs overall survival compared to melphalan and prednisone alone.12 this report highlights the presentation, diagnostic work-up and management done in a case of an unusual facial swelling. it shows a rare initial presentation of multiple myeloma which can be addressed medically to improve overall health outcomes. although financially burdened, the patient is currently contented with his state, highly optimistic and hopeful for his complete remission and recovery from the disease. philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles philipp j otolaryngol head neck surg 2020; 35 (2): 11-16 c philippine society of otolaryngology – head and neck surgery, inc. efficacy of carragelose® nasal spray impregnated versus mupirocin ointment impregnated nasal packs on mucosal healing after endoscopic sinus surgery: a double-blind, non-randomized, right-left side comparison joseph bernard b. lo, md emmanuel tadeus s. cruz, md, department of otorhinolaryngology head and neck surgery quezon city general hospital correspondence: dr. emmanuel tadeus s. cruz department of otorhinolaryngology head and neck surgery quezon city general hospital seminary road, barangay bahay toro, quezon city 1106 philippines phone: (632) 908 872 8655 email: emancrz@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery analytical research contest. december 6, 2019. palawan ballroom, edsa shangri-la hotel, mandaluyong city. abstract objective: to determine the efficacy of carragelose® nasal spray versus mupirocin ointment impregnated nasal packs on postoperative mucosal healing among chronic rhinosinusitis with nasal polyposis (crswnp) patients after endoscopic sinus surgery (ess). methods: design: double-blind, non-randomized, right-left side comparison setting: tertiary government training hospital participants: fifteen (15) patients diagnosed with chronic rhinosinusitis with nasal polyposis (crswnp) who had ess were included in the study. nasal packs (netcell®) impregnated with carragelose® nasal spray or mupirocin ointment were respectively applied in right and left nostrils. postoperative mucosal healing was graded by a blinded consultant using the lundkennedy endoscopic scoring system and perioperative sinus endoscopy (pose) scoring system. results: six patients (12 nasal sides) completed the study. comparing nasal packs impregnated with carragelose® nasal spray mupirocin ointment, the carragelose® group had lower lundkennedy median scores than the mupirocin group on the 7th post-operative day; and this was statistically significant (p = .027). there were no significant differences in lund-kennedy postoperative scores on days 4 (p = .217), 14 (p = .171) and 28 (p = .151). conclusion: carragelose® nasal spray impregnated nasal packs may be comparable with, and may be an alternative to mupirocin ointment impregnated nasal packs in terms of postoperative mucosal healing among ess patients with crswnp. keywords: carragelose; mupirocin; nasal pack, endoscopic sinus surgery, nasal polyp creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles application of nasal packs is common practice after endoscopic sinus surgery (ess) to control post-operative bleeding, facilitate remucosalization of the sinonasal cavity and convey medications to the operative site.1-3 in our institution, mupirocin topical ointment usp, 2% has been commonly used to impregnate nasal packs with good experience and no untoward effects.2-4 however, mupirocin is not the only available agent. various medications can be applied to nasal packs and there appears to be no agreement on which drug is better.5-6 carragelose® is a polysaccaharide carbohydrate obtained from red seaweeds, chondrus crispuse species.6 this species is common in the atlantic ocean and also abundant in the philippines.6 it is used for meat processing, personal care and pet food products and in recent years as medicine.6 carragelose® is claimed to have multiple properties including anticoagulant, antithrombotic, anti-tumor and immunomodulatory.6-8 carragelose® nasal spray (betadine™ marinomed biotech ag, mundipharma laboratories gmbh) is used to shorten the duration of common colds primarily by trapping and clearing viruses in mucus, hindering their binding or entry into the cell.6 to the best of our knowledge, a search of herdin, medline (pubmed), cochrane and google scholar revealed no published study on the use of carragelose® on nasal packing after ess. as part of our quest for alternative medications to apply on nasal packs, this study was conducted to determine the efficacy of carragelose® nasal spray impregnated versus mupirocin ointment impregnated nasal packs on postoperative mucosal healing after ess for chronic rhinosinusitis with nasal polyposis (crswnp). methods this prospective, double-blind, non-randomized, right-left side comparison was conducted with approval of the bioethics committee of the quezon city general hospital. patients diagnosed with crswnp who underwent ess from october 2018 to august 2019 were considered for inclusion in the study. the following were excluded: patients with past history of nasal surgery because of a tumor other than nasal polyp, recurrent nasal polyposis, presence of co-morbidities such as diabetes mellitus, uncontrolled hypertension, immunocompromised condition, those on anticoagulant therapy and with bleeding disorders. the sample size was computed with mean difference and standard deviations based on the data presented in the study of promentilla et al.9 a significance level of 0.05 and power of 80% were used in computation. a drop-out rate of 20% was used to calculate the adjusted sample size using the following formula. where: n is the minimum sample size for each group to detect whether the stated difference exists between the two means z α/2 is the critical value of the normal distribution at α/2 (e.g. for a confidence level of 95%, α is 0.05 and the critical value is 1.96) z β is the critical value of the normal distribution at β (e.g. for a power of 80%, β is 0.2 and the critical value is 0.84), σ2 is the population variance; and d is the difference you would like to detect. the sample size used in this study had a 95% confidence level and a power of 80%, with detectable difference of 1.0 and standard deviation of 1.0. the ideal sample size was 16 subjects with a total of 32 nasal sides. histories with emphasis on rhinologic problems were obtained, and otorhinolaryngoscopic examinations, nasal endoscopies and subsequent grading of nasal polyposis using the lund-mckay classification were performed. preoperatively, patients were prescribed cefuroxime 500mg/tab twice a day for one week and prednisone 20mg/tab every eight hours for one week. the ess was performed on each patient by an assigned ear, nose and throat (ent) senior surgical resident. in patients with an antrochoanal polyp, ess with caldwellluc procedure was performed on the affected side with ess on the contralateral side for chronic rhinosinusitis. after surgery, an ent surgical resident who was not part of the study inserted a 4cm x 2cm nasal pack (netcell®) impregnated with carragelose® nasal spray or mupirocin ointment in the right and left nostrils respectively, under supervision by the principal investigator. the patients (still under anesthesia) were blinded to this treatment. the identity of medications was not concealed from the surgeons because the containers were recognizable and the medications were applied differently: carragelose® was sprayed on the right nasal packs after pack insertion, while mupirocin was coated on the left nasal packs before pack insertion. intravenous cefuroxime 750mg every 8 hours and ketorolac 30mg as needed were given post-operatively for the first 24 hours after surgery then shifted to oral cefuroxime 500mg/tab twice daily and celecoxib 200mg/cap twice daily as needed for the next 7 days. philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles nasal packs in both nostrils were removed on the 4th post-operative day then nasal saline irrigation with suctioning to clean the nasal cavity was followed by video-endoscopy using a karl-storz tricam sl ii and xenon nova 300, all performed by the assigned surgeon. patients visited the out-patient department on the 7th, 14th and 28th postoperative days for follow-up and documentation of post-operative site healing using the same video nasal endoscopy set-up, also performed by the same surgeon. the lund-kennedy endoscopic scoring system10 and perioperative sinus endoscopy (pose) scoring system11 were used to grade postoperative mucosal healing. the former scored each of 5 parameters (presence of nasal polyp, discharge severity of mucosal edema, scarring, crusting) on a scale of 0 to 2.10 the latter additionally assessed the middle turbinate (normal, synechia, lateralized), middle meatus (normal, narrowed, complete obstruction / stenosis) maxillary sinus content (normal, edema or thin discharge, purulent or allergic mucin), maxillary and ethmoid cavity, as well as frontal and sphenoid sinuses (if operated on), also scoring each on a scale of 0 to 2.11 a lund-kennedy score of 10 or pose score of 16 were used to indicate post-operative complications which may compromise healing; with lower scores signifying better healing. a blinded ent consultant graded the recorded video endoscopic findings of each patient (for the 4th, 7th, 14th, and 28th day) in one sitting, using the lund-kennedy endoscopic scoring system10 and perioperative sinus evaluation scoring system.11 the consultant-recorded score, and demographic and clinical characteristics of patients were collated, tabulated and recorded in microsoft® excel version 2016 (microsoft corp., redmond wa usa). numerical data were summarized using mean, median and standard deviation with minimum and maximum values. categorical data were presented as frequencies and percentages. group means of numerical variables were computed, then compared using mann-whitney u test and friedman test at 5% level of significance. additional computations were performed using ph stat version 4.51 (prentice-hall, inc., pearson education, london, uk). results initially, there were 17 patients who satisfied inclusion and exclusion criteria, but two patients did not complete the study because one was diagnosed postoperatively with inverting papilloma and another had profuse bleeding due to hypertension. hence, a total of 15 patients (30 nasal cavities) were initially included in this study; 8 males (53.3%) and 7 females (46.7%) with mean age of 41.8 ± 15.8 years (range 14 to 74 years old). twelve (12) out of 15 patients were diagnosed with chronic rhinosinusitis with bilateral nasal polyposis and underwent bilateral endoscopic sinus surgery under general anesthesia. two (2) out of these 12 patients had deviated nasal septum and underwent septoplasty as well. three (3) out of 15 patients were diagnosed with chronic rhinosinusitis with antrochoanal polyp and underwent bilateral endoscopic sinus surgery and a caldwell-luc procedure under general anesthesia. one patient was lost to follow-up on day 7 and 4 patients each were lost to follow up on days 14 and 28. hence, only 6 patients or 12 nasal cavities completed the study. lund-kennedy median scores were only significantly different on day seven for the carragelose® side (mdn = 2.50, iqr = 2.50) compared to the mupirocin side (mdn = 4.00, iqr = 3.75) [mann-whitney u = 50.0; p = .027]. they were not significant on day four (carragelose® mdn = 3.00, iqr = 2.00; mupirocin mdn = 5.00, sd = 3.75) [mann-whitney u = 82.0; p = .217]; day 14 (carragelose® mdn = 2.00, iqr = 1.25; mupirocin mdn = 4.00, iqr = 4.00) [mann-whitney u = 39.0; p = .171]; and day 28 (carragelose® mdn = 2.00, iqr = 1.25; mupirocin mdn = 2.00, iqr =2.00) [mann-whitney u = 38.5; p = .151]. (table 1) using the friedman test statistic to evaluate differences in medians among the lund-kennedy scores on the carragelose® side showed significant differences (χ2(3) = 15.1,  p  = .002); evaluation of the mupirocin side also showed significant differences in medians (χ2(3) = 16.2, p = .001). (table 1) peri operative sinus evaluation (pose) median scores were not significant on day four (carragelose® mdn = 5.00, iqr = 0.25; mupirocin mdn = 5.00, iqr = 1.50) [mann-whitney u = 82.0; p = .217]; day seven (carragelose® mdn = 4.00, iqr = 2.25; mupirocin mdn = 5.00, iqr = 2.25) [mann-whitney u = 70.5; p = .210]; day 14 (carragelose® mdn = 3.00, iqr = 1.50; mupirocin mdn = 4.00, iqr = 2.00) [mann-whitney u = 40.0; p = .481]; and day 28 (carragelose® mdn = 2.00, iqr = 1.25; mupirocin mdn = 3.00, iqr = 3.25) [mann-whitney u = 33.0; p = .218]. table 1. comparison of lund-kennedy scores for carragelose® and mupirocin sides days from operation friedman test n = 11 df = 3 chi-square = 15.1 p-value = .002sig n = 11 df = 3 chi-square = 16.2 p-value = .001sig n p-valueu-scoremedian medianiqr iqr mann-whitney u-testcarragelose® side mupirocin side 4 7 14 28 3.00 2.50 2.00 2.00 5.00 4.00 4.00 2.00 82.0 50.0 39.0 38.5 15 14 11 11 2.00 2.50 1.25 1.25 3.75 4.25 4.00 2.00 .217ns .027sig .171ns .151ns philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles using the friedman test statistic to evaluate differences in medians among the pose scores on the carragelose® side showed significant differences (χ2(3) = 22.3,  p  = < .001); evaluation of the mupirocin side also showed significant differences (χ2(3) = 15.1 , p = .002). (table 2) the overall post-operative outcomes based on pose median scores were not significant on day four (carragelose® mdn = 5.00, iqr = 1.00; mupirocin mdn = 5.00, iqr = 1.00) [mann-whitney u = 82.0; p = .217]; day seven (carragelose® mdn = 4.00, iqr = 1.00; mupirocin mdn = 5.00, iqr = 1.00) [mann-whitney u = 70.5; p = .210]; day 14 (carragelose® mdn = 3.00, iqr = 1.00; mupirocin mdn = 4.00, iqr = 1.00) [mann-whitney u = 40.0; p = .418] and day 28 (carragelose® mdn = 2.00, iqr = 3.00; mupirocin mdn = 3.00, iqr = 1.00) [mann-whitney u = 33.0; p = .218]. (table 4) discussion our findings suggest that carragelose® nasal spray-impregnated nasal packs may be comparable with mupirocin ointment-impregnated nasal packs in terms of postoperative mucosal healing after ess for chronic rhinosinusitis with nasal polyposis (crswnp). a previous study by promentilla et al., found that dexamethasoneimpregnated absorbable nasal packs yielded better post-operative outcomes than saline-impregnated absorbable packing9 while a study by grzeskowiak et al. found that bethamethasone and ciprofloxacinimpregnated nasal packs resulted in a better post-operative healing process than saline.12 another study by sabarinath et al. found that triamcinolone impregnated nasal packs decreased mucosal edema and crusting in the post-operative nasal cavity.13 the outcomes in the aforementioned studies may be attributed to the anti-inflammatory effect of steroids, but there may be concerns with their safety, adverse effects, and acceptability to prospective users.14 table 2. comparison of peri operative sinus evaluation (pose) scores for carragelose® and mupirocin sides days from operation friedman test n = 10 df = 3 chi-square = 22.3 p-value < .00 sig n = 10 df = 3 chi-square = 15.1 p-value = .002 sig n p-valueu-scoremedian medianiqr iqr mann-whitney u-testcarragelose® side mupirocin side 4 7 14 28 5.00 4.00 3.00 2.00 5.00 5.00 4.00 3.00 82.0 70.5 40.0 33.0 15 14 10 10 0.25 2.25 1.50 1.25 1.50 2.25 2.00 3.25 .217 ns .210 ns .481 ns .218 ns the overall post-operative outcomes based on lund-kennedy endoscopic scoring system median scores were significant on day seven (carragelose® mdn = 2.50, iqr = 2.00; mupirocin mdn = 4.00, iqr = 2.00) [mann-whitney u = 50.0; p = .027]. they were not significant on day four (carragelose® mdn = 3.00, iqr = 2.00; mupirocin mdn = 5.00, iqr = 1.00) [mann-whitney u = 82.0; p = .217]; day 14 (carragelose® mdn = 2.00, iqr = 4.00; mupirocin mdn = 4.00, iqr = 1.00) [mann-whitney u = 39.0; p = .171] and day 28 (carragelose® mdn = 2.00, iqr = 2.00; mupirocin mdn = 2.00, iqr = 1.00) [mann-whitney u = 38.5; p = .151]. (table 3) table 3. comparison of post-operative outcomes for carragelose® and mupirocin sides based on lund-kennedy endoscopic scoring system lund-kennedy day 4 day 14day 7 day 28 md mdmd mdmd mdmd mdiqr iqriqr iqriqr iqriqr iqr carragelose® carragelose®carragelose® carragelose®mupirocin mupirocinmupirocin mupirocin polyp u-score | p-value edema u-score | p-value discharge u-score | p-value scarring u-score | p-value crusting u-score | p-value overall lund u-score | p-value 0.00 97.50 76.5 55.0 60.5.539 .329 .748 1.000 0.000.00 0.000.00 0.000.00 0.000.00 0.000.00 0.000.00 0.001.00 0.00 0.00 81.5 81.5 48.5 60.5.683 .454 .438 1.00 0.001.00 0.001.00 1.001.00 0.002.00 1.001.00 0.002.00 1.000.00 0.00 3.00 82.0 50.0 39.0 38.5.271 .027 s .171 .151 2.002.50 2.005.00 4.004.00 2.002.00 4.002.00 2.001.00 1.002.00 1.00 0.00 102.5 81.0 49.5 49.5.683 .454 .478 .478 0.000.00 0.000.00 1.001.00 0.001.00 1.001.00 0.001.00 1.001.00 1.00 1.00 109.5 38.5 48.0 50.5.902 .050 .438 .519 1.000.00 1.001.00 1.001.00 1.001.00 1.001.00 1.001.00 1.001.00 0.00 2.00 105.5 98.0 51.5 39.0.775 1.00 .562 .171 1.001.00 0.002.00 1.001.00 1.001.00 1.001.00 1.001.00 1.001.00 1.00 ssignificant using mann-whitney u-test philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles table 4. comparison of post-operative outcomes for carragelose® and mupirocin sides based on pose pose day 4 day 14day 7 day 28 md mdmd mdmd mdmd mdiqr iqriqr iqriqr iqriqr iqr carragelose® carragelose®carragelose® carragelose®mupirocin mupirocinmupirocin mupirocin middle turbinate u-score | p-value middle meatus: stenosis u-score | p-value middle meatus: maxillary sinus content u-score | p-value mucosal edema u-score | p-value polypoid change u-score | p-value polyposis u-score | p-value discharge u-score | p-value crusting u-score | p-value overall pose u-score | p-value 1.00 87.0 44.0 50.0 50.0.305 .190 1.00 1.00 0.001.00 0.001.00 0.001.00 0.000.00 0.001.00 0.000.00 0.001.00 0.00 1.00 92.0 50.5 50.0 41.0.412 .347 1.00 .529 1.001.00 0.501.00 1.001.00 1.001.00 1.000.00 1.000.00 1.000.00 1.00 0.00 90.0 66.0 50.0 50.0.367 1.00 1.00 1.00 0.000.00 0.000.00 0.000.00 0.000.00 1.000.00 0.000.00 1.000.00 0.00 0.00 105.0 65.5 43.5 48.5.775 .976 .631 .912 0.000.00 0.000.00 0.000.00 0.000.00 1.000.00 1.000.00 1.000.00 0.00 0.00 105.0 38.5 50.0 41.0.775 .091 1.00 .529 1.000.00 0.000.00 1.001.00 0.501.00 1.001.00 1.001.00 1.000.00 1.00 0.00 105.0 64.5 50.0 50.00.775 .928 1.00 1.00 0.500.00 0.001.00 0.500.00 0.001.00 1.001.00 0.001.00 1.000.50 0.00 5.00 82.0 70.5 40.0 33.0.271 .210 .418 .218 3.004.00 2.005.00 4.005.00 3.001.00 1.001.00 3.001.00 1.001.00 1.00 1.00 112.5 57.0 39.5 35.01.00 .608 .436 .280 0.001.00 0.001.00 0.001.00 0.000.00 0.000.00 0.000.00 1.000.00 1.00 1.00 108.5 58.0 45.0 41.5.870 .561 .739 .529 0.001.00 0.001.00 0.001.00 0.001.00 0.001.00 0.001.00 0.001.00 1.00 ssignificant using mann-whitney u-test carragelose® (or carrageenan) appears to be a potent inflammatory agent, demonstrated in an experiment on rodent and mice leucocytes to produce tumor necrosis factor – alpha and a potent macrophage activator.15 perhaps the anti-inflammatory effect is mediated by the action of macrophages on neutrophilic inflammation that occurs during wound repair.16 in contrast with steroids, carragelose® when used as a topical medication intranasally is relatively safe. hebar et al. claim that 0.12% iota-carrageenan (active ingredient of carragelose nasal spray) applied intranasally will not penetrate nasal mucosa and does not reach the blood stream, concluding that it is clinically safe specially when applied topically on nasal mucosa.17 given its mechanism to promote wound healing and its other biological attributes, carragelose® may be a promising post-operative medication on patients who underwent ess. because our study can only suggest that carragelose® and mupirocin may be comparable in terms of a relatively good effect on postoperative mucosal healing, a trial involving a larger sample should be initiated to validate these findings. the lund and kennedy endoscopic scoring system10 and wright and agrawal’s perioperative sinus endoscopy scoring system or the pose scoring system11 were used in this study. using the 2-scoring systems may confer advantages in terms of content validity and sensitivity to change with the additional information regarding secondary sinuses and the ethmoid cavity.16 although reliable, using pose was taxing on the part of the blinded consultant because of the detailed features of the parameters especially when grading in 4 separate sessions. limitations of this study include lack of randomization that should have been initiated at the outset to minimize differences and to ensure equal chances of distribution, in this case both nasal cavities. the small sample size of participants that completed the study is another limitation. instead of the minimum computed sample size of 16 per group (32 sides), we ended up with only 6 participants (12 sides). ideally, both drugs should have been concealed in similar containers although this was not feasible because of the differing consistencies philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 original articles references 1. vermin a, seneldir l, naiboglu b, karace ct, kulekci s, toros sz, oysu c. role of nasal packing in surgical outcome for chronic rhinosinusitis with polyposis. laryngoscope. 2014 jul; 124(7):152935. doi: 10.1002/lary.24543. pubmed pmid: 24284971. 2. michael p, farid m, kwok m, o’leary s. routine nasal packing versus no nasal packing following functional endoscopic sinus surgery. cochrane database of systematic reviews. 2016 sep 27; 2016 (9). doi: 10.1002/14651858.cd011587.pub2. pubmed central pmcid: pmc6457635. 3. chang eh, alandejani t, akbari e, ostry a, javer a. double-blinded, randomized, controlled trial of medicated versus nonmedicated merocel sponges for functional endoscopic sinus surgery. j otolaryngol head neck surg. 2011 feb. 40:s14-s19. pubmed pmid: 21453656. 4. suat b, yusuf md, ozgur y, aysel k, cansu c, muzaffer f, ali rıza g. the effect of mupirocin and fusidic acid–nasal packings, placed after septoplasty, on the nasal bacterial profile. allergy rhinol. 2016; 7(4):e207–e212. doi: 10.2500/ar.2016.7.0181. pubmed pmid: 28683247 pubmed central pmcid: pmc5244280. 5. xu jj,  bustato gm,  c.  mcknight,  j.m.  lee. absorbable steroid-impregnated spacer after endoscopic sinus surgery to reduce synechiae formation. ann otol rhinol laryngol. 2016. 125:195-198. . doi: 10.1177/0003489415606446. pubmed pmid: 26391092. 6. necas j, bartosikova l. carrageenan: a review. veterinarni medicina. 2013; 58(4): 187-205. available from: http://vri.cz/docs/vetmed/58-4-187.pdf. 7. koenighofer m,  lion t,  bodenteich a,  prieschl-grassauer e,  grassauer a,  unger h, et al. carrageenan nasal spray in virus confirmed common cold: individual patient data analysis of two randomized controlled trials. multidiscip respir med. 2014 nov; 9(1):57. doi: 10.1186/20496958-9-57. 8. eccles r, winther b, johnston sl, robinson p, trampisch m, koelsch s. efficacy and safety of iotacarrageenan nasal spray versus placebo in early treatment of the common cold in adults: the icicc trial. respir res. 2015 oct;16:121. doi: 10.1186/s12931-015-0281-8. 9. promentilla sma, onofre rdc, campomanes bsa. effects of dexamethasone versus saline-impregnated nasal packing on the postoperative outcome of patients with chronic rhinosinusitis and nasal polyps after endoscopic sinus surgery: a randomized controlled trial. philipp j otolaryngol head neck surg. 2016 jan-jun; 31(1):10-13. doi: https://doi.org/10.32412/ pjohns.v31i1.301. 10. de conde a, bodner t, mace j, alt j, rudmik l, smith t. development of a clinically relevant endoscopic grading system for chronic rhinosinusitis using canonical correlation analysis. int forum allergy rhinol. 2016 may; 6(5): 478–485. doi:10.1002. 11. côté d, wright e. objective outcomes in endoscopic sinus surgery. advances in endoscopic surgery. 2011 november 25. available from: http://www.intechopen.com/books/advances-inendoscopic-surgery/objective-outcomes-in-endoscopic-sinussurgery. doi: 10.5772/22191. 12. grzeskowiak b, wierzchowska m, walorek r, seredyka-burduk m, wawrzyniak k, burduk pk. steroid vs. antibiotic impregnated absorbable nasal packing for wound healing after endoscopic sinus surgery: a randomized, double blind, placebo-controlled study. braz j otorhinolaryngol. jul-aug 2019; 85(4):473-480. doi: 0.1016/j.bjorl.2018.04.002. pubmed pmid: 29807811. 13. sabarinath v, harish mr, divakaran s. triamcinolone impregnated nasal pack in endoscopic sinus surgery: our experience. indian j otolaryngol head neck surg. 2017 mar; 69(1):88-92. doi: 10.1007/s12070-016-1041-x. pubmed pmid: 28239586 pubmed central pmcid: pmc5305642. 14. kimmerle r, rolla ar. iatrogenic cushing’s syndrome due to dexamethasone nasal drops. am j med. 1985 oct; 79(4):535-7. doi: 10.1016/0002-9343(85)90046-4. pubmed pmid: 4050838. 15. wright ed, agrawal s. impact of perioperative systemic steroids on surgical outcomes in patients with chronic rhinosinusitis with polyposis: evaluation with the novel perioperative sinus endoscopy (pose) scoring system. laryngoscope. 2007 nov; 117(115):1-28. doi: 10.1097/ mlg.0b013e31814842f8. pubmed pmid: 18075447. 16. pajić-penavić i. endoscopic monitoring of postoperative sinonasal mucosa wounds healing. advances in endoscopic surgery. 2011; 419-436. doi: 10.5772/21868. 17. hebar a, koller c, seifert j-m, chabicovsky m, bodenteich a, bernkop-schnürch a, et al. nonclinical safety evaluation of intranasal iota-carrageenan. plos one. 2015 apr; 10(4):e0122911. doi: 10.1371/journal.pone.0122911. pubmed pmid:  25875737 pubmed central pmcid: pmc4395440. (liquid in a plastic bottle and ointment in tube form) of the commercially available stock preparations in the market. however, we believe that both patients and the consultant who evaluated the videorecorded endoscopic examinations were sufficiently blinded. for future studies, we recommend increasing the number of participants to meet the minimum sample size, ensuring proper randomization, using similar containers, using a simple but reliable scoring system, and limiting the number of days of observation. despite all these limitations, the findings of our study may still suggest that carrageenan® nasal spray impregnated nasal packs are comparable with mupirocin ointment coated nasal packs and may be a viable alternative for post-operative care among patients who undergo ess. philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 editorial philippine medical association president dr. jojo santiago, missy and my central tagalog region one day family; singapore association of medical journal editors president professor wilfred peh and my singapore familymom, bernie, miranda, angie and lilli; philippine association of medical journal editors (pamje) president-elect professor cecile maramba – lazarte and asawa ramel, anak miggy, pamangkin zoe, tatay dr. tomas maramba and nanay professor emeritus dr. nelia cortez-maramba; my dear pamje colleagues professors caster palaganas and joseph quebral and doctors phel esmaquel and mads tandoc, pamje members and our hardworking secretariat, philippine council for health research and development -department of science and technology (pchrd-dost) director mel opeña and belle intia, world health organization western pacific region office (who-wpro) ms. alma prosperoso, guests, friends, ladies and gentlemen: “it was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair.” — charles dickens, a tale of two cities1 who would have thought that our vision of 2020 had been so blurred, so obscured by rose-colored lenses and peripheral blinders of what we once considered normal, that we were oblivious to the insidious turn of events that continues even today to change our lives and our world? this evening is an example (however small) of that change originally set for march 16 at ibarra’s garden, we are celebrating virtually and remotely from separate venues five months hence. what will today be seen as from the perspective of another five months? indeed, the past months have seen the worst of times. we remember our fears and frustrations as we battled an unseen enemy that mercilessly claimed our plans and programs as it killed our friends and colleagues. it was an age of foolishness as we witnessed the unrelenting spread of covidiots in disbelief and bewilderment. an epoch of incredulity as our scientific expertise and social interventions proved inutile while our so-called leaders failed to lead, engaging in petty pathetic distractions as they selfishly pillaged and plundered our nation and people instead. a depressing season of darkness heralding a cold, cruel winter of despair. correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 telefax: (632) 8524 4455 email: lapenajf@upm.edu.ph, jflapena@up.edu.ph the author declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the author, that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. *valedictory address during the turnover and induction ceremonies of the philippine association of medical journal editors inc. on august 7, 2020 josé florencio f. lapeña, jr. ma, md department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila department of otorhinolaryngology head and neck surgery east avenue medical center seasons and times, reasons and rhymes: di niyo ba naririnig?* c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philipp j otolaryngol head neck surg 2020; 35 (2): 4-5 philippine journal of otolaryngology-head and neck surgery 54 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 editorial but we did not surrender. as medical professionals and researchers, reviewers and editors, we took up stethoscope and scalpel, pen and paper and patiently plodded on. informing ourselves with the latest and best evidence (or engaging in research to add to that evidence), we sifted through the “infodemic” to cope with the pandemic as we navigated seemingly-endless zoom meetings and webinars, researched, reviewed or edited and published our findings, and attended to patients. the boundaries between night and day, weekday and weekend, office and home disappeared as we worked from home, or tried to make a home of our workplaces (fearful of contaminating our families with the dread disease). thus, these are the best of times, because we continue to hold the fort, the last line of defense. against all odds (including personal burnout and the very real possibility of becoming covid positive ourselves), we persist in upholding our sacred pledge to consecrate our lives to the service of humanity, in whatever manner possible. it is an age of wisdom. those of us who continue to pursue research, to review and edit, to write and publish, and who facilitate the means for others to do so in these trying times add to that wisdom. indeed, as the novelist-playwright edward bulwer-lytton has cardinal richelieu (on discovering a plot to kill him) proclaim: “the pen is mightier than the sword!”2 none are more cognizant of this than we who have taken up the daunting but thankless role of editor. if in the words of the great doctor josé protacio rizal (through the jeweler simoun’s discourse with basilio)3 “it is a useless life that is not consecrated to a great ideal … like a stone wasted on a field without becoming a part of any edifice,” then our lives consecrated to publishing vital health information and dispelling disinformation for the benefit of our patients and the public, and informing clinical practice and health policy are far from useless. let us continue to serve as sentinels of science and bring about the epoch of belief. it is time to move forward, and we do that by looking back. as doctor rizal also said, drawing on the popular tagalog proverb4 “ang hindi marunong lumingon sa pinanggalingan hindi makakarating sa paroroonan” (they who do not know how to look back at whence they came from will not reach their destination). the past decade would not have been possible without the many people who made pamje happen. in particular, i thank the pchrd-dost for the unwavering support of our plans, programs and projects. director merl opeña and “merl’s girls” headed by ms. belle intia, our secretary tine alayon, and executive director dr. jimmy montoya. the who wpro ms. alma mila prosperoso (and the medical and health librarian’s association of the philippines, mahlap), chandani thapa, marie villemin-partow, and charlie raby. we have come a long way from the first set of office bearersvice presidents drs. ric guanzon (the filipino family physician) and nenet santiago san juan (philipp j obstetrics and gynecology), secretary dr. madeline sosa (philipp j neurology) and treasurer dr. gerard goco (philipp j nuclear medicine), dr. pat khu (philipp j opthalmol), the other joey avila (acta medica philippina) and linda varona (pjim), and so many others. forgive a senior citizen’s memory if i inadvertently failed to mention you. to my steadfast colleagues, cecile maramba-lazarte, caster palaganas, joseph quebral and phel esmaquel, none of this would have been possible without you. maraming salamat po. it is but fitting that together with mads tandoc, you take up the torch and usher in a season of light and awaken a spring of hope. ikaw ba’y makikibaka at hindi maduduwag, na gisingin ang mga panatikong bingi’t bulag kasinungalingan labanan hanggang mabuwag di niyo ba naririnig? tinig ng bayan na galit himig ito ng pilipinong di muli palulupig dudurugin ang dilim, ang araw ay mag-aalab at mga pusong nagtimpi ay magliliyab! —  di niyo ba naririnig5 mabuhay kayo; mabuhay tayo. mabuhay ang pamje! references 1. dickens c. a tale of two cities: a story of the french revolution. the project gutenberg ebook # 98. boss j, widger d (producers). last updated 2018 march 4. [cited 2020 august 7] available from: https://www.gutenberg.org/files/98/98-h/98-h.htm. 2. bulwer-lytton e. richelieu; or, the conspiracy: a play in five acts. 1839. london: saunders and otley. page 52. digitized by internet archive; original from the university of california. [cited 2020 august 7] available from: https://hdl.handle.net/2027/uc2.ark:/13960/t9g44qv7s. 3. rizal j. el filibusterismo. (the reign of greed. complete english version from the spanish). derbyshire c. (translator). 1912. manila: philippine education company. chapter vii (simoun). the project gutenberg ebook #10676. hellingman j et al. (producers). 2005 october 10. [cited 2020 august 7] available from: https://www.gutenberg.org/files/10676/10676-h/10676-h.htm and from http://www.geocities.ws/qcpujoserizal/rizal/pdf/el%20fili.pdf. 4. ocampo ar. rizal’s morga and views of philippine history. philippine studies. 1998;46(2):184214. [cited 2020 november 12]. available from: https://www.philippinestudies.net/files/ journals/1/articles/2570/public/2570-2568-1-pb.pdf. 5. di niyo ba naririnig? filipino translation by vincent a. de jesus; additional lyrics by rody vera and joel sancho. “do you hear the people sing” from les miserables by schönberg c-m, boublil a, natel j-m, kretzmer h. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery review article abstract background: olfactory dysfunction (od) in covid-19 presents as a sudden onset smell loss commonly seen in mild symptomatic cases with or without rhinitis but can occur as an isolated symptom. the reported prevalence of od among covid-19 patients ranged from 5% to 98%. although numerous studies have been conducted about their association, these were mainly based on self-reported cases and subjective questionnaires. objective: this study investigates whether there is a significant difference in the prevalence of olfactory dysfunction between self-reported and objective testing using validated objective olfactory tests among rt-pcr confirmed covid-19 patients. methods: pubmed (medline), cochrane, web of science, and google scholar were searched for studies investigating the prevalence of od by using objective olfactory tests among patients who self-reported od (november 1, 2019 to july 31, 2020). all studies were assessed for quality and bias using the cochrane bias tool. patient demographics, type of objective olfactory test, and results of self-reported od and objective testing were reported. results: nine studies encompassing 673 patients met the inclusion criteria. validated objective olfactory tests used in the included studies were cccrc, sst and sit. overall prevalence of od among patients who self-reported was higher after objective testing (71% versus 81%). this was also seen in when we performed subgroup analysis based on the objective tests that were used. however, meta-analysis using random effects model showed no significant difference in the overall prevalence of od (p-value=.479, 95% ci 56.6 to 84.0 versus 71.2 to 89.8) as well as in the subgroups. conclusion: to the best of our knowledge, this is the first meta-analysis that statistically reviewed articles that evaluated the difference between self-reported and objective tests done on the same patients. results showing that self-reporting od approximates the results of the objective tests among covid-19 positive patients may imply that self-reporting can be sufficient in contact tracing and triggering swabbing and self-quarantine during the time of covid-19 and objective prevalence of olfactory dysfunction among covid-19 patients with self-reported smell loss versus objective olfactory tests: a systematic review and meta-analysis joyce anne f. regalado, md mariel mae h. tayam, md romiena a. santos, md january e. gelera, md department of otorhinolaryngology head and neck surgery ‘amang’ rodriguez memorial medical center correspondence: dr. january e. gelera department of otorhinolaryngology head and neck surgery ‘amang’ rodriguez memorial medical center sumulong highway, sto. niño, marikina city 1800 philippines phone: +63 915 490 4673 email: januarygelera@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. funding: no funding support was received for this study. presented at the philippine society of otolaryngology head and neck surgery covid-19 research forum 2020 (1st place). november 18, 2020. philipp j otolaryngol head neck surg 2021; 36 (1): 6-14 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery review article tests can be used as an adjunct in the diagnosis particularly in research. however, this study was limited by small sample size and articles done in european countries hence, interpretation and application of the results of this study must be approached with care. further studies documenting the difference between self-reporting and objective test in large scale setting involving different countries may be helpful in establishing a definitive consensus. registration: prospero id crd42020204063 keywords: anosmia; hyposmia; olfactory dysfunction; sars-cov-2; pandemic; 2019-ncov; covid-19 increasing reports of olfactory dysfunction (od) during the current coronavirus disease 2019 (covid-19) pandemic have been a point of interest for clinicians and authorities.1-4 olfactory dysfunction in covid-19 presents as a sudden onset smell loss commonly seen in mild symptomatic cases with or without rhinitis but can occur as an isolated symptom.5-6 the reported prevalence of od among covid-19 patients ranged from 5% to 98%,7-23 where higher prevalence is seen in european countries. a large-scale meta-analysis of 38 cohorts involving 12,154 covid-19 positive patients in 18 countries showed a 38% prevalence rate of smell loss.24 although numerous studies have been conducted about their association, these were mainly based on selfreported cases and subjective questionnaires.25-27 due to patient biases that are inherent in self-reporting such as recall and social desirability bias, and the tendency of patients to exaggerate or understate their symptoms based on their expected gain, the question of the true association of covid-19 and od has been raised.28-29 furthermore, the poor correlation of subjective questionnaires to actual olfactory status and poor sensitivity in detecting dysfunction calls for the use of objective tools.30 olfactory status can be evaluated objectively using different methods such as olfactory threshold, odor discrimination and odor idenitification.31 tests such as the connecticut chemosensory clinical research center (cccrc), sniffin’ stick test (sst) and the university of pennsylvania smell identification test (upsit), are the most commonly used validated tools for objective olfactory testing. differences between self-reported od and objective tests has been reported in the literature. studies comparing the overall prevalence of od among covid-19 patients who self-reported od with those who underwent olfactory tests showed a significant difference between the two groups. this was corroborated by meta-analyses that were recently conducted.25-26 however, these meta-analyses compared the individual articles that were categorized into “self-reporting” and “objective testing” based on their final result. upon review, analysis of studies that compare the prevalence of od before and after using objective tests on same subjects has not yet been done. the purpose of this study was to conduct a meta-analysis of the published literature to investigate if there is a significant difference in the prevalence of olfactory dysfunction between self-reported dysfunction and objective test results among rt-pcr confirmed covid-19 patients. this will give an idea if simply asking patients about their history of smell loss is enough in establishing the association of od in covid-19, or if there is a need for an objective test to ascertain the accurate prevalence of od. furthermore, this study could help clinicians decide on how to evaluate patients with olfactory dysfunction during the covid-19 pandemic. methods this study followed the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines. search strategy and data sources to identify studies that are eligible for inclusion in our study, we conducted a computerized search using pubmed (medline), cochrane, web of science, and google scholar from november 1, 2019 to july 31, 2020. the search terms used were ([“covid-19” or “2019-ncov” or “sars-cov-2” or “coronavirus disease 2019”] and [“anosmia” or “hyposmia” or “olfactory dysfunction” or “smell loss”]). searches were performed using the keywords as medical subject headings (mesh). inclusion and exclusion criteria two authors (jar, mmt) independently selected studies for analysis according to the following inclusion criteria: 1) participants: patients with rt-pcr confirmed covid-19 disease who self-reported smell loss, 2) clinical test: validated objective tests, 3) outcome measure: prevalence of olfactory dysfunction, 4) type of study: cross-sectional or cohort. studies were excluded if they had: 1) incomplete and/or no proper outcomes data, 2) no full text available, 3) non-english language without available english version. editorials, commentaries, case reports and literature reviews as well as animal experiments and cellular studies were excluded. letters to the editor were reviewed for shared data and were included if data fit the inclusion criteria. two independent authors (jar, mmt) screened the studies and disagreements were resolved by a third author (ras). the studies were identified by title, abstract, and text in the first screening, and then the full text of relevant studies was retrieved for validation before final inclusion in the present systematic review. a flow chart of the study selection process is shown in figure 1. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery review article methodological quality assessment the risk of bias in the selected studies was assessed using an adaptation of the cochrane collaboration risk-of-bias tool and the risk-of-bias assessment tool for non-randomized studies (robis). the criteria involved assessing studies for selection bias caused by inadequate selection of participants or inadequate confirmation and consideration of confounding variables, performance bias caused by inadequate measurement of intervention, detection bias caused by inadequate blinding of outcome assessment, attrition bias caused by inadequate handing of incomplete outcome data, or reporting bias caused by selective outcome reporting. a judgment related to risk of bias was assigned to each study by answering a pre-specified question about the adequacy of the study in relation to the entry. a judgment of “green” indicated a low risk of bias, “red” indicated a high risk of bias, and “yellow” indicated an unclear or unknown risk of bias. the methodological quality of the included studies was independently assessed by two researchers (jar and mmt) and disagreements were resolved by a third author (ras). data extraction independent data extraction was done by two investigators (jar, ras) and disagreements were resolved by discussion. data extracted from each study were: 1) patient characteristics (mean age, gender, country, setting), 2) clinical test: (i.e. self-reporting, objective test), 3) outcome measure (with or without olfactory dysfunction). due to variability in outcome presentation, patients were considered “with olfactory dysfunctions” when they: 1) report both olfactory and gustatory dysfunction, 2) reported as with anosmia, hyposmia, cacosmia or phantosmia. other study data extracted included author, year of publication, research design, number of samples. furthermore, articles having the same authors were examined further to avoid duplication of data. statistical analysis using medcalc statistical software version 16.4.3 2016 (https://www. medcalc.org) (medcalc software, ostend, belgium), point estimates for gender proportion and od were calculated by dividing the number of cases by the total number of covid-19 patients included in the studies. prevalence rates of od were reported based on the type of reporting as to self-reported and objective test. forest plots were generated for visual representation to show variations between studies and pooled analyses. test for heterogeneity was carried out using cochran’s q and i2. significant cochran q-value with p-value less than .05 and i2 > 50% was considered for high heterogeneity. for this case, a random effects model was used to provide a conservative prevalence estimate, otherwise fixed effect model was used. subgroup analysis of specific objective tests cccrc, sniffin’ stick and smell identification test, were done to further investigate the difference between the studies. results search characteristics initial literature search yielded 286 articles, 189 of which were duplicates. during screening, 83 studies were excluded based on selection criteria. among the 14 remaining studies, 5 were excluded with reasons. (figure 1) thus, 9 studies (n=784) met the selection criteria and were eligible for qualitative analysis. (figure 1, table 1) study sample sizes ranged from 18 to 345, all were rt-pcr confirmed covid-19. the mean age of patients in the included studies was 47 ± 14 years, ranging from 28 to 63. all were cross-sectional studies and were published in 2020. majority of the studies were conducted in europe3 in italy, 2 in belgium, 2 in germany, and the other 2 were done in asia. methodological quality and risk of bias assessment of risk of bias for the studies is presented in figure 2. all the included studies showed adequate selection of participants and low risk of confounding. the risk of bias in classification of intervention was low in 8 studies (88%) included. separately, the risk of bias due to deviations from intended intervention and measurement of outcome was low in 6 studies (66%) and unclear in four. the risk of bias due to missing data was low in 4 studies (44%). overall, most of the included studies were classified as low risk for bias. prevalence of olfactory dysfunction: combined prevalence estimates complaints of od were reported by 33.3% to 65% of covid-19 patients who were asked about their sense of smell. (table 1) there were 3 studies35,39,40 that had subjects who all had od. validated objective olfactory tests were used in all the articles. in 4 studies,35,36,39,40 the authors failed to include all the subjects in the objective evaluation due to logistic issues. hence, the number of data were adjusted prior to statistical analysis. in summary, there were 784 covid-19 positive patients confirmed by rt-pcr, however only 673 were included in this meta-analysis. specific tests used were cccrc in 3 studies,32-34 sniffin’ stick test in another 3 studies,35-37 and smell identification tests in 3 studies.38,40 the detected od among covid-19 patients who underwent objective olfactory tests ranged from 33.3% to 98.3%, with 1 study38 confirmed od on all of the participants. the prevalence of od after using cccrc, sniffin’ stick and sit were 69% to 83.3%, 60% to 84% and 83.3% to 98.3%, respectively. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery review article table 1. main characteristics of included studies first author, year published country no. (male%) mean age, yr±sd (+) (+)(-) (-) objective test difference†, n (%) self-reported, n (%)subject objective test, n (%) vaira, 2020 (a)32 vaira, 2020 (b)33 vaira, 2020 (c)34 lechien, 2020 (a)35 lechien, 2020 (b)36 hornuss, 202037 moein, 202038 bertlich, 202039 chung, 202040 italy italy italy belgium belgium germany iran germany hong kong 72 (37.5) 345 (42.3) 33 (33.3) 78 (41.0) 86 (34.9) 45 (55.6) 60 (66.7) 47 (72.3) 18 (38.9) 49.2 ±13.7 48.5 ±12.8 47.2 ±10 40.6 ±11.2 41.7 ±11.8 56 ±16.9 46.55 ±12.17 63.3 ±13.9 28 ±19 44 (61.1) 224 (65) 17 (51.5) 28 (100)* 52 (74.3)* 22 (48.9) 17 (28.3) 14 (100)* 6 (100)* 28 (38.9) 121 (35) 16 (48.5) 0 (0)* 18 (25.7)* 23 (51.1) 43 (71.7) 0 (0)* 0 (0)* 60 (83.3) 241 (69.9) 25 (75.8) 21 (75)* 42 (60.0)* 38 (84.4) 59 (98.3) 14 (100)* 5 (83.3)* 12 (16.7) 104 (30.1) 8 (24.2) 7 (25)* 28 (40.0)* 7 (15.6) 1 (1.7) 0 (0)* 1 (16.7)* cccrc cccrc cccrc sniffin’ stick sniffin’ stick sniffin’ stick upsit bsit sit + 16 (22.2) + 17 (4.9) + 8 (23.2) 7 (25)* -10 (14.3)* + 16 (35.5) + 42 (70.0) 0 (0)* 1 (16.7)* * sample size was reduced to 28 from 78 for meta-analysis since part of the subjects did not underwent objective test. the percentage was adjusted to the sample size. † difference in results after objective test interpretation: (+) = number of patients who self-reported a normal od but was positive for od after olfactory test; (-) = number of patients who self-reported having od but was negative for od after olfactory test cccrc = connecticut chemosensory clinical research center; upsit = university of pennsylvania smell identification test; sit = smell identification test; bsit = brief smell identification test the difference in prevalence of od between self-reporting and objective testing is summarized in table 1. all studies showed a notable difference in the prevalence of od after objective testing aside from one40 which showed no difference. however, the characteristic differences between the studies were not the same. five studies32-34,38,40 using cccrc and sit, showed an increase in the prevalence of od after objective testing which ranges from 4.9% to as high as70%. on the other hand, 2 studies35,36 using sniffin’ stick test showed a decreased incidence of od among tested subjects at 14 to 25%. one study37 had a different result from the sniffin’ stick subgroup showing an increase in prevalence of od after objective testing. substantial to considerable heterogeneity was seen on both selfreporting (i2 = 91.9%) and objective olfactory testing (i2 = 86.46%), hence random effects model was used. (figure 3) out of 673 pooled subjects, the prevalence proportions of self-reported od were 71.3% and 81.4% after objective testing. the difference in point estimates between groups was 10% (p-value=.479, 95% ci 56.6 to 84.0 versus 71.2 to 89.8). prevalence of od based on specific objective olfactory test connecticut chemosensory clinical research center test. three studies32-34 reported the prevalence of olfactory dysfunction using the cccrc, which includes both threshold and identification measures. (figure 4a, b) olfactory threshold was performed using butanol placed in a squeezable bottle with decreasing concentration and another identical bottle containing deionized water. the threshold was identified when the subject gave the correct answer four times. the threshold was quantified for each of the two nostrils with a score from 0 to 8 corresponding to the less concentrated bottle that the patient was able to correctly detect. the average between values of the two nostrils expressed the overall score. the odor identification on the other hand used common odorants placed inside 180 ml opaque jars covered with gauze. one at a time, the samples were presented to the patient in the same way as the threshold test. therefore, the patient was asked to identify the odorant on a list containing the 10 test items and 10 distractors. (table 1) score ranged from 0 to 10 and was obtained from the average of the two nostrils. figure 1. flowchart of the process for selecting studies for systematic review and meta-analysis. id en ti fic at io n sc re en in g el ig ib ili ty in cl ud ed records identified through database searching pubmed, cochrane, wos, google scholar (n = 286) records after duplicates removed (n = 97) records screened (n = 97) full-text articles assessed for eligibility (n = 14) studies included in qualitative synthesis (n = 9) studies included in quantitative synthesis (meta-analysis) (n = 9) full-text articles excluded, with reasons: (n=5) inappropriate study design (2) no proper outcome data (2) duplicated data (1) records excluded (n = 83) philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery review article olfactory status using cccrc in the included studies was classified as a test composite score of 0-10 as anosmia, 20-80 as hyposmia and 90-100 as normal. in this study, anosmia and hyposmia are grouped as olfactory dysfunction. self-reported od among covid-19 patients in the cccrc group ranged from 51% to 65%. after the objective test, prevalence increased to 70% to 83%. test of heterogeneity showed minimal heterogeneity in the self-reporting group and substantial heterogeneity in cccrc, hence fixed effect and random model was used, respectively. reported pooled prevalence of self-reported od was 62% and 76% after cccrc. the difference in point estimates between groups was 12% (p-value=.088, 95% ci 58.6 to 67.7 versus 65.8 to 83.9). sniffin’ sticks test. three studies35-37 reported the prevalence of olfactory dysfunction using the sniffin’ stick test, which comprised of odor threshold, odor discrimination, and odor identification. (figure 4. c, d) using the identification sniffin’ sticks test (medisense, groningen, the netherlands), a total of 16 scents were presented via a pen device to patients for 3 seconds followed by a forced choice from four given options with a total possible score of 16. self-reported od occurred in 48% to 100%. olfactory status using sst score was classified as normosmia (between 12 to 16), hyposmia (between 9 to 11), and anosmia (8 or below). prevalence of od after sst was 60% to 84% among covid-19 patients. substantial and considerable heterogeneity was seen in both group with i2 of 94% and 76% hence random effects model was used. the combined prevalence of overall olfactory dysfunction in patients who self-reported smell loss was 79% and 73% after sst. the difference in point estimates between groups was 6% (p-value=.636, 95% ci 45.4 to 98.4 versus 56.3 to 86.4). smell identification test. three studies38-40 reported the prevalence of od on covid-19 patients using sit which tests odor identification. (figure 4e, f) one used the university of pennsylvania smell identification test (upsit), another one used brief smell identification test (b-sit), and last used smell identification test (sit, sensonics international haddon heights, nj). these tests consist of odorants embedded per page of a test kit. stimuli are contained in plastic microcapsules on a brown strip on the footnote. the examiner asks the patient to scrape the strip with a pencil, which releases the odor. the patient then marks the option that best describes the odor. the test score was the total of all correct answers. among the 80 subjects, prevalence of self-reported od was 28% to 100% and 83% to 100% after testing. test of heterogeneity showed a considerable heterogeneity in self-reporting group (i2 =96%) and minimal in sit group (i2 = 27%) hence random and fixed effects model was used, respectively. pooled prevalence of self-reported od was 81% and sit was 97%. the difference in point estimates between group was 16.2% (p-value=.636, 95% ci 45.4 to 98.4 versus 56.3 to 86.4). figure 2. assessment of risk of bias in the included clinical studies. domains: d1: bias due to confounding d2: bias in selection of participants into the study d3: bias in classification of interventions d4: bias due to deviations from intended interventions d5: bias due to missing data d6: bias in measurement of outcomes d7: bias in selection of the reported results x high some concerns + low overall vaira, 2020 (a) vaira, 2020 (b) vaira, 2020 (c) lechien 2020 (a) lechien 2020 (b) hornuss 2020 moein 2020 bertlich 2020 chung 2020 d1 + + + + + + + + + d2 + + + + + + + + + d3 + + + ? + + + + + d4 + ? + ? + ? + ? + d5 + ? + + ? ? ? ? + d6 + + + ? ? + ? + + d7 + + + + + + + + + bias + + + + + + + + + discussion in this systematic review, the overall reported prevalence of od in 637 covid-19 patients who were asked about their sense of smell was 71%. after objective testing, the prevalence of od increased to 81%. however, meta-analysis using random effects model found no significant difference between self-reporting and objective testing (p-value=.479, 95% ci 56.6 to 84.0 versus 71.2 to 89.8). furthermore, subgroup analyses based on the type of objective test performed also showed no significant difference when compared to self-reporting. the noted difference between the 2 groups in the overall and subgroup analysis is important to mention although the analysis of the point estimates was not significant. when objective tests were done in patients who self-reported smell loss, the prevalence of od increased. the observed increase in the prevalence of od after objective testing shows the tendency of self-reporting to underestimate olfactory dysfunction. this was also seen in the subgroup analysis using cccrc. interestingly, this was reversed when sniffin stick test and sit were used wherein a decrease in the prevalence of od were noted. the accuracy of objective olfactory tests has been shown to increase when multiple components of olfaction were measured.41 hence, the discordance between the subgroups may be due to the philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery review article figure 3. forest plots of meta-analysis comparing the prevalence of olfactory dysfunction between self-reporting (a) and objective olfactory test (b). ci = confidence interval; cccrc = connecticut chemosensory clinical research center; upsit = university of pennsylvania difference in the olfactory function that is being measured by a specific technique. the sit measures odor identification at a suprathreshold level, whereas cccrc (threshold and identification) and sst (threshold, discrimination, and identification) measures multiple components. future research using objective olfactory tests that measure composite scores are needed. in the clinical setting, olfactory tests are usually performed on both nostrils. however, the presence of side differences between the two nostrils, called lateral discrepancy, have been documented in literature.42 bi-rhinal testing has been shown to reflect the function of the better nostril resulting in a masked improvement of olfactory function compared to monorhinic testing.42-43 out of the 9 included studies, only 3 studies32-34 that used cccrc mentioned using a monorhinic method. a std diff in means and 95% ci vaira, 2020 (a) vaira, 2020 (b) vaira, 2020 (c) lechien 2020 (a) lechien 2020 (b) hornuss 2020 moein 2020 bertlich 2020 chung 2020 fixed random sample size 673 673 72 345 33 28 70 45 60 14 6 proportion (%) 64.269 71.302 61.111 64.928 51.515 100.000 74.286 48.889 28.333 100.000 100.000 95% ci 60.544 to 67.871 56.608 to 83.997 48.894 to 72.385 59.636 to 69.961 33.544 to 69.204 87.656 to 100.000 62.439 to 83.993 33.703 to 64.226 17.451 to 41.444 76.836 to 100.000 54.074 to 100.000 model study statistics for each study b std diff in means and 95% ci vaira, 2020 (a) vaira, 2020 (b) vaira, 2020 (c) lechien 2020 (a) lechien 2020 (b) hornuss 2020 moein 2020 bertlich 2020 chung 2020 fixed random sample size 673 673 72 345 33 28 70 45 60 14 6 proportion (%) 76.108 81.447 83.333 69.855 75.758 75.000 60.000 84.444 98.333 100.000 83.333 95% ci 72.725 to 79.263 71.239 to 89.831 72.696 to 91.080 64.712 to 74.653 57.741 to 88.908 55.128 to 89.309 47.593 to 71.533 70.545 to 93.509 91.060 to 99.958 76.836 to 100.000 35.877 to 99.579 model study statistics for each study they evaluated both nostrils separately and the average between the values of the two nostrils were taken as the overall score. this may explain the increase in the occurrence of od in the cccrc group compared to the other studies. given these, it is important to consider the possibility of the discrepancy that may have occurred in the studies based on the methods of olfactory testing that were conducted which may have underestimated the prevalence of olfactory loss. future studies that take these factors into consideration are needed. the timing of objective testing might have an effect on the results. studies showed that od in covid-19 occurs early in the disease (approximately 3 days), and the majority resolve after 1-3 days, with highest rate of recovery seen in the first week from the time of onset.44-45 hence, the timing of the objective testing is important in documenting philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery review article a. self-reported od b. cccrc vaira, 2020 (a) vaira, 2020 (b) vaira, 2020 (c) fixed random sample size 72 345 33 450 450 proportion (%) 83.333 69.855 75.758 72.462 75.393 95% ci 72.696 to 91.080 64.712 to 74.653 57.741 to 88.908 68.101 to 76.528 65.795 to 83.861 model study statistics for each study c. self-reported od lechien, 2020 (a) lechien, 2020 (b) hornuss, 2020 fixed random sample size 28 70 45 143 143 proportion (%) 100.000 74.286 48.889 74.450 78.708 95% ci 87.656 to 100.00 62.439 to 83.993 33.703 to 64.226 66.578 to 81.302 45.393 to 98.378 model study statistics for each study d. sst lechien, 2020 (a) lechien, 2020 (b) hornuss, 2020 fixed random sample size 28 70 45 143 143 proportion (%) 75.000 60.000 84.444 70.835 72.700 95% ci 55.128 to 89.309 47.593 to 71.533 70.545 to 93.509 62.747 to 78.056 56.323 to 86.411 model study statistics for each study std diff in means and 95% ci std diff in means and 95% ci std diff in means and 95% ci std diff in means and 95% ci vaira, 2020 (a) vaira, 2020 (b) vaira, 2020 (c) fixed random sample size 72 345 33 450 450 proportion (%) 61.111 64.928 51.515 63.274 62.457 95% ci 48.894 to 72.385 59.636 to 69.961 33.544 to 69.204 58.649 to 67.724 56.546 to 68.188 model study statistics for each study philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery review article the prevalence of od in covid-19. unfortunately, due to logistical issues, there were difficulties in conducting timely testing. majority of the studies that were included failed to indicate the timing of testing. the 2 studies32,34 that mentioned the timing of objective test from the clinical onset of anosmia reported a time laps of 14 to 20 days. this time lag is important to note because the olfactory dysfunction of the patients who were evaluated may have already resolved or gradually improved by the time of assessment causing an underestimation of od. early olfactory evaluation of covid-19 patients with od is important in future studies. moreover, the presence of the self-reported od at the time of actual objective olfactory testing, which was not reported clearly by any of the studies included, must be taken into account to avoid errors in reporting. this study has several limitations that is needed to be considered. first, due to novelty of the topic investigated, this study is limited by the small number of articles and sample size available for analysis which limits the authors to formulate a reliable conclusion. difficulty in conducting objective olfactory testing during this time of the pandemic prevents researchers from conducting these kinds of studies. studies using objective tests that were validated for home-settings would be helpful for future research. furthermore, since olfactory tests are expensive, not readily available and a logistic problem, evaluation of validated olfactory questionnaires that would approximate objective tests would be advantageous as temporary replacement. second, marked heterogeneity was seen between the studies which may be due to a large difference in the prevalence of od seen in individual studies as well as the variability seen in the sample size. lastly, the studies that were selected were limited to mostly european populations, which may mask the factor of cultural difference. further studies that address these limitations are needed. in conclusion, this meta-analysis indicates that self-reporting approximates objective testing in documenting the prevalence of od among covid-19 patients. when both groups were compared, no significant differences were seen in both the overall and subgroup analysis. based on the results, self-reporting can be used as a threshold to test covid-19 suspects and to advise self-quarantine. on the other hand, objective tests can be used as adjuncts in the diagnosis particularly in conducting research studies about the association of covid-19 and olfactory dysfunction. however, due to the limitations mentioned, careful interpretation of our results is advised. although self-reporting is valuable to assist in the initial screening of covid-19 suspects, further studies evaluating the use of validated olfactory objective tests must be done. f. sit moein,2020 bertlich, 2020 chung, 2020 fixed random sample size 60 14 6 80 80 proportion (%) 98.333 100.000 83.333 96.872 96.311 95% ci 91.060 to 99.958 76.836 to 100.000 35.877 to 99.579 90.499 to 99.451 88.810 to 99.794 model study statistics for each study figure 4. forest plots comparing the prevalence of olfactory dysfunction between self-reporting and specific objective test used: (a, b) connecticut chemosensory clinical research center, (c, d) sniffin’ stick test (e, f) smell identification test e. self-reported od moein,2020 bertlich, 2020 chung, 2020 fixed random sample size 60 14 6 80 80 proportion (%) 28.333 100.000 100.000 50.640 80.693 95% ci 17.451 to 41.444 76.836 to 100.000 54.074 to 100.000 39.434 to 61.799 19.130 to 95.725 model study statistics for each study std diff in means and 95% ci std diff in means and 95% ci philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery review article 24. von bartheld cs, hagen mm, butowt r. prevalence of chemosensory dysfunction in covid-19 patients: a systematic review and meta-analysis reveals significant ethnic differences. acs chem neurosci. 2020 oct 7;11(19):2944-2961. doi: 10.1021/acschemneuro.0c00460; pubmed pmid: 32870641; pmcid: pmc7571048. 25. hannum me, ramirez va, lipson sj, herriman rd, toskala ak, lin c, et al. objective sensory testing methods reveal a higher prevalence of olfactory loss in covid-19–positive patients compared to subjective methods: a systematic review and meta-analysis. medrxiv. 2020 jul 6;2020.07.04.20145870. doi: 10.1101/2020.07.04.20145870; pubmed pmid: 32676608; pmcid: pmc7359533. 26. tong j, wong a, zhu d, fastenberg j, tham t, the prevalence of olfactory and gustatory dysfunction in covid-19 patients: a systematic review and meta-analysis otolaryngol head neck surg. 2020 jul;163(1):3-11. doi: 10.1177/0194599820926473; pubmed pmid: 32369429 27. agyeman aa, chin kl, landersdorfer cb, liew d, oforio-asenso r. smell and taste dysfunction in patients with covid-19: a systematic review and meta-analysis. mayo clin proc. 2020 aug;95(8):1621-1631. doi: 10.1016/j.mayocp.2020.05.030; pubmed pmid: 32753137; pmcid: pmc7275152. 28. philpott cm, wolstenholme cr, goodenough pc, clark a, murty ge. comparison of subjective perception with objective measurement of olfaction. otolaryngol head neck surg. 2006 mar;134(3):488-90. doi: 10.1016/j.otohns.2005.10.041; pubmed pmid: 16500450. 29. althubaiti a. information bias in health research: definition, pitfalls, and adjustment methods. j multidiscip healthc. 2016 may;9:211-217. doi: 10.2147/jmdh.s104807; pubmed pmid: 27217764; pmcid: pmc4862344. 30. seok j, shim yj, rhee cs, kim jw. correlation between olfactory severity ratings based on olfactory function test scores and self-reported severity rating of olfactory loss. acta otolaryngol. 2017 jul;137(7):750-754. doi: 10.1080/00016489.2016.1277782; pubmed pmid: 28112015. 31. doty rl, laing dg. psychophysical measurement of human olfactory function. handbook of olfaction and gustation. 2015 jun: 225–260. doi: 10.1002/9781118971758.ch11. 32. vaira la, deiana g, fois ag, pirina p, madeddu g, de vito a, et al. objective evaluation of anosmia and ageusia in covid‐19 patients: a single‐center experience on 72 cases. head neck. 2020 jun;42(6):1252-1258. doi: 10.1002/hed.26204; pubmed pmid: 32342566; pmcid: pmc7267244. 33. vaira la, hopkins c, salzano g, petrocelli m, melis a, cucurullo m, et al. olfactory and gustatory function impairment in covid ‐19 patients: italian objective multicenter‐study. head & neck. 2020 jul;42(7):1560-1569. doi: 10.1002/hed.26269; pubmed pmid: 32437022; pmcid: pmc7280583. 34. vaira la, salzano g, petrocelli m, deiana g, salzano fa, de riu g. validation of a selfadministered olfactory and gustatory test for the remotely evaluation of covid-19 patients in home quarantine. head neck. 2020 jul;42(7):1570-1576. doi: 10.1002/hed.26228; pubmed pmid: 32357379; pmcid: pmc7267597. 35. lechien jr, cabaraux p, chiesa-estomba cm, khalife m, plzak j, hans s, et al.  psychophysical olfactory tests and detection of covid-19 in patients with sudden onset olfactory dysfunction: a prospective study. ear nose throat j. 2020 nov;99(9):579-583. doi: 10.1177/0145561320929169; pubmed pmid: 32469246. 36. lechien jr, cabaraux p, chiesa‐estomba cm, khalife m, hans s, calvo‐henriquez c, et al.  objective olfactory evaluation of self‐reported loss of smell in a case series of 86 covid ‐19 patients.  head neck. 2020 jul;42(7):1583-1590. doi: 10.1002/hed.26279; pubmed pmid: 32437033; pmcid: pmc7280665. 37. hornuss d, lange b, schröter n, rieg s, kern wv, wagner d. anosmia in covid-19 patients. clin microbiol infect. 2020 oct;26(10):1426-1427. doi: 10.1016/j.cmi.2020.05.017; pubmed pmid: 32447049; pmcid: pmc7242197. 38. moein st, hashemian smr, mansourafshar b, khorram‐tousi a, tabarsi p, doty rl.  smell dysfunction: a biomarker for covid‐19. int forum allergy rhinol. 2020 aug;10(8):944-950. doi: 10.1002/alr.22587; pubmed pmid: 32301284; pmcid: pmc7262123. 39. bertlich m, stihl c, weiss b, canis m, haubner f, ihler f. characteristics of impaired chemosensory function in hospitalized covid-19 patients. ssrn electron j. 2020 jan. doi: 10.2139/ssrn.3576889. 40. chung twh, sridhar s, zhang aj, chan kh, li hl, wong fkc, et al.  olfactory dysfunction in coronavirus disease 2019 patients: observational cohort study and systematic review. open forum infect dis. 2020 jun 5;7(6):ofaa199. doi: 10.1093/ofid/ofaa199; pubmed pmid: 32548209; pmcid: pmc7284010. 41. lotsch j, reichmann h, hummel t. different odor tests contribute differently to the evaluation of olfactory loss. chem senses. 2008 jan;33(1):17-21. doi: 10.1093/chemse/bjm058; pubmed pmid: 17761724. 42. gudziol v, hummel c, negoias s, ishimaru t, hummel, t.  lateralized differences in olfactory function. laryngoscope. 2007 may;117(5):808-11.  doi: 10.1097/mlg.0b013e3180330092; pubmed pmid: 17473673. 43. klimek l, hummel t, moll b, kobal g, mann wj. lateralized and bilateral olfactory function in patients with chronic sinusitis compared with healthy control subjects. laryngoscope. 1998 jan;108(1 pt 1):111-4. doi: 10.1097/00005537-199801000-00021; pubmed pmid: 9432078 44. hopkins c, surda p, whitehead e, kumar bn.  early recovery following new onset anosmia during the covid-19 pandemic – an observational cohort study. j otolaryngol head neck surg. 2020 may 4;49(1):26. doi: 10.1186/s40463-020-00423-8; pubmed pmid: 32366299; pmcid: pmc7196882. 45. parente-arias p, barreira-fernandez p, quintana-sanjuas a, patiño-castiñeira b. recovery rate and factors associated with smell and taste disruption in patients with coronavirus disease 2019. am j otolaryngol. 2020 jul 14 : 102648. doi: 10.1016/j.amjoto.2020.102648; pubmed pmcid: pmc7358151. acknowledgement we would like to thank mr. roy alvin j. malenab for helping us with the statistical analysis for our study. references: 1. hopkins c, surda p, kumar n. presentation of new onset anosmia during the covid-19 pandemic. rhinology. 2020 jun; 58(3): 295-298. doi: 10.4193/rhin20.116; pubmed pmid: 32277751. 2. yan ch, faraji f, prajapati dp, ostrander bt, deconde as. self‐reported olfactory loss associates with outpatient clinical course in covid‐19. int forum allergy rhinol. 2020 jul;10(7):821-831. doi: 10.1002/alr.22592; pubmed pmid: 32329222; pmcid: pmc7264572. 3. joffily l, ungierowicz a, david ag, melo b, brito clt, dos santos psc, et al. the close relationship between sudden loss of smell and covid-19. braz j otorhinolaryngol. sep-oct 2020;86(5):632638. doi: 10.1016/j.bjorl.2020.05.002; pubmed pmid: 32561220; pmcid: pmc7247493. 4. haehnera a, drafa j, dräger s, de withb k, hummel t. predictive value of sudden olfactory loss in the diagnosis of covid-19. orl j otorhinolaryngol relat spec. 2020;82(4):175-180. doi: 10.1159/000509143; pubmed pmid: 32526759; pmcid: pmc7360503. 5. vaira la, salzano g, deiana g, de riu g. anosmia and ageusia: common findings in covid-19 patients. laryngoscope. 2020 jul;130(7):1787. doi: 10.1002/lary.28692; pubmed pmid: 32237238; pmcid: pmc7228304. 6. gane s, kelly c, hopkins c. isolated sudden onset anosmia in covid-19 infection. a novel syndrome?. rhinology. 2020 jun 1;58(3):299-301. doi: 10.4193/rhin20.114; pubmed pmid: 32240279. 7. al-ani rm, acharya d. prevalence of anosmia and ageusia in patients withcovid-19 at a primary health center, doha, qatar. indian j otolaryngol head neck surg. 2020 aug 19;1-7. doi: 10.1007/s12070-020-02064-9; pubmed pmid: 32837952; pmcid: pmc7435125. 8. mao l, jin h, wang m, hu y, chen s, he q, et al. neurologic manifestations of hospitalized patients with coronavirus disease 2019 in wuhan, china. jama neurol. 2020 jun 1;77(6):683690. doi: 10.1001/jamaneurol.2020.1127; pubmed pmid: 32275288; pmcid: pmc7149362. 9. gudbjartsson df, helgason a, jonsson h, magnusson ot, melsted p, norddahl gl, et al. spread of sars-cov-2 in the icelandic population. n engl j med. 2020 jun 11;382(24):2302-2315. doi: 10.1056/nejmoa2006100; pubmed pmid: 32289214; pmcid: pmc7175425. 10. mishra p, gowda v, dixit s, kaushik m. prevalence of new onset anosmia in covid-19 patients: is the trend different between european and indian population? indian j otolaryngol head neck surg. 2020 jul 21;72(4):1-4. doi: 10.1007/s12070-020-01986-8; pubmed pmid: 32837939; pmcid: pmc7373335. 11. wee le, chan yfz, teo nwy, cherng bpz, thien sy, wong hy, et al. the role of self-reported olfactory and gustatory dysfunction as a screening criterion for suspected eur arch otorhinolaryngol. 2020 aug;277(8):2389-2390. doi: 10.1007/s00405-020-05999-5; pubmed pmid: 32328771; pmcid: pmc7180656. 12. giacomelli a, pezzati l, conti f, bernacchia d, siano m, oreni l, et al. self-reported olfactory and taste disorders in sars-cov-2 patients: a cross-sectional study. clin infect dis. 2020 jul 28;71(15):889-890. doi: 10.1093/cid/ciaa330; pubmed pmid: 32215618; pmcid: pmc7184514 13. levinson r, elbaz m, ben-ami r, shasha d, levinson t, choshen g, et al. anosmia and dysgeusia in patients with mild sars-cov-2 infection. infect dis (lond). 2020 aug;52(8):600-602. doi: 10.1080/23744235.2020.1772992; pubmed pmid: 32552475. 14. bénézit f, le turnier p, declerck c, paillé c, revest m, dubée v, et al. utility of hyposmia and hypogeusia for the diagnosis of covid-19. lancet infect dis. 2020 sep;20(9):1014-1015. doi: 10.1016/s1473-3099(20)30297-8; pubmed pmid: 32304632; pmcid: pmc7159866. 15. klopfenstein t, kadiane-oussou nj, toko l, royer py, lepiller q, gendrin v, et al. features of anosmia in covid-19 med mal infect. 2020 aug;50(5):436-439. doi: 10.1016/j. medmal.2020.04.006; pubmed pmid: 32305563; pmcid: pmc7162775. 16. menni c, valdes a, freidin m, sudre c, nguyen l, drew d, et al. real-time tracking of selfreported symptoms to predict potential covid-19. nat med. 2020 jul;26(7):1037-1040. doi: 10.1038/s41591-020-0916-2; pubmed pmid: 32393804; pmcid: pmc7751267. 17. spinato g, fabbris c, polesel j, cazzador d, borsetto d, hopkins c, et al. alterations in smell or taste in mildly symptomatic outpatients with sars-cov-2 infection. jama. 2020 may 26;323(20):2089-2090. doi: 10.1001/jama.2020.6771; pubmed pmid: 32320008; pmcid: pmc7177631. 18. heidari f, karimi e, firouzifar m, khamushian p, ansari r, ardehali mm, et al. anosmia as a prominent symptom of covid-19 infection. rhinology. 2020 jun 1;58(3):302-303. doi: 10.4193/ rhin20.140; pubmed pmid: 32319971. 19. yan ch, faraji f, prajapati dp, boone ce, de conde a. association of chemosensory dysfunction and covid‐19 in patients presenting with influenza‐like symptoms. int forum allergy rhinol. 2020 jul;10(7):806-813. doi: 10.1002/alr.22579; pubmed pmid: 32279441; pmcid: pmc7262089 20. lechien jr, chiesa-estomba cm, de siati dr, horoi m, le bon sd, rodriguez a, et al. olfactory and gustatory dysfunctions as a clinical presentation of mild to moderate forms of the coronavirus disease (covid-19): a multicenter european study. eur arch otorhinolaryngol. 2020 aug;277(8):2251-2261. doi: 10.1007/s00405-020-05965-1; pubmed pmid: 32253535; pmcid: pmc7134551. 21. carignan a, valiquette l, grenier c, musonera jb, nkengurutse d, marcil-héguy a, et al. anosmia and dysgeusia associated with sars-cov-2 infection: an age-matched case–control study. cmaj. 2020 jun 29;192(26):e702-e707. doi: 10.1503/cmaj.200869; pubmed pmid: 32461325; pmcid: pmc7828887. 22. bagheri shr, asghari am, farhadi m, shamshiri ar, kabir a, kamrava sk, et al. coincidence of covid-19 epidemic and olfactory dysfunction outbreak. med j islam repub iran. 2020 jun 15;34:62. doi: 10.34171/mjiri.34.62; pubmed pmid: 32974228; pmcid: pmc7500422. 23. qiu c, cui c, hautefort c, haehner a, zhao j, yao q, et al. olfactory and gustatory dysfunction as an early identifier of covid-19 in adults and children: an international multicenter study. otolaryngol head neck surg. 2020 oct; 163(4): 714–721. doi: 10.1177/0194599820934376; pmcid: pmc7298561; pmid: 32539586. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles philippine journal of otolaryngology-head and neck surgery 27 abstract objective: to determine the prevalence of benign vocal cord lesions among filipino patients in a tertiary institution and identify the demographic characteristics and possible risk factors found among these patients. methods: design: retrospective case series setting: private tertiary hospital participants: records of 2,375 patients who underwent laryngeal video endoscopy and stroboscopy from 2012-2014 were reviewed. results: there were 632 records of patients with benign vocal fold lesions, of which nodules were most common (211, 33.38%) followed by reinke’s edema (165, 26.10%), cysts (122, 19.30%) and polyps (74, 11.70%) with hoarseness as the most common symptom (542, 85.76%). more than half (336, 53.16%) were aged 21-40 years and almost two-thirds (469, 74.21%) were female. the most common associated factors were caffeine intake (445, 70.41%) and inadequate water intake (370, 58.54%), followed by alcohol (253, 40.03%). smoking was only present in 146 (23.19%). conclusions: baseline evidence on the prevalence of benign vocal fold lesions in this institution as well as baseline data on the common characteristics and associated factors seen in the sample population may assist us in current practices and guide future studies directed toward treatment and prevention. keywords: vocal cord; stroboscopy; vocal cord nodules; benign vocal cord; stroboscopy/benign; stroboscopy/nodules current advances in technology have led to the development of tools for easier visualization and diagnosis of the larynx. particularly useful is laryngeal videoendoscopy and stroboscopy (lves).1, 2 over 50% of patients presenting with voice complaints have have benign vocal cord lesions,1, 3-5 among which nodules are most prevalent,2, 5, 7 followed by vocal cord polyps, reinke’s edema, cysts and papillomas.8, 9 hoarseness is the most frequent presenting symptom although other symptoms such as cough, foreign body sensation, heartburn, throat-clearing, pain, breathlessness and vocal breaks are also noted.2,5,7 benign vocal cord lesions are more often diagnosed in males than females and are more often found in the 20-60 year old age group.5, 8 commonalities include talkative personalities and voice-requiring occupations related to voice demographic profile and risk factors of patients with benign vocal fold lesions diagnosed through laryngeal videoendoscopy and stroboscopy tracy camille p. chan, md ma. clarissa s. fortuna, md patrick s. enriquez md department of otorhinolaryngology head and neck surgery the medical city correspondence: dr. ma. clarissa s. fortuna department of otorhinolaryngology head and neck surgery the medical city ortigas avenue, pasig city 1600 philippines phone: (632) 635 6789 local 6250 fax: (632) 687 3349 email: ent@medicalcity.com.ph the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest (3rd place), september 24, 2015. natrapharm, the patriot bldg., paranaque city, philippines. philipp j otolaryngol head neck surg 2017; 32 (1): 27-29 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 28 philippine journal of otolaryngology-head and neck surgery original articles abuse and misuse.2, 5-7, 9 other factors that may play a role are smoking, alcohol intake, reflux, allergies, chronic cough and infection,5, 7 with smoking contributing heavily to the appearance of lesions.8 however, other data has shown no significant relationship between smoking and the presence of benign vocal cord lesions.6 moreover, data about the prevalence of benign vocal cord lesions as well as the patient profiles and postulated risk factors associated with them are available in foreign but not local literature and it is important to establish if such data is applicable and comparable to local data. this study seeks to determine the prevalence of benign vocal cord lesions among filipino patients in a tertiary institution and identify the demographic characteristics and possible risk factors found among these patients. methods with institutional review board protocol approval, a retrospective review of records of all patients who underwent laryngeal videoendoscopy and stroboscopy (lves) at the voice and swallowing laboratory of our tertiary hospital from january 1, 2012 to december 31, 2014, and were subsequently diagnosed to have benign vocal cord lesions (nodules, cysts, polyps, granulomas, reinke’s edema, papillomas) were considered for inclusion. excluded were records of caucasian patients, lesions that were diagnosed as neither benign nor malignant (i.e. atrophy, varices, web), overtly malignant lesions and lesions of infectious etiology. primary sources of data included patient questionnaires and printed-out lves results. prior to undergoing lves, patients were routinely interviewed using the questionnaire. data obtained from this questionnaire included the presenting symptom, age, sex, occupation, prior treatment, concomitant medical conditions and risk factors. all lves had been conducted using a kay rls 9100 rhino-laryngeal stroboscope and digital videostroboscopy system (kay elemetrics, nj, usa). printouts included pertinent images and the subsequent diagnosis. data on voice usage was excluded from the study as this was a subjective factor and could not be quantified. the reflux symptom index (rsi) was also excluded as this was considered more relevant for reflux as a separate disease entity. patient anonymity was protected in the collection of data. confidential patient data was only known to the authors who were also the physicians who conducted lves examinations. data was compiled and analyzed with descriptive statistics using microsoft excel for mac 2011 version 14.6.8 (microsoft corporation, redmond, wa, usa). results a total of 2,375 patient records were reviewed for inclusion in this study. of these, 632 had a diagnosis of benign vocal cord lesions and were included. excluded were 1,743 records; 265 with laryngopharyngeal reflux (lpr), 688 with other laryngeal pathologies (i.e. infectious, cancer), 442 with non-glottic/non-laryngeal pathologies, 84 with normal laryngeal findings, 201 without a written diagnosis and 63 with insufficient data. of the 632 patients included, the majority (178, 28.16%) belonged to the 21-30 year old age bracket closely followed by the 31-40 year-old (158, 25.00%), and 41-50 year-old (131, 20.73%) age groups. there were thrice more females (469, 74.21%) than males (160, 25.32%). the most common occupations were customer service representative (200, 31.64%) and office employee (64, 10.12%). other occupations included teachers (49, 7.75%), housewives (29, 4.58%) and businessmen (27, 4.27%). of the benign vocal cord lesions, nodules were most common (211, 33.38%) followed by reinke’s edema (165, 26.10%), cysts (122, 19.30%), and polyps (74, 11.70%). least common were laryngeal papilloma (7, 1.10%), sulcus (26, 4.11%) and granuloma (27, 4.27%). a total of 246 (38.92%) were found to have concomitant lpr. the majority presented with hoarseness (542, 85.76%) followed less commonly by pain (22, 3.48%), globus sensation (13, 2.06%) and throat discomfort (13, 2.06%). aside from their primary diagnosis, 353 (55.85%) had a past history of other illnesses (i.e. gerd, rhinitis, asthma), and 257 (40.66%) had received some form of treatment (i.e. antibiotics, antihistamines, ppi) prior to the evaluation. among the risk factors evaluated, the most common were caffeine intake (445, 70.41%) and inadequate water intake (370, 58.54%) followed by alcohol (253, 40.03%). surprisingly, smoking was only present in 146 (23.19%). discussion consistent with previous studies,5,8 benign lesions were predominantly found in the 20-60 year-old age group. however, unlike these studies5, 8 benign lesions in our study were more predominant in females than in males. also consistent with previous studies,2, 5, 7 vocal cord nodules were the most common of the benign vocal cord lesions. however, certain differences were noted in this study that may be attributed to differences in culture and possibly to the local surge in call center workers whose profession requires long hours of voice use. the second most common benign lesion in this study was reinke’s edema followed by cysts then polyps in contrast to studies elsewhere8, 9 where polyps are second most common followed by reinke’s edema and cysts. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles philippine journal of otolaryngology-head and neck surgery 29 it is well established that benign lesions are most frequently diagnosed in those with voice abuse related occupations. 2, 5, 7, 9 this was affirmed in our study where a large number were customer service representatives whose jobs are very much voice-dependent. our finding of hoarseness as the most common presenting symptom is also consistent with the literature.2,5,7 on the other hand, contrary to previous reports,5, 7, 8 caffeine intake, rather than smoking, was the most common risk factor in our study. this study was intended to benefit both clinicians and professionals in the academe who wish to acquire locally based descriptive data about the prevalence and demographic profile of patients with benign vocal cord disorders. the study is limited in that despite the availability of data with which references samlan ra, gartner-schmidt j, kunduk m. visualization of the larynx. in flint pw, haughey bh, 1. lund vj, niparko jk, richardson ma, robbins kt, et al (editors). cummings otolaryngology head and neck surgery. 5th ed., vol. 1. philadelphia, pa: elseviermosby. 2010. pp.813-824. yogesh s, daharwal a, prasad r, singh s, shankari -raipur v. shankari -raipur (chhatisgarh). 2. videostroboscopy study of larynx in primary school teachers. national journal of otolaryngology and head and neck surgery. 2014 jan; 11(1), 32-33. [retrieved 2015 feb 13]. available from: https://www.researchgate.net/publication/281889037_videostroboscopy_study_of_larynx_ in_primary_school_teachers. bohlender j. diagnostic and therapeutic pitfalls in benign vocal fold diseases. 3. gms curr top otorhinolaryngol head neck surg. 2013 dec 13; 12: doc01. [retrieved 2015 feb 14]. available from http://www.egms.de/static/pdf/journals/cto/2013-12/cto000093.pdf. doi: 10.3205/ cto000093; pmid: 24403969; pmcid: pmc3884536. dabirmoghadam p, azimian s, mokhtari z. stroboscopic findings in patients with benign 4. laryngeal lesions: a brief report. tehran univ med j. 2012 nov; 70(8): 508-513. [retrieved 2015 feb 13]. available from http://tumj.tums.ac.ir/browse.php?a_id=88&sid=1&slc_lang=en. wani aa, rehman a, hamid s, akhter m, baseena s. benign mucosal fold lesion as a cause of 5. hoarseness of voice a clinical study. otolaryngology. 2012; 2(3). [retrieved 2015 feb 13]. available from: https://www.omicsonline.org/benign-mucosal-fold-lesion-as-a-cause-of-hoarseness-ofvoice-a-clinical-study-2161-119x.1000120.pdf. doi:10.4172/2161-119x.1000120. byeon h. exploring potential risk factors for benign vocal fold mucosal disorders using weighted 6. logistic regression. international journal of bio-science and bio-technology. 2014; 6(4), 77-86. [retrieved 2015 feb 13]. available from: http://www.sersc.org/journals/ijbsbt/vol6_no4/8.pdf. doi: dx.doi.org/10.14257/ijbsbt.2014.6.4.08. smith s, underbrink m. benign vocal fold lesions. grand rounds presentation, the university 7. of texas medical branch in galveston, department of otolaryngology. 2013 nov 26. [retrieved 2015 feb 13]. available from http://www.utmb.edu/otoref/grnds/vocal-cord-benign-lesions2013-11/vocal-cord-2013-11.pdf. gupta n, gurnani d, patel n, patel t, sharma p, jindal s, et al. benign vocal cord lesions. national 8. journal of otorhinolaryngology and head & neck surgery. 2013 jan; 1(2): 19-20. [retrieved 2015 feb 13]. available from: https://www.researchgate.net/publication/291911634_benign_ vocal_cord_lesions. nunes rb, behlau m, nunes mb, paulino jg. clinical diagnosis and histological analysis of vocal 9. nodules and polyps. braz j otorhinolaryngol. 2013 aug; 79(4): 434-440. [retrieved 2015 feb 14]. available from http://www.scielo.br/pdf/bjorl/v79n4/en_v79n4a07.pdf. doi: 10.5935/18088694.2013007; pmid: 23929142. perez fernandez ca, preciado lopez j. vocal fold nodules, risk factors in teachers. a case control 10. study design. acta otorrinolaringol esp. 2003 apr; 54(4): 253-260. [retrieved 2015 feb 14]. available from http://www.ncbi.nlm.nih.gov/pubmed/12825241. pmid: 12825241. may be inadequate and should not be considered a representative sample of the population. this may be resolved by extending the period of the study to more than just 5 years or by increasing the number of subjects by obtaining data from other institutions/facilities. in conclusion, laryngeal videoendoscopy and stroboscopy plays a valuable role in the detection of vocal pathologies and has enabled us to gather baseline evidence on the prevalence of benign vocal fold lesions in our institution as well as baseline data on the common characteristics and associated factors seen in the sample population. knowing these factors may assist us in current practices and guide future studies directed toward the treatment and prevention of these lesions. philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 case reports philipp j otolaryngol head neck surg 2020; 35 (2): 48-50 c philippine society of otolaryngology – head and neck surgery, inc. a case report of maxillary calcifying epithelial odontogenic tumor in a teenage girl jose pedrito m. magno, md1 josefino g. hernandez, md2 daryl anne a. del mundo, md2 1department of otorhinolaryngology philippine general hospital university of the philippines manila 2department of otorhinolaryngology college of medicine philippine general hospital university of the philippines manila correspondence: dr. daryl anne a. del mundo department of otorhinolaryngology ward 10, philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 email: dadelmundo@up.edu.ph the authors declare that this represents original material, that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the 2017 philippine general hospital expanded hospital research office (pgh-ehro) resident’s research forum (3rd place), october 10, 2017, hrdd training room, philippine general hospital, manila city. abstract objective: to report the case of a rare benign odontogenic tumor in an adolescent girl which was successfully managed by complete excision and curettage of underlying bone. methods: design: case report setting: tertiary national university hospital patient: one result: a 15-year-old girl with a 3-year history of a large calcifying epithelial odontogenic tumor (pindborg tumor) atypically occurring in the posterior maxillary alveolar ridge and compressing the maxillary antrum underwent tumor excision via gingivobuccal approach and curettage of the remaining mucosa in the cavity in consideration of her patient’s aesthetic concerns. no recurrence has been observed two years post-op and she remains asymptomatic on regular follow-up. conclusion: a calcifying epithelial odontogenic tumor can be managed conservatively with close follow-up to monitor recurrence. keywords: calcifying epithelial odontogenic tumor; pindborg tumor; conservative surgery; adolescent when planning to perform surgical excision of a mass that could potentially alter maxillofacial growth of a pediatric patient, one must be knowledgeable of the histology and clinical behavior of the disease entity encountered, in order to plan the most conservative approach that will yield a desirable outcome. this case highlights the successful removal of a maxillary pindborg tumor in a young female with excision and curettage. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 case reports discussion the calcifying epithelial odontogenic tumor (ceot ) was first described in 1955 by dutch pathologist jens jorgen pindborg.1 it is a benign expansile slow-growing neoplasm which behaves clinically like an ameloblastoma but has a lower rate of recurrence. it has a peak incidence in the age range of 40-60 years, with no apparent sex predilection and a greater tendency to appear in the mandible rather than the maxilla, with a ratio of 3:1.2 the central or intraosseous variant is more common and is described in approximately 96% of documented cases, while the peripheral or extraosseous variant comprises the remainder.3 figure 1. a. representative axial computed tomography (ct) image showing a soft tissue mass with irregular calcific densities and an imbedded unerupted tooth occupying the space where the maxillary sinus should have been; b. representative coronal computed tomography (ct) image showing the mass extending inferiorly below the occlusal line and laterally into the gingivobuccal sulcus, with its superior aspect pushing the floor of the maxillary sinus upwards but without causing dehiscence. a b figure 2. a. intraoperative images showing a well-encapsulated, nodular intra-oral mass expanding the left maxillary alveolar ridge; b. excision via blunt dissection revealed an expanded cavity on the alveolar ridge, but the floor of the maxillary sinus was intact. a b (hematoxylin – eosin , 100x) figure 4 a.frontal image taken pre-operatively; b. frontal image taken 2 years post-operatively; c. intra-oral image taken 2 years post-operatively showing good mucosal healing, decrease in the size of the surgical cavity and no tumor recurrence. a b c case report a 15-year-old girl presented in our hospital with an enlarging left upper alveolar mass that evolved over three years. she initially consulted the dentistry service for a painless pea-sized gingival mass that radiographically appeared as a unilocular radiolucency extending from the second premolar to the first molar in the left maxillary alveolar ridge. incision biopsy revealed an eruption cyst which was marsupialized. a year later, the patient noted recurrence of the mass in the previous surgical site. a panoramic radiograph showed mixed radioopacities and radiolucencies. computed tomography revealed an expansile unilocular osseous lesion with multiple calcific densities at the alveolar aspect of the left lateral maxilla, compressing the left maxillary sinus supero-medially towards the orbital floor. (figure 1) she was referred to otorhinolaryngology for incision biopsy, which yielded findings consistent with calcifying epithelial odontogenic tumor. upon admission, the patient had obvious enlargement of the left cheek, stretching the skin without causing any induration or ulcerations. in the oral cavity, the mass appeared as a 5 x 4 x 3 cm firm, multilobulated, movable mass occupying the area from the first premolar to the second molar of the left maxillary alveolar ridge and abutting the buccal mucosa laterally and medially overhanging towards the hard palate. rather than perform a lateral rhinotomy to achieve optimal exposure, the patient’s aesthetic concerns were considered, and the mass was completely excised intra-orally through a gingiva-buccal incision, leaving a cavity in the expanded but intact alveolar ridge. curettage removed the remaining mucosa and a thin portion of underlying bone. (figure 2) final histopathologic examination confirmed the diagnosis of pindborg tumor. (figure 3) the patient has been on follow-up for two years with marked improvement in the symmetry of her face, and no note of recurrence at the surgical site. (figure 4) figure 3. a. gross specimen consisting of a 7 x 7 x 4 cm firm nodular well-encapsulated mass with left canine and molar; b. sheets of eosinophilic, polyhedral cells in a cribriform pattern with welldefined cell borders and distinct intercellular borders (asterisk), with liesegang calcification (arrow) and amyloid-like material (arrowhead). (hematoxylin-eosin, 100x magnification) a b philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 2 july – december 2020 case reports early in its growth, ceot may appear on radiograph as a unilocular radiolucency and becomes progressively more radio-opaque as calcium deposits start to accumulate. subsequently, a mixed radio-lucent/radioopaque appearance can manifest as bone is simultaneously eroded. furthermore, 60% of cases have been shown to involve an impacted tooth. this conglomeration of radiographic findings, all observed in this patient, may explain why such cases may easily be initially diagnosed and managed as an odontogenic cyst.4 this stresses that ceot should not be left out of the differential diagnosis despite its rarity, as it may have a very similar appearance to more common entities. establishing the diagnosis of ceot is dependent upon histopathologic features. typically, there is scanty connective tissue stroma arranged in sheets of polyhedral epithelial cells surrounded by a homogenous eosinophilic material, thought to be amyloid. the pathognomonic finding is described as concentric calcifications within the amyloid substance, called “leisegang rings.”5 unlike the majority of ceot this case occurs in a less common location, in an unusual age demographic, exhibiting both intraosseous and extraosseous components. apart from the atypical features seen in this patient, perhaps the most important aspect of this case lies in the management dilemma it presents. lesions of the maxilla are known to be more locally invasive and grow more rapidly, possibly warranting more aggressive surgery.6 but in this case, we had an adolescent girl for whom aesthetic outcome was a major consideration, making it necessary to plan the least invasive and disfiguring surgery possible. in this unique situation there is only a small volume of available literature from which to draw recommendations. a case report and literature review by fazeli et al. outlined 14 cases of ceot in pediatric patients, with only 4 occurring in the maxilla;7 ungari et al. performed enucleation and curettage of a 0.8 cm ceot of the maxilla in a 9-year-old boy;8 mopsik et al. documented intra-oral access and enucleation for a cystic ceot of the maxilla in a 13-year-old girl;9 gopalakrishnan et al. reported a large invasive cystic ceot situated within the maxillary sinus itself which was enucleated via caldwell-luc approach;10 and mandal et al. described a 6 x 5 cm ceot of the hard palate causing lytic changes in adjacent bony structures, although the type of excision was unspecified.11 no recurrence was documented for any of these cases, but follow-up periods for these cases ranged only from 1 month to 1 year. perhaps the case most similar to ours was presented in a separate report by tiwari, which involved a 12-year-old boy presenting with a 5-month history of cheek swelling due to a 6 x 4 cm maxillary ceot.5 excision was performed, and although there was no mention of curettage of underlying bone for additional margins, the patient likewise exhibited no recurrence after 2 years of follow-up.5 there is some evidence suggesting that ceot does not infiltrate inter-trabecular bony spaces, supporting the consideration of acknowledgements the authors would like to acknowledge dr. dahlia teresa r. argamosa, dr. erick martin h. yturralde and dr.marvin c. masalunga, our colleagues from the pathology section of the philippine general hospital department of laboratories for providing photodocumentation of the histopathologic slides. references 1. akhtar k, khan n, zaheer s, sherwani r, hasan a. pindborg tumor in an adolescent. oman med j. 2010 jan; 25(1):47-8. doi: 10.5001/omj.2010.12; pubmed pmid: 22125699; pubmed central pmcid: pmc3215391. 2. shah ks, butt fma, dimba eao. case report: calcifying epithelial odontogenic tumor (pindborg tumor). anat j afr. 2015 jul; 2 (2): 135-136. available from http://www.anatomyafrica.com/ vol2issue2/kshah.pdf. 3. singh n, sahai s, singh s, singh s. calcifying epithelial odontogenic tumor (pindborg tumor).  nat j maxillofac surg. 2011 jul-dec;  2(2): 225–227. doi: 10.4103/0975-5950.94489; pubmed pmid: 22639521 pubmed central pmcid: pmc3343415. 4. halaj-mofrad a, rajabi m, dabiri s. calcifying epithelial odontogenic (pindborg) tumor involving a 16-year-old girl with no prominent clinical manifestation: a case report.  j oral health oral epidemiol. 2015 feb; 4(1): 51-57. available from: http://johoe.kmu.ac.ir/article_84816.html. 5. tiwari m. 12 year pediatric patient having pindborg tumour an intraosseous variant: a rare case presentation affecting the maxilla. oral health case rep. 2016 mar.2(1). doi:10.4172/ ohcr.1000109. 6. rani v, masthan mk, aravindha b, leena s. aggressive calcifying epithelial odontogenic tumor of the maxillary sinus with extraosseous oral mucosal involvement: a case report. iran j med sci. 2016 mar. 41(2): 145–149. pubmed pmid: 26989286 pubmed central pmcid: pmc4764965. 7. fazeli s, giglou k, soliman m, ezzat w, salama a, zaho q. calcifying epithelial odontogenic (pindborg) tumor in a child: a case report and literature review. head and neck pathol. 2019 dec; 13(4): 580-586. doi: 10.1007/s12105-019-01009-1; pubmed central pmcid: pmc6853849. 8. ungari c, poladas g, giovannetti f, carnevale c, ianetti g. pindborg tumor in children. j craniofac surg. 2006 mar; 17(2):365-9. doi: 10.1097/00001665-20060300-00029; pubmed pmid: 16633191. 9. mopsik e, gabriel s. calcifying epithelial odontogenic tumor (pindborg tumor). report of two cases. oral surg oral med oral pathol. 1971 jul; 32(1):15-21. doi: 10.1016/0030-4220(71)90245-3; pubmed pmid: 5281552. 10. gopalakrishnan r, simonton s, rohrer m, koutlas i. cystic variant of calcifying epithelial odontogenic tumor. oral surg oral med oral pathol oral radiol endod. 2006 dec; 102(6):773-7. doi: 10.1016/j.tripleo.2005.09.029; pubmed pmid: 17138180. 11. mandal s, varma k, khurana n, mandal a. calcifying epithelial odontogenic tumor: report of two cases. indian j pathol microbiol. 2008 jul-sep; 51(3):397-8. doi: 10.4103/0377-4929.42529; pubmed pmid: 18723969. 12. vigneswaran t, naveena r. treatment of calcifying epithelial odontogenic tumor/pindborg tumor by a conservative surgical method. j pharm bioallied sci. 2015 apr; 7 (suppl 1): s2915. doi: 10.4103/0975-7406.155961; pubmed pmid: 26015736 pubmed central pmcid: pmc4439696. enucleation and curettage of thin remaining bone. however, these reports involved less aggressive tumors found in the mandible.12 it has been postulated that certain histologic features such as the presence of more amyloid and calcific tissue, in contrast to more clear cells, confers less aggressive potential.5 recommendations regarding radicality of surgery vary due to the unpredictable behavior of ceots, but most authors are in agreement that it is imperative to achieve tumor-free hard and soft surgical margins to minimize recurrence.6 in our case, the decision to adapt a more conservative surgical approach was arrived at by weighing the risk of recurrence against leaving an unsightly scar on a young face, which could yield detrimental psychological effects. in the absence of clear-cut recommendations, the patient’s wish for a better aesthetic outcome took precedence. as a compromise, close follow-up was planned in order to facilitate early detection of possible recurrence, which is said to be 10 to 20% following conservative management.6 fortunately, good healing and no sign of recurrence has been observed in the last two years of follow-up. there is a need to further document the longterm outcomes of ceot, and the occurrence of these tumors in the pediatric population presents that opportunity. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to determine the prevalence of dysphonia, defined as any perceived voice pathology, in conventional cigarette smokers and e-cigarette users and to quantify and compare the filipino voice handicap index (vhi) scores of the two groups based on the mean scores for each of the three domains of this tool, as well as the mean total score for each group. methods: design: cross-sectional study setting: tertiary national university hospital participants: 52 adults between the ages 18-65 with no previously known laryngeal illness or condition were divided into 26 conventional smokers and 26 e-cigarette users and completed the self-administered filipino voice handicap index. results: the prevalence of impairment in the sample using a total vhi score cut-off of 18 was 17.31% (9 out of 52, ci 8.23-30.32%) and the prevalence of dysphonic symptoms in the sample was 86.54% (45 out of 52, ci 74.21-94.41%). there were no significant differences between smokers and e-cigarette users for impairment using this cut-off (z: -1.36, p: .07) and dysphonic symptoms (z: 0.4063, p: .68). the prevalence of moderate impairment was 3.85% (1 out of 26, ci: 0.10-19.64%) among those using e-cigarettes; and 1.92% (1 out of 52, ci: 0.04-10.26%) among the entire sample population. conclusion: there appears to be no statistically significant difference between the filipino vhi scores of conventional smokers and e-cigarette users. further inquiry into the subject would benefit from a larger sample size, comparison with a control group, inclusion of other factors relevant to the development of dysphonia, and correlation with objective means for voice analysis. keywords: dysphonia; smoking, vaping; e-cigarette, cigarette, voice handicap dysphonia in smokers of combustible cigarettes and e-cigarettes measured using the filipino voice handicap index maria angela s. dealino, md anna pamela c. dela cruz, md department of otolaryngology-head and neck surgery philippine general hospital university of the philippines manila correspondence: dr. anna pamela c. dela cruz department of otolaryngology-head and neck surgery philippine general hospital university of the philippines manila taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 email: acdelacruz14@up.edu.ph the authors declared that this represents original material that is not being considered or publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by both authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest presented at the philippine society of otolaryngology – head and neck surgery 2nd virtual analytical research contest, november 10, 2021 and at the residents’ original research forum, analytical category (2nd place), department of otolaryngology-head and neck surgery, philippine general hospital, university of the philippines manila, july 16, 2021. philipp j otolaryngol head neck surg 2022; 37 (1): 27-32 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles the global adult tobacco survey (gats) in 2015 estimated that 0.8% of the philippine population use electronic cigarettes or e-cigarettes.1 as opposed to combustible cigarettes that burn tobacco, these handheld devices vaporize electronic liquids (e-liquids) at a lower temperature to produce a wide array of flavors and vapor.2 e-liquids or e-juice potentially contain substances such as nicotine derivatives, impurities, heavy metals, and volatile organic compounds.2 these are marketed as an alternative to smoking, with the republic of the philippines house of representatives issuing a resolution in 2018 urging the department of health to promote harm reduction measures including the use of e-cigarettes.3 some physiological effects of e-cigarettes have been investigated by several studies but none of these focus on dysphonia.4-6 cardiovascular, pulmonary, and immunologic effects have been noted, but the associated health consequences of e-cigarette use have yet to be determined over the long-term.4-6 a single case reported a vaping-related vocal fold injury in a 55-year-old female with a 20 pack-year tobacco history after misuse.7 smoking has been demonstrated to have an association with dysphonia in the korean general population.8 female smokers were also demonstrated to have significant group differences in dysphonia severity index scores compared to nonsmokers.9 a meta-analysis showed that cigarette smoking had an intermediate level significant difference for the physical subscale of the voice handicap index, although this was not observed for the functional and emotional subscales. this study also showed an intermediate level significant difference for pitch (f0) and maximum phonation time.10 however, there seems to be conflicting evidence on the effect of smoking on perceived vocal handicap, with other studies suggesting that smoking does not affect patient handicap in relation to dysphonia.11 in the case of e-cigarettes, the data is lacking even further. being a relatively new technology, the possible clinical effects of e-cigarette use have yet to be determined.4 this is a relevant area for investigation as voice disorders significantly affect patients’ quality of life and incur considerable healthcare costs.12 this study aims to contribute to the lacking epidemiological data on e-cigarette health effects in relation to dysphonia. specifically, we aim to determine the prevalence of dysphonia, described as any perceived voice impairment, in conventional cigarette smokers and e-cigarette users and to quantify and compare psychosocial handicap by comparing the filipino voice handicap index (vhi) mean scores of the two groups for each domain as well as for total scores. methods with university of the philippines manila research ethics board (upmreb 2019-449-01) approval, this cross-sectional study considered for inclusion, adults between the ages 18-65 with no previously known laryngeal illness or condition. prospective participants were excluded if they had been diagnosed with chronic respiratory disorders such as asthma and chronic obstructive pulmonary disease, had frequent episodes of heartburn, reflux, chronic cough, dysphagia, or if they were previously diagnosed with medical conditions consistent with laryngopharyngeal reflux, or gastroesophageal reflux disease. two groups were defined conventional cigarette smokers, or any participant who at the time of the study had exclusively smoked at least 1 combustible cigarette per day for at least one year, and e-cigarette smokers or participants who at the time of the study had used a smokeless nontobacco device for at least one vaping session once daily. the calculated sample size was 26 for each group to demonstrate a large effect size of 0.8 between two means, a type i error rate at 0.05, and power at 0.80 using the following formula: the study was not limited to recruiting e-cigarette users that had been exclusively vaping for at least one year regardless of the possibility of dual use with conventional cigarettes because of the limited population of vapers. participants were recruited mainly through face-to-face meetings in the metro manila area. snowball sampling was also employed as prospective participants were able to refer other potential study participants. after obtaining informed consent in both english and filipino, demographic data and frequency and quantification of smoking and vaping were recorded. the filipino vhi was then accomplished by each participant. the vhi is a self-administered questionnaire consisting of 30 statements of reactions and experiences to voice disorders, divided into functional, emotional, and physical subscales.13 a five-point likert scale is used (0-never, 1-almost never, 2-sometimes, 3-almost always, 4-always), with the mean score for each of the 10 questions per subscale corresponding to the subscale score.13 minimal handicap is considered for a total score of 0 to 30, a moderate handicap is reflected by a total score of 31 to 60, and a total score of 61 to 120 is associated with severe handicap.14 deidentified data were tabulated, encoded, and summarized using microsoft excel v2016 (microsoft corp., redmond, wa, usa). statistical analysis was performed using stata statistical data analysis 13 software (statacorp llc, college station, tx, usa). descriptive statistics such as means, standard deviations, frequencies and percentages were used to provide an overview of the study population. a series of independent mean group1 mean group2 pooled std deviation d = philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery original articles t-tests were used to compare age between the groups, as well as compare the total and sub-scale scores of the filipino vhi tool across select variables; and chi-square tests of association were rendered to compare sex, education, and duration of use between the said groups. pearson correlation was used to determine a relationship between age and the ratings for the same tool. the prevalence for impairment was calculated for e-cigarette users and conventional smokers as proportions with confidence intervals. odds ratios were also computed for the presence of impairment and dysphonic symptoms. the level of significance for all sets of analysis was set at a p-value less than .05 using two-tailed comparisons. results there were 52 participants in this study, 26 each in the combustible cigarette and e-cigarette groups, respectively. there was no concurrent or dual use of combustible cigarettes and e-cigarettes among the participants. the former had 20 (76.92%) males and 6 (23.08%) females with ages ranging from 20 to 60 years of age (m = 34.19; sd ± 10.12). the latter had 18 (69.23%) males and 8 (30.77%) females with ages ranging from 21 to 36 years of age (m = 28.50; sd ± 4.70). the filipino vhi scores according to sex are compared in table 1. participants who used e-cigarettes tended to be younger (t: 2.60, df: 50, p = .01) than those who used combustible ones. the correlation of filipino vhi scores with age is shown in table 2. there was no association with the vhi scores for the variables of age and sex. duration of use for the combustible cigarette group was less than 6 months for 1 (3.85%), 6-12 months of use for 1 (3.85%), 1-2 years for 2 (7.69%) and more than 2 years for 22 (84.62%) participants. for the e-cigarette group, the duration of vaping was less than 6 months for 4 (15.38%), 6-12 months for 1 (3.85%), 1-2 years for 8 (30.77%), and more than 2 years for 13 (50%) participants. smokers of combustible cigarettes in the sample tended to have longer duration of use, compared to vapers (χ2 (3, n = 52) = 7.71, p = .03). cigarette use of the combustible cigarette group was characterized as light, moderate, and heavy. of the combustible cigarette group, 18 (69.23%) had light use or smoked less than 10 sticks per day. moderate use, or smoking of 11-19 sticks per day, was reported by 6 (23.08%); and heavy use, or consumption of more than 20 sticks per day, was reported by 2 (7.69%) participants. nicotine content of e-liquid consumed by the e-cigarette users were as follows: 1 (3.85%) consumed e-liquid without any nicotine (0 mg/ml), 17 (65.38%) consumed e-liquid of 1-6 mg/ ml, 6 (23.08%) reported consumption of e-liquid of 7-12 mg/ml and 2 (7.69%) consumed e-liquid with more than > 13 mg/ml. of the combustible cigarette group, 4 (15.38%) were of high school level and 22 (84.62%) had collegiate level of education. for the e-cigarette group, 1 (3.85%) completed elementary schooling, 6 (23.08%) reached high school level, and 19 (73.08%) attained collegiate level education. participants who reached college level tended to have lower ratings for the physical (t: 4.33, df: 50, p<.01), and total sub-scale items (t: 3.07, df: 50, p<.01) than those who reached elementary and high school only. this was also apparent to a certain extent for the functional sub-scale (t: 1.68, df: 50, p=.10). the average functional subscale score for the combustible group was 3.58 + 4.43, and for the e-cigarette group was 4.77 + 7.60 (p = .49). for the physical subscale, the average score for the combustible group was 3.46 + 4.25 and for the e-cigarette group it was 4.38 + 5.69 (p = .51). the average for the emotional subscale for the combustible group was 1.81 + 2.38 and for the e-cigarette group it was 1.96 + 2.82 (p = .83). the average total scores were 8.85 + 7.64 and 11.12 + 12.86 (p = .44) for the combustible group and e-cigarette group, respectively. there was no significant difference between the average subscale and total scores for the two groups. using a cut-off for total vhi score of 18 to indicate impairment, there were no significant differences between smokers (3 out of 26; 11.54%) and e-cigarette users (6 out of 26; 23.08%) using a test of proportions (z: -1.36, p = .17). the prevalence of impairment in the sample using this cut-off was 17.31% (9 out of 52; ci 8.23-30.32%). the prevalence of dysphonic symptoms in the sample was 86.54% (45 out of 52; ci 74.21-94.41%) and similarly there was no noted difference between e-cigarette users (23/26; 88.46%) and smokers (22/26; 84.62%) in terms table 1. comparison of filipino vhi scores according to sex functional physical emotional total 4.14 ± 5.23 4.07 ± 3.56 1.29 ± 2.05 9.50 ± 6.45 4.18 ± 6.57 3.87 ± 5.47 2.11 ± 2.75 10.16 ± 11.76 -0.02 .98 0.13 .90 -1.01 .25 -0.20 .84 vhi domains females m ± sd males m ± sd student t test t p-value note: n = 52, degrees of freedom = 50 table 2. correlation of filipino vhi scores with age functional physical emotional total -0.07 -0.17 0.00 -0.12 -0.34, 0.21 -0.42, 0.11 -0.27, 0.27 -0.38, 0.16 .62 .23 .99 .39 vhi domains r pearson correlation p-value95% ci philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles of this outcome (z: 0.4063, p = .68). one e-cigarette user reported a total vhi score of 58, corresponding to moderate impairment. the calculated odds ratio for the presence of dysphonic symptoms in e-cigarette users compared to smokers was 1.39 [ci: 0.28-6.95]. e-cigarette users had 2.3 [ci 0.51-10.41] odds of having impairment using a cut-off of 18. with a cut-off 20 on the other hand, e-cigarette users had odds of 3.6 [ci: 0.6519.84] compared to smokers. there was no noted association for the variables of age, study groups and sex across the scale scores. discussion this study showed that the prevalence of dysphonic symptoms in the sample was 86.54% (45 out of 52; ci 74.21-94.41%). there was no noted difference between the prevalence among e-cigarette users (23/26; 88.46%) and smokers (22/26; 84.62%) (z: 0.4063, p = .6845). although local prevalence studies are lacking, two cross-sectional studies in united states-based populations by cohen and benninger, respectively, reported a prevalence of dysphonia of 0.98% and 1.7%.15,12 in south korea, cho reported a prevalence of 6.7%.16 the prevalence of impairment in our sample using a cut-off of total vhi of 18 was 17.31% (8.23-30.32%). cho’s study16 was a nationwide cross-sectional survey that was representative of the korean population as it employed a more complex, stratified, multistage probability sampling design. benninger’s study12 employed a large administrative database from which nationwide estimates were projected. our current study on the other hand, only employed convenience and snowball sampling within metro manila. also, for the korean study,16 the presence of dysphonia was self-reported instead of based on a voice handicap index. cultural differences in the perception of dysphonia or impairment cannot be disregarded.17 the voice handicap index originally developed by jacobson and colleagues has been established as a reliable tool for identifying patients with vocal dysfunction.18 psychosocial handicap from voice disorders is psychometrically measured using this validated questionnaire.19 a filipino version was adapted by umali and hernandez in 2006, which was deemed by lim and colleagues to be compatible with other versions of the vhi.13 in our study sample, participants who attained collegiate level education tended to have lower ratings for the physical (t: 4.33, df: 50, p<.01), and total sub-scale items (t: 3.07, df: 50, p<.01) than those who completed elementary and high school levels only. lim and colleagues reported similar findings of significantly higher scores in the primary and secondary education group compared to the college education group.13 there was no association shown for the variables of age, study groups and sex of the participants across the scale scores in this study. in contrast, lim’s study reported significantly higher scores for patients < 40 years old, female, and who were voice professionals.13 a possible explanation for the higher scores reported was that lim’s study13 involved patients already known to have dysphonia from a tertiary referral hospital, whereas this study was limited to participants with no previously diagnosed condition that could predispose to dysphonia. several studies have shown an association between smoking and dysphonia. awan’s study implied the difference between smokers and nonsmokers could herald changes in vocal function at an early stage.9 pinto and colleagues described the influence of smoking on acoustics parameters in particular, smoking decreased fundamental frequency values in both sexes.20 byeon explored the association between lifetime cigarette smoking and dysphonia in the korean general population based on a national health survey, and implied that chronic smoking has a significant relationship with dysphonia.8 an odds ratio of 1.8 was reported for current smokers in terms of self-reported voice problems compared to non-smokers.8 another study by byeon explored the relationships among smoking, organic, and functional voice disorders in the korean general population and found that current smokers were more likely have organic voice disorders compared to nonsmokers (with an odds ratio of 3.22).21 the effect of smoking on dysphonia as suggested by voice handicap index (vhi) scores has yet to be established as conflicting data exists.11 in polish and persian studies, female smokers were found to have higher mean vhi total scores compared to dysphonic patients, but had lower mean vhi total scores for a greek study, as well as one by taguchi as interpreted by tafiadis.22 glas reported that german patients that were smokers did not exhibit a significant difference in vhi scores compared to non-smokers.23 byeon’s meta-analysis evaluated smoking effects on voice, and found that smoking had significant and moderate effects on fundamental frequency, maximum phonation time, and the voice handicap index, particularly the physical subscale.10 our study reports an odds ratio of 1.39 [ci: 0.28-6.95] for the presence of dysphonic symptoms in e-cigarette users compared to smokers. moreover, e-cigarette smokers had 2.3 [ci 0.51-10.41] odds of having a vhi of greater than or equal to 18, which may indicate impairment. using a cut-off value of 20, on the other hand, revealed e-cigarette users to have odds of 3.6 [ci 0.65-19.84] compared to conventional smokers. the cut-off values for the vhi range from 12 to 20, as different cut-off scores are observed for different versions of the vhi.22 the prevalence of moderate impairment in the sample was 3.85% (1 out of 26; ci: 0.1019.64%) among those using e-cigarettes; and 1.92% (1 out of 52; ci: 0.0410.26%) among the entire sample population of this study and there were no significant difference for moderate impairment observed (z: -1.36, p = .17) for the e-cigarette group compared to the study sample. only a large effect size is expected to be detected given the sample philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery original articles size employed by the study. with this, a clinically significant yet small effect size might not be detectable.24 to the best of our knowledge this is the first local study to characterize dysphonic symptoms experienced by e-cigarette users compared to smokers of combustible cigarettes as measured by the filipino vhi. in our sample, e-cigarette smokers tended to come from the younger age group (t: 2.60, df: 50, p: 0.01) than conventional smokers. the gats released by the republic of the philippines department of health had previously reported that e-cigarettes are more popular among younger adults aged 15-24 years.1 e-cigarettes were released in 2003 and had only been in the u.s. market by the mid-2000s25 and as expected for this study, there was a longer duration of use observed for cigarette smokers (χ2 (3, n = 52) = 7.71, p = .03). although previous studies have reported on the significant effect of smoking on dysphonia and voice disorders, we believe ours is the first study to apply this for e-cigarette use. studies on the effect of e-cigarettes on the impact of voice disorders as measured by the voice handicap index are sorely lacking in the literature. a case report on vocal fold injury from vaping misuse surmised that inhalation of hot vapor led to a mucosal burn, appearing as an ulcerative and erythematous lesion.7 since tobacco-control advocates consider e-cigarettes as a viable option for smoking cessation,1 knowledge contributing to the clinical effects of smoking, as well as that of its alternatives may prove to be valuable to the medical community as well as the general public. this study also focused on clinical, albeit perceived, effects of vaping, as opposed to previous studies which were mostly pre-clinical.4 the literature suggests that causes for dysphonia in adults are multifactorial.26,27 this study was limited to comparing the filipino voice handicap index scores of conventional cigarette smokers and e-cigarette users. despite recruitment not being limited to sole users of cigarette users and combustible cigarette smokers (as a paucity of vaping participants was expected given a prevalence of vaping in the philippines only estimated to be 0.8%,1) dual use was not reported by the participants. mutually exclusive groups as well as a nonsmoker control group should be recruited for future studies. covariates such as income, occupation, alcohol consumption, hydration, existing pain or discomfort and comorbidities should also be recorded and adjusted for as with other studies5,28 on dysphonia. the cross-sectional nature of the study also precludes its usefulness in establishing causation. employing a larger sample size may also better demonstrate if indeed there is a difference between filipino vhi scores of conventional smokers and e-cigarette users, as it may detect a smaller effect size. the incorporation of a follow-up period could be adapted for future studies as this would help establish baseline data for comparison, as well as detect effects that might manifest only after prolonged use. it has been suggested that percentage change in score may be more clinically relevant than the absolute vhi score26 and it may be of interest to follow changes in the vhi scores through time. additionally, future studies may endeavor to correlate the filipino vhi with objective measures for voice assessment as well as other perceptual ratings. examples of such are videolaryngostroboscopy, acoustic parameters, the dysphonia risk screening protocol and voicerelated quality of life.28,29 notably, the measurement of e-cigarette use has yet to be standardized, and at present different methods are being used to report consumption.30 further studies are needed to arrive at precise measures of e-cigarette consumption that would allow comparison with combustible cigarette use.30 in conclusion, our study found no statistically significant difference between the filipino vhi scores of e-cigarette users and smokers. dysphonic symptoms were present in 86.54% (ci 74.21-94.41%) in the population, while 17.31% (ci 8.23-30.32%) presented with impairment corresponding with a total vhi score of 18 or more. similarly, there was no significant difference found between e-cigarette users and smokers in terms of these outcomes. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery original articles acknowledgements our gratitude goes out to dr. ryner jose c. carrillo, for continuously following up on the status of our research. we also acknowledge our research assistant, ms. mary jane o. yapo, for her efforts in recruitment and data-collection. many thanks to dr. emilio q. villanueva iii, for his inputs on the statistical analysis. and finally, we would also like to thank dr. jose florencio f. lapeña, jr. for his invaluable suggestions for the improvement of this paper. references 1. republic of the philippines department of health. global adult tobacco survey: country report 2015. [internet] [cited 2022 april 8] available from: https://doh.gov.ph/sites/default/ files/publications/2015gatscountryreport_0.pdf. 2. papaefstathiou e, stylianou m, agapiou a. main and side stream effects of electronic cigarettes. j environ manage. 2019 may 15; 238:10-17. doi: 10.1016/j.jenvman.2019.01.030; pubmed pmid: 30836280. 3. a resolution urging the department of health to promote harm reduction measures, as part of its national tobacco control strategy, particularly the use of electronic cigarettes as an alternative for smokers act, h.r. 973, 17th cong. 2018. [cited 2022 april 8] available from: https://hrep-website.s3.ap-southeast-1.amazonaws.com/legisdocs/first_17/cr00735.pdf. 4. eltorai ae, choi ar, eltorai as. impact of electronic cigarettes on various organ systems. respir care. 2019 mar;64(3):328-33. doi: 10.4187/respcare.06300; pubmed pmid: 30401756. 5. tsai m, byun mk, shin j, crotty alexander le. effects of e-cigarettes and vaping devices on cardiac and pulmonary physiology. j physiol. 2020 nov; 598(22):5039-5062. doi: 10.1113/ jp279754. epub 2020 oct 12. pubmed pmid: 32975834. 6. callahan-lyon p. electronic cigarettes: human health effects. tob control. 2014 may;23 suppl 2 (suppl 2):ii36-40. doi: 10.1136/tobaccocontrol-2013-051470. pubmed pmid: 24732161; pubmed central pmcid: pmc3995250. 7. lechien jr, papon jf, pouliquen c, hans s. e-cigarette vaping-related vocal fold injury: a case report. j voice. 2021 aug 10:s0892-1997(21)00241-1. doi: 10.1016/j.jvoice.2021.06.034. epub ahead of print. pubmed pmid: 34389219. 8. byeon h. the association between lifetime cigarette smoking and dysphonia: findings from a national survey. peerj. 2015 apr 28;3:e912. doi: 10.7717/peerj.912; pubmed pmid:  25945309; pubmed central pmcid: pmc4419546. 9. awan sn. the effect of smoking on the dysphonia severity index in females. folia phoniatr logop. 2011;63(2):65-71. doi: 10.1159/000316142; pubmed pmid: 20926888. 10. byeon h, cha s. evaluating the effects of smoking on the voice and subjective voice problems using a meta-analysis approach. sci rep. 2020 mar 13;10(1):4720. doi: 10.1038/s41598-02061565-3. pubmed pmid: 32170174; pubmed central pmcid: pmc7069957. 11. tafiadis d, tatsis g, ziavra n, toki ei. voice data on female smokers: coherence between the voice handicap index and acoustic voice parameters. aims medical science. 2017 may;4(2):151163. doi: 10.3934/medsci/2017/2/151. 12. benninger m, holy ce, bryson pc, milstein cf. prevalence and occupation of patients presenting with dysphonia in the united states. j voice. 2017 sep; 31(5):594-600. doi: 10.1016/j. voice.2017.01.011; pubmed pmid: 28416083. 13. lim ac, hernandez ml, llanes egd. measurement of the handicap of dysphonic patients using the filipino voice handicap index. philipp j otolaryngol head neck surg. 2010 jan-jun;25(1):7-12 doi: 10.32412/pjohns.v25i1.647. 14. maertens k, de jong fi. the voice handicap index as a tool for assessment of the biopsychosocial impact of voice problems. b-ent. 2007;3(2):61-66. pubmed pmid: 17685046. 15. cohen sm, kim r, roy n, asche c, courey m. prevalence and causes of dysphonia in a large treatment-seeking population. laryngoscope. 2012 feb;122(2):343-8. doi: 10.1002/lary.22426; pubmed pmid: 22271658. 16. cho jh, guilminault c, joo yh, jin sa, han kd, park cs. a possible association between dysphonia and sleep duration: a cross-sectional study based on the korean national health and nutrition examination surveys from 2010 to 2012. plos one. 2017 aug 4;12(8):e0182286 doi: 10.1371/ journal.pone.0182286; pubmed pmid: 28783741; pubmed central pmcid: pmc5544220. 17. yiu em, ho em, ma epm, abbott kv, richardson k, li nyk. possible cross-cultural differences in the perception of impact of voice disorders. j voice. 2011 may;25(3):348-53. doi: 10.1016/j. jvoice.2009.10.005; pubmed pmid: 20335004. 18. niebudek-bogusz e, kuzanska a, woznicka e, sliwinska-kowalska m. assessment of the voice handicap index as a screening tool in dysphonic patients. folia phoniatr logop. 2011;63(5):26972. doi: 10.1159/000324214; pubmed pmid: 21372589. 19. johnson af, jacobson bh, grywalski c, silbergleit a, jacobson g, benninger ms. the voice handicap index (vhi). am j speech language pathol. 1997 august;6(3),66-70. 20. pinto ag, crespo an, mourao lf. influence of smoking isolated and associated to multifactorial aspects in vocal acoustic parameters. braz j otorhinolaryngol. 2014 jan-feb;80(1):60-7. doi: 10.5935/1808-8694.20140013; pubmed pmid: 24626894. 21. byeon h. relationships among smoking, organic, and functional voice disorders in korean general population. j voice. 2015 may;29(3):312-6. doi: 10.1016/j.jvoice.2014.07.015; pubmed pmid: 25510162. 22. tafiadis d, chronopoulos sk, helidoni me, kosma ei, voniati l, papadopoulos p, et al. checking for voice disorders without clinical intervention: the greek and global vhi thresholds for voice disordered patients. sci rep. 2019 jun 27;9(1):9366. doi: 10.1038/s41598-019-45758-z. pubmed pmid: 31249329; pubmed central pmcid: pmc6597569 23. glas k, hoppe u, eysholdt u, rosanowski f. smoking, carcinophobia and voice handicap index. folia phoniatr logop. 2008;60(4):195-8. doi: 10.1159/000131103. epub 2008 may 9. pubmed pmid: 18467847. 24. page p. beyond statistical significance: clinical interpretation of rehabilitation research literature.  int j sports phys ther. 2014 oct; 9(5):726-736. pubmed pmid:  25328834; pubmed central pmcid: pmc4197528. 25. e-cigarette use among youth and young adults. a report of the surgeon general. atlanta, ga: u.s. department of health and human services centers for disease control and prevention, national center for chronic disease prevention and health promotion, office on smoking and health. 2016. [cited 2022 april 8] available from: https://e-cigarettes.surgeongeneral.gov/ documents/2016_sgr_full_report_non-508.pdf. 26. bainbridge ke, roy n, losonczy kg, hoffman hj, cohen sm. voice disorders and associated risk markers among young adults in the united states. laryngoscope. 2017 sep;127(9):2093-2099. doi: 10.1002/lary.26465; pubmed pmid: 28008619; pubmed central pmcid: pmc5481531. 27. hidayat rc, saragih ar, zahara d, adenin li, zaluchu f. dysphonia causative diagnosis linked to voice handicap index of the patients with dysphonia. int j sci stud. 2018;6(1):134-137. doi: 10.17354/ijss/2018/126. 28. nemr k, cota a, tsuji d, simões-zenari m. voice deviation, dysphonia risk screening and quality of life in individuals with various laryngeal diagnoses. clinics (sao paulo). 2018 mar 12;73:e174. doi: 10.6061/clinics/2018/e174. pubmed pmid: 29538494; pubmed central pmcid: pmc5840824. 29. schindler a, mozzanica f, vedrody m, maruzzi p, ottaviani f. correlation between the voice handicap index and voice measurements in four groups of participants with dysphonia. otolaryngol head neck surg. 2009 dec;141(6):762-9. doi: 10.1016/j.orohns.2009.08.021; pubmed pmid: 19932851. 30. yingst j, foulds j, veldheer s, cobb co, yen ms, hrabovsky s, allen si, bullen c, eissenberg t. measurement of electronic cigarette frequency of use among smokers participating in a randomized controlled trial. nicotine tob res. 2020 apr 21;22(5):699-704. doi: 10.1093/ntr/ nty233. pubmed pmid: 30365024; pubmed central pmcid: pmc7171268. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 3736 philippine journal of otolaryngology-head and neck surgery case reports philipp j otolaryngol head neck surg 2021; 36 (1): 37-40 c philippine society of otolaryngology – head and neck surgery, inc. smell training in prolonged covid-19 postinfectious olfactory dysfunction: a case report paulina maria angela c. villar, md, mba ryan u. chua, md ruby p. robles, md department of otorhinolaryngology head and neck surgery the medical city correspondence: dr. ruby p. robles department of otorhinolaryngology head and neck surgery the medical city ortigas avenue, pasig city 1600 philippines phone: (632) 8635 6789 local 250 fax: (632) 8687 3349 email: ruby_robles_ph@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. abstract objective: to report the case of a woman who underwent smell training for post-infectious olfactory dysfunction presumably from covid-19. methods: design: case report setting: tertiary private training hospital patient: one result: a 41-year-old woman who developed olfactory dysfunction attributed to covid-19 underwent smell training. at baseline, her responses were mostly “no smell,” and those reported as “can smell a bit” were rated as distorted. after three months, she could now smell items that she previously could not smell, but these smells were still distorted. at the time of this writing, she was on her 4th month of smell training. conclusion: although we cannot rule out spontaneous resolution of anosmia in our patient, we would like to think that smell training contributed to her recovery of smell. keywords: anosmia; covid-19; olfactory bulb; olfaction disorders viruses that cause upper respiratory tract infections (such as rhinovirus, coronavirus, parainfluenza virus) are known to cause a condition called post-infectious olfactory dysfunction (piod).1 patients with this condition often continue to experience impaired smelling capabilities despite the resolution of other symptoms. olfactory dysfunction has been recognized by the center for disease and control prevention (cdc)2 and the world health organization (who)3 as a symptom of covid-19 caused by sars-cov-2. initially, it was described by lechien et al. as acute sudden onset of olfactory dysfunction without nasal congestion or obstruction,4 but as more studies emerged, its characteristic and duration seem to be more varied with some cases not having complete resolution.5 smell training has been known to improve olfactory sensitivity and is recommended for patients with post infectious olfactory dysfunction, but to the best of our knowledge, based on a search of herdin plus, the asean citation index, the who global index medicus (western pacific region index medicus and index medicus of the south east asia region), and pubmed (medline, pubmed central) using the keywords “olfactory dysfunction”, “anosmia”, “post-infectious olfactory dysfunction”, “covid-19”, we found no published studies on patients with persistent olfactory dysfunction from covid-19 infection. we report the case of a woman who underwent smell training for prolonged post-infectious olfactory dysfunction presumably from covid-19. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery figure 1. mri of the olfactory bulbs (t2 weighted ciss sequence, coronal slice). there is symmetrical flattening with apparent loss of the normal oval configuration of the olfactory bulbs (red arrows). the right olfactory bulb measures 0.8mm while the left measures 1.1mm in maximum thickness. case reports case report a 41-year-old woman complained of loss of sense of smell at the start of the covid-19 pandemic in the philippines. she had no known exposure to a confirmed covid-19 case and no recent travel history. although she had mild intermittent allergic rhinitis she had not experienced any changes or dysfunction in her sense of smell before this. aside from allergic rhinitis, she also had a history of mild epilepsy 18 years prior, with no recurrence and no maintenance medications (corroborated by a normal electroencephalography). she previously smoked one cigarette per week for four years but stopped one year before this present illness. she had just returned to work from maternity leave on march 2, 2020, when after one week (march 9, 2020), she experienced sore throat and nasal congestion which she attributed to her allergic rhinitis. on day nine (march 17, 2020), she developed post-nasal drip which she treated with her usual allergy medication -fluticasone furoate, one spray per nostril once a day, and loratadine 10 mg/tab once a day, both of which were only used as needed. she also started to develop severe persistent frontal headache and non-productive cough. thirteen days after her first symptoms (march 21, 2020), she lost her sense of smell and taste. she also developed pain in her left maxillary area, prompting teleconsultation with a general practitioner. she was prescribed prednisone 20mg/tab one tablet twice a day for three days followed by one tablet thrice a day for 3 days; cefuroxime 500mg/tab, one tablet twice a day for five days, and salbutamol nebulization. all of her symptoms resolved after five days, except for anosmia. two months after onset of her first symptoms (june 1 to 6, 2020), she developed phantosmia. she would smell smoke despite there being no evidence of smoke or other odorant in the immediate area. on june 4, 2020, she consulted an ent specialist. because all her other covid-19 symptoms had resolved, she was no longer a candidate for reverse transcriptase polymerase chain reaction (rt pcr) assay based on the protocols at that time. nasal endoscopy showed unremarkable results with no note of mucus discharge, polyps, obstructive septal deformity, or abnormalities in the olfactory cleft. a paranasal magnetic resonance imaging (mri) and cranial mri (requested by a co-managing neurologist) showed symmetrical atrophy of the olfactory bulbs. (figure 1) the radiographic report measured the right olfactory bulb at 0.8mm and the left at 1.1 mm in maximum thickness. the patient scored 22/40 (corresponding to severe microsmia) on the university of pennsylvania smell identification test (upsit). she was prescribed oral steroids 40 mg/ day for 21 days with decreasing dose, omega 3 supplementation taken once a day, and advised her to continue fluticasone furoate, one spray once a day. two months and 2 weeks after her first symptom (3rd week of june), she began smell training which consisted of inhaling 4 scents (clove, ylang-ylang, lemon, and eucalyptus) for 20 seconds each, twice a day (before breakfast and before bedtime). at the start of smell training, she underwent a modified baseline smell evaluation. using commonly encountered household items, she was asked to rate whether she could detect the smell (“can smell”), was slightly aware of the smell (“can smell a bit”), or could not smell at all (“no smell”); and then determine if the smell was as she expected it to be, or if it was distorted. the items were listed in categories: fruit, vegetable, herbs and spices, nuts, beverages, cleaning/grooming items, personal items, and items seen inside and outside the house. at baseline, her responses were mostly “no smell,” and those she reported she “can smell a bit” were rated as distorted. she subsequently recorded what scents she could smell around her household, monitoring her progress daily in a smell journal. weekly online consultations documented and assessed improvement in terms of smell identification, discrimination, and threshold. three months after the first symptom (july 10, 2020), a sarscov-2 electrochemiluminiscence immunoassay (eclia) antibody test revealed covid-19 igg antibodies corresponding to either the recovery or convalescence phase. although no repeat upsit was performed (due to financial constraints), the patient reported that she could now smell items that she previously could not smell during the modified baseline smell evaluation, but these smells were still distorted or not how she expected them to be. at the time of writing of this paper, she was on her 4th month of smell training. discussion in this case, we described a patient who had symptoms attributed to allergic rhinitis that eventually were considered as post-infectious olfactory dysfunction most likely due to covid-19. unlike most cases reported in the literature, she did not undergo rt pcr testing. at the onset of her smell dysfunction, it was not yet well known that olfactory disturbances were part of the symptomatology of covid-19 and she did not consult or have a test done immediately. when she finally did consult, the patient was mostly asymptomatic except for anosmia and 14 days had elapsed from symptom onset. protocols in place at the time reserved viral rt pcr testing to diagnose current infections.6 however, antibody testing could determine previous covid-19 because philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 3938 philippine journal of otolaryngology-head and neck surgery case reports antibodies only develop one to three weeks after infection.7 three months after onset of symptoms, our patient had an eclia antibody test (that has an 82.4% sensitivity if used at least 14 days from onset of symptoms, with lower sensitivity anytime earlier).7 although the eclia test is not recommended for the diagnosis of covid-19, it supports the possibility of a past covid-19 infection to explain her abrupt and severe olfactory dysfunction. our patient experienced nasal congestion which resolved before the onset of her olfactory dysfunction. she also experienced frontal headache and maxillary pain together with her loss of sense of smell. although anosmia in covid-19 usually presents suddenly without nasal congestion or evidence of nasopharyngeal abnormalities, this does not mean that it exclusively occurs without other ear, nose, throat symptoms. a study describing features of anosmia in covid-19 by klopfenstein et al. noted that 57% presented with rhinorrhea and 30% had nasal obstruction, while 84% also experienced headache along with other symptoms of fatigue, myalgia, fever and cough.8 the olfactory bulbs of our patient appeared atrophic on paranasal and cranial mri. earlier studies that documented covid-19 anosmia with supporting mri studies showed normal olfactory bulbs.9,10 however, chiu et al. showed evidence of olfactory bulb atrophy in a 19-year-old rt pcr confirmed case of covid-19 compared to their patient’s pre-covid mri images.11 other studies show that olfactory bulb volume correlates with olfactory function.12-15 unfortunately, only olfactory bulb thickness (and not volume) was measured in our case, and the impression of olfactory bulb atrophy was based on radiologist experience rather than standardized protocols. moreover, we had no pre-morbid mri images available for comparison. the exact mechanism of olfactory loss in covid-19 is still debatable but studies reviewed by han et al. have made speculations based on the understanding of respiratory viruses.16 similarly, butowt et al. explored and considered four different scenarios that could explain smell dysfunction in covid-19: nasal obstruction/congestion and rhinorrhea, loss of olfactory receptor neurons, brain infiltration affecting olfactory centers, and damage of support cells in the olfactory epithelium.17 given that they analyzed mostly cases of isolated acute onset olfactory dysfunction, they focused on the entry, infection, and death of the sustentacular cells but not on the olfactory receptor neurons that have the capacity to regenerate.17 furthermore, they observed that compared to western countries, regardless of whether it is due to underreporting, or to mutations, or genetic variability of the virus and host, there seems to be a difference between the presentation of anosmia in western and east asian cultures.17 the upsit is a well-validated 40-odorant test that objectively measures the sense of smell of a patient and can be used as a biomarker for covid-19 especially for patients who have mild to moderate symptoms.18 a study by moein et al. noted that some degree of smell loss was present in nearly all covid-19 patients near the end of their acute recovery period, and suggested that quantitative smell tests might serve as a rapid and inexpensive alternative screening tool for covid-19 among large numbers of people.18 however, because most smell tests would take relatively longer to accomplish compared to a temperature check, and since they cannot account for pre-existing olfactory loss, ent uk noted that wide scale mass testing would have limited application as a screening tool.19 the upsit itself may have limited use in the filipino context, as evidente et al. found that only 25 (out of 40) test odor items were familiar (both in nature and smell) to 95% of the patients they surveyed in a study of smell dysfunction among filipinos with x-linked dystonia-parkinsonism in the panay islands.20 the 15 unfamiliar odors excluded from the culturally corrected upsit were cherry, clove, fruit punch, licorice, cinnamon, cedar, gingerbread, lilac, turpentine, peach, dill pickle, lime, wintergreen, pine, and natural gas.20 a filipino version of upsit developed by david et al. in 199421 was not used in this patient as the upsit was more readily accessible. new-onset anosmia in covid-19 is a relatively novel condition and local protocols for management have not yet been established. however, as early as may 19, 2020 recommendations for management were published in the entuk website (https://www.entuk.org/guidelinemanagement-covid-19-anosmia). an algorithm can be found in this website recommending smell training for patients with anosmia that persisted for more than two weeks. smell training has been known to improve olfactory sensitivity through structured, short term exposure to odors.22 anosmic patients are advised smell training by being exposed to four odorants twice a day over three months, and then another four odorants in the next three months.23 this therapy to enhance or amplify olfactory recovery was proposed by hummel et al.,22 speculating that it improves odor thresholds (and by implication the architecture of the peripheral olfactory system), and that olfactory training changes the processing of olfactory information. based on their 2009 study, patients who underwent smell training noted increases in their olfactory function over baseline compared to those who did not.22 a follow up study in 2015 reported increased improvement in smell discrimination and identification when scents were changed after 3 months.23 smell training traditionally utilizes four scents – clove, rose, lemon, and eucalyptus.22 in our case, rose was changed to ylang-ylang as it was more readily available and less expensive. the main extract of rose in essential oils is phenylethyl alcohol which gives a mild rose odor and is commonly used as a test odorant. ylang-ylang on the other hand, contains 2-phenyl ethyl acetate, a chemical derived from condensation of acetic acid and phenylethyl alcohol which gives off a rose and honey scent.24 aside from practicality, substituting ylang-ylang for rose was also based on the principle of “odor prism” by henning where primary odor categories were identified: flowery, foul, fruity, and aromatic, burnt, and resinous.22 the traditional scents used by hummel et al. were chosen to represent the said odor categories.22 although our patient was not able to undergo a repeat upsit, she recorded her progress based on threshold/detectability and likeness (how similar the smell was to the way she remembered it before). after shifting scents on the fourth month, she reported increased intensity or likeness in her sense of smell. in terms of threshold, she was able to smell the scents from the amber test jars without having to bring them as close to her nose as before. however, there were still scents from the baseline evaluation that she could not identify. given that most documented cases of covid-19 anosmia recover completely, studies regarding olfactory training in covid-19 are philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 4140 philippine journal of otolaryngology-head and neck surgery case reports largely unavailable. this makes our documentation of this patient’s therapy with smell training even more valuable, as it may serve as a reference for other covid-19 patients that also experience a prolonged course of anosmia or hyposmia that does not resolve spontaneously. abscent,25 a uk-based organization dedicated to raising awareness of anosmia, provides online instructional materials on how to conduct smell training at home based on the therapy designed by hummel et al.22 this may be helpful to those unable to seek professional help due to the pandemic. as mentioned earlier, aside from performing smell training daily, the patient also kept a smell journal which aided in documenting her progress or the extent of smell distortion, as well as providing psychological insight into the prolonged course of parosmia as improvements may seem too subtle for patients such as her to recognize.25 there are several limitations to this case report. first and foremost, we cannot attribute resolution of anosmia to any intervention, including smell training, as spontaneous resolution of anosmia and recovery of smell have to be considered. moreover, our patient was not tested for antigens at the onset of her anosmia and the antibody test eventually utilized could only detect past infection. future studies acknowledgements we would like to thank our patient who voluntarily shared her condition and experience for this case report. references 1. suzuki m, saito k, min wp, vladau c, toida k, itoh h, et al. identification of viruses in patients with postviral olfactory dysfunction. laryngoscope. 2007 feb;117(2):272-277. doi: 10.1097/01. mlg.0000249922.37381.1e pubmed pmid: 1727762; pubmed central pmcid: pmc7165544. 2. lechien jr, chiesa-estomba cm, de siati dr, horoi m, le bon sd, rodriguez a, et al. olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (covid-19): a multicenter european study. eur arch otorhinolaryngol. 2020 aug;277(8):2251-2261. doi:10.1007/s00405-020-05965-1 pubmed pmid:  32253535; pubmed central pmcid: pmc7134551. 3. coronavirus disease (covid-19) [internet]. who.int. 2021 [cited 2021 apr 29]. available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answershub/q-a-detail/coronavirus-disease-covid-19. 4. lechien jr, chiesa-estomba cm, de siati dr, horoi m, le bon sd, rodriguez a, et al. olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (covid-19): a multicenter european study. eur arch otorhinolaryngol. 2020 aug;277(8):2251-2261. doi:10.1007/s00405-020-05965-1 pubmed pmid:  32253535; pubmed central pmcid: pmc7134551. 5. moein st, hashemian sm, tabarsi p, doty rl. prevalence and reversibility of smell dysfunction measured psychophysically in a cohort of covid-19 patients. int forum allergy rhinol. 2020 oct;10(10):1127-1135. doi: 10.1002/alr.22680. epub 2020 aug 19. pubmed pmid: 32761796; pubmed central pmcid: pmc7436559. 6. covid-19 and your health [internet]. centers for disease control and prevention. 2021 [cited 2020 sep 19]. available from: https://www.cdc.gov/coronavirus/2019-ncov/testing/diagnostictesting.html. 7. tan-lim c, burog a. should electrochemiluminescence immunoassay (eclia) tests be used in the diagnosis of covid-19? psmid.org. 2020 [cited 2020 sept 19] [about 19 pages. available from: https://www.psmid.org/wp-content/uploads/2020/08/eclia-20200823_180625.pdf. 8. klopfenstein t, kadiane-oussou nj, toko l, royer py, lepiller q, gendrin v, zayet s. features of anosmia in covid-19. med mal infect. 2020 aug;50(5):436-439. doi: 10.1016/j. medmal.2020.04.006. epub 2020 apr 17. pubmed pmid: 32305563; pubmed central pmcid: pmc7162775. 9. eliezer m, hautefort c, hamel a-l, verillaud b, herman p, eloit c. sudden and complete olfactory loss of function as a possible symptom of covid-19.  jama otolaryngol head neck surg.  2020 jul;146(7):674–675. doi:10.1001/jamaoto.2020.0832 pubmed pmid: 32267483. 10. galougahi mk, ghorbani j, bakhshayeshkaram m, naeini as, haseli s. olfactory bulb magnetic resonance imaging in sars-cov-2-induced anosmia: the first report.  acad radiol. 2020;27(6):892-893. doi:10.1016/j.acra.2020.04.002 pubmed pmid: 32295727 pubmed central pmcid: pmc7151240. 11. chiu a, fischbein n, wintermark m, zaharchuk g, yun p, zeineh m. covid-19-induced anosmia associated with olfactory bulb atrophy. neuroradiology. 2021 jan;63(1):147-148. doi:10.1007/ s00234-020-02554-1 pubmed pmid: 32930820 pubmed central pmcid: pmc7490479. can document covid-19 at the outset, especially now that anosmia is a recognized symptom. furthermore, olfactory bulb volume was not measured conventionally, and atrophy was based on subjective experience. standard acquisition of mri images may facilitate measurement of olfactory bulb in future studies of olfactory function. finally, our therapy (including substitution of odorants, documentation of progress, tele-monitoring and reporting) was personalized and subjective, with no objective corroboration. standardized procedures, reporting and documentation of patients undergoing smell training, especially for covid-19, may contribute to better understanding and improving their management, and contribute toward developing a local smell training protocol. ultimately, a case-control series (or even a randomized controlled trial) may demonstrate the role of smell training in post-infectious olfactory dysfunction. in summary, we reported the case of a patient who underwent smell training for prolonged post-infectious olfactory dysfunction presumably from covid-19. although we cannot rule out spontaneous resolution of anosmia in our patient, we would like to think that smell training contributed to her recovery of smell. 12. buschhüter d, smitka m, puschmann s, gerber jc, witt m, abolmaali nd, hummel t. correlation between olfactory bulb volume and olfactory function. neuroimage. 2008 aug 15;42(2):498502. doi: 10.1016/j.neuroimage.2008.05.004. epub 2008 may 10. pubmed pmid: 18555701. 13. mueller a, rodewald a, reden j, gerber j, von kummer r, hummel t. reduced olfactory bulb volume in post-traumatic and post-infectious olfactory dysfunction. neuroreport. 2005 apr 4;16(5):475-8. doi: 10.1097/00001756-200504040-00011. pubmed pmid: 15770154. 14. rombaux p, mouraux a, bertrand b, nicolas g, duprez t, hummel t. olfactory function and olfactory bulb volume in patients with postinfectious olfactory loss. laryngoscope. 2006 mar;116(3):436-9. doi: 10.1097/01.mlg.0000195291.36641.1e. pubmed pmid: 16540905. 15. yao l, yi x, pinto jm, yuan x, guo y, liu y, wei y. olfactory cortex and olfactory bulb volume alterations in patients with post-infectious olfactory loss. brain imaging behav. 2018 oct;12(5):1355-1362. doi: 10.1007/s11682-017-9807-7. pubmed pmid: 29234959. 16. han ay, mukdad l, long jl, lopez ia. anosmia in covid-19: mechanisms and significance. chem senses. 2020 jun 17:bjaa040. doi: 10.1093/chemse/bjaa040. epub ahead of print. pubmed pmid: 32556089; pubmed central pmcid: pmc7449368. 17. butowt r, von bartheld c. anosmia in covid-19: underlying mechanisms and assessment of an olfactory route to brain infection. neuroscientist. 2020 sep 11:107385842095690. doi:10.1177/1073858420956905 pubmed pmid:32914699 pubmed central pmcid:pmc7488171. 18. moein st, hashemian sm, mansourafshar b, khorram-tousi a, tabarsi p, doty rl. smell dysfunction: a biomarker for covid-19. int forum allergy rhinol. 2020 aug;10(8):944-950. doi: 10.1002/alr.22587. epub 2020 jun 18. pubmed pmid: 32301284; pubmed central pmcid: pmc7262123. 19. widespread smell testing has limited application as a screening tool for covid-19 [internet]. entuk.org. 2021 [cited 2021 jan 29]. available from: https://www.entuk.org/sites/default/files/ ent%20uk%20and%20brs%20statement%20-%20widespread%20smell%20testing%20 has%20limited%20application%20as%20a%20screening%20tool%20for%20covid-19.pdf. 20. evidente vgh, esteban rp, hernandez jl, natividad ff, advincula j, gwinn-hardy k, hardy j, singleton a, singleton a. smell testing is abnormal in ‘lubag’ or x-linked dystoniaparkinsonism: a pilot study. parkinsonism relat disord. 2004 oct;10(7):407-10.  doi:10.1016/j. parkreldis.2004.04.011 pubmed pmid:15465396. 21. david jf, campomanes bsa, dalupang ji, loberiza fv. -smell identification test (-sit). philipp j otolaryngol head neck surg. 1994;14:62-68. [cited 2020 sep 19] available from: https://pjohns. 22. hummel t, rissom k, reden j, hähner a, weidenbecher m, hüttenbrink kb. effects of olfactory training in patients with olfactory loss. laryngoscope. 2009 mar;119(3):496-9. doi: 10.1002/ lary.20101. pubmed pmid: 19235739. 23. altundag a, cayonu m, kayabasoglu g, salihoglu m, tekeli h, saglam o, hummel t. modified olfactory training in patients with postinfectious olfactory loss. laryngoscope. 2015 aug;125(8):1763-6. doi: 10.1002/lary.25245. epub 2015 jun 2. pubmed pmid: 26031472. 24. surburg h, panten j. common fragrance and flavor materials: preparation, properties and uses. 6th ed. wiley; 2016. 25. smell training techniques to do at home | olfactory training | abscent [internet]. abscent.org. 2021 [cited 2020 sep 30]. available from: https://abscent.org/learn-us/smell-training. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles abstract objective: to measure the levels of environmental noise in the medical intensive care unit, surgical intensive care unit, and adult ward of the makati medical center for the morning, afternoon, and evening shifts, on weekdays and weekends, and to compare noise levels across shifts, and between weekdays and weekends. methods: design: environmental noise survey setting: tertiary private training hospital participants: none results: the overall mean environment noise levels in all the areas surveyed (medical intensive care unit, surgical intensive care unit and adult ward) exceeded world health organization recommendations by more than 20 db across different working shifts on both weekdays and weekends. there was no significant difference in noise levels between weekdays and weekends across shifts in all areas, except for the afternoon shift in the medical icu. using repeated measures anova, results showed that there is no sufficient evidence to conclude that at least one shift has significantly different mean noise level in any of the 3 areas (micu: f(2)=4.73, p-value=.1124; sicu: f(2)=7.91, p-value=.0540; ward: f(2)=2.73, p-value=.1948) conclusion: the overall environmental noise levels in the different areas of micu, sicu and adult ward exceeded the who recommendation. it is recommended that a change in strategy is needed for prevention of environmental noise, setting guidelines and policies to assure quality health care and noise control. further investigations to ascertain exact sources may give rise to feasible solutions. keywords: noise; decibel; hospital; sound; noise, occupational; occupational exposure/analysis; intensive care unit. the world health organization (who) states that “health is not only the absence of disease or infirmity but a state of complete physical, mental and social well-being.”1 hospital spaces are built and equipped with staff and medical equipment to diagnose, treat and serve the needs of the sick. the hospital environment should be conducive to quick recovery and wellness. since the hospital environment is vital to the optimum recovery of patients and efficient health care delivery by providers, the who recommends that noise levels in hospital environments be kept within 35 db during the night and 40 db during the day.2 determination of ambient noise levels in the medical and surgical intensive care units and adult ward of the makati medical center jacquelyn p. chan-zamora, md joseph richard ray r. cedeño, md patricio b. guzman, jr md jomar l. bigalbal, bsn, rn department of otorhinolaryngology head and neck surgery makati medical center correspondence: dr. joseph richard ray r. cedeño department of otorhinolaryngology head and neck surgery makati medical center no. 2 amorsolo st. legaspi village, makati city 1229 philippines phone: (632) 8888 8999 local 2282 email: okcedeno@gmail.com; joseph.cedeno@makatimed.net. ph the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and that each author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngology head and neck surgery descriptive research contest. december 6, 2019. palawan ballroom, edsa shangri la hotel, mandaluyong city. philipp j otolaryngol head neck surg 2021; 36 (2): 18-21 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles several studies have shown that most hospital spaces have exceeded the recommendation and several guidelines and steps are needed to assure quality health care.2,3-5 in particular, several hospital areas, like the intensive care units, have been associated with greater noise levels than others.2 ironically, it may be argued that patients in such units are in need of more healing than those in other units. adverse effects of noise pollution include noise-induced hearing impairment, disturbance of rest and sleep, psychophysiological, mental-health, performance effects and interference with speech communication, and the critical effects of noise can cause sleep disturbances, irritation and communication interference.1 this study aims to measure the levels of environmental noise in the medical intensive care unit, surgical intensive care unit and adult ward of our hospital for the morning, afternoon, and evening shifts, on weekdays and weekends, and compare noise levels across shifts, and between weekdays and weekends. methods with institutional review board exemption dated march 7, 2019, this environmental noise survey was undertaken at the makati medical center from may 4 to 18, 2019. the areas surveyed were the designated nurses’ stations of the medical intensive care unit (icu), surgical icu and adult ward. in the medical and surgical icu, the nearest distance from the nurses’ station to the enclosed patient’s rooms is 5.5 meters and the farthest is 60 meters, while in the adult ward, the nurses’ station is separated from the patient area by the nearest distance of 10 meters and farthest distance of 22 meters. these units were chosen because of their proximity, physical layout and patient population. environmental noise levels were measured within different shifts (6 am-2 pm, 2 pm-10 pm and 10 pm6 am) on weekdays (monday and wednesday) and weekends (friday and saturday). sound levels in the designated stations were recorded using a calibrated sound level meter (iso-tech slm-52n, iso-tech, taiwan, china) operated by a certified occupational health and safety officer. environmental noise levels were measured in decibels (db) using the sound level meter for durations of 1-minute sampling time per measurement recorded by the certified occupation health and safety officer twice per shift in the 2-week period. recorded measurements were averaged and tabulated, and descriptive statistics such as mean and standard deviation were used to summarize the data. a comparison of noise levels on weekdays (monday and wednesday) and weekends (friday and saturday) was determined using paired t-test for the different shifts. a comparison of noise levels for morning and afternoon, morning and evening, and afternoon and evening shifts was also determined using paired t-test. repeated measures analysis of variance (anova) was computed to determine whether any one shift had a significantly different mean noise level in any of the 3 areas. p-values less than .05 were considered significant. all computations were performed using stata statistical software version 15. (stata corp. llc, college station, tx, usa). results the overall mean environment noise levels measured in the different areas on weekdays and weekends all exceeded who recommendations. the overall ambient noise levels ranged between 60.5 db to 81.2 db, at least 20 db above the who recommended thresholds of 35 db during the night and 40 db during the day. average environmental noise levels in the medical icu, surgical icu and ward during the different shifts are shown in tables 1-3, respectively. the majority of sounds generally picked by the sound level meter came from the nurse’s station. identifiable contributors to the noise were conversations coming from medical staff, visitors, sounds created by medical machines, ventilation system, computer noise, rattling trolleys, sliding or swinging doors and even phones. paired t-tests to compare weekday and weekend noise levels per shift in the medical icu revealed no significant differences between weekdays and weekends (79.3 ± 2.7 db vs. 76.7 ± 4.9 db; t(2)=0.6529 p=.5809 and 69.4 ± 0.4 db vs. 67.2 ± 3.2 db; t(2)=1.0160 p= .4166) for the morning and evening shifts, respectively. however, there was a significant difference between weekdays and weekends (79.0 ± 0.5 db vs. 66.0 ± 3.7 db; t(2)=4.8634 p=.0398) for the afternoon shift. for the surgical icu, there were no significant differences between weekday and weekend noise levels for the morning (72.9 ± 0.7 db vs. 71.9 ± 3.8 db; t(2)=0.3642 p=.7506), afternoon (70.0 ± 2.0 db vs. 68.6 ± 1.7 db; t(2)=0.7173 p=.5477) and evening (62.4 ± 1.1 db vs. 64.5 ± 5.7 db; t(2)=0.5037 p=.6645) shifts, respectively. the adult ward noise levels also showed no significant differences between weekdays and weekends for the morning (69.4 ± 2.6 db vs. 70.0 ± 1.0 db; t(2)=0.2781 p=.8071), afternoon (69.0 ± 1.1 db vs. 64.0 ± 1.8 db; t(2)=3.2982 p=.0809) and evening (66.6 ± 2.5 db vs. 67.4 db; t(2)=0.4444 p=.7002) shifts, respectively. overall mean environment noise levels in all three areas ranged between 67.1 ± 2.8 db to 75.9 ± 5.2 db, which were all exceeded who recommendations by at least 20 db. there was no significant difference in the overall mean environmental noise levels between weekdays and weekends for all three areas despite the noted difference in the afternoon shift in the medical icu as mentioned earlier. ( table 4) repeated measures anova results showed that there is no sufficient evidence to conclude that at least one shift has significantly different mean noise level in any of the 3 areas (micu: f(2)=4.73, p-value=.1124; philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles weekends for all three areas of the medical icu, surgical icu, and ward. the significant difference between weekdays and weekends for the afternoon shift in the medical icu may be attributed to more activities done during this shift such as rounds by the medical staff, imaging, and other diagnostic procedures. specific activities occurring in the afternoon shift should be observed in the medical icu to determine the definite reason for the variance. although there are external and internal factors that may contribute to the environmental noise in a hospital,9 the research only tried to identify internal sources since the external factors, such as construction and automobile noise are not far from the areas being investigated. the nurses’ station in each area is where health care providers carry out administrative tasks and clinically associated functions that impact on the delivery of care to patients. thus, it is not only the registered nurses that go about performing their functions but the physicians, nurse manager, in-patient pharmacist, charge nurse, nursing aides and orderlies that work in the same area who add to the produced noise. it is not only the patients who are affected by the environmental noise causing physical, mental and psychological consequences but healthcare workers as well that may bring poor performance, stress, burnout, fatigue and even work accidents.1 the medical intensive care unit (micu) is a facility that closely monitors, observes and cares for acute or chronically ill patients with potentially severe and physiologically unstable conditions that require sophisticated technical and/or artificial support. treatment of several table 1. environmental noise levels (db) in medical icu during different shifts and days morning (6am 2pm) afternoon (2pm-10pm) evening (10pm-6am) 81.2 79.4 69.7 77.4 78.7 69.2 73.2 68.7 64.9 80.2 63.4 69.4 micu shift monday average noise level (db) wednesday average noise level (db) friday average noise level (db) saturday average noise level (db) table 5. repeated measures anova results comparing mean noise levels in the 3 areas micu sicu ward 78. 0 ± 3.6 72.4 ± 2.3 69.7 ± 1.6 72.6 ± 7.8 69.3 ± 1.7 66.5 ± 3.1 68.3 ± 2.3 63.5 ± 3.5 67.0 ± 1.5 .1124 .0540 .1948 morning afternoon evening p-value micu sicu ward 78. 0 ± 3.6 72.4 ± 2.3 69.7 ± 1.6 72.6 ± 7.8 69.3 ± 1.7 66.5 ± 3.1 t(6) = 1.2678 t(6) = 2.1656 t(6) = 1.8475 .2519 .0735 .1142 morning afternoon t value p-value micu sicu ward 78. 0 ± 3.6 72.4 ± 2.3 69.7 ± 1.6 68.3 ± 2.3 63.5 ± 3.5 67.0 ± 1.5 t(6) = 4.5718 t(6) = 4.2306 t(6) = 2.4175 .0038 .0055 .0520 morning evening t value p-value micu sicu ward 72.6 ± 7.8 69.3 ± 1.7 66.5 ± 3.1 68.3 ± 2.3 63.5 ± 3.5 67.0 ± 1.5 t(6) = 1.0441 t(6) = 2.9548 t(6) = -0.3026 .3367 .0255 .7724 afternoon evening t value p-value table 2. environmental noise levels (db) in surgical icu during different shifts and days morning (6am-pm) afternoon (2pm-10pm) evening (10pm-6am) 73.4 68.5 63.2 72.4 71.4 61.7 74.6 69.8 60.5 69.2 67.4 68.5 sicu shift monday average noise level (db) wednesday average noise level (db) friday average noise level (db) saturday average noise level (db) table 3. environmental noise levels (db) in adult ward during different shifts and days morning (6am-2pm) afternoon (2pm-10pm) evening (10pm-6am) 71.3 69.7 68.4 67.6 68.2 64.8 69.3 65.3 67.4 70.7 62.7 67.4 adult ward shift monday average noise level (db) wednesday average noise level (db) friday average noise level (db) saturday average noise level (db) table 4. comparison of overall mean environmental noise levels (db) between weekdays and weekends in the different designated areas medical icu surgical icu adult ward 75.9 ± 5.2 68.4 ± 4.9 68.3 ± 2.2 70.0 ± 6.1 68.3 ± 4.6 67.1 ± 2.8 .0975 .9717 .4315 location weekday overall noise level (db) weekend overall noise level (db) p-value sicu: f(2)=7.91, p-value=.0540; ward: f(2)=2.73, p-value=.1948). ( table 5) discussion our results showed the overall mean of environment noise levels in the different designated areas on weekdays and weekends ranged between 67.1 ± 2.8 db to 75.9 ± 5.2, exceeding who recommendations by more than 20 db. although who guidelines for community noise state that environmental noise levels vary over time such as different parts of the day or season to season,1 we found no significant difference in the overall mean environmental noise levels between weekdays and philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles conditions such as problems of the heart, lungs, kidney, blood and digestive system, as well as severe asthma, renal failure, diabetes and sepsis are accommodated in this facility. the presence of essential devices to administer ideal medical management in order to sustain life should account for the noise these machines produce in the areas they occupy. the surgical intensive care unit (sicu) provides intensive post-surgery care for various major elective and emergency surgical procedures that require close, constant attention by a team of specially trained health professionals. indications include, but are not limited to, neurologic, cardiac, thoracic, vascular, and trauma caused by natural disasters, accidents such as falls and vehicular collisions. it is unavoidable for the sound of oxygen, suction equipment and respirators to occur in such areas; however, steps should be made to minimize noise exposure.2 the sicu team uses the latest technologies to monitor and guide therapeutic post-surgical management. identical to the micu, the sicu is filled with vital medical devices needed by the patient that contribute to the noise picked by the sound level meter. some of these medical apparatuses are also found in the adult ward that provides care for acute and chronically ill patients with no impending severe critical conditions. there are several limitations to this study. first, the limited number of ambient noise levels measured per shift, as well as the selection of time sampling points per shift may not reflect the true average noise levels throughout each shift. moreover, the choice of mondays and wednesdays to represent weekdays, and fridays and saturdays to represent weekends, may not account for the actual differences between weekdays and weekends. it is usually not feasible to measure noise continuously over a long period of time to completely define the environmental noise exposure; in practice, only a small part of total exposure is actually measured.1 second, the locations of ambient noise testing were the nurses’ stations in each area, and not the patient’s beds. a more appropriate reflection of actual noise exposure endured by patients would be shown by obtaining ambient noise levels from multiple patient locations. this is further reflected in the absence of feedback from the patients in the said areas. future studies may improve on the process of collection of the ambient noise levels over different patient areas and perhaps utilize a validated questionnaire on noise perception or sleep evaluation of the patients in their areas. third, although we generally identified numerous sources of noise that could be modifiable (e.g. discussions among medical staff and guests, sounds created by medical equipment, ventilation system, computer noise, rattling trolleys, sliding or swinging doors and phones), individual noise-emanating or noise-generating sources were not acknowledgements the authors thank crystal b. gonzales for statistical assistance. references 1. berglund b, lindvall t, schwelt dh. guidelines for community noise. geneva: world health organisation; 1999. [cited 2019 jun 17]; available from: http://whqlibdoc.who.int/hq/1999/ a68672.pdf. 2. qutub ho, el-said kf. assessment of ambient noise levels in the intensive care unit of a university of hospital. j family community med. 2009 may; 16(2): 53-57. pubmed pmid: 23012191; pubmed central pmcid: pmc3377030. 3. valizadeh s, hosseini mb, alavi n, asadollahi m, kashefimeh s. assessment of sound levels in a neonatal intensive care unit in tabriz, iran. j caring sci. 2013 feb 26; 2(1): 19-26. doi: 10.5681/ jcs.2013.003; pubmed pmid: 25276706; pubmed central pmcid: pmc4161105. 4. park mj, yoo jh, cho bw, kim kt, jeong w-c, ha m. noise in hospital rooms and sleep disturbance in hospitalized medical patients. environ health toxicol. 2014 aug 18; 29: e2014006. doi: 10.5620/eht.2014.29.e2014006; pubmed pmid: 25163680; pubmed central pmcid: pmc4152942. 5. joshi g, tada n. analysis of noise level in neonatal intensive care unit and post natal ward of a tertiary care hospital in an urban city. int j contemp pediatr. 2016 nov; 3(4): 1358-1361. doi: http://dx.doi.org/10.18203/2349-3291.ijcp20163677. 6. khademi g, imani b. noise pollution in intensive care units: a systematic review article. rev clin med. 2015 may; 2(2): 58-64. 7. darbyshire jl, young jd. an investigation of sound levels on intensive care units with reference to the who guidelines. crit care. 2013 sep 3; 17(5): r187. doi: 10.1186/cc12870; pubmed pmid: 24005004; pubmed central pmcid: pmc4056361. 8. wang x, zeng l, li g, xu m, wei b, li y, et al. a cross-sectional study in a tertiary care hospital in china: noise or silence in the operating room. bmj open. 2017 sep 18; 7(9): e016316. doi: 10.1136/bmjopen-2017-016316; pubmed pmid: 28928180; pubmed central pmcid: pmc5623468. 9. de lima andrade e, da cunha e silva dc, de lima ea, de oliveira ra, zannin pht, martins acg. environmental noise in hospitals: a systematic review.  environ sci pollut res int.   2021 apr;28(16:19629–19642. doi: 10.1007/s11356-021-13211-2 pubmed pmid: 33674976 pubmed central pmcid: pmc7935697. 10. de lacerda costa g, moreira de lacerda ab, marques j. noise on the hospital setting: impact on nursing professionals’ health. cefac. 2013 may-jun;15(3):642-652. available from: https://www. scielo.br/j/rcefac/a/7mhtvpw563m7jkynqn4jmpj?lang=en7format=pdf. isolated in this study, which only measured the sum total ambient noise from a particular vantage point (the nurses’ station) in each study area (micu, sicu and adult ward). future studies can isolate and quantify the noise from separate sources in order to address them. proper monitoring, setting of guidelines and strategies are needed to assure quality health care and noise control. there should be further investigation to ascertain the exact source of noise in order for feasible solutions to be proposed. establishing systems for interpersonal endorsements among staff and educating the public regarding reduction of modifiable noise should be in place.6 the use of building sound insulation or using sound absorbent materials can be utilized to develop noise barriers.7 finally, developing noise mapping in order to provide an overall picture of exposure and characteristics of noise environment can help implement and develop noise management plans.1 encouraging community involvement in raising awareness on the effects of noise exposure can help decrease the levels of noise in a health care facility.6,8 in conclusion, the overall mean of the environmental noise levels in the specialized areas of the hospital exceeded the who recommendations. necessary steps should be taken to address these concerns in order to promote overall patient healthcare. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles abstract objective: to evaluate the preliminary surgical results of endoscopic type i tympanoplasty among patients with inactive chronic otitis media without ossicular pathology. methods: design: prospective series setting: tertiary government hospital participants: seventy patients with inactive mucosal chronic otitis media (com) with air bone gap (abg) of ≤ 40 db on the preoperative audiogram scheduled to undergo type i tympanoplasty between july 2018 and december 2020 were enrolled. results: seventy-three (73) ears were evaluated. the overall rate of graft uptake was 95.9% at 12 weeks. there was a statistically significant (p<.001) improvement in hearing on comparison of pre-operative (25.74 ± 7.34 db) and post-operative (14.82 ± 6.55 db) air bone gap. the duration of surgery was less than one hour in 76.7% and 77.2 % patients experienced only mild postoperative pain. conclusion: endoscopic tympanoplasty can provide good results with respect to graft uptake and hearing gain with short surgical duration and minimum postoperative morbidity. longer follow up of at least 6 months (for graft uptake) and preferably not less than 12 months (for hearing results) may confirm our preliminary findings. keywords: chronic otitis media; type i tympanoplasty; endoscopic; post-operative pain; tympanic membrane perforation; hearing; morbidity chronic otitis media (com) is a widespread disease in developing countries characterized by long standing infection of a part or whole of the middle ear cleft.1 it was defined by the world health organization as a stage of ear disease in which there is chronic infection of the middle ear in the presence of a tympanic membrane perforation and ear discharge.2 myringoplasty and tympanoplasty are surgical procedures that are used for repair of the tympanic membrane and endoscopic type i tympanoplasty in 70 patients with chronic otitis media: a preliminary report bikramjit singh, ms1 pooja pal, ms, dnb2 hardeep singh osahan, ms2 arvinder singh sood, ms2 1surgical oncology government medical college, amritsar 2department of ent sri guru ram das institute of medical sciences and research sri guru ram das university of health sciences correspondence: dr. pooja pal 25 guru nanak avenue, phase ii, majitha road amritsar 143001, punjab india email: drpoojapal@gmail.com phone: +91 950 111 4524 disclosure: the authors declare that this presents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and each author believes that the manuscript represents honest work. approval was initially obtained for the thesis of hso supervised by ass and pp, comparing 30 cases each of endoscopic and microscopic tympanoplasty, and extended to 70 cases of endoscopic tympanoplasty with bs as lead author for the study concept, design, analysis, and drafting. the authors declare that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. philipp j otolaryngol head neck surg 2021; 36 (2): 13-17 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles middle ear respectively, with microscope assisted tympanoplasty being one of the commonest operations performed on the middle ear. surgical management of com aims to eradicate middle ear disease thereby giving the patient a dry ear, and to improve hearing by closure of the tympanic membrane perforation and ossicular reconstruction if required. despite various advancements in the operating microscope, the perfect surgical outcome has eluded surgeons as the basic optics have remained unchanged over the years. with the advent of rigid endoscopes for sinus surgery, extended applications in other fields have emerged. mer and colleagues introduced middle ear endoscopy in 1967, following which endoscopes have been used in various middle ear surgeries.3 the results of tympanoplasty are measured in terms of success or failure of graft-take and hearing improvement. superior results in terms of 93 – 97% graft uptake rates and 85 – 90% chance for a hearing gain to within 20 db of bone conduction levels can be expected in patients with mucosal com with simple ossicular pathology.4,5 hence, to evaluate the surgical outcome, these cases should be separated from those with cholesteatoma, severe mucosal disease, eustachian tube dysfunction, severe ossicular pathology and revision cases. this study was undertaken to evaluate the surgical results of endoscopic type i tympanoplasty among patients with inactive chronic otitis media without ossicular pathology and present our preliminary findings. methods this prospective series was conducted at the department of ent, sri guru ram das (sgrd) institute of medical sciences and research, sgrd university of health sciences, amritsar, punjab, between july 2018 and december 2020. it was performed in compliance with the declaration of helsinki and prior clearance was obtained from the institutional ethics committee. patients with inactive mucosal chronic otitis media (com) were screened for eligibility. inclusion criteria were adults between 18 50 years of age with inactive mucosal com with a central perforation and a dry ear for 3 months, and an air bone gap (abg) of ≤ 40 db on the preoperative audiogram. excluded were those with cholesteatoma, revision cases, and any indications of ossicular pathology, sensorineural or mixed hearing loss on preoperative audiogram. suitable candidates were enrolled in the study after obtaining informed consent and were scheduled to undergo type i tympanoplasty, involving reconstruction of the tympanic membrane with normal ossicular chain.6 for each patient, demographic details were recorded. a detailed history was obtained, and complete evaluation of the ears, nose and throat was done. in addition, preoperative audiological evaluation was performed on all patients using an interacoustics model ad629 (interacoustics a/s, middelfart, denmark) audiometer to assess the degree and nature of hearing loss. surgical technique the surgeries were performed either under general or local anesthesia as per the choice and comfort of the patient by a single surgeon (pp), who had been performing endoscopic ear surgeries as part of routine practice for at least five years before this study. a conventional 0° 18mm stryker endoscope with 4mm diameter and stryker 1288 full hd endoscopic camera system (stryker corp., kalamazoo, michigan, usa) were used. local anesthesia was infiltrated using 2% xylocaine with 1:2,00,000 adrenaline in all quadrants of the external auditory canal, and at the site of graft harvest. temporalis fascia graft was harvested via a 1.5 cm supraauricular incision above the hairline. the perforation was visualized, and margins freshened to remove redundant epithelium. an incision was made in the external auditory canal from the 12 o’clock to 6 o’clock position around 4 mm lateral to the annulus and a tympanomeatal flap was elevated. the middle ear was inspected for any mucosal edema or granulations and ossicular continuity and mobility were confirmed. gelfoam® absorbable gelatin sponge was placed in the middle ear to form a bed for the graft and temporalis fascia graft was placed by underlay technique. a simple dressing was applied on the site of graft harvest and all patients were discharged the next day. evaluation and follow-up post-operative pain was evaluated using the wong baker scale on the first post-operative day. the patients were called for follow up at 1 week, 3 weeks and 6 weeks postoperatively. final assessment for this preliminary series was performed (pp and hso) at 12 weeks, when graft uptake was assessed with 0° endoscopy and hearing reevaluated with pure tone audiometry. a successful outcome was defined as complete graft uptake and a postoperative abg of ≤ 20 db. data analysis the collated results were analyzed using paired t-test calculated using statistical package for the social sciences (spss) software version 23 (ibm corporation, ny, usa). a p value of less than .05 was considered statistically significant. results a total of 88 patients were enrolled in the present study. of these, 4 were revision cases, 4 had mixed hearing loss, 8 had an air-bone gap more than 40 db suggesting possible ossicular pathology, and 2 had philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles retraction pockets on endoscopy and were hence excluded from the study population. of the 70 patients eligible for the study, 3 underwent bilateral tympanoplasty at the same sitting resulting in 73 operated ears for evaluation. of these, 47 (67.1%) were done under general anesthesia, while 23 (32.9%) were performed under local anesthesia. the mean age of the patients was 32.4± 6.36 years (range 19-44 years). twenty eight (40%) were males while 42 (60%) were females. out of the 73 ears operated, 39 (53.4%) were on the left ear while the right ear was operated in 34 (46.6%) cases. the mean duration of symptoms was 14.6 ± 6.8 months. the most common perforation was the central perforation seen in 31 (42.5%) cases, while 11 (15.1%) had a subtotal perforation. (figure 1) the mean size of perforation was 18.93 ± 8.61 mm2. seventy (70) ears showed complete graft uptake at the time of final assessment at 12 weeks resulting in an overall rate of graft uptake of 95.9%. of the remaining 3 ears, 2 had residual perforation anteriorly, while one developed a perforation inferiorly following a bout of upper respiratory tract infection at 6 weeks postoperatively. the hearing gain was evaluated by comparing the preand postoperative abg. on pre-operative evaluation, 26 (35.6%) had an abg between 10 -20 db, 28 (38.4%) between 21 – 30 db and 19 (26%) between 31 – 40 db, with a mean abg of 25.74 ± 7.34 db. at the time of final assessment at 12 weeks, the mean abg improved to 14.82 ± 6.55 db, with 27 (37%) with an abg of ≤ 10db, 30 (41.1%) with an abg of 10-20 db, 14 (19.2%) with an abg of 21-30 db and only 2 (2.7%) patients with an abg of 31-40 db. comparison of the preand post-operative mean abg by dependent t-test indicated a significant improvement; paired t (69) = 22.938, p < .001. (figure 2) the mean duration of surgery was 53.83 ± 7.86 minutes, with 56 cases (76.7 %) being completed within one hour. the mean wong baker scale pain score was 2.46 ± 1.26, with a majority (54; 77.2%) of patients reporting only mild pain, while 16 (22.8%) patients had moderate pain. none of the patients reported severe pain. discussion since the introduction of tympanoplasty in the treatment of chronic otitis media, a variety of modifications and alternatives in the choice of approach and graft materials have been used in an effort to improve outcomes with minimum morbidity. even though conventional microscopic tympanoplasty with a post aural incision is the most commonly used procedure, it may result in significant morbidity namely surgical scar and post-operative pain.7 in addition, in our clinical practice we encounter several patients suffering from chronic otitis media who do not opt for tympanoplasty via post aural incision, stressing the need for an alternative approach. hence, we undertook the present study to evaluate our results with endoscopic tympanoplasty with regards to surgical results and postoperative morbidity. since the introduction of endoscopic ear surgeries in the late 1950’s, its application in otologic surgery has expanded from myringoplasty, tympanoplasty, cholesteatoma surgery, ossiculoplasty and cochlear implantation.8,9 in the surgical management of com, the advent of the endoscope aims to facilitate equivalent or superior results to the microscope with regards to the closure of tympanic membrane perforation and hearing gain, while minimizing morbidity. in the present study, graft uptake with complete closure of tympanic membrane perforation was seen in 70 (95.9%) patients at 12 weeks. similar results with uptake rates of over 90% have also been observed by various authors in their respective studies.10-12 on evaluating the success in terms of hearing improvement following surgery, a statistically significant improvement in the air bone gap on comparing the preand post-operative hearing thresholds and abg was found, with 27 (37 %) patients achieving a post-operative abg of ≤ 10 db. saini et al. their study in 42 patients subjected to endoscopic figure 1. site-wise distribution of tympanic membrane perforations figure 2. distribution of patients according to abg categories before (diagonal lines) and after (stippled) surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles tympanoplasty also found a significant improvement in the mean abg following surgery, while in his study on 36 cases of chronic otitis media, el guindy achieved an air bone gap of less than 10db in 83.3%, with a graft uptake rate of 91.7%.11,13 one of the main advantages of the endoscope is that it places the surgeon’s view at the tip of the scope, facilitating close-up and wideangle views by simply advancing or withdrawing the endoscope. there is no need to frequently adjust the patients head or to do canaloplasty thereby saving operating time. also, using angled scopes can further widen the field of vision to evaluate the anterior margin of the perforation, hypotympanum and attic, obviating the need for any bony work.14 in our study, none of the 73 cases required any canaloplasty or chordal crest curettage for visualization of the tympanic membrane or evaluation of the ossicular chain, even in the present of tortuous external auditory canal or bony overhang. this translated into a shorter duration of surgery, with a mean duration of 53.83 minutes and 56 cases (76.7%) being completed within an hour. similar observations were also made by tseng et al.15 and huang et al.16 in their respective studies. dundar et al.17 compared endoscopic and microscopic approaches in paediatric patients undergoing type 1 tympanoplasty and found a shorter operative time in the endoscopic tympanoplasty group. however, it is pertinent to state that endoscopic tympanoplasty, like any surgery, has a learning curve, with initial cases requiring a longer operative time. endoscopic ear surgery has its own limitations. being a onehanded technique, it leaves one hand free for surgery, making it disadvantageous especially in the event of excessive bleeding, requiring halting the surgical procedure to secure hemostasis. this may result in a longer intraoperative duration. khafagy et al.18 found the duration of surgery in endoscopic tympanoplasty to be longer compared to the use of the transcanal approach for microscope technique. gadag et al.19 also documented longer duration of surgery in patients of endoscope technique due to difficulty in graft placement and frequent soiling of the tip of the endoscope with blood. duration of surgery is an important factor determining postoperative results in terms of duration of anesthesia, the surgeon’s concentration and the increased risk of iatrogenic complications17, with arm fatigue by the weight of the scope, neck strain and backache as some of the other known disadvantages of endoscopic ear surgery. however, proper patient preparation and meticulous attention to hemostasis may help in reducing operative time and preventing these consequences. avoiding a post aural incision in endoscopic tympanoplasty results in less dissection of normal tissue, less intra operative bleeding, risk of auricular displacement and less postoperative pain.12 saggu et al. found that only 6.6% patients of endoscopic tympanoplasty complained of pain.20 majority of patients in the present study also experienced only mild to moderate pain in the postoperative period. in addition to the above-mentioned advantages, we noticed that endoscopic tympanoplasty can be a superior approach for perforations situated anterior to the handle of malleus. traditionally anterior perforations are considered difficult to treat surgically owing to poor visualization of the perforation, poor vascularity, as well as reduced graft stability due to limited anterior margin requiring anterior tucking of the graft.21 we would like to highlight that in 3 patients of ours, endoscopic tympanoplasty was done via an anterior transcanal approach with an incision over the anterior canal and raising an anterior tympanomeatal flap, circumventing these disadvantages. although this approach will need further prospective studies comparing it with microscope assisted tympanoplasty, we found it quite promising. although prospectively conducted on a fairly large number of patients subjected to uniform follow-up, our present study has several limitations. the foremost limitation is that our 6-week period of follow up may have been too short to obtain conclusive results. our study referenced several articles that reported results after a period of not less than 3 months.10-12, 16, 22, 23 however, guidelines have been published with regards to the reporting of hearing results, particularly the aao-hnsf committee on hearing and equilibrium (1995) that has been frequently cited as a reference for the reporting of hearing results, and it advocates a post-treatment interval of one year or longer when clinical hearing improvement is being addressed.24 likewise, numerous published articles on tympanoplasty results that date back to 2011, particularly those that discuss graft take rates, all show a minimum follow-up period of 6 months, with most having a minimum of 12 months.25-29 a longer follow up period for the reporting of results of at least 6 months (for graft uptake) and preferably not less than 12 months (for hearing results), that is consistent with current publications on the same topic, or that adheres to an internationally accepted guideline may confirm our preliminary results. another limitation is that this study only evaluated patients undergoing endoscopic tympanoplasty with no comparative arm, and hence no final conclusion can be made regarding its superiority or inferiority to another approach such as microscopic tympanoplasty. however, microscope assisted tympanoplasty is a well-established procedure, and comparing our results with the extensive literature available on surgical outcomes of microscopic tympanoplasty may give an indication to its probable superiority in decreasing post-operative morbidity with comparable results of graft uptake and hearing gain. the first 30 cases of endoscopic tympanoplasty in this series were philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles references 1. jahn af. chronic otitis media: diagnosis and treatment. med clin north am. 1991 nov; 75(6):1277-91. doi: 10.1016/s0025-7125(16)30388-1; pubmed pmid: 1943320. 2. chowhury ma, alauddin m. comparative study between tubotympanic and atticoantral types of chronic suppurative otitis media. bangladesh med res council bull. 2002 apr;28(1):36-44. pubmed pmid: 12587759. 3. mer sb, derbyshire aj, brushenko a,  pontarelli da. fiberoptic endotoscopes for examining the middle ear. arch otolaryngol. 1967 apr;85(4):387-93. doi: 10.1001/ archotol.1967.00760040389009; pubmed pmid: 6021747. 4. glasscock me iii, jackson cg, nissen aj, schwaber mk. postauricular undersurface tympanic membrane grafting: a follow-up report. laryngoscope. 1982 jul;92(7 pt 1):718-27. doi: 10.1288/00005537-198207000-00002; pubmed pmid: 7087638. 5. sheehy jl, anderson rg. myringoplasty. a review of 472 cases. ann otol rhinol laryngol. 1980 jul-aug;89(4 pt):331-4. doi: 10.1177/000348948008900407; pubmed pmid: 7416683. 6. wullstein h. theory and practice of tympanoplasty. laryngoscope. 1956 aug;66(8):1076-93. doi: 10.1288/00005537-195608000-00008. pubmed pmid: 13358259. 7. choi n, noh y, park w, lee jj, yook s, choi je, et al. comparison of endoscopic tympanoplasty to microscopic tympanoplasty. clin exp otorhinolaryngol. 2017 mar;10(1):44-49. doi: 10.21053/ ceo.2016.00080; pubmed pmid: 27334511; pubmed central pmcid: pmc5327595. 8. zollner f. the principles of plastic surgery of the sound conducting apparatus. j laryngol otol. 1955 oct;69(10):637-52. pubmed pmid: 13263770. 9. kozin ed, gulati s, kaplan ab, lehmann ae, remenschneider ak, landegger ld, et al. systematic review of outcomes following observational and operative endoscopic middle ear surgery. laryngoscope. 2015 may;125(5):1205-14. doi: 10.1002/lary.25048; pubmed pmid: 25418475; pubmed central pmcid: pmc4467784. 10. raj a, meher r. endoscopic transcanal myringoplasty-a study.  indian j otolaryngol head neck surg. 2001 jan;53(1):47-49. doi:10.1007/bf02910979 pubmed pmid:  23119751 pubmed centrall pmcid: pmc3450869. 11. el-guindy a. endoscopic transcanal myringoplasty.  j  laryngol otol.  1992 jun;106(6):493–495. doi: 10.1017/s0022215100119966 pubmed pmid: 1624881. 12. akyigit a, karlidag t, keles e, kaygusuz i, yalcin s, polat c, eroglu o. endoscopic cartilage butterfly myringoplasty in children.  auris nasus larynx. 2017 apr; 44(2):152-5. doi:  10.1016/j. anl.2016.05.005 pubmed pmid: 27262221. 13. saini a, saroch m, gargi g. endoscopic transcanal myringoplasty: is learning curve a myth?.  j otol. 2018 sep;13(3):101-104. doi:10.1016/j.joto.2018.05.002 pubmed pmid:  30559774 pubmed central pmcid: pmc6291632. 14. tarabichi m. endoscopic middle ear surgery. ann otol rhinol laryngol. 1999 jan;108(1):39-46. doi: 10.1177/000348949910800106: pubmed pmid: 9930539. 15. tseng cc, lai mt, wu cc, yuan sp, ding yf. cost-effectiveness analysis of endoscopic tympanoplasty versus microscopic tympanoplasty for chronic otitis media in taiwan. chin med j. 2018 mar;81(3):284-290. doi: 10.1016/j.jcma.2017.06.024; pubmed pmid: 29287705. 16. huang ty, ho ky, wang lf, chien cy, wang hm. a comparative study of endoscopic and microscopic approach type 1 tympanoplasty for simple chronic otitis media. j int adv otol. 2016 apr;12(1):28-31. pubmed pmid: 27340979. 17. dundar r, kulduk e, soy fk, aslan m, hanci d, muluk nb, et al. endoscopic versus microscopic approach to type 1 tympanoplasty in children. int j pediatr otorhinolaryngol. 2014 jul;78(7):1084-9. doi: 10.1016/j.ijporl.2014.04.013; pubmed pmid: 24816224. 18. shams el-din khafagy m, salah el-din el-habashy h, tarek mouhie el-din el-hamshary m. comparative study between endoscopic and microscopic tympanoplasty through transcanal approach. al-azhar med j. 2020;49(1):83-90. doi: 10.12816/amj.2020.67539. 19. gadag rp, godse a, narasaiah md, shetty n, salian pl. comparative study of outcomes of microscopic versus endoscopic myringoplasty. med inn. [internet] 2016 jul;5(1):3-6. [cited 2020 jan 2] available from: http://www.medicainnovatica.org/2016-july%20issue/2.%20med%20 inn%20july%202016.pdf. 20. saggu s, kuchhal v, rawat a. a comparative study to compare the outcomes of myringoplasty (endoscopic versus microscopic). ann int med dent res. 2018 jul;4(4):16-20. [cited 2020 jan 2] available from: http://imsear.searo.who.int/handle/123456789/192679. 21. tseng cc, lai mt, wu cc, yuan sp, ding yf. endoscopic transcanal myringoplasty for anterior perforations of the tympanic membrane. jama otolaryngol head neck surg. 2016 nov;142(11):1088-1093. doi:10.1001/jamaoto.2016.2114 pubmed pmid: 27540858. 22. shankar r, virk rs, gupta k, gupta ak, bal a, bansal s. evaluation and comparison of type i tympanoplasty efficacy and histopathological changes to the tympanic membrane in dry and wet ear: a prospective study. j laryngol otol. 2015 oct;129(10):945-9. doi: 10.1017/ s0022215115002091. epub 2015 aug 17. pubmed pmid: 26279256. 23. lin yc, wang wh, weng hh, lin yc. predictors of surgical and hearing long-term results for inlay cartilage tympanoplasty. arch otolaryngol head neck surg. 2011 mar;137(3):215-9. doi: 10.1001/archoto.2011.10. pubmed pmid: 21422303. 24. committee on hearing and equilibrium guidelines for the diagnosis and evaluation of therapy in menière’s disease. american academy of otolaryngology-head and neck foundation, inc. otolaryngol head neck surg. 1995 sep;113(3):181-5. doi: 10.1016/s0194-5998(95)70102-8. pubmed pmid: 7675476. 25. jolink c, zwemstra mr, de wolf mjf, ebbens fa, van spronsen e. success rate of tympanic membrane closure in the elderly compared to younger adults. otol neurotol. 2018 jan;39(1):e34-e38. doi: 10.1097/mao.0000000000001649. pubmed pmid: 29194226. 26. kazikdas kc, onal k, boyraz i, karabulut e. palisade cartilage tympanoplasty for management of subtotal perforations: a comparison with the temporalis fascia technique. eur arch otorhinolaryngol. 2007 sep;264(9):985-9. doi: 10.1007/s00405-007-0291-3. pubmed pmid: 17401572. 27. kaya i, benzer m, gode s, sahin f, bilgen c, kirazli t. pediatric type 1 cartilage tympanoplasty outcomes: a comparison of short and long term hearing results. auris nasus larynx. 2018 aug;45(4):722-727. doi: 10.1016/j.anl.2017.11.002. pubmed pmid: 29157625. 28. özdamar k, sen a. comparison of temporal muscle fascia and tragal cartilage perichondrium in endoscopic type 1 tympanoplasty with limited elevation of tympanomeatal flap. braz j otorhinolaryngol. 2020 jul-aug;86(4):483-489. doi: 10.1016/j.bjorl.2019.06.014. pubmed pmid: 31431343. 29. shakya d, kc a, tamang n, nepal a. endoscopic versus microscopic type-i cartilage tympanoplasty for anterior perforation a comparative study. acta otolaryngol. 2021 feb;141(2):135-140. doi: 10.1080/00016489.2020.1834616. pubmed pmid: 33118838. compared with another 30 cases of microscopic tympanoplasty in a separate study that we hope to publish soon. meanwhile, for this series, we conclude that endoscopic tympanoplasty performed with the routine endoscope and no additional specialized equipment can provide good results with respect to graft uptake and hearing gain, with short surgical duration and minimum postoperative morbidity. longer follow up of at least 6 months (for graft uptake) and preferably not less than 12 months (for hearing results) may confirm our preliminary findings. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 4948 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 surgical innovations and instrumentation philipp j otolaryngol head neck surg 2021; 36 (2): 49-51 c philippine society of otolaryngology – head and neck surgery, inc. addressing difficulty in communication while wearing a respirator mask during the covid-19 pandemic by using a laryngophone laine valerie c. kongsun ching, md philip lance anthony a. liu, md department of otolaryngology-head and neck surgery the medical city correspondence: dr. laine valerie c. kongsun ching department of otolaryngology-head and neck surgery the medical city ortigas avenue, pasig city 1600 philippines phone: (632) 8988 1000 email: laine_ching@yahoo.com the authors declared that this presents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by both authors, and the authors believe that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationship, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. presented at the philippine society of otolaryngology head and neck surgery 1st virtual surgical instrumentation contest november 25, 2020. abstract objective: to describe the use of a laryngophone to aid in verbal communication when wearing elastomeric respirator masks. methods: design: instrumentation innovation setting: tertiary private training hospital participants: five volunteers using elastomeric respirator masks rated laryngophone use, afterwhich they individually rated an additional volunteer on speech intelligibility before and after laryngophone use. results: on a scale of 1-10, the average score of the five volunteers for the laryngophone was 8.8 for ease of use, 8.0 for comfort, and 8.0 for ease of communication. their average speech intelligibility score for the additional volunteer using the respirator mask alone was 2.0, and for use of the respirator mask with laryngophone was 3.6 on a scale of 1-4. conclusion: this portable laryngophone speaker may be useful in aiding otolaryngologists and health care providers using elastomeric respirator masks in verbal communication by amplifying speech without needing an external microphone, preventing vocal strain. keywords: laryngophone, communication; covid-19; pandemic; microphone, speaker, respirator mask the covid-19 pandemic has led to the use of enhanced personal protective equipment such as elastomeric respirator masks. however, these respirator masks tend to produce a muffled voice.1 this leads to challenges in communicating with patients, nurses, and colleagues. some otolaryngologists compensate by talking in a loud voice or shouting, using portable external microphones, or lifting the for a mask momentarily to speak. however, even with the aid of a lapel or external microphone, the wearer needs to speak in a loud voice for the lapel or microphone to detect a more audible sound, causing vocal fatigue and strain. thus, we explored the use of alternative devices, turning to the laryngophone. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 surgical innovations and instrumentation the first laryngophone or throat microphone was made by wiley post in 1934, an aviator who combined earphones and laryngophones into a pressure suit for long distance flights.2 laryngophones are contact microphones that absorb vibrations from the throat via a transducer which in turn detects speech using the vibrations of the soft tissue, bone and cartilage. these vibrations are then transmitted via radio to produce sound.3 we describe the use of a modified laryngophone attached to an amplifier as a novel approach to the problem of verbal communication challenges posed by respiratory protective equipment such as the elastomeric respiratory mask. methods materials device assembly we used a generic wired laryngophone with a sensitivity of 96db, frequency response range of 20-20,000hz, and resistance of 32ohm (unbranded generic, china). it was plugged onto a portable mini audio speaker with a maximum loudness of 128 db (rolton k400 portable wired mini speaker, china) via a converter (generic aux connector, china) and attached to a power source with a 3.7v or 18650 external battery (unbranded generic, china). (figure 1a, b) device set-up the laryngophone was placed at the level of the hyoid and secured using the strap of the respirator mask. the speaker was attached to the clothing. (figure 2) procedure participants and survey with institutional review board approval, a total of five volunteers already familiar with using elastomeric respirator masks were asked to test our set-up and answer a feedback survey with the following parameters: ease of use, comfort, and ease of communication. each parameter was graded 1 to 10; 1 being the lowest and 10 being the highest. speech intelligibility was assessed by having an additional volunteer don the laryngophone device and recite “the rainbow passage”4 while the five initial volunteers individually scored speech intelligibility before and after use of the laryngophone. speech intelligibility was subjectively rated on a scale of 1-4 based on the perceived percentage of understood words from the passage. a score of 1 was given to 0-25% of words understood, a score of 2 for 26-50% words, a score of 3 for 5175% of words, and a score of 4 for 76-100% of words. data analysis user ratings were tabulated and averaged, while additional comments were recorded. speech intelligibility scores before, and after use of the laryngophone were likewise recorded and averaged. figure 2. laryngophone receivers positioned at the level of the hyoid and speaker attached to the protective gown. figure 1 a. laryngophone and speaker; and b. schematic outline of set-up device set-up a b philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 surgical innovations and instrumentation results the five volunteers included a 35-year-old female otolaryngologist, a 54-year-old male otolaryngologist, a 60-year-old male otolaryngologist, a 32-year-old female audiometry technician, and a 24-year-old female ent center technician. their ages ranged from 24-60 years old (m = 41; sd = 15.29). the additional volunteer was a 33-year-old female ent resident physician. all six volunteers had been using an elastomeric respirator mask since april to may 2020. the average score of the five volunteers for the laryngophone was 8.8 out of 10 for ease of use of the device, 8.0 out of 10 for comfort, and 8.0 out of 10 for ease of communication. additional comments were that the laryngophone was “significantly better than regular lapel,” “comfortable to wear,” “comfortable to wear and does not restrict movements,” “placement of the position of the laryngophone is very particular but once in the right position, intelligibility of speech is not bad,” “a bit hard to use with respirator mask but it has promise,” and “clearer speech as compared to just a mask.” their average speech intelligibility rating for the additional volunteer who recited “the rainbow passage” using the respirator mask alone was 2.0 out of 4, and for use of the respirator mask with laryngophone was 3.6 out of 4. discussion respiratory protective equipment covering the nose and mouth decrease speech intelligibility and impair verbal communication.1 this is because they attenuate sound transmission and impinge on the nasal alae. compromised speech with elastomeric respirator mask use can occur even at ambient noise levels as low as 40db (e.g. quiet library sounds, refrigerator humming).4 in a normal hospital setting, peak noise levels may exceed 85-90db due to alarms and machines leading to challenges in verbal communication.5 in a hospital staff survey in ontario, canada after the severe acute respiratory syndrome(sars) in 2002, 47% of the 2,001 respondents reported that wearing facial and respiratory personal protective equipment was associated with difficulty in communication.6 a study in occupational therapy in 2016 revealed that the use of elastomeric respirator masks has a speech intelligibility rating of 72%.7 a laryngophone detects vibrations from speech and converts them into acoustic signals. these acoustic signals are then transmitted via radio to enable communication. we modified the laryngophone to enable direct output to a speaker. to use a laryngophone as a microphone, it must be attached to a converter, speaker, and a power source.3 speech is clearer at the level of the hyoid because of the vibrations received from formed pronunciation of words and resonance of voice. the laryngophone can be used safely, as it is positioned outside the mask, such that it does not compromise the respiratory protection provided by the mask nor does it violate mask approvals and certification. furthermore, placement did not obstruct the user’s movements and was lightweight. our survey confirmed a good rating for ease of use, comfort and ease of communication. another advantage of this device is that it is less sensitive to external or environmental noise, although it is sensitive to internal noises such as swallowing or whispering. however, these noises seemed negligible in this pilot study. the speech intelligibility scores of the respirator mask with a laryngophone were higher compared to those using a respirator mask alone. our pilot study has several limitations. first, there may be selection bias since the participants were all part of the same healthcare team. there was also lack of blinding. although our resources were constrained due to the ongoing pandemic, a larger sample of healthcare personnel wearing elastomeric respirator masks may be considered for future studies, with blinding and controls. moreover, our rating scale was not validated, and future studies should consider using a validated scoring system for speech discrimination. despite these limitations, we think that our device may be useful in aiding healthcare personnel wearing elastomeric respirator masks in verbal communication without needing an external microphone and preventing vocal strain. future studies involving more participants may evaluate speech intelligibility based on a validated scoring tool. acknowledgements we thank the otolaryngologists and ent staff who participated in our survey. references 1. american speech-language-hearing association. communicating effectively while wearing masks and physical distancing. [internet]. [cited 2020 september 15]. available from: https:// www.asha.org/public/communicating-effectively-while -wearing-masks-and-physicaldistancing/. 2. goldthwaite j. throat microphones – then and now. sensear blog. [internet]. [cited 2020 september 15]. available from: https://www.sensear.com/blog/throat-microphones-then-andnow. 3. dupont s, ris c, bachelart d. combined use of close-talk and throat microphones for improved speech recognition under non-stationary background noise. isca archive. 2004 aug. [cited 2020 september 15]. available from: https://www.isca-speech.org/archive_open/archive_ papers/robust2004/rob4_31.pdf. 4. fairbanks g. voice and articulation drillbook 2nd ed. new york: harper & row; 1960, p. 127. 5. caretti dm, strickler lc. speech intelligibility during respirator wear: influences of respirator speech diaphragm size and background noise. aiha j (fairfax, va). 2003 nov-dec;64(6):846-50. doi: 10.1202/537.1; pubmed pmid: 14674794. 6. nickell la, crighton ej, tracy cs, al-enazy h, bolaji y, hanjrah s, et al. psychosocial effects of sars on hospital staff: survey of a large tertiary care institution. cmaj. 2004 mar 2;170(5):793-8. doi: 10.1503/cmaj.1031077; pubmed pmid: 14993174; pubmed central pmcid: pmc343853. 7. palmiero aj, symons d, morgan jw 3rd, shaffer re. speech intelligibility assessment of protective facemasks and air-purifying respirators. j occup environ hyg. 2016 dec;13(12):960968. doi: 10.1080/15459624.2016.1200723; pubmed pmid: 27362358; pubmed central pmcid: pmc5065390. philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles 14 philippine journal of otolaryngology-head and neck surgery abstract objective: to determine bleeding time using moringa oleifera leaf extract versus saline control in an experimental epistaxis model. methods: design: randomized controlled trial setting: tertiary government training hospital participants: ten adult male new zealand white rabbits were acclimatized for 1 week in a standard environment. one-centimeter long, full-thickness mucosal wounds in the junction of the nasal floor and anterior part of the septum were treated randomly with topical moringa oleifera extract or colored isotonic saline control in either right or left nasal cavity, one site at a time. the duration of bleeding – time bleeding started to time bleeding stopped -was recorded in seconds. data was subjected to a t-test for paired samples. results: the mean bleeding time for wounds treated with moringa extract was 53 seconds (range 38-70 secs), versus 159 seconds (range 100-218 secs) for controls. the bleeding time in the former was significantly shorter than in the latter (p = .000019, t-stat = 8.139), with a mean difference of 106 seconds between the two groups. conclusion: moringa oleifera leaf extract was associated with significantly shorter bleeding time than saline control in this experimental epistaxis model and may be worth investigating further as a hemostatic agent for epistaxis. keywords: epistaxis, malunggay, moringa oleifera extract, topical hemostatic agent epistaxis is one of the most common acute conditions seen in the emergency department and a common problem encountered by primary care physicians and ear, nose and throat surgeons alike. recurrent epistaxis can be troublesome and alarming especially in the pediatric and the elderly groups.1 at least once in their lifetime, 60% of the population will experience epistaxis, 6% of which require medical attention.2 its high frequency is associated to the nasal septum’s abundant vascularity and risk for external trauma. between 90 to 95% of epistaxis originates from kiesselbach’s plexus in the antero-inferior nasal septum.3 traditional treatment includes nasal packing, cautery, and topical hemostatic agents. however, most of these interventions have accompanying side effects and complications such as increase in blood pressure for some of the topical hemostatic agents, infection, septal perforation and even aspiration with prolonged or bleeding time using moringa oleifera (malunggay) leaf extract versus saline control in a rabbit epistaxis model: a randomized controlled trial paula luz g. caballero, md joseph e. cachuela, md department of otorhinolaryngology head and neck surgery southern philippines medical center, davao city philippines correspondence: dr. joseph e. cachuela department of otorhinolaryngology head and neck surgery ent clinic, 2nd floor, jica building southern philippines medical center jp laurel avenue, bajada, davao city 8000 philippines phone: +6382-227-2731 local 4707 email address: j_cachuela_md@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not yet been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each author, and that each author believes that the manuscript represents honest work. the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to conflict of interest. presented at the philippine society of otolaryngology – head and neck surgery analytical research contest (2nd place). november 17, 2016. bella ibarra, quezon city. presented at southern philippines medical center 9th annual interdepartmental oral research contest (3rd place). december 15, 2016. southern philippines medical center, davao city. philipp j otolaryngol head neck surg 2017; 32 (1): 14-16 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles philippine journal of otolaryngology-head and neck surger 15 dislodged nasal packing. thus, investigators have continued to look for alternative methods to treat this common problem.3 moringa oleifera, also known as malunggay, mulangay, horseradish tree, drumstick tree, or ben oil tree, is a perennial softwood tree with low timber quality. it has long been known for its traditional medicinal as well as its industrial uses, and has been attributed with antibiotic and anti-inflammatory properties.4 studies revealed that topical application of its extract promotes wound healing.5,6 however, its hemostatic effect on epistaxis has yet to be established. using the keywords “moringa,” “hemostatic” and “epistaxis,” we found no published study regarding the hemostatic effect of moringa on epistaxis in a search of pubmed, the cochrane library, science direct, philippine e-journals, and the journals philippine journal of health research and development, otolaryngol head neck surg, and philipp j otolaryngol head neck surg. in order to explore its potential hemostatic effects, the objective of this study is to determine the bleeding time using moringa oleifera leaf extract versus saline control in an experimental epistaxis model. methods preparation of moringa extract and control a modification of extract preparation yielding 13% aqueous extract was utilized.7 fresh, green moringa oleifera leaves procured from the local market were authenticated by a local biologist. the leaves were chopped and air-dried under shade for 72 hrs. powdered leaves were obtained by crushing the dried leaves using a mortar and pestle. one hundred grams of powdered leaves was soaked in 500 ml of distilled water and left standing for 48 hours at 30˚c, then filtered using whatman no. 1 filter paper to obtain moringa extract. a liter of isotonic saline solution with 20 ml of green food coloring (mccormick, mccormick philippines inc., novaliches, quezon city) made up control solution with similar appearance to the moringa extract. the moringa extract and control solutions were separately put in opaque specimen bottles with 20 ml solution per bottle. the bottles were labeled solution a and solution b by the principal investigator, with solution a (moringa extract) and solution b (control) unknown to the blinded examiner, a licensed veterinarian. the solutions in each bottle were only used once. animal experiment ten adult male new zealand white rabbits with a mean weight of 1.26 kg (range, 1.1 – 1.5 kg) were purchased from a certified animal distributor and acclimatized for 1 week in a standard environment. they were housed in standard cages of 1m2 area each, in a room with a constant temperature of 22°c ± 4°c and a 12-hour light/dark cycle, fed twice daily with 200g generic rabbit growing pellets, and unlimited access to tap water. the study was approved by the institutional animal care and use committee (iacuc): <iacuc protocol number m003>. the experiment was conducted in the clinic of one licensed veterinarian, who performed all the procedures with one assistant. both veterinarian and assistant were blinded. all animals were intramuscularly sedated using 0.02 mg/kg acepromazine (labistress® 5 mg/ml,labiana life sciences, barcelona, spain) and 11 mg/kg ketamine chloride (ceva ketamine 100 mg/ml, ceva santé animale, sydney, australia). one-centimeter long full-thickness longitudinal mucosal wounds, not advancing to the cartilage, were made using blade #11(kai medical, kai industries co. ltd., seki city, japan), at the junction of the nasal floor and anterior part of the septum of the right and left nasal cavity, one site at a time. (figure 1) the wounds were randomized to be treated with either solution a or b on either side. solutions were topically applied with cotton pledgets soaked in either solution as soon as bleeding started, and pressed gently on the wounds for 1 second, every 30 seconds (re-soaking the cotton pledget in solution for every application), until the bleeding stopped. the duration of bleeding – time bleeding started to time bleeding stopped-was recorded in seconds by the assistant.3 post-operative care consisted of application of topical clotrimazole 10 mg, gentamicin sulfate 1 mg, betamethasone dipropionate 500 mcg, per gram cream (polyderm 3, lloyd laboratories inc., malolos, bulacan) on the wounds, right after the procedure. the rabbits were observed and monitored after 1 hour and 24 hours after conclusion of the procedure for any adverse effects or complications such as recurrence of bleeding, swelling, or mucosal irritation, and donated to a local animal habitat 3 days after the procedure. figure 1. the area of the rabbit’s nose where the incision was done (▲). philippine journal of otolaryngology-head and neck surgery vol. 32 no. 1 january – june 2017 original articles 16 philippine journal of otolaryngology-head and neck surgery sample size computation sample size was computed using an online sample size calculator (select statistical services ltd., exeter, devon, uk) to compare 2 means (http://select-statistics.co.uk/sample_size_calculation_two_means). assuming a 95% confidence level with a power of 80 to detect a mean difference of 30 seconds with a variance of 500 seconds, 10 samples each were needed for the moringa and control groups. statistical analysis data was subjected to the wilk-shapiro test for normality (w statistic, 0.842), with computed w statistic of 0.889 (normal distribution). data was then analyzed manually using the t-test for paired samples. results ten adult male new zealand white rabbits with ages ranging from 16 – 20 weeks completed the study. none of the rabbits died or acquired any disease during the time of acclimatization. the weight of the rabbits during the study period ranged from 1.1 – 1.5 kg. the mean bleeding time for wounds administered moringa extract was 53 seconds (range, 38 – 70 secs) compared to 159 seconds (range, 100 – 218 secs) for controls. the bleeding time in the former (mean, 53.3 secs) was significantly shorter than in the latter (mean, 159.3), with a mean difference of 106 seconds between the two groups (p = .000019, t-stat = 8.139). no adverse effects or complications were noted. discussion mucosal healing undergoes a process that follows the stages of fibroplasia, angiogenesis, and reepithelialization.8 topical application of moringa oleifera extract has been shown to promote wound healing.5,6 application of the extract on wounds increases its tensile strength through rapid re-epithelialization and collagen formation.5 it also increases fibroblast proliferation.6 moringa extract has also been known to act on the blood coagulation cascade. the presence of proteolytic activity is one of the important characteristic features of moringa oleifera. in a study by satish et al., both extracts from the leaves and roots of the plant showed proteolytic activity in a dose-dependent manner with the leaf extract exhibiting a significantly higher activity. the study suggested that both extracts exhibited procoagulant activity and reduced recalcification time in clot formation by activation of factors involved in the blood coagulation cascade or by precipitation of the co-factors. both extracts also exhibited fibrinogenolytic and fibrinolytic activities.9 whether procoagulant activity and reduced recalcification time in clot formation or fibrinogenolytic and fibrinolytic properties of moringa extract were involved in reducing bleeding time in this study were acknowledgement the authors would like to thank mr. reynaldo g. abad for authentication of the malunggay leaves, dr. rojim sorrosa for sharing his inputs in the writing process, and mr. jesse mari f. santos, mr. arturo e. caballero, and mrs. luz-minda g. caballero for helping the authors in processing the animal ethics approval and data gathering. references kotecha b, fowler s, harkness p, walmsley j, brown p, topham j. management of epistaxis: 1. a national survey.ann r coll surg engl. 1996 sep;78(5):444-446. pmid: 8881728; pmcid: pmc2502947. pope le, hobbs cg. epistaxis: an update on current management. 2. postgrad med j. 2005 may;81(955):309-314. doi: 10.1136/pgmj.2004.025007. pmid: 15879044; pmcid: pmc1743269. kurtaran h, ark n, ugur ks, sert h, ozboduroglu aa, kosar a, et al. effects of a topical hemostatic 3. agent on an epistaxis model in rabbits. curr ther res clin exp. 2010 apr;71(2):105-110. doi: 10.1016/j.curtheres.2010.03.003. pmid: 24683256; pmcid: pmc3967325. fahey j. moringa oleifera: a review of the medical evidence for its nutritional, therapeutic, and 4. prophylactic properties part 1. trees for life journal. 2005 december; 1:5. [cited 2016 january 15]. available from: http://www.tfljournal.org/article.php/20051201124931586. vijay l, kumar u. evaluation of in vivo wound healing activity of 5. moringa oleiferabark extracts on different wound models in rats. pharmacologia. 2012;3(11):637-640. doi: 10.5567/ pharmacologia.2012.637.640. muhammad aa, pauzi nas, arulselvan p, abas f, fakurazi s. in vitro wound healing potential 6. and identification of bioactive compounds from moringa oleiferalam. biomed research international. 2013 nov; 2013, article id 974580. doi: 10.1155/2013/974580. moyo b, masika pj, muchenje v. antimicrobial activities of 7. moringa oleiferalam leaf extracts. african journal of biotechnology. 2012 feb;11(11): 2797-2802. doi: 10.5897/ajb10.686. wabnitz d. factors affecting mucosal healing, reciliation, and ciliary function after endoscopic 8. sinus surgery in the sheep [dissertation]. university of adelaide; 2005. [cited 2016 aug 8]. available from: http://hdl.handle.net/2440/37719. satish a, sairam s, ahmed f, urooj a. moringa oleifera lam.: protease activity against blood 9. coagulation cascade. pharmacognosy res. 2012 jan;4(1):44-9. doi: 10.4103/0974-8490.91034. pmid: 22224061; pmcid: pmc3250039. not established, and can at best be inferred. however, the significant difference in bleeding time between treatment and controls makes a compelling argument to pursue the potential hemostatic effects of moringa for epistaxis. further studies are recommended to determine the histopathologic effects of moringa extract on nasal mucosa; its toxic dose and approximate effective dose; the effect of tonicity, ph and temperature settings of moringa extract in the coagulation process; the hemostatic effect of moringa extract versus such usual topical agents as oxymetazoline and epinephrine; sterilization techniques in the preparation of the extract; before actual clinical trials. our study has established that moringa oleifera leaf extract was associated with significantly shorter bleeding time than saline control in this experimental epistaxis model, and may thus be worth investigating further as a hemostatic agent for epistaxis. philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles abstract objective: to measure the average distances from anterior lacrimal crest (alc) to anterior ethmoidal foramen (aef), anterior ethmoidal foramen to posterior ethmoidal foramen (pef) and posterior ethmoidal foramen to optic canal (oc) using plain paranasal sinus (pns) computed tomography (ct) scans of adults in a tertiary private hospital in the philippines. methods: design: retrospective review of plain pns ct scans setting: tertiary private teaching hospital participants: one hundred four (104) plain pns ct scans from january 2018 to december 2020 were considered for inclusion. results: of the 104 pns ct scans, 35 were excluded seven for age less than eighteen, six for undistinguishable pef and twenty-two for chronic rhinosinusitis. the remaining 69 pns ct scans demonstrated identifiable structures, with overall average distances from alc to aef of 23.71 ± 2.43 mm, aef to pef of 10.87 ± 2.39 mm and pef to oc of 7.39 ± 2.28 mm. conclusion: our study suggests average distances for localization of vital structures such as the anterior ethmoidal artery, posterior ethmoidal artery and optic nerve among filipinos. because of considerable variation between and within sexes, individual measurements should still be obtained for each patient in performing endonasal, skull base and orbital surgery. keywords: skull base; orbital surgery; paranasal sinus; optic nerve; anterior ethmoidal artery; posterior ethmoidal artery; anterior lacrimal crest the anterior ethmoid artery (aea) and the posterior ethmoid artery (pea) are major vessels supplying the ethmoid sinus, nasal septum and anterior skull base. control of these vessels is a key step in performing extended sinus, skull base and orbital procedures. iatrogenic damage to these vessels due to their critical location which traverse the orbit and roof of ethmoid sinus, is potentially dangerous during endoscopic sinus, anterior skull base and orbital surgery. retraction of the aea into the orbit can lead to permanent vision loss if not managed appropriately.1 there is also an increased risk of optic nerve injury during coagulation of the posterior ethmoidal artery.2 radiologic evaluation of the anterior and posterior ethmoidal foramen and optic canal by paranasal sinus computed tomography scan among adult filipinos maria katerina a. palacios, md1 jay pee m. amable, md1 kea t. capio, md2 1department of otorhinolaryngology head and neck surgery university of the east ramon magsaysay memorial medical center 2department of radiology university of the east ramon magsaysay memorial medical center correspondence: dr. jay pee m. amable department of otorhinolaryngology head and neck surgery 5th floor, ent office, hospital service bldg., uermmmc, inc., 64 aurora blvd., quezon city 1113 philippines phone: (632) 8715 0861 local 257 fax: (632) 8716 1789 email: jpamablemd@gmail.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by both authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest presented at the philippine society of otolaryngology head and neck surgery descriptive research contest. november 8, 2021. philipp j otolaryngol head neck surg 2022; 37 (1): 20-22 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery original articles thus, the approximate localization of these vital structures should be known pre-operatively to anticipate and prevent complications in performing endonasal, skull base and orbital surgeries. after an exhaustive search in medline (pubmed), herdin plus and google scholar, we found no studies on the location, course and relationship of these structures among adult filipinos. this study aims to determine the average distances of the anterior ethmoidal foramen (aef) from the anterior lacrimal crest (alc), aef to posterior ethmoidal foramen (pef) and pef to optic canal (oc) on plain paranasal sinus computed tomography (pns ct) scans of adults in a tertiary private hospital in the philippines. methods with approval of the university of the east ramon magsaysay memorial medical center (uermmmci) research institute for health sciences ethics review committee (rihs erc code: 1121/h/2021/201), this retrospective review analyzed pns ct scans obtained at our tertiary private hospital from january 2018 to december 2020. all plain pns ct scans performed in uermmmci for various indications during the study period were retrieved chronologically and reviewed by the authors, two otolaryngologists and one radiologist. the inclusion criteria for all plain pns ct scans to be reviewed were those of male and female patients aged 18 years or older. excluded were scans of patients who underwent previous endonasal surgery prior to performing the imaging study, those with extensive sinonasal tumors which had invaded the orbital apex, dura, brain, middle cranial fossa, nasopharynx and clivus, those of patients with craniofacial injuries and anomalies or with chronic rhinosinusitis, and ct scans with no demonstrable pef. all pns ct scans were obtained using a hitachi multi-slice supria 64 ct scanner (htsi healthcare solutions, fl, usa) and evaluated using radiant dicom software for windows 11/10/8.1/8/7 (https:// www.radiantviewer.com). the software showed the three planes simultaneously (axial, coronal, and sagittal) in bone window and allowed taking measurements in the actual scale. the thickness of the cuts where the actual measurements were obtained was 0.625 mm. localization of the structures were consensually arrived at by the authors using the 24-12-6mm landmark mentioned by naidoo and wormald.1 the location of the alc, aef, pef and oc were obtained in multiplanar cuts. using the sagittal cuts of the plain pns ct scan, the measurements of the distances of the following: alc to aef, aef to pef and pef to oc and the averages were obtained. all data was recorded and tabulated using microsoft excel for mac v. 16.52 (21080801) (microsoft corp., redmond, wa, usa). the average means and standard deviations were computed by sex, and overall, using microsoft excel. results the sample for this study was obtained using the largest available number of plain pns ct scans done in uermmmci during the study period. a total of 104 plain pns ct scans were reviewed with seven excluded for age less than 18, six excluded for undistinguishable posterior ethmoidal foramen and 22 excluded for chronic rhinosinusitis. none had previous endonasal surgery, extensive sinonasal tumors, craniofacial anomalies or facial fractures. of the 69 finally included (66.34%) out of 104 pns ct scans, 39 were of male patients and 30 were of females, and all demonstrated identifiable and complete structures. figures 1 to 4 show representative pns ct scan localizations of the alc, aef, pef and oc respectively, and figure 5 shows a representative scan of how the distances were measured. we obtained the following average distances for alc to aef: 23.87 ± 2.56 mm (males), 23.67 ± 2.27 mm (females); aef to pef: 11.08 ± 2.44 mm (males), 10.54 ± 2.28 mm (females); pef to oc: 7.79 ± 2.40 mm (males), 7.03 ± 2.20 mm (females); with overall averages of: 23.71 ± 2.43 mm for alc to aef, 10.87 ± 2.39 mm for aef to pef and 7.39 ± 2.28 mm for pef to oc. figure 1. representative pns ct scan images (bone windows) demonstrating localization of the anterior lacrimal crest (alc) at intersections of lines in multiplanar views: a. sagittal view; b. coronal view; and c. axial view. a b c figure 2. representative pns ct scan images (bone windows) demonstrating localization of the anterior ethmoidal foramen (aef) at intersections of lines in multiplanar views: a. sagittal view; b. coronal view; and c. axial view. a b c figure 3. representative pns ct scan images (bone windows) demonstrating localization of the posterior ethmoidal foramen (pef) at intersections of lines in multiplanar views: a. sagittal view; b. coronal view; and c. axial view. a b c philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery vol. 37 no. 1 january – june 2022 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery original articles discussion computed tomography has been used in few studies on the distances of ethmoidal foramen and the optic canal.3 traditionally, surgeons have used the “24-12-6mm rule” measuring from the alc-aef, aef – pef and pef-oc to navigate critical medial orbital wall structures.4 in contrast our study suggests overall average distances from alc to aef of 23.71 ± 2.43 mm, aef to pef of 10.87 ± 2.39 mm and pef to oc of 7.39 ± 2.28 mm. we compared our findings with previous studies on radiologic evaluation of anterior and posterior ethmoidal foramen and optic canal using plain pns ct scans. the study of nitek et al. on morphometry of the orbit in an east european population based on three-dimensional ct reconstruction measured the minimal safe distances of 50 caucasian patients from alc-aef, aef-pef, and pef-oc at 27.7 ± 2.8 mm, 10.6 ± 3.3 mm, and 5.4 ± 1 mm, respectively which as compared to our study has a 4 mm difference for alc-aef, 0.27 mm difference for aef-pef and 1.99 mm difference for pef-oc.5 cankal et al. obtained average distances of 13.7 mm and 8.5 mm for the aec-pec and pec-oc respectively in their study of 150 pns ct scans in turkey which also differs from our study from which there is a 2.83 mm difference for aef-pef and 1.11 mm difference for pef-oc.6 cánovas et al. measured 11.24 ± 2.14 mm for the aef-pef and 7.26 ± 1.33 mm for the pef-oc in their study of 20 ct scans of cadaver heads in spain which also did not match our study with a 0.37 mm difference for aef-pef and 0.13 mm difference for pef-oc.7 preoperative computed tomography imaging has become a mainstay in surgical planning prior to endonasal, skull base and orbital surgery and affords the opportunity to identify anatomic variants that predispose patients to surgical complications.8 inadequate pre-operative analysis of pns ct scans by the surgeon may lead to accidental damage to crucial structures such as the aea, pea and optic nerve, hence our goal was to measure the average distances from anterior lacrimal crest (alc) to anterior ethmoidal foramen (aef), anterior ethmoidal foramen to posterior ethmoidal foramen (pef) and posterior ethmoidal foramen to optic canal (oc) using plain paranasal sinus (pns) computed tomography (ct) scans that are consistent with adult filipino patients. however, simple this study may seem, it is not without limitations. there were no associations made with pathologic findings. selection bias was present, because all of our plain pns ct scans were obtained from patients with non-excluded indications for the scans and may not represent the larger normal population to which our results can be applied. further radiologic studies may be done to increase the sample size and facilitate the data collection process. correlations with pathologic findings on pns ct scans may also be explored. our study also focused only on adults and further studies can be performed in pediatric age groups. despite these limitations, our study may help provide data for further analysis by future investigators. in conclusion, our study suggests average distances for localization of vital structures such as the anterior ethmoidal artery, posterior ethmoidal artery and optic nerve among filipinos. because of considerable variation between and within sexes, individual measurements should still be obtained for each patient in performing endonasal, skull base and orbital surgery. figure 4. representative pns ct scan images (bone windows) demonstrating localization of the optic canal (oc) at intersections of lines in multiplanar views: a. sagittal view; b. coronal view; and c. axial view. a b c figure 5. representative pns ct scan sagittal sections (bone windows) demonstrating measurement of the distances (lines between dots) from: a. alc to aef; b. aef to pef; and c. pef to oc. a b c acknowledgements we would like to acknowledge the invaluable insights of dr. ardie frencer v. dizon, dr. jan paul d. formalejo and dr. cathrine p. miura in the technical writing of this paper. references 1. naidoo y, wormwald pj. chapter 4. endoscopic and open anterior/posterior artery ligation. in: chiu ag, palmer jn, adappa nd (editors). atlas of endoscopic sinus and skull base surgery. 2nd ed. elsevier. 2018. pp. 25–32. 2. yamamoto h, nomura k, hidaka h, katori y, yoshida n. anatomy of the posterior and middle ethmoidal arteries via computed tomography. sage open med. 2018 apr 27; 6: 2050312118772473. doi:  10.1177/2050312118772473; pubmed pmid:  29760919; pubmed central pmcid: pmc5946601. 3. felding ua, karnov k, clemmensen a, thomsen c, darvann ta, buchwald c, et al. an applied anatomical study of the ethmoidal arteries: computed tomographic and direct measurements in human cadavers. j craniofac surg. 2018 jan;29(1):212–216. doi: 10.1097/ scs.0000000000004157; pubmed pmid: 29287000. 4. piagkou m, skotsimara g, dalaka a, kanioura e, korentzelou v, skotsimara a, et al. bony landmarks of the medial orbital wall: an anatomical study of ethmoidal foramina. clinical anatomy. 2014 may; 27(4): 570–577. doi: 10.1002/ca.22303. 5. nitek s, bakoń l, sharifi m, rysz m, chmielik lp, sadowska-krawczenko i. morphometry of the orbit in east-european population based on three-dimensional ct reconstruction. advances in anatomy. 2015 oct; 101438:1–10. doi:10.1155/2015/101438. 6. cankal f, apaydin n, acar h, elhan a, tekdemir i, yurdakul m. et al. evaluation of the anterior and posterior ethmoidal canal by computed tomography. clin radiol. 2004 nov;59(11):1034-1040. doi:10.1016/j.crad.2004.04.016; pubmed pmid: 15488853. 7. monjas-cánovas i, garcía-garrigós e, arenas-jiménez jj, abarca-olivas j, sánchez-del campo f, gras-albert jr. anatomía radiológica de las arterias etmoidales: estudio por tc en cadáver. acta otorrinolaringol esp. 2011 sep oct; 62(5):367–374. doi:10.1016/j.otorri.2011.04.006 pubmed pmid: 21683934. 8. o’brien wt, hamelin s, weitzel ek. the preoperative sinus ct: avoiding a “close” call with surgical complications. radiology. 2016 oct; 281(1): 10–21. doi:  10.1148/radiol.2016152230 pubmed pmid: 27643765. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles abstract objective: to present our in-house 3d planning protocol utilizing open-source computer-aided design software and discuss specific applications in reconstruction of various craniomaxillofacial defects, demonstrating a free, accessible, efficient, accurate, and easily learnable alternative to expensive counterparts. methods: design: case series setting: tertiary private training hospital participants: ten (10) patients who underwent cad assisted reconstructive surgeries from february 2017 – may 2018. results: a total of 10 patients were included; 7 mandibular reconstructions were surgically reconstructed using our 3d planning protocol and achieved symmetric mandibular contour, with good functional occlusion after surgery; 1 cranioplasty and 1 orbital trauma case also achieved good symmetry and adequate correction of enophthalmos respectively. however, inadequate soft tissue correction was seen in 1 case of maxillary reconstruction despite achieving symmetric bony contour. conclusion: our 3d planning protocol using open-source cad applications is a viable alternative to expensive professional counterparts. additional prospective studies may better demonstrate benefits in terms of accuracy and decreasing intraoperative time in craniomaxillofacial and head and neck reconstruction. keywords: 3d planning, computer-aided design; craniomaxillofacial reconstruction functionality and aesthetics are two important aspects that remain a challenge in reconstruction of craniomaxillofacial (cmf) defects.1,2 over a decade, advancements in 3d application of open-source 3d planning software in virtual reconstruction of complex maxillofacial defects dann joel c. caro, md ferdinand g. pamintuan, md department of otorhinolaryngology head and neck surgery university of santo tomas hospital correspondence: dr. ferdinand g. pamintuan department of otorhinolaryngology head and neck surgery university of santo tomas hospital españa boulevard, sampaloc, manila 1015 philippines phone: +63 917 840 4354 email: ferdiepamintuan@yahoo.com the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that the authors believe that the manuscript represents honest work. the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. presented at the philippine society of otolaryngologyhead and neck surgery poster session contest on surgical innovation & surgical instrumentation held on october 24, 2018, at the foyer, manila hotel. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philipp j otolaryngol head neck surg 2021; 36 (2): 30-35 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 3130 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles planning aimed to address these challenges by improving efficiency and precision.3 the 3d planning technique enables the operator to virtually inspect and manipulate a 3d object and transform it into a physical object through 3d printing. this is accomplished using computer-aided design (cad) applications. proprietary or paid software dedicated for biomedical 3d designs are offered by professional companies for a fee. such a service has demonstrated benefits in cmf reconstruction in other countries, while it remains underutilized in our country. this is due to unavailability of such a service locally, entailing additional costs and delays in surgery. on the other hand, free, open-source software are readily available for download in the internet with functions that are adapted to aid surgical reconstruction. we present our in-house 3d planning protocol utilizing opensource cad programs and discuss their utility in reconstruction of various craniomaxillofacial defects, thereby providing a free, accessible, efficient, accurate, and easily learnable alternative to expensive counterparts. methods with institutional review board approval, this case series retrospectively reviewed patients in whom 3d planning was done using open-source cad software, prior to surgical reconstruction of cmf defects between february 2017 and may 2018 at the university of santo tomas hospital. patients with defects caused by neoplastic conditions (benign or malignant), trauma, and secondary defects caused by previous surgery who were candidates for surgery and cad-assisted surgical reconstruction were all included. patients with bilateral defects were not included since mirroring of the unaffected side (as a basis for reconstruction) could not be carried out. data of these patients including age, gender, surgical indications, location of defect, operative time, preoperative and post-operative photo documentation, and actual 3d planning data were gathered and collated from medical records. 3d planning protocol using open-source software the 3d planning protocol included the 3d design of the anatomical model that would serve as guide for pre-bending of titanium implants that would be used for reconstruction. basically, it starts from the acquisition and analysis of 3d data in the computer, up to virtual reconstruction of surgical or trauma defects. the following protocol was followed in every patient whom 3d planning was applied: 1. data acquisition from digital imaging and communications in medicine (dicom) files for this protocol, computed tomography (ct) scans without contrast were used as an imaging modality in all patients since it better delineates the bony outline of involved structures. slice thickness was not standardized among patients, however thin cuts (1-2 mm) are preferable as it translates to higher quality of the 3d reconstructed model. the ct dicom data (used to store, exchange, and transmit medical images) was loaded in 3d slicer (http://www.slicer.org), an open-source software designed for analysis and visualization of medical images.4 once loaded, the images were cropped and limited to the area of interest (e.g. upper face, midface, mandible). this was followed by segmentation of the images by changing the threshold settings. segmentation enables the user to delineate structures (e.g. bone or soft tissue) based on the parameters set. (figure 1) for this protocol, only the bony structures were delineated which were then converted into a 3d object and saved as an stl file – a type of file recognized by cad and 3d printing applications. the 2d images seen in the ct scans were now reconstructed into a 3d object which could be visualized, analyzed, and manipulated in three dimensions in a computer. these were all accomplished using 3d slicer. 2. virtual surgery virtual surgery involves the visualization, analysis of defect, resection of the involved segment (for tumors), mirroring, and virtual reconstruction. these steps were primarily done using meshmixer® version 3.5 (autodesk inc., san rafael, ca, usa), a free software that enables the user to redesign a 3d object or 3d mesh. the first step was to further isolate the area of interest. this step further decreased the cost of 3d printing by eliminating much of the uninvolved areas of the craniofacial skeleton. the next steps differed for each case depending on the affected craniofacial segment. mandible for tumors involving the mandible, the next step was to identify the lines of resection and virtually perform a segmental mandibulectomy of the involved side. (figure 2) the affected segment was highlighted and deleted. this mimics the segmental mandibulectomy during actual surgery. the next challenge was to bridge the gap caused by virtual resection. this was done by selecting the same area on the unaffected side based on bony landmarks. the selected segment was mirrored and dragged to the side of defect to bridge the gap. (figure 3) these 2 parts were combined and saved as an stl file. the saved file was loaded to 3d printing software and printing was initialized. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles cranial vault our protocol was used in one patient who underwent cranioplasty due to a unilateral temporoparietal defect. for this case, the initial steps were also similar to those of the other segments except that no mirroring was done. after converting into stl file, the 3d model of the cranial vault was printed as is (unreconstructed). 3. 3d printing once reconstruction of the 3d object was completed, it was loaded in the 3d printing software to prepare for printing. we used the ultimaker cura version 3.6 (ultimaker b.v., utrecht, netherlands), a free and open-source application as our 3d printing software. the 3d printer was a creality ender 3 (creality 3d technology co., shenzhen, china), a fused deposition modelling (fdm) 3d printer which prints an object by adding layer by layer of melted polylactic acid (pla) filament. each layer has a minimum height of 0.4 mm which causes poor printing quality for bony structures less than 0.4 mm thick (e.g. medial orbital wall, orbital floor). pre-contouring of titanium implants were made once 3d prints were available. actual surgeries were performed using the pre-contoured implants. results a total of 10 patients who underwent cmf reconstruction using our in-house 3d planning protocol during the study period were included in this series. there were three males and seven females, with ages ranging from 14-62 years old (mean age, 33 years old; median age 30 years old). the most common clinical indication for reconstruction was neoplasm resection. a total of seven patients had neoplastic conditions, of which six were benign tumors with one malignant tumor. one patient suffered orbital trauma. other conditions included one postsurgical defect secondary to decompressive craniectomy, and one maxillary mucocele. a total of seven patients underwent mandibulectomy; four segmental resections and three marginal resections. all four segmental resections were reconstructed using fibular osteocutaneous free flaps with titanium reconstruction plates. mandibular defects after segmental resection were all classified as class l defects (lateral defect not crossing the contralateral central segment of the mandible) based on the classification used by boyd.5 in all seven patients who underwent mandibulectomy, virtual resection and reconstruction was followed by mirroring of the uninvolved side to re-establish the normal contour of the mandible. pre-bending of titanium reconstruction plate was done using the 3d printed anatomic model as a guide for the plate contour. the average time needed for pre-bending of titanium plates was 70 minutes. figure 1. segmentation (dotted outline) and conversion of axial, sagittal, and coronal 2d images into 3d model (solid outline) using a 3d slicer. figure 2. virtual segmental resection of the involved side of the mandible a. tumor and margins; and b. virtual segmental resection a b figure 3. a. virtual segmental mirroring of the uninvolved side b. to fill in the defect gap in the involved side. a b midface and orbit the steps for virtual reconstruction of these segments were the same as those for the mandible except for the mirroring technique. mirroring of the midface and orbit was done by cutting the 3d model midline in its sagittal plane followed by duplicating and mirroring of the unaffected side. we noticed that this technique was not applicable to the mandible since this method disrupts its normal curvature especially when the lesion or resection extends to the anterior portion of the mandible. segments of the midface and orbit could then be combined and loaded into the printing software. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 3332 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles intraoperatively, adjustments in reconstruction plate contour were made for the first two cases due to poor adaptation to the mandible, while only minor adjustments were needed in the succeeding cases. among the four patients receiving a fibular free flap, operative time was decreased from 15 hours to seven hours as we also improved our technique in 3d planning. reconstructions were all performed by a single microvascular reconstruction consultant. all patients who received mandibular reconstruction aided by 3d planning achieved symmetric mandibular contour with correct post-operative dental occlusion. no complications were observed. figure 4 shows a representative example of one patient who underwent segmental mandibulectomy with reconstruction using fibular free flap and prebent titanium reconstruction plate. the one patient who had orbital floor and medial wall fractures secondary to a motor vehicular accident had enophthalmos of her right eye. our 3d planning protocol was also applied resulting in adequate correction of enophthalmos. the aesthetic outcome was likewise satisfactory. for the secondary reconstruction of cranial defect secondary to decompressive craniectomy, a pre-shaped titanium mesh was used. intraoperatively, the mesh accurately fit the defect with no additional bending required. post-operative symmetry of the cranium was re-established. last was an interesting case of complex maxillary defect reconstruction. preoperative planning showed a defect involving the entire anterior maxillary wall, including the malar prominence, leaving only a deformed zygomatic arch. the defect was caused by the compressive forces from a huge mucocele causing excessive bone loss of the midfacial area. the mirror image of the uninvolved side served as a guide for contouring the titanium mesh which was used in this case as a scaffold for the denser bone cement applied over it. post-operative figure 5. case of maxillary mucocele reconstructed by titanium mesh with bone cement a. shows the 3d printed model demonstrating large maxillary defect, b. shows the preoperative shaping of titanium mesh, and c. shows the post-operative ct scan imaging of patient. a b c a b figure 4. representative case of a left segmental mandibulectomy reconstructed by fibular free flap with reconstruction plate a. shows the actual 3d planning, while b. and c. demonstrate the preoperative and 1 year post-operative photos of the patient, respectively. c philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles ct scan showed adequate reconstruction of the bony structure and contour. however, we failed to consider the soft tissue contracture that was persisted post-operatively. figure 5 illustrates the planning and outcome of this case. discussion our initial experience demonstrates the viability of our in-house 3d planning protocol utilizing open-source cad programs and illustrates their utility in reconstruction of various craniomaxillofacial defects. they provide a free, accessible, efficient, accurate, and easily learnable alternative to expensive counterparts. mandibular reconstruction was the most common indication for our 3d planning protocol which was consistent with the literature review of louvrier et al.6 other structures reconstructed include the cranium, orbit and maxilla. all achieved satisfactory functional and aesthetic outcomes except for one whose skin and soft tissue contracture remained a problem post-operatively. surgeries involving craniomaxillofacial structures are always a challenge because it is difficult to achieve facial symmetry especially when dealing with complex defects.1,2 precision is often the key to achieve symmetry but entails long and tedious surgeries. with the aid of 3d planning in surgery, surgeons are able to simultaneously achieve precision and efficiency.6,7 previous studies showed that 3d planning in craniomaxillofacial surgery reduced operative time which indirectly decreased actual or costs, duration of hospital stay, and improved patient’s quality of life.3,8 other specific advantages include improved adaptation of reconstruction plates, decreased bone plate gap, decreased metal fatigue by reducing trial and error, aids in patient education, and serves as a teaching tool. 9 such 3d planning has been used as a means to create 1) surgical guides, 2) patient-specific implants, 3) contour models, 4) occlusal splints, and 5) facial prosthesis.6,10 currently, the most advanced function of 3d planning and manufacturing is the creation of patient-specific implants.8 an implant that is designed in the computer, with dimensions specific to the patient’s defect, is printed directly using biocompatible materials.6,8,13 however, this technology is not yet available in our local setting. in our experience, 3d planning along with 3d printing has offered the advantages of preoperative planning of osteotomy, visualization of defect after virtual resection, and pre-contouring of reconstruction plates prior to actual surgery. it has also facilitated patient education and understanding through the use of patient-specific 3d printed anatomic models. we were able to accomplish these steps using opensource 3d applications that are widely available for download in the internet. the advantage of free applications is that many users will be able to test their functions, share their experiences, and demonstrate their own way of doing 3d design. our team started creating virtual models by learning from video tutorials uploaded by other users, and eventually coming up with our own 3d planning protocol. although proprietary software used by professional manufacturers may be ideal, the cost of whole 3d planning and manufacturing by such companies usually ranges from p180,000 to 300,000.11 this is very costly for our local setting, offsetting any possible advantages. using our own protocol, the cost may range from p500-1000 (depending on model size) when printing 3d designed models using our office-based, nonmedical grade 3d printer. this offers a solution to both cost and logistic challenges that come with this technology. our 3d planning protocol has been applied in various craniomaxillofacial and head and neck reconstructions, most commonly in the reconstruction of mandibular defects. reconstructing the original contour of the mandible is important and at the same time challenging since it may result in poor aesthetic and functional outcomes when inadequately corrected. in this case series, all seven mandibular reconstructions achieved satisfactory aesthetic results based on mandibular symmetry as well as good functional outcomes demonstrated by correct post-operative dental occlusion. the average time of 70 minutes spent for pre-bending of titanium implants may be considered as the minimum time saved during surgery since the shaping of implants were already done preoperatively. however, plate contour adjustments were still made during our first two mandibular reconstructions due to poor adaptation of the preshaped implants to the mandible. we noticed that mirroring the whole unaffected side alters the contour and location of the condyle, hence the adjustments made during surgery. this problem was also noticed in the study of khalifa et al.12 accuracy of the implants were improved when we changed our technique to segmental mirroring in which only the length and segment of the defect was selected and mirrored from the unaffected side causing only minor plate adjustments during surgery. furthermore, the decreasing trend in intraoperative time seen over four consecutive cases of fibular free flap reconstruction aided by our protocol may reflect an improvement in the accurate shaping of the implants. the aforementioned problem was not experienced in other reconstructed craniofacial segments such as the orbit, maxilla and cranium. the time spent for the entire planning including printing using our protocol was approximately 10 hours for one mandibular model. this may vary depending on the size of the 3d model being printed. in comparison, professional planning and manufacturing of these models may require four sessions of 45-minute web meetings with a biomedical engineer who does the designing, and one to two weeks production time and delivery to the usa and europe which may take philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery 3534 philippine journal of otolaryngology-head and neck surgery philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 2 july – december 2021 original articles references 1. ren w, gao l, li s, chen c, li f, wang q, et al. virtual planning and 3d printing modeling for mandibular reconstruction with fibula free flap. med oral patol oral cir bucal. 2018 may 1;23(3): e359-e366. doi: 10.4317/medoral.22295; pubmed pmid: 29680849; pubmed central pmcid: pmc5945234. 2. roser sm, ramachandra s, blair h, grist w, carlson gw, christensen am, et al. the accuracy of virtual surgical planning in free fibula mandibular reconstruction: comparison of planned and final results. j oral maxillofac surg. 2010 nov;68(11):2824-32. doi: 10.1016/j.joms.2010.06.177; pubmed pmid: 20828910. 3. cohen a, laviv a, berman p, nashef r, abu-tair j. mandibular reconstruction using stereolithographic 3-dimensional printing modeling technology. oral surg oral med oral pathol oral radiol endod. 2009 nov;108(5):661-6. doi: 10.1016/j.tripleo.2009.05.023; pubmed pmid: 19716728. 4. fedorov a, beichel r, kalpathy-cramer j, finet j, fillion-robin j-c, pujol s, et al. 3d slicer as an image computing platform for the quantitative imaging network. magn reson imaging. 2012 nov;30(9):1323-41. doi:  10.1016/j.mri.2012.05.001 pubmed pmid: 22770690. pubmed central pmcid: pmc3466397. 5. raith s, rauen a, möhlhenrich sc, ayoub n, peters f, steiner t, et al. introduction of an algorithm for planning of autologous fibular transfer in mandibular reconstruction based on individual bone curvatures. int j med robot. 2018 apr;14(2). doi: 10.1002/rcs.1894; pubmed pmid: 29423929. 6. louvrier a, marty p, barrabé a, euvrard e, chatelain b, weber e, et al. how useful is 3d printing in maxillofacial surgery? j stomatol oral maxillofac surg. 2017 sep;118(4):206-212. doi: 10.1016/j. jormas.2017.07.002; pubmed pmid: 28732777. 7. king bj, park ep, christensen bj, danrad r. on-site 3-dimensional printing and preoperative adaptation decrease operative time for mandibular fracture repair. j oral maxillofac surg. 2018 sep;76(9):1950.e1-1950.e8. doi: 10.1016/j.joms.2018.05.009; pubmed pmid: 29859953. 8. jo yy, kim sg, kim mk, shin sh, ahn j, seok h. mandibular reconstruction using a customized three-dimensional titanium implant applied on the lingual surface of the mandible. j craniofac surg. 2018 mar;29(2):415-419. doi: 10.1097/scs.0000000000004119; pubmed pmid: 29215451. 9. salgueiro mi, stevens mr. experience with the use of prebent plates for the reconstruction of mandibular defects. craniomaxillofac trauma reconstr. 2010 dec;1(212):201-208. doi: 10.1055/ s-0030-1268520; pubmed pmid: 22132258 pubmed central pmcid: pmc3052711. 10. jacobs ca, lin ay. a new classification of three-dimensional printing technologies: systematic review of three-dimensional printing for patient-specific craniomaxillofacial surgery. plast reconstr surg. 2017 may;139(5):1211-1220. doi:10.1097/prs.0000000000003232; pubmed pmid: 28445375. 11. dell’aversana orabona g, abbate v, maglitto f, bonavolonte p, salzano g, romano a, et al. lowcost, self-made cad/cam-guiding system for mandibular reconstruction. surg oncol. 2018 jun;27(2):200-207. doi:10.1016/j.suronc.2018.03.007; pubmed pmid: 29937172. 12. khalifa ga, moniem naae, elsayed sae, qadry y. segmental mirroring : does it eliminate the need for intraoperative readjustment of the virtually pre-bent reconstruction plates and is it economically valuable ? j oral maxillofac surg. 2016 mar;74(3):621-630. doi:10.1016/j. joms.2015.09.036; pubmed pmid: 26519751. 13. numajiri t, morita d, nakamura h, tsujiko s, yamochi r, sowa y, et al. using an in-house approach to computer-assisted design and computer-aided manufacturing reconstruction of the maxilla. j oral maxillofac surg. 2018 jun;76(6):1361-1369. doi:10.1016/j.joms.2017.11.042; pubmed pmid: 29294353. longer for our country.7 unlike engineers, surgeons are well-versed with the anatomy and surgical plans for the patient which may be considered advantageous when surgeons do the 3d planning themselves. this also makes web meetings unnecessary. despite the known advantages of an in-house 3d planning protocol, some challenges are still encountered in its use. the learning curve for 3d designing may vary depending on the computing skills of the operator who are surgeons themselves. a six-month duration and 10 cases were required to adequately learn the in-house approach for 3d planning, consistent with the experience of numajiri et al.13 moreover, intraoperative changes were sometimes noted that could affect the adherence of surgeons to the initial plan. problems included sclerosis of surrounding tissues and local tissue contracture due to prior surgery, and shrinkage of tumor due to effects of preoperative chemotherapy or radiation.13 in our experience, the actual intraoperative defect became larger compared to the preoperative 3d planning due to increase in tumor size caused by delays in surgery. this required additional, but minimal bending of the reconstruction plate. our protocol is currently limited to the creation of anatomic models. functions of our currently used free software may not permit the creation of more advanced 3d models such as cutting guides or patient-specific implants. rapid advancements in technology may soon allow users to design these models using free, and more advanced open-source cad software. in summary, our 3d planning protocol has been used in reconstruction of various craniomaxillofacial defects and has resulted in good surgical outcomes. the utilization of open-source cad applications is an affordable, widely accessible, and viable alternative to expensive professional counterparts. additional prospective studies using more objective assessments of surgical outcomes may better demonstrate these benefits. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation philipp j otolaryngol head neck surg 2021; 36 (1): 50-56 c philippine society of otolaryngology – head and neck surgery, inc. the use of commercially available non-medical grade usb cameras for physician guided ent out-patient self-examination during the covid-19 pandemic rentor y. cafino, md department of ears, nose, throat head and neck surgery zamboanga city medical center correspondence: dr. rentor y. cafino department of ears, nose, throat head and neck surgery zamboanga city medical center, outpatient bldg, dr. d. evangelista st., sta. catalina, zamboanga city 7000 philippines phone: +63 917 301 5910 email: rcafino@gmail.com the author declared that this presents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by the author, and the author believes that the manuscript represents honest work. disclosures: the author signed a disclosure that there are no financial or other (including personal) relationship, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. presented at the philippine society of otolaryngology head and neck surgery 1st virtual surgical innovation contest (1st place) november 25, 2020. abstract objective: to describe the use of commercially available, non-medical grade usb cameras in a non-contact examination of simple cases involving the ears, nose and oral cavity of patients during the covid-19 pandemic. methods: design: instrument innovation setting: tertiary government training hospital participants: patients who consulted at the ent-hns outpatient department during the covid-19 pandemic. results: commercially available usb cameras were able to provide basic visualization of the ears, nose and oral cavity. the non-medical grade usb cameras captured lower quality images when compared to the medical grade endoscopes but provided enough visualization to aid in the examination and diagnosis of simple cases. there was a learning curve in using the set-up but patients were able to adjust well, taking an average time of 2.7 minutes to complete the examination. conclusion: non-medical grade usb cameras may play a role in aiding otolaryngologists in examining simple cases during the covid-19 pandemic. integration of this system into current examination practices may offer an extra layer of protection for otolaryngologists and patients alike. however, the use of these instruments as part of regular ent practice may be controversial and will need further study.  keywords: usb camera; no-contact examination; virtual physical examination; onsite virtual examination (onvex); covid-19 the covid-19 pandemic has changed the face of the medical world as we know it. because many health care professionals around the world were infected while providing care to their patients, health care institutions turned to telemedicine to avoid the high risk of infection. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 5150 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation although telemedicine with thorough history taking and augmented patient self-examination may aid the physician in making a diagnosis, this is often not enough. in particular, otolaryngology patients need to consult or are referred to have their orifices visualized in person.1 the majority of outpatient otolaryngology consults involve such ear diseases as otitis media, externa and impacted cerumen followed by nasal stuffiness and throat pain.2,3 these diseases are difficult to diagnose with clinical history alone, and treatment depends on physical examination findings, necessitating visualization. this places otolaryngologists in a unique and risky position. extra precautions taken when attending to patients who are physically present during the pandemic include screening, appropriate personal protective equipment (ppe), proper distancing, and standard disinfection protocols.4 despite the availability of protocols and recommendations, hospitals are faced with ppe and supply shortages,5,6 forcing health care providers to adapt, some for better and some for worse.7,8 in adapting to the changing health situation, the use of unconventional methods may offer temporary solutions. we describe one such attempt at adaptation, using commercially available usb cameras for no-contact examinations of the ears, nose, and oral cavity which we termed as onsite virtual examination (onvex). this paper also describes their uses and applications in face-to-face otolaryngologic consultations during the covid-19 pandemic. methods materials 1. two pen type usb cameras for the ears and nose and 1 usb camera mounted on the camera handle for the oral cavity (see figure 1a, b), choosing the usb cameras and fabricating the usb camera handle). 2. a laptop or desktop with a minimum processor of intel i3 (intel, sta. clara, california) running the latest operating system (os) of choice. 3. a 16-inch generic computer monitor (led monitor, aoc, taipei, taiwan) with compatible connectors (video graphics array or better). 4. a table measuring 1 x 0.65 x 0.73 (l x w x h) meters. (any kind of table can be used as long as the minimum length of 1 meter is met in order to afford 1 meter distancing from the patient. we chose to use a plastic table (model 280478, lifetime, utah, usa) due to its affordability and portability. 5. two standard sized armless monobloc chairs (ruby 1, cofta mouldings corporation, philippines). 6. any transparent barrier to separate the examiner from the patient. we chose to use ordinary gauge 8 polyvinyl chloride (pvc) transparent sheet plastic measuring 68 x 58 cm (w x h). a frame for the plastic barrier consisted of two 3d printed c clamps printed using petg in a prusa i3 mk3s (prusa research, prague, czech republic) and two pvc pipes 2.6 cm in diameter and 68 cm in length. choosing the usb cameras a commercially available pen type usb camera (model i96, unbranded, unspecified manufacturer, china) measuring 15 cm long with a 5.5 mm diameter was selected for examination of both the external auditory canal and nasal cavity. (figure 1a) although medical grade rigid oto-endoscopes measure 2mm in diameter, the average diameter  of the external auditory canal is 6 to 8mm9,10 (theoretically accommodating a 5.5 mm diameter device), while medical grade rigid nasal endoscopes have a diameter of 4 mm. a shorter 5 cm usb camera with the same 5.5 mm diameter (unspecified model, unbranded, unspecified manufacturer, china) was selected for examination of the oral cavity. (figure 1b) all these usb cameras had 2-meter-long cables. the shorter 5 cm usb camera was ingress protection code (international protection code) ip67 rated, with ip code 6 denoting figure 1. commercially available usb cameras a. pen type usb camera for ear and nose examination, b. short usb camera for oral cavity examination. a b a b c figure 2. assembly of usb camera for oral cavity examination a. camera handle (a) is inserted into the camera-tongue depressor attachment (b); b. the usb camera is mounted onto the camera slot; c. a disposable tongue depressor is inserted on the specified slot. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation solid protection from contact with harmful dust, and ip code 7 denoting temporary protection from immersion in water (no specified depth from manufacturer).11 the usb cameras selected for the examination of the ear and nose were not waterproof and had no specified ip rating. fabricating the usb camera handle the usb camera for examining the oral cavity required a handle that could mount the camera on top of a disposable wooden tongue depressor. inspired by the reusable stainless steel tongue depressor (weider, presica, philippines), the handle was modeled in fusion 360 (autodesk, san rafael, california) software for 3d computer aided design (cad), modeling, manufacturing, industrial design, electronics and mechanical engineering, and 3d printed using polyethylene terephthalate glycol (petg) in a prusa i3 mk3s (prusa research, prague, czech republic). assembling the usb camera and handle for oral cavity examination after 3d printing the camera handle, part a was attached to part b as illustrated in figure 2a. the fit had to be snug so no adhesives needed to be applied. the usb camera was then mounted on the slot atop the handle (figure 2b) and oriented by pointing the camera at an object or image and rotating it until appropriate orientation was achieved. marking the usb camera with a small piece of tape at the 12-o-clock location helped decrease the time needed to reorient the camera in between patients. lastly, a wooden tongue depressor was inserted in the specified slot about 2/3 of the way for each use. (figure 2c) the author designed the tongue depressor slot to be 2 mm but observed that some wooden tongue depressors were thinner than others, in such cases, a small piece of paper was inserted into the slot with the tongue depressor to improve the fit. setting up the examination space the examination table was positioned with a standard monobloc chair on either side in an area with good ventilation. (figure 3a) the 3d printed c-clamps (figure 3b) were applied to the middle of the table (figure 3c, d) and the pvc pipes were inserted into the slots on the c-clamps. (figure 3e) a transparent pvc plastic sheet was cut to about 70 cm and each side taped to the pvc pipe. the pipes were then turned in a clockwise direction until the clear plastic became taut and a final piece of tape was applied to prevent the plastic from unrolling. one side was designated as the examiner’s side and was outfitted with a laptop/desktop computer (figure 4a) and another computer monitor was placed on the patient’s side. (figure 4b) the computer monitor was attached to the computer on the physician’s side via a vga cable with a usb type c connector. display settings on the computer were then set to duplicate screen mode. each usb camera was figure 3. onvex table. a. table with a minimum length of 1 meter; b. 3d-printed c-clamp; c. securing the clamp to the side of the table; d. attachment of the c clamp to the middle of the examination table as shown; e. attach the pvc pipes fitted with pvc plastic sheet onto the c clamp slots as shown. e a c d b separately labeled and laid on a clean linen sheet on the patient’s side while its cables were passed underneath the transparent plastic barrier to the examiners side with the usb connectors placed within reach of the physician. the usb connectors were also labeled according to what each camera would be used for. figure 5 shows the entire onsite virtual examination (onvex) physical setup. patient criteria we pilot tested our onvex set up on patients 7 years old and above regardless of gender, who physically consulted or were referred for conditions involving the ears, nose and mouth at the zcmc ent-hns outpatient department from july 2020 to october 2020. all patients had been cleared by the covid-19 pre-triage, and were considered for pilot testing if they were cooperative and able to follow instructions (or were accompanied by an adult who was able to follow instructions). hospital employees consulting for routine annual ent examinations were excluded. philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 5352 philippine journal of otolaryngology-head and neck surgery a b cd e f surgical innovations and instrumentation instructed to grasp the camera using the hand opposite to the ear being examined. the patient was then instructed to hold the camera like a pen and orient it by pointing it to his/her face and turn the camera while looking at the screen until proper orientation was achieved. the patient was instructed to pull his/her ear upwards and backwards using his/her free hand (backwards and downwards for pediatric population). following this, the camera was then inserted into the external auditory canal (eac) and the tympanic membrane visualized and examined. (figure 6a) the procedure was then repeated on the opposite ear. if there was presence of discharge or debris, the patient was instructed to clean the ear by gently inserting a cotton pledget and swabbing the ear canal to clear the debris. examination was discontinued if the eac was too narrow or obstructed with cerumen. once examination of the ear was performed, the usb was removed from its port. 4. the usb connector of the camera labeled “nose” was then plugged into the computer and the camera program started. the patient was instructed to hold the camera upright and orient it using the same method described in step 3. once proper orientation was achieved, the patient was instructed to insert the camera into the nostril opposite the hand holding the camera pointing slightly upwards and towards the midline at about a 15o angle. (figure 6b) the camera was advanced into the nasal cavity until the inferior turbinate, middle turbinate and septum was visualized. the procedure was then repeated on the other side. once examination of the nose was performed, the usb was removed from its port. 5. the usb connector of the camera labeled “mouth” was plugged next into the computer and the camera program started. the patient was instructed to hold the camera handle with the camera facing the patient. proper orientation was already done prior to mounting the camera to the handle, however in cases where the camera was displaced, the patient was instructed to orient the camera using the same method described in step 3. the patient was instructed to open his/her mouth and while keeping the tongue inside, gently depress his/ her tongue using the tongue depressor. (figure 6c) with the tongue depressor in position, the patient was instructed to say “ah”. after oral cavity was examined, the camera was disconnected. disinfection after use, all endoscopes were replaced and the area wiped down with 1:100 hypochlorite solution prepared according to doh guidelines.12 the used endoscopes were then wiped down using the 1:100 hypochlorite solution and the camera used for the oral cavity including its handle was soaked in bis (3-aminopropyl) dodecylamine, didecyldimethyl ammonium chloride (virusolve® + eds, amity international health care, south yorkshire, u.k.) disinfectant solution for 15 minutes. the pen type usb cameras were placed lens down in a sterile bottle with about 5ml of virusolve® + eds disinfectant solution or figure 4. view of examiners and patient’s sides; a. examiner’s side; b. patient’s side a b figure 5. physical setup for on-site virtual examination (onvex). a. physician; b. patient; c. clear plastic barrier; d. computer/laptop facing physician; e. screen facing patient; f. table measuring at least 1 meter in length. figure 6. patient’s self-examination. a. examination of the ear; b. examination of the nose; c. examination of the oral cavity a b c procedure 1. the patient was seated on the table opposite the examiner and the procedure was explained in the patient’s language/dialect or the common language/dialect understood by both the patient and the examiner. the patient was expected to be wearing a mask and was only instructed to remove it during examination of the nose and mouth. the examiner was wearing level i ppe (surgical face mask, alcohol hand wash or spray). small children were held by an adult companion (carried, or sitting on the lap). 2. a brief and focused history taking was obtained. 3. the usb connector of the camera labeled “ear” was plugged into the computer and the camera program started. the patient was philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation with just enough solution to soak the tips of the camera. after soaking, the usb cameras were wiped down once again and left to air dry. examination flow patients who consulted at the ent-hns opd first passed through the covid-19 pre-triage area where they were pre-screened by the medical officer in charge. once cleared, the patients were directed to the outpatient department and triaged by the resident-in-charge. patients who sought consult for conditions of the ears, nose and oral cavity were then directed towards the onvex examination area where history and examination using the described method was performed by three ent-hns resident physicians. special interventions patients with ear discharges and cerumen in the ear canal were first asked to perform ear cleaning by gently swabbing the ear canal with a cotton pledget to remove the debris. if the ear canal remained obstructed, the patient was taken to the department’s makeshift negative pressure booth where the examination was completed after ear cleaning and suctioning. patients that required further examination and special ent procedures were directed to the makeshift negative pressure booth where the procedures were performed and examination carried out. documentation and data analysis examinations were performed by the author and two other ent-hns resident physicians. the procedure was practiced among all 3 residents prior to implementation on patients. however, no formal training was done. documentation was performed by the junior residents and the results were logged in google sheets (google, california, usa). photo documentation was obtained by the respective examiner. data was analyzed using simple sums and frequencies. no evaluation/feedback tool was administered to the patients or physicians. suggestions for improvement were gathered among the physicians in an informal manner. results a total of 17 patients (7 females and 10 males) were examined using onvex during the pilot trial period. there were four children (ages 7 to 11 years old) and 13 adults (ages 18 to 63 years old). age distribution was skewed to the left with a median age of 22 and an interquartile range of 12. three ent-hns physicians including the author performed the examinations during the study period. all three residents were adept at performing a basic ent examination and had tested the onvex system prior to examining patients. all patients examined during this time had ear complaints and the most common diagnosis was otitis externa. further examination of the a b figure 7. overtly abnormal ear findings seen on ear examination. a. picture of a patient’s ear canal with otomycosis taken using a usb camera; b. picture of a patient’s ear canal with a foreign body taken using a usb camera. figure 9. comparison of photos taken by non-medical grade endoscopes (left) and those taken by a storz endoscope system (right) figure 8. patient with bilateral cholesteatoma. a. right tympanic membrane with whitish debris behind the tympanic membrane and a suspected attic retraction pocket; b. left tympanic membrane with a near total perforation and whitish debris. a b a b c d e f philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 5554 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation nose and oral cavity showed normal results with an average examination time of 2.7 minutes. two patients had to undergo additional procedures in the makeshift negative pressure booth, one had otomycosis (figure 7a) and underwent ear cleaning while the other had a retained foreign body (rubber) (figure 7b) in his left ear. one patient was diagnosed as bilateral chronic suppurative otitis media with cholesteatoma (figure 8a, b) and was admitted for further evaluation and management. images captured using the usb cameras were of a significantly lower quality compared to that of a medical grade camera. figure 9 shows a side-by-side comparison of photos taken by non-medical grade endoscopes and those taken by a storz endoscope system (telecam c-mount one chip camera head ntsc, storz, tuttinlingen, germany). at the time of documentation, the author had no access to a digital video recorder for the storz system and the screen of the endoscope tower was photographed using a mobile phone camera (iphone 10, apple, ca, usa). the figures on the left were taken using the usb cameras while those on the right were taken using the storz telecam documentation system. the pictures on the right showed paler mucosa than their counterparts. the images on the right were sharper and better illuminated. discussion endoscopic visualization is usually part of the otolaryngology examination battery and is performed by a trained operator with specialized endoscopes. however, due to the covid-19 pandemic, most of these procedures place the examiner at risk and would require the physician to be in full personal protective equipment (ppe) in order to mitigate the risk.13,14 due to the shortage of ppes caused by the pandemic, their use has been reserved for limited situations.14 endoscopic visualization performed by patients on themselves under supervision of an otolaryngologist at a safe distance could theoretically allow examination without close physical contact. however, medical grade endoscopes are costly and require specialized training. we used commercially-available usb cameras with dimensions similar to endoscopes used in ent examinations in place of the medical grade endoscopes. the cameras are relatively inexpensive and can be handled by an untrained person. melder and mair15 compared a digital camera to the traditional 35mm lens system in endoscopic photography and found that images taken using a digital camera were comparable and sometimes even superior to the traditional counterpart. the aforementioned usb cameras use the same digital camera system but have lower resolution due to their size, explaining the lower image quality when compared to a medical grade endoscopy system. endoscopic examination performed by a trained individual can visualize the intended structures in standardized fashion with full focus and proper orientation. however, if performed by an untrained individual, visualization will be expected to vary. examples of such figure 10. compilation of images taken during onvex showing differences in exposure, focus and orientation. b d f h j l a c e g i k philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery vol. 36 no. 1 january – june 2021 philippine journal of otolaryngology-head and neck surgery 5756 philippine journal of otolaryngology-head and neck surgery surgical innovations and instrumentation acknowledgements i wish to thank our department chairman dr. justin elfred lan b. paber for advice on patient examination flow, optimizing physical setup and coining the term onvex, our research coordinator dr. nurhada a. israel for guiding me in writing this paper, and my co-resident physicians dr. maria monique theresita soliven for serving as an examiner and providing photographs and line drawings, and dr. audrey ann cortez for serving as an examiner for onvex. references 1. mccoul ed. grasping what we cannot touch: examining the telemedicine patient. jama otolaryngol head neck surg. 2020 jun 18;146(8):685–686. doi: 10.1001/jamaoto.2020.1266; pubmed pmid: 32556313. 2. fasunla aj, samdi m, nwaorgu og. an audit of ear, nose and throat diseases in a tertiary health institution in south-western nigeria.  pan afr med j.  2013 jan;14(1) doi: 10.11604/ pamj.2013.14.1.1092 pubmed pmid: 23503692 pubmed central pmcid: pmc3597854. 3. zamboanga city medical center department of ent-hns annual census 2019. unpublished data. 4. pso-hns covid-19 advisory no. 5: recommendations on the opd workflow during the covid-19 pandemic, 04 may 2020. [internet] [cited 2020 june 16] available from: https:// pso-hns.org/2020/05/04/advisory-no-5-recommendations-on-the-opd-workflow-during-thecovid-19-pandemic/. 5. park cy, kim k, roth s, beck s, kang jw, tayag mc, griffin m. global shortage of personal protective equipment amid covid-19: supply chains, bottlenecks, and policy implications. asian development bank briefs. 2020 april (130). 6. duque f iii. department circular 2020-0175 (republic of the philippines department of health, office of the secretary). manila: department of health. 2020. pp. 1-3. 7. press c. coronavirus: the nhs workers wearing bin bags as protection. [internet] bbc news. april 5 2020. available from: https://www.bbc.com/news/health-52145140. 8. armijo pr, markin nw, nguyen s, ho dh, horseman th, lisco, sj, schiller am. 3d printing of face shields to meet the immediate need for ppe in an anesthesiology department during the covid-19 pandemic. american journal of infection control. 2021(49): 302-308. 9. yu jf, lee kc, wang rh, chen ys, fan cc, peng yc, et al. anthropometry of external auditory canal by non-contactable measurement. appl ergon. 2015 sep;50:50-5. doi: 10.1016/j. apergo.2015.01.008; pubmed pmid: 25959317. 10. graceck rr . anatomy of the auditory and vestibular system. in : snow jb, wackym pa, balenger jj, editor. ballenger’s otolaryngology: head and neck surgery 17th ed. shelton: london; pmph usa. 2009. p. 62-66. 11. ingress protection (ip) ratings. 2013. [cited 2021 march 30] available from https://www.iec.ch/ ip-ratings. 12. department memorandum 0157, guidelines on cleaning and disinfection. republic of the philippines department of health; 2020. available from: https://doh.gov.ph/sites/default/files/ health-update/dm2020-0157.pdf. 13. mick p, murphy r. aerosol-generating otolaryngology procedures and the need for enhanced ppe during the covid-19 pandemic: a literature review. journal of otolaryngology head and neck surgery (2020) 49:29. 14. dofitas rb, say as, lahoz er, de leon jrc, inso rs, aison ds, et al. recommendations for the rational and effective use of personal protective equipment: guidelines for the extended use, re-use, and acceptable reprocessingmethods. [internet]. philippine college of surgeons. 2020 [cited 2020 may 13]. available from: http://pcs.org.ph/assets/images/pcs-covid-10rationale-use-of-ppe.pdf. 15. melder pc, mair ea. endoscopic photography: digital or 35 mm?. arch otolaryngol head neck surg. 2003 may;129(5):570-5. doi: 10.1001/archotol.129.5.570; pubmed pmid: 12759272. 16. lapeña jf, abes fl, gomez ma, villafuerte cv, roldan r, fullante pb, et al. otorhinolaryngology out-patient practice in the “post”-covid-19 era: ensuring a balance between service and safety. philipp j otolaryngol head neck surg, 2020; 35(1): 6-29. doi:10.32412/pjohns.v35i1.1249. 17. kim si, lee jy. walk-through screening center for covid-19: an accessible and efficient screening system in a pandemic situation. j korean med sci. 2020 apr 20;35(15):e154 https:// doi.org/10.3346/jkms.2020.35.e154 eissn 1598-6357·pissn 1011-8934. images are shown in figure 10. these images were taken after a maximum of 5 attempts to instruct the patient. some pictures were well focused and centered (a, d, e, j and l) while others were poorly focused and not well-oriented (b, c, f, g, h and k). despite these limitations, examination of the intended structures was still possible. despite the lower image quality and occasional poor orientation, the examiners were able to diagnose simple cases. examination of the ears, nose, and throat using medical grade endoscopes through a small hole in a mask or a mask with an endoscopy valve may lessen aerosolization during routine ent examination15 but this still requires the examiner to be in close contact with the patient (less than 1 meter). onvex has the advantage of a no-touch setup and physical distancing of 1 meter separated by a physical barrier which could theoretically allow for use of level i ppe.14,16 however, unlike the the previously mentioned methods, onvex requires a wide open space which may not be feasible in small clinics, and procedures such as removal of foreign bodies and laryngoscopy cannot be performed. the makeshift negative pressure booth inspired by the korean walk in swab booths17 was designed to allow otolaryngologists to perform aerosol generating procedures (agp) safely but was used to perform a full ent examination as well. compared to onvex, preparation time took longer (1 minute versus 5 minutes) and less resources was required (e.g. cleaning solution, ppe). this pilot trial had other limitations. due to the pandemic, the trial sample was limited and the cases seen were not varied. because the trial was performed during the early stages of the covid-19 pandemic, extreme caution was implemented thus limiting physician patient interaction to only the bare essentials. documentation of the patients educational status, literacy, language/dialect spoken, and experience feedback was not complete, and we cannot speculate on any associations between these variables and the outcomes of the onvex examination. should a formal clinical trial of this innovation be performed, the author recommends including a larger and more varied patient population and investigation of other factors that may affect the outcome of the onvex examination. this initial experience demonstrated that non-medical grade usb cameras when integrated into a physician guided self-examination by patients was able to provide basic visualization of the ears, nose, and oral cavity. although the image quality and orientation were not as good as endoscopic documentation performed by the examiner using a medical grade endoscope, visualization using usb cameras aided the examiners in making a diagnosis without having to come in close contact with the patient. non-medical grade usb cameras may play a role in the examination of the ent patient. simple complaints such as ear pain, nasal stuffiness, and dysphagia may be initially assessed by means of no-contact examination using the described camera system. although there was a learning curve to using the usb cameras, patients were generally able to adjust well. integration of this system into current examination practices may provide an extra layer of protection for the otolaryngologist and patient alike during the covid-19 pandemic. the use of these instruments as part of the regular ent practice however may be controversial and will need further study. philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery review article abstract objective: to review available resources and provide evidence-based recommendations that may optimize otorhinolaryngologic out-patient health care delivery in the “post”-covid-19 era while ensuring the safety of our patients, healthcare workers and staff. data sources: relevant peer-reviewed journal articles; task force, organizational and institutional, government and non-government organization recommendations; published guidelines from medical, health-related, and scientific organizations. methods: a comprehensive review of the literature on the covid-19 pandemic as it pertained to “post”-covid-19 out-patient otorhinolaryngologic practice was obtained from peer-reviewed articles, guidelines, recommendations, and statements that were identified through a structured search of the data sources for relevant literature utilizing medline (through pubmed and pubmed central pmc), google (and google scholar), herdin plus, the world health organization ( who) global health library, and grey literature including social media (blogs, twitter, linkedin, facebook).  in-patient management (including orl surgical procedures such as tracheostomy) were excluded. retrieved material was critically appraised and organized according to five discussion themes: physical office set-up, patient processing, personal protection, procedures, and prevention and health-promotion. conclusion: these recommendations are consistent with the best available evidence to date, and are globally acceptable while being locally applicable. they address the concerns of otorhinolaryngologists and related specialists about resuming office practice during the “post”-covid-19 period when strict quarantines are gradually lifted and a transition to the “new” normal is made despite the unavailability of a specific vaccine for sars-cov-2. while they target practice settings in the philippines, they should be useful to ent (ear, nose & throat) surgeons in other countries in ensuring a balance between service and safety as we continue to serve our patients during these challenging times. keywords: covid-19; sars-cov-2; otorhinolaryngology; otolaryngology head and neck surgery; ent; out-patient practice; clinic practice otorhinolaryngology out-patient practice in the “post”-covid-19 era: ensuring a balance between service and safety josé florencio f. lapeña, jr. ma, md,1,2,4 franco louie l. abes, md, msc,3,4 mark anthony t. gomez, md, mpm,2,5,6 cesar vincent l. villafuerte iii, md,1,4,7 rodante a. roldan, md,6 philip b. fullante, md,1,4 ryner jose c. carrillo, md, msc,1,8 justin elfred lan b. paber, md,9 armando t. isla, jr., md,10 rose alcances – inocencio, md, moh,11 jose benedicto a. cabazor, md,12 ruzanne m. caro, md,13 ma. fita p. guzman, md14 1department of otorhinolaryngology college of medicine – philippine general hospital university of the philippines manila, philippines 2department of otorhinolaryngology head and neck surgery east avenue medical center, diliman, quezon city philippines 3department of otorhinolaryngology head and neck surgery faculty of medicine and surgery university of santo tomas, manila, philippines 4department of otorhinolaryngology manila doctors hospital, manila, philippines 5department of otorhinolaryngology head and neck surgery jose r. reyes memorial medical center, manila, philippines 6department of otorhinolaryngology head and neck surgery rizal medical center, pasig city, philippines 7department of otolaryngologyhead and neck surgery far eastern university nicanor reyes medical foundation quezon city, philippines 8department of anatomy, college of medicine, university of the philippines manila, philippines 9department of otorhinolaryngology head and neck surgery zamboanga city medical center, zamboanga city philippines philipp j otolaryngol head neck surg 2020; 35 (1): 6-29 c philippine society of otolaryngology – head and neck surgery, inc. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 76 philippine journal of otolaryngology-head and neck surgery review article 10mercy community hospital, iligan city lanao del norte, philippines 11energy development corporation, ortigas center pasig city, philippines 12metro north medical center and hospital quezon city, philippines 13capitol medical center, quezon city, philippines 14asian hospital and medical center, alabang muntinlupa city, philippines correspondence: prof. dr. josé florencio f. lapeña, jr. department of otorhinolaryngology ward 10, philippine general hospital taft avenue, ermita, manila 1000 philippines phone: (632) 8554 8467 telefax: (632) 8524 4455 email: lapenajf@upm.edu.ph, jflapena@up.edu.ph the authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere, in full or in part, in print or electronic media; that the manuscript has been read and approved by the authors, that the requirements for authorship have been met by each author, and that all the authors believe that the manuscript represents honest work. disclosures: the authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. creative commons (cc by-nc-nd 4.0) attribution noncommercial noderivatives 4.0 international the novel coronavirus 2019 (covid-19) pandemic has become the singular defining feature of the year 2020.1 caused by the sars-cov-2,2,3 it has quickly spread to every continent and taken a devastating toll on human lives, resources, systems and institutions.4–6 despite various efforts to contain the virus, slow its spread, and “flatten the curve,”7,8 the end seems nowhere in sight, with no available vaccine in the near future9,10 and achieving natural herd immunity fraught with unacceptably high mortalities.11,12 asymptomatic transmission, possible relapse, re-infection of or reactivation among previously-healed patients,13–15 and detection of virus in tears,16,17 saliva,18 mucus, nasopharyngeal, oropharyngeal, tracheobronchial secretions, even feces19–21 that can be transmitted via droplets, direct contact, fomites22 and even aerosolization,23 are among the many possible reasons for the continuing menace. otorhinolaryngologists are particularly susceptible to direct infection from viral particles in the nose, nasopharynx, oral cavity, oropharynx, and tracheobronchial tree.24 indeed, the first physician to die worldwide during the initial covid-19 outbreak in wuhan, china was an otolaryngologist.25 as direct examination of the ears, nose, throat, head and neck, and aerosolgenerating procedures (agps) including ear-cleaning (which may stimulate a cough reflex) constitute a very high level of occupational exposure to sars-cov-2, the resumption of office practice even as enhanced extended community quarantine (ecq) restrictions and lockdowns are gradually eased, become a major concern in the “post’-covid-19 era before a vaccine is available and herd immunity is achieved.26–28 this article aims to review available resources and provide evidence-based recommendations that may optimize otorhinolaryngologic out-patient health care delivery in the “post”-covid-19 era while ensuring the safety of our patients, healthcare workers, and staff. methods a comprehensive review of the literature on the covid-19 pandemic as it pertained to “post”-covid-19 out-patient otorhinolaryngologic practice was obtained from peer-reviewed journal articles, task force and organizational, government and non-government organization recommendations, published guidelines from medical, health-related, and scientific organizations. articles, guidelines, recommendations, and statements were identified through a structured search of the data sources for relevant literature utilizing medline (through pubmed and pubmed central pmc), google (and google scholar), herdin plus, the who global health library, and grey literature including social media (blogs, twitter, linkedin, facebook).  data sources were queried for studies and articles related to evolving epidemiology (including re-conversion to positive status), clinical presentation (including neurologic and otolaryngologic symptoms, asymptomatic individuals and carriers), transmission and contamination (including droplets, aerosolization, oral-fecal route, fomites), and diagnosis (including symptoms, signs, imaging, other labs, and tests rt-pcr & rapid igg/igm). these were reviewed to support a general recommendation to consider all patients encountered as potentially covid-19 positive. in-patient management (including orl surgical procedures such as tracheostomy) was excluded. relevant search terms used alone and in combination included: “covid-19,” “sars-cov-2,” philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery “coronavirus”, “virus”, “otorhinolaryngology,” “otolaryngology,” “ent,” “head and neck surgery,” “facial plastic surgery,” “craniomaxillofacial surgery,” “office practice,” “clinical practice,” “office procedures,” “out-patient,” “ambulatory,” “telemedicine,” “viral particles,” “aerosol,” “aerosol generating procedures,” “disinfection,” “antiseptics”, “ppe,” “personal protection,” “respiratory protection,” “personal protective equipment,” “endoscopy,” “rhinoscopy,” “pharyngoscopy,” “laryngoscopy” “prevention”, “health promotion”, “re-emergence.” retrieved material was critically appraised and reviewed, and recommendations were formulated organized according to five discussion themes: 1. physical office set-up;  2. patient processing;  3. personal protection;  4. procedures; and 5. prevention and healthpromotion. the draft recommendations were externally reviewed by otolaryngologist-clinical epidemiologists who were asked to critique, comment on, suggest corrections, check consistency, and correct references or suggest additional or better references. they were asked to determine whether the recommendations were relevant to clinical practice in the setting(s) they were intended for. following review, the recommendations were revised accordingly, citing additional evidence as needed. a cut-off for citations was set on 2020 may 10 after all post-review revisions had been completed. discussion the “post”-covid-19 era is envisioned to continue until such time that a vaccine is widely available,9 and/or natural herd immunity has been achieved for the current strains.12 following this, the possibility of seasonal re-emergence (similar to influenza) must also be considered. during the “post”-covid-19 era, our primary and overarching recommendation is to consider all patients encountered as potentially covid-19 positive.29 this is not only based on documented infectivity by asymptomatic individuals and super carriers,30,31 but by cases of possible re-infection as well among previously recovered patients.32 such a stance is reflected in our recommendations, grouped into five main discussion themes. physical office set-up post visual alerts at the entrance to health-care facilities reminding all persons to   wear a mask (and practice respiratory hygiene/ cough etiquette) before entering. the postage of signages in appropriate languages at the entrance and inside the clinic to alert patients with respiratory symptoms serves to notify staff as well as to teach/remind patients and companions about correct respiratory hygiene and cough etiquette.33 paper signages need to be replaced regularly to keep them clean, or covered in clear plastic and cleaned daily. practitioners may opt not to see any symptomatic, probable, or suspect patients in their private clinics; a notice to this effect may be posted outside the office, requesting such patients to report directly to the appropriate facility for screening.34  previously the world health organization ( who) advised that only individuals with symptoms or those taking care of at-risk people should use masks.35 subsequently, both the us36 and singapore37 switched to advising citizens to wear masks when they leave their homes. the philippines requires masks (whether cloth or surgical) be worn outside one’s residence,38 with some areas implementing this more strictly than others.39 the us centers for disease control and prevention (us cdc) now recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain especially in areas of significant community-based transmission although it still maintains that the cloth face coverings recommended are not surgical masks or n-95 respirators.36  those are critical supplies that must continue to be reserved for healthcare workers and other medical first responders.36 furthermore, patients are advised to keep masks on in reception areas and other first contact locations for patients and visitors.40  consider installing a disinfection doormat at the building or floor entrance or clinic entrance. viral particles in footwear have been well documented41 leading to recommendations to leave footwear outside homes42 and to change footwear or use booties or shoe covers inside health care facilities (although there is no good evidence for booties or shoe covers).43 when footwear cannot be removed or covered, stepping in footbaths may be considered to reduce viral load. commerciallyavailable disinfection mats use various disinfectants (aldehydes, quaternary ammonium compounds, phenolics, and halogens)  to safely kill viruses.44 alternatively, a chlorinated doormat or towel soaked in 0.5% (1:10) bleach solution (1 part sodium hypochlorite in 9 parts water)45 may be installed outside the clinic (followed by a dry rug), or at the entrance to the building or floor (outside the lift) to prevent tracking mud into the clinic. visibly dirty doormats should be cleaned or replaced. disinfect doorknobs or handles regularly, or install hands-free door handles. the first and last surface contact for persons entering and exiting the clinic should be regularly disinfected, using 60-90% isopropyl or ethyl alcohol spray or wipe.46 this measure is more effective than review article https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 98 philippine journal of otolaryngology-head and neck surgery asking patients and accompanying persons to wear gloves.47 handsfree alternatives, such as twist handles that can be operated by elbow-pressure, or foot-handles may be installed. patients and accompanying persons should be seated at least 2 meters apar t inside the clinic and in the waiting area. this measure serves to establish physical distancing between patients and accompanying persons as well as clinic staff.  the who and philippine doh (department of health) recommend at least a 1-meter distance.48,49 the us cdc recommends maintaining a distance of at least 6 feet (2 meters).50 a study on the transmission of influenza showed that at a distance of 1 meter, the average cough centre-line velocity measured 1 meter away from the mouth was 1.2 m/s.51 in a room with an infected person with ineffective and inadequate ventilation, the concentration of the virus in the air of the room can build up, and the distance of 6 ft (2 meters) is not sufficient to protect against infections.52 people who are obviously sick and coughing are likely to spread droplets containing coronavirus particles further than people who are simply breathing or talking. hence, recent literature does not support the 1-2 meter rule of spatial separation and raises concerns about viral transmission even when breathing or talking,53 further supporting the use of masks by all persons. the national university of singapore recommends that patients be told where exactly to be seated in the waiting area and that seats outside the consultation room should be spaced 2 meters apart.54 a small clinic can practice this by only admitting one patient at a time, with physical-distancing markers (or seats) placed outside. accompanying persons can also be limited to those with patients who are children, elderly or infirm. consider installing physical barriers such as clear plastic sneeze guards. source control measures for all persons with respiratory symptoms include respiratory hygiene/cough etiquette.55 in order to prevent the transmission of all respiratory infections in healthcare settings, implementation of control measures should be done at the first point of contact with a potentially infected person.56  in a typical otolaryngology clinic, the first point of contact are the waiting rooms.  waiting rooms provide potential opportunities for transmission of infections transmitted via droplet and airborne routes.57  the us occupational safety and health administration recommends where possible, to install physical barriers such as clear plastic sneeze guards in reception or intake areas.58 the use of barrier protections, such as sneeze guards, is common practice for both infection control and industrial hygiene.50  however, physical barriers have the potential to serve as sources of infection, and should be disinfected after every patient encounter, cleaned after every clinic day and changed whenever transparency is reduced.55 barriers should be firmly fixed in order to prevent accidental dislodgement and contamination of people on either side. they can also impede ventilation and laminar flow of air, trap heat and humidity and limit visibility for both patients and clinicians so care must be exercised in setting them up.  examples of such barriers have been produced locally using 0.25” thick clear acrylic, extra thick 300 micron clear acetate, or thick plastic sheets and can be installed around the reception desk (figure 1a), between physician desks and patient chairs (figure 1b), or around examination chairs (figure 1c).  a b c figure 1. physical office barriers in ent clinic, general santos city: a. reception area; b. consultation desk; and c. examination chair. courtesy of dr. cesar anthony p. yabut. (photos published in full, with permission) specialized negative-pressure ventilation should ideally be installed in otolaryngology clinics for agps. a study published in emerging infectious diseases found a wide distribution of covid-19 virus genetic material on surfaces and in the air about 4 meters (13 feet) from patients in two hospital wards in wuhan, china.41 aerosolized covid-19 particles were detected near air vents (5/14 [35.7%]), in patient rooms (8/18 [44.4%]), and in the doctor’s office area (1/8 [12.5%]).41 aerosolized virus was detected in the airflow upstream from the patients but was concentrated near and downstream of the patients.41 procedures that could generate infectious aerosols should ideally be performed in an airborne infection isolation room (aiir).59 such aiirs are single-patient rooms at negative pressure relative to the surrounding areas, and with a minimum of 12 air changes per hour (ach).60 air from these rooms should be ducted to the outside environment after passing through a high-efficiency particulate air (hepa) filter.59  if an aiir is not available, guides for setting up a negative pressure room such as the minnesota department of health comprehensive review article philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery guide for setting up a negative pressure room to prevent infectious particles from escaping the room envelope61 may be consulted.  salient features for such negative pressure rooms include:  a. pressure differential, pascals (pa) of 2.5 pa measured between room and corridor; b. recommended air change rate is 12 ach; and c. air from negative pressure rooms and treatment rooms exhausted directly to the outside if possible.61 the zamboanga city medical center department of otorhinolaryngology head and neck surgery under our co-author dr. justin elfred lan b. paber has developed special negative pressure examination booths.62 (figure 2a, b) in existing clinic rooms, negative air pressure can be produced by balancing the air intake (pumped into the room by the air conditioning system) and outflow of air from a room (sucked out by an exhaust fan). negative pressure rooms have higher outflow than intake rates. a negative pressure room does not need a hepa filter inside the room because the filter is placed inside the air duct so that air exhausted into the environment is clean.    there are two possible ways of exhausting filtered air from negative pressure rooms. in figure 3a, the exhaust fan draws hepafiltered room air outside through a window. if a window is not available, the filtered air can be ducted to the building exhaust system as seen in figure 3b. because the discharged air is hepa filtered, no extra consideration for air discharge location is required.61 without such negative pressure, air-conditioned rooms are vulnerable, as air conditioning may circulate infectious droplets containing sars-cov-2. a previous report showed how one asymptomatic diner managed to infect diners away from him as infectious droplets were circulated by the air conditioning system.63 virus-laden aerosols mainly concentrate near and downstream of airflow from the patients although risk was also present in the upstream area.41 an easy way to induce negative pressure in a windowless room (if there is an exhaust fan in the bathroom) is to open the bathroom door and keep the aircon unit running. if the exhaust fan is appropriate to the size of the room and there are no obstructions to air flow, then it can efficiently drain air out of the room. because “air from toilet rooms or other soiled areas is usually exhausted directly to the atmosphere through a separate duct exhaust system,”60 a portable hepa filter can help keep viral load down if there is enough air change inside the room. regular cleaning and decontamination of the clinic and clinic facilities is recommended. appropriate and recommended products should be used on both hard and soft surfaces. cleaning and decontamination of clinic instruments and electronic items (i.e. tablets, monitors, keyboards, etc.) should follow manufacturer’s instructions. the virus that causes coronavirus disease 2019 (covid-19) is stable for several hours to days in aerosols and on surfaces.64 severe acute respiratory syndrome coronavirus 2 (sars-cov-2) was detectable in aerosols for up to three hours, up to four hours on copper, up to figure 2. negative pressure booth: a. schematic diagram; b. photos. a b figure 3. a. exhaust fan discharging hepa filtered clean air through an outside-facing window. solid-fill box, clean air supply; stippled box, hepa filter and exhaust fan; black-outlined rectangle, window facing outside. figure 3. b. hepa filtered air ducted by exhaust fan to a building exhaust system. solid-fill box, clean air supply; stippled box, hepa filter and exhaust fan; black-outlined rectangle and shaded duct leading to interior exhaust. review article philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 1110 philippine journal of otolaryngology-head and neck surgery 24 hours on cardboard and up to two to three days on plastic and stainless steel.64 these findings affirm the us cdc guidance on the cleaning of frequently touched objects and surfaces.65 the united states environmental protection agency (epa) has a list of chemicals and products for use against sars-cov-2.66 when using an epa-registered disinfectant, follow the label directions for safe, effective use. make sure to follow the contact time, which is the amount of time the surface should be visibly wet.66 the philippine doh recommends the use of  0.5% (1:10) bleach solution (1 part sodium hypochlorite in 9 parts water) for surface disinfection.45 best practices in reprocessing reusable and single-use devices in otolaryngology, with particular attention to flexible fiberoptic endoscopes/nasopharyngoscopes, nasal speculums, and other clinic and operating room instruments should be observed (see section on procedures). reprocessing standards should be based on risk level.  high-risk devices require sterilization, whereas lower risk devices may be reprocessed using various disinfection procedures.67 among these procedures are initial cleaning with soap and water, soaking in or wiping with disinfectant solution, autoclaving, microwave, and ultraviolet (uv ) light.  the clinic should maintain a supply of instrument sterilants or disinfectants that are readily available for philippine use. among those recommended by the us fda are high-level disinfectants 2.4% glutaraldehyde (cidex®) which can be used for a 45 minute soak (with the solution reusable for 14 days); 3.4% glutaraldehyde (cidexplus®) which can be used for a 20 minute soak (with the solution reusable for 28 days;68 and hand and instrument surface disinfectants such as alcohol-based solutions (70% isopropyl or ethyl alcohol) and propanol-based solutions (cutasept® and sterillium®).   other methods of sterilization include autoclaving and uv light type c.67,69,70 caution is advised with using uv light as this may injure skin and eyes.71 cleaning instructions specific to manufacturer’s instructions such as the karl storz endoscopes can be downloaded from the company website.72  uv light may be an effective measure for decontaminating clinic rooms and surfaces, in addition to chemical surface disinfection. according to the us cdc, the application of uv radiation in the health-care environment (i.e., operating rooms, isolation rooms, and biologic safety cabinets) is limited to destruction of airborne organisms or inactivation of microorganisms on surfaces.69 it may also have use in decontaminating surgical instruments,70 and is widely used in various settings, including dental clinics.73 no data is available specifically testing the uv susceptibility of the sars-cov-2 virus. however, tests on related coronaviruses such as the sars coronavirus have concluded that they are highly susceptible to uv inactivation.71 considering that the health technology assessment in ontario was unable to make a firm conclusion about the effectiveness of uv technology on hospital acquired infections,74 the use of uv disinfecting devices during the covid-19 pandemic should be guided by such recommendations as those issued by the us fda.75 moreover, although a 2012 study concluded that “uv radiation appears to provide a quick alternative disinfection technique to chemical disinfectants (e.g. ethanol) for some surgical tools that is less harmful to both humans and fish while not producing chemical waste,” it does “not recommend using this method for tools such as needle holders having overlapping parts or other structures that cannot be exposed directly to uv radiation.”76  special guidelines are recommended for the use and disinfection of washrooms and toilets.  because of the possibility of oral-fecal transmission of sarscov-2,77,78 clinics should determine their own guidelines for the use and disinfection of washrooms and toilets. apart from viral shedding from the upper airway, aerosolization of the virus from excreta possibly during valsalva or during flushing may also occur and may lead to droplets that may be inhaled by the next toilet user or may persist on hard surfaces such as tiles, mirrors and faucets.79  therefore, as much as possible, patients and companions should not use clinic washrooms and toilets (using building facilities if available). using negative-pressure exhaust fans and closing the lid before flushing to minimize aerosol generation in addition to strict hand washing before and after using the washroom or toilet, and disinfecting doorknobs, tap and flush handles, and light switches (or installing no-touch faucets and switches) are some measures to consider.80 in addition, periodic cleaning with detergent and chemical surface disinfection plus uv light (if available) before closing the clinic for the day are recommended.81 no touch disposal of all clinic-generated waste as biohazardous waste is recommended. to be consistent with our overarching recommendation to consider all patients as potentially covid-19 positive, all clinic– generated waste material should be considered biohazardous waste and disposed of accordingly.82 clearly marked biohazard bags, or yellow garbage-disposal bags should be sealed and disposed of according to local health code standards. unfortunately, such standards vary widely, and generate enormous covid-19 hazardous waste, especially in resource-challenged lowand middle-income country settings. the asian development bank has compiled a list review article philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery of considerations and recommendations that should be consulted in this regard.83 patient processing optimizing the otorhinolaryngologic – head and neck surgery (orl-hns) physician-patient clinical encounter during the covid-19 pandemic entails ensuring the safety of everyone involved including the patient, accompanying persons, health care workers (hcw ), and auxiliary staff. this can be done by promoting telemedicine, and when actual consultation is required, by focusing on actionable steps prior to, during, and after each patient encounter. here are some recommendations:  telemedicine should be utilized as much as possible to lower risk of exposure for patients and physicians. telemedicine should be utilized as much as possible during the covid-19 pandemic for its ability to provide patient care without the need to go to the hospital or clinic. through this avenue, patients with symptoms such as cough or colds can still be managed and monitored appropriately in the safety of their homes. this decongests health facilities and allocates resources to those who really need faceto-face care. moreover, teleconsults also reduce viral transmission for both patients and healthcare staff. 84  telemedicine has been used by orl specialists in the usa.  in a retrospective cohort study of 1,385 ent encounters with 2,008 individual diagnoses at the us veteran affairs medical center, the rate of telemedicine eligibility among outpatient consults in a general otolaryngology practice was 62%.85 problems of the middle and inner ear were most eligible because they do not commonly require a procedure to reach a diagnosis.  conditions affecting the larynx and outer ear were the least eligible.85 although rules in the usa were relaxed in response to the covid-19 crisis, the amercan academy of otolaryngology head and neck surgery (aao-hns) telemedicine committee emphasized that healthcare providers still have the responsibility to ensure privacy and manage encryption settings of the applications. approved remote communication products include apple face time, facebook messenger video chat, google hangouts video and skype.86   in the philippines, medical consultations over the phone, by chat, short messaging service (sms), and other audio and videoconferencing platforms (such as viber, whatsapp, telegram, and zoom) fall within the scope of telemedicine.87 physicians have utilized communication applications such as viber, facebook messenger and direct sms or text messaging. some physicians have also utilized applications created for teleconsults such as seriousmd (https://seriousmd.com) and medifi (https://www.medifi.com) that provide electronic medical records and prescriptions as well as facilitate professional fee collection using debit or credit cards.  the philippine doh collaborated with the national privacy commission (npc) to provide 24/7 hotlines (telemed management, medgate, globe telehealth, inc. or konsultamd) that can connect patients to volunteer doctors for free consults. this service is limited to the national capitol region (ncr) but more collaborations are underway for expansion to other regions.87 being a covid-19 referral center, the university of the philippinesphilippine general hospital (up-pgh) collaborated with phillppine long distance telephone compnay (pldt ) to provide a hotline for the covid-19 bayanihan operations center allowing patients to consult with professionals regarding their symptoms and coordinate transfers from other hospitals. notably, this hotline also facilitates receiving donations and supplies such as personal protective equipment (ppe).88 prior to the patient clinical encounter, all efforts should be made to screen, triage, and isolate patients who are suspected to have or are positive for covid-19, according to existing protocols. as discussed in the previous recommendation, patients can be advised to tele-consult remotely from home beforehand in order to screen for symptoms and to provide a designated appointment time in order to minimize the number of patients accommodated at the facility at a particular time. they can also be advised to wait outside the clinic while awaiting their turn.59, 89 if unable to do prior teleconsultation remotely from home, consideration for developing an on-site system where the patient can be interviewed in a separate area with the aid of phone or web cameras and microphones can be used in order to pre-screen the patient prior to face-to-face consultation. history taking and inspection of easily visible areas can be done using the said phone or web cameras. in addition, vital signs measurement using commonly available household instruments such as digital thermometers, and self-administered automated bp monitors can be used during remote site evaluation. the us cdc recommends developing protocols so that the clinic or health care facility can triage and assess patients prior to or immediately upon entry.89 everyone, including patients, staff, and hcws should be actively screened for fever and other symptoms of covid-19.59 use of screening questionnaires according to updated case definitions can be helpful to systematize the process.90   examples of screening questionnaires include but are not limited to: 1) the philippine society of otolaryngology-head and neck surgery (pso-hns) covid-19 screening and triaging tool for use in the outreview article https://seriousmd.com/ https://www.medifi.com/ philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 1312 philippine journal of otolaryngology-head and neck surgery patient clinic;91 and 2) the american health care association and national center of assisted living covid-19: screening checklist – for visitors and staff.92 ideally, all patients attending the out-patient clinic should have their temperatures checked on arrival, and patients who probably have, or are suspected to have covid-19 should be directed to the nearest hospital emergency room (or closest covid-19 triage center or barangay health emergency response team (bhert ) for further evaluation.25,34 the use of other tools for screening such as pulse oximetry testing for 02 desaturation have also been suggested,93 but there are as yet no published studies to support its use for screening, as well as conflicting public opinion on its utility for screening.94, 95 during the patient clinical encounter, all steps should be taken so that it is safe, efficient, and effective.   suggestions include but are not limited to pre-screening and prior history taking to optimize time spent during the in-person clinical encounter; using a directed physical examination; minimizing number of exposed staff; and ensuring use of appropriate personal protective equipment (ppe) and an optimized clinic set-up. the initial patient encounter with the receptionist or secretary (after initial screening) begins with ensuring compliance with proper wearing of masks, performing hand hygiene and observing physical distancing in the waiting area. this encounter usually includes handling of referral notes, filling out or updating hard-copy or electronic medical records, and obtaining vital signs. physicians and clinic staff may agree on modified procedures that entail less contact (such as foregoing with routine sphygmomanometry and taking the pulse and respiratory rate), and only obtaining weight (especially for children) during this period. with regards to the actual physician – patient encounter, the united kingdom’s ministry of health recommends that whenever face-to-face contact is essential, this should be kept to 15 minutes or less wherever possible.96 this is echoed by the us cdc which recommends the use of telemedicine in order to reduce facility risk.59 the usual paraphernalia for this encounter may be minimized during this period. for instance, only an ear speculum and curette may be prepared (without a nasal speculum, cheek retractor, tongue depressor, and mirrors) for a routine work-clearance otologic referral for ear cleaning. the section on procedures discusses this further.  specific guidance on the head and neck patient clinical encounter during the covid-19 pandemic from givi, et al.  include:29 1) that the examination be preferably performed in a separate room away from other patients, 2) only the necessary personnel should be present, 3) examination should be performed by the most experienced person present, and might be a more focused assessment based on the judgement of the examining physician; and that 4) proper doffing and disposal of ppe are of utmost importance. more detailed recommendations are in our section on procedures. the world health organization ( who) also recommends the following administrative measures among others: provision of adequate training for hcws; ensuring an adequate patient-to-staff ratio; monitoring hcw compliance with standard precautions and providing mechanisms for improvement as needed.90 if patients seen in clinic are subsequently found to be positive for covid-19, there should be a system to trace and isolate them as soon as possible and perform immediate contact-tracing of all persons present in the clinic around the same time. patients and possible contacts should then be managed accordingly depending on prevailing protocols of the doh, local government unit, and of the individual health care facility.   after the patient clinical encounter, steps should be taken to minimize transmission following possible sars-cov-2 exposure. all staff should continue observing proper hand hygiene and avoid touching the mucosal surfaces of the face (eyes, mouth, nose); the use of electronic medical records, electronic prescriptions, and cashless billing to minimize transfer of the virus through fomites (e.g. physical chart, prescription forms, or cash) should be considered; and there should be proper disinfection of the patient area and used instruments.  all clinic staff should clean visibly unsoiled hands with an alcoholbased hand rub or 70% alcohol or better yet, wash them properly with soap and water before and after each patient encounter.97 clinic staff should avoid touching their face (especially the eyes, mouth or nose).98  following the consultation session, measures should be put in place for processing laboratory requests, prescriptions, referrals to other physicians or health professionals, and other communications. while electronically generated paperless communications are ideal, careful handling of hard-copy materials emanating from the consultation area should ensure protection of clinic staff and patients. many receptionists and secretaries double-check these materials and reiterate instructions and follow-up schedules to patients and accompanying persons. the use of appropriate ppe (including gloves, masks and face shields) should be practiced. extra care should be taken in handling payments. although cashless means of payment have been recommended by some,99 many payments are made in bills and coins. because “there is currently no evidence to confirm or disprove that covid-19 can be transmitted through coins review article philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery or banknotes,”100 cash should be treated as contaminated material which should be stored in a covered container and handled with gloves. a process for safely handling payments should be established by each clinic. the who reports that the covid-19 virus has been shown to survive for up to 72 hours on stainless steel and plastic, less than 24 hours on cardboard, and less than 4 hours on copper.98,64 therefore, handling of these fomites can transmit the virus through direct contact. post-consultation cleaning and disinfection are discussed further in our sections on physical office set-up and procedures. personal protection personal protective equipment (ppe): orl specialists and their staff should be familiar with types and levels of appropriate ppe. routine otorhinolaryngological (orl), head and neck examinations and office procedures pose significant risk of covid-19 viral transmission. due to the risk, office procedures such as those concerning the upper airway like nasal or laryngeal endoscopy should be deferred unless absolutely necessary or until covid-19 diagnostic tests are negative.27,101 but since many of the orl cases present with urgent life-threatening conditions such as airway compromise, some procedures need to be done right away without prior covid-19 diagnostic testing. thus, it is highly important that orl specialists and their staff protect themselves with appropriate ppe.  as defined by the who, ppe is equipment worn to minimize exposure to occupational hazards such as the sars-cov-2 virus that causes covid-19.90 proper ppe usage is important in prevention and control of spread of the disease.90 in the setting of the covid-19 pandemic, there are various systems that classify ppes or combinations of ppes according to the setting. two examples are summarized in table 1. use of ppe in orl out-patient clinics: orl specialists and their clinic staff should always wear appropriate ppes such as gloves, protective clothing, face shields and respirators, during a patient encounter in the outpatient, ambulatory care setting.  china reported that 2,055 of its health workers were infected by sars-cov-2 at the start of the epidemic with 22 deaths.105 chinese authorities attributed these to the apparent inadequacy of personal protection for hcws in the early days or weeks of the epidemic as well as prolonged interaction with infected patients.105 interestingly, they also mentioned the weak sense of awareness for the need for strong personal protection among their hcws.105 italy likewise reported that about 5,000 of their hcws were infected by the sars-cov-2 virus due to lack of protective clothing and equipment during the onset of the review article table 1. levels of personal protective equipment for health care workers philippine general hospital hospital infection control unit102, 103 national health service, united kingdom104 level level 1 level 2 level 3 level level 1 standard infection control procedures (sicp) level 2 contact direct or indirect contact precautions level 2 droplet droplet precautions ppe goggles surgical mask or face shield cap goggles n95 respirator gloves gown or coverall cap goggles and face shield n95 respirator gloves shoe covers surgical gown scrub suits ppe · disposable apron · disposable gloves consider (if risk of spraying or splashing): · fluid-resistant type iir surgical face mask & full face visor or goggles · disposable apron · fluid-resistant disposable gown · disposable gloves consider (if risk of spraying or splashing): · fluid-resistant type iir surgical face mask · goggles or full face visor · disposable apron · consider fluid-resistant disposable gown if apron provides inadequate cover for the procedure/ task being performed · disposable gloves · fluid-resistant type iir surgical face mask and goggles or fluid-resistant type iir surgical face mask and full face visor philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 1514 philippine journal of otolaryngology-head and neck surgery outbreak.106 forty-one of them died, most of whom were not wearing appropriate protection and their health system was not prepared for such an emergency.106 remuzzi and remuzzi reported in their lancet article that around 20% of italy’s first-responder hcws had become infected.106 the primary route for the spread of covid-19 is thought to be through droplets that are expelled during coughing, sneezing, or breathing.59 however, there are concerns about possible airborne transmission in healthcare facilities as infection rates among front liners can be as high as 14%.107   among the strategies for preventing infection among clinicians and hcws in high-risk patient encounters is the use of the appropriate ppe, specifically n95 and equivalent respirators, goggles or face shields, protective clothing (gowns and aprons), and gloves.  in patient encounters and procedures that may induce airborne transmission, the use of more protective respiratory equipment is advocated.29, 108 this is particularly true for orl specialists who are always exposed to pathogens in respiratory droplets and aerosols when examining the nasal and oral cavities, and pharynx and larynx, especially when mucosal manipulation is done in both endoscopic and non-endoscopic procedures.  this covid-19 pandemic has already infected more ent surgeons than other specialists in china and other countries.105, 109 out-patient encounters without any agp: orl specialists (and clinic staff ) should wear single-use gloves, a single-use plastic apron, a sessional-use n95 respirator (or its equivalent), and sessional-use eye and/or face protection (pgh hicu ppe level 2) during a direct patient encounter in the out-patient, ambulatory care setting, with no intention of performing any agp.  in the setting of out-patient care and in the context of direct patient care of possible or confirmed cases, the recommended ppe by public health england include: single use disposable gloves, single use disposable plastic apron, a fluid-resistant (type iir) surgical mask, and eye/face protection for single or sessional use.110 however, ent specialists are advised to use an n95 or equivalent respirator, especially when examining patients with unknown covid status.28, 29 substitutes and equivalents for n95 respirators include ffp2 respirators (united kingdom and european market), which have been recommended by the who as adequate and effective protection against aerosolized coronavirus particles.111–113 apart from the ffp2, china’s kn95, australia/new zealand’s p2, korea’s 1st class and japan’s ds ffr respirators are also considered n95equivalent.114, 115 an n95 respirator and the like should be fit-tested prior to use in the clinics to ensure a tight seal around the face which translates to actual protection from coronavirus contamination.116,117   it is important to note that valved n95 substitute or equivalent review article note: the blank cells in rows indicate that the corresponding levels of the two ppe level classifications are not equivalent due to differences in levels of skin and respiratory protection. philippine general hospital hospital infection control unit102, 103 national health service, united kingdom104 level 4 coveralls surgical caps goggles/face shield n95 respirator / papr(powered, air purifying respirator) double gloves shoe covers dedicated shoes scrub suits level 2 airborne airborne precautions level 3 enhanced • disposable apron • consider fluid-resistant disposable gown if apron provides inadequate cover for the procedure/ task being performed • disposable gloves • filtering face piece 3 (ffp3) respirator and eye protection or a powered hood respirator · reinforced fluid-resistant long-sleeve surgical gown · disposable fluid-resistant hood (if wearing a gown without an attached hood) · full length disposable plastic apron · ffp3 respirator or powered hood respirator · disposable full face visor · 2 sets of long or extended cuff non-sterile, non-latex disposable gloves · surgical wellington boots or closed shoes · disposable boot covers level levelppe ppe philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery respirators allow unfiltered air from the wearer to contaminate room air, thus the us cdc recommends their use in the healthcare setting where sterility is not required, such as in outpatient clinic visits and procedures.118 communication issues while wearing respirators have been documented and confirmed by speech intelligibility tests on various respirators, with elastomeric respirators faring poorly compared to n95 facepiece respirators and paprs. in addition, face shields and visors (worn over masks and respirators) can further mitigate sound conduction and communication. however, the impact of the decreased communication on patient care and performance of hcws have yet to be documented.119   out-patient encounters with an agp: orl specialists (and any staff assisting) should always wear single-use gloves, a single-use or reusable protective garment (gown or coverall), a single-use fittested facepiece respirator with more than 95% filtration efficiency (niosh-approved n99 or its equivalent or a respirator with better filtration efficiency and/or assigned protection factor, or a reusable respirator), and reusable eye and/or face protection (nhs uk ppe level 2 airborne precautions) during a direct patient encounter in the out-patient, ambulatory care setting, with intention of performing one or more aerosol-generating procedures. consider using a surgical mask or face shield over the facepiece respirator if there is a plan to reuse the latter, or use a reusable respirator instead. in the setting of out-patient care where the clinician will perform an agp on possible or confirmed covid-19 cases, health authorities (such as public health england and us health institutions) recommend the single-use of the following ppes: disposable gloves, a disposable fluid-repellant coverall or gown, a filtering facepiece respirator, and an eye and/or face protection.29, 108-110 some agps are listed in table 2. the ent specialist has the option of using an n95 or equivalent respirator, especially when examining the ears, nose, mouth or throat of a covid confirmed, covid-suspect or asymptomatic patient.29 however, the british association of oral and maxillofacial surgeons and ent uk consider oral and nasal examination as agps and jointly strongly recommend the use of ffp3 respirators (equivalent to niosh-approved n99 respirators with 99% filtration efficiency) during patient encounters.120 alternatively, reusable respirators may be used by clinicians instead of the disposable facepiece respirators.114 these reusable respirators provide better respiratory protection to its wearers (assigned protection factor [apf] ranges between 25 to 1000), compared to the disposable facepiece respirators (apf = 10).   among the ppes, a powered air-purifying respirator (papr) can be used for high-risk procedures by a health worker at risk from aerosol or droplet spread.122 otolaryngologists around the world have declared their preference for powered air-purifying respirators (paprs) over the use of n95 respirators and face-shields. 29, 104,123–125   patient (and accompanying person) use of ppe in orl out-patient clinics: all orl patients (and accompanying persons) are strongly encouraged to wear a surgical mask during an outpatient visit in an orl healthcare facility especially if with respiratory symptoms or if they are being evaluated as a case of covid-19. orl specialists may require compliance, and consider providing surgical masks for patients (and accompanying persons) wearing only cloth masks before they enter the premises.  in the setting of out-patient care and in the context of direct patient care of possible or confirmed cases, patients (and accompanying persons) are also encouraged to wear face masks during the entire duration of consultation (except during actual trans-nasal and trans-oral examinations) to decrease the risk of transmission.26, 29, 126 cloth masks are not recommended under any circumstance inside a healthcare facility by the who.126 therefore, if possible, the orl clinic or facility should provide surgical masks for patients who do not have one.  it is also important to educate patients and accompanying persons that the use of a surgical mask must be combined with hand hygiene and other infection prevention and control measures, such as proper cough etiquette, to prevent the transmission of sarscov-2.56, 126 orl specialists and their staff should practice proper donning and doffing of ppes, disposal of single-use ppes, and disinfection and recycling of reusable ppes. proper donning and doffing should be observed prior to and after the out-patient encounter. various instructional resources are available online, such as the up-pgh guides to donning and doffing p-value table 2. list of agps in orl-hns91,121 upper aerodigestive tract examination which include nasal cavities, sinuses, oral cavity, pharynx and larynx. outpatient procedures on the upper aerodigestive tract such as endoscopies, nasal cautery, foreign body removal, biopsies and microbiology sampling. examination of and interventions on patients with airway modifications such as post-laryngectomy patients. management of orl emergencies such as epistaxis, foreign bodies, complications of acute sinusitis and airway compromise. otologic procedures that may also provoke aerosol generation, e.g. aural toilette or suctioning of ears that may induce coughing. review article philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 1716 philippine journal of otolaryngology-head and neck surgery level 3 ppes available from:127 http://www.pgh.gov.ph/static/media/ uploads/covid19filesemployees/donning3272020.jpg and from:128 http://www.pgh.gov.ph/static/media/uploads/covid19filesemployees/ doffing3272020.jpg and for level 4 ppes, available from:129 https:// youtu.be/rvq63c5lync. the us cdc website on preventing health care infections also provides instructional materials for guidance on effective ppe use (us cdc protecting healthcare personnel) available from:130 https://www.cdc.gov/hai/prevent/ppe.html. ideally single-use personal protective equipment should be disposed of according to local health code standards. in this regard, the philippine doh has issued a memorandum on the interim guidelines on the management of health care waste in health facilities with cases of coronavirus disease.131 in resource-challenged circumstances where re-use of ppe (such as respirators, goggles, face shields) may be necessary, guidelines for acceptable disinfection and recycling of reusable ppes should be observed.26, 125,126 in the event of supply shortage during an epidemic or pandemic, reuse of the facepiece respirator is acceptable and recommended by the us cdc.122 to reuse a facepiece respirator, a surgical mask or a reusable and cleanable face shield may be worn over it to prevent soiling or contamination of its outer surface; and the user should always observe proper hand hygiene before and after removing the respirator.111-115 several methods or techniques have been suggested by dr. peter tsai, the n95 inventor, on the proper reuse of n95 and similar respirators.132 ( table 3) plastic face shields, whether commercially available or improvised (e.g., 3d printed), may be disinfected using agents included in the list of disinfectants for use for sars-cov-2 published by the us epa.66 the u.s. national institutes of health 3d print exchange recommends soaking of 3d printed parts of improvised face shields in soap and water or 10% chlorine bleach solution.133 goggles or protective eyewear can also be disinfected using soap and water or chlorine solution as described by the national science teaching association.134 “hazardous materials” (hazmat) suits or coveralls, should be decontaminated and reused according to manufacturer’s instructions.135 staff engaged in disinfecting and recycling reusable ppe should themselves wear appropriate ppe and observe proper precautions during the entire process, as discussed in our sections on physical office set-up and procedures. procedures based on experiences from china, italy, and iran, otolaryngologists are among the hcws with the highest risk of being infected with sars-cov-2.136-138 this is probably due to close contact with orl patients, and the high viral density in the nose and nasopharynx, followed by the oropharynx, as well as instrumentation in these areas that may aerosolize virus resulting in increased risk.138 the possibility of asymptomatic virus carriage in the nose,139 or even in saliva,140 and consequently the possibility of asymptomatic transmission,141 adds another dimension to the risks that otolaryngologists face.  consider all orl out-patients and accompanying persons as covid-19 positive until proven otherwise.  due to stringent testing criteria and limited testing ability of the government, any orl patient (and accompanying persons) should be considered covid-19 positive until proven otherwise.142 there are multiple reports of asymptomatic carriers and pre-symptomatic transmission.139,143,144 even in patients who have contracted the virus and recovered, there are reports of repeat tests turning out positive – although this may also mean that the initial results postinfection were false negatives, or that the repeat test detected inactive viral particles.13,143,145,146 to this end, extra care must be practiced when obtaining the clinical history (including ensuring patients wear at least a surgical mask), and performing procedures that are considered high risk for sars-cov-2 infection, particularly endoscopies and routine non-endoscopic examination of the nasal and oral cavities.136,142,147   p-value table 3. methods of reusing n95 respirators132 case rate from phic (php) method 1 method 2 “when reusing n95 masks, leave a used respirator in dry, atmosphere air for 3-4 days to dry it out. polypropylene in n95 masks is hydrophobic, and contains zero moisture. covid-19 needs a host to survive--it can survive on a metal surface for up to 48 hours, on plastic for 72 hours, and on cardboard for 24 hours. when the respirator is dry in 3-4 days, the virus will not have survived. take four n95 masks, and number them (#1-4). on day 1, use mask #1, then let it dry it out for 3-4 days. on day 2, use mask #2, then let it dry out for 3-4 days. same for day 3, and day 4…” “you can also sterilize the n95 mask by hanging it in the oven (without contacting metal) at 70c (158f) for 30 minutes—it is reported that covid-19 cannot survive at 65c (149f) for 30 minutes. use a wood clip to hang the respirator in the kitchen oven to do the sterilization. when sterilizing n95 masks, be wary of using uv light--keep n95 masks away from uv light / sunlight. n95 masks are degraded by uv light because it damages the electrostatic charges in the polypropylene material. it is unclear how long the masks can be exposed to uv light before they are ineffective. “ review article http://www.pgh.gov.ph/static/media/uploads/covid19filesemployees/donning3272020.jpg http://www.pgh.gov.ph/static/media/uploads/covid19filesemployees/donning3272020.jpg http://www.pgh.gov.ph/static/media/uploads/covid19filesemployees/doffing3272020.jpg http://www.pgh.gov.ph/static/media/uploads/covid19filesemployees/doffing3272020.jpg https://youtu.be/rvq63c51ync https://youtu.be/rvq63c51ync https://www.cdc.gov/hai/prevent/ppe.html philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery most otolaryngologic office procedures are potentially agp and have to be approached with utmost precautions.  an aerosol is defined as a “collection of solid and liquid particles suspended in a gas.”148  when air flows across the surface of liquid film an aerosol is produced.149   following these definitions, almost all procedures performed by the otolaryngologist, even office-based ones, are potential avenues for aerosol transmission.  coughing and sneezing produce droplets that are aerosolized148 while talking, and even breathing produces microdroplets that are also aerosolized.150-152   these aerosolized microdroplets may transmit covid-19.41, 64, 153,154 it is important to note that nasal and laryngeal endoscopies do not inherently produce aerosols, but the associated risk of coughing and sneezing, even the risk of vomiting, classifies these procedures as aerosol–generating.149 the other parts of the orl physical examination such as otoscopy and head and neck palpation may not have as high a risk of aerosolization compared to oral, oropharyngeal, nasal, nasopharyngeal, and laryngeal examinations.  however, the risk is still there, as when a cough might be induced by palpating the anterior neck too deeply, or when manipulation in the ear canal might elicit the ear-cough reflex.155, 156   by virtue of being less than 2 meters away from the patient, otolaryngologists will be at greater risk of infection if the patient inadvertently generates aerosols.157, 158 this risk is not trivial, as available studies show droplets travel up to 8 meters, and “infections cannot neatly be separated into the dichotomy of droplet versus airborne transmission routes.”53 examination of orl patients should be done in an airborne infection isolation room (aiir) whenever available. an aiir should have a negative pressure of > -2.5pa (0.01” water gauge) and at least 12 ach.60 it should also have an ante room for donning and doffing ppes, a sink for hand hygiene and trash bins for disposing contaminated material. examinations should be limited to patients who clearly need them and must be performed by the least number of the most experienced personnel available in an expedient way.  the ppe used should be appropriate to the risk attending the specific procedure, as detailed in our subsection on personal protection.  a focused or directed orl physical examination may be considered in the setting of the current covid-19 pandemic.  ideally, the full orl physical examination must be performed to ensure excellent quality care for our patients.  however, it is left to the individual clinician to determine and discuss the risks and benefits of a focused ent physical examination with their respective patients, in the setting of the current covid-19 pandemic and the immediate “post’-covid-19 period before a vaccine is developed and herd immunity has been achieved.  things that must be considered include, but are not limited to, obtaining informed consent, clinical suspicion of covid status, availability of appropriate ppe, judicious and careful use (and disposal or disinfection for reuse) of aural and nasal specula, cheek retractors, tongue depressors, mirrors, otoscopes, endoscopes, and video systems. hybrid systems incorporating telemedicine tools (for pre-accomplishing clinical information, initial history-taking, and even physical inspection) as well as camera-based physical examinations (that increase the distance between patient and examiner) may also be considered.138, 147, 159 ear cleaning (cerumen extraction by curette, syringing, suctioning), wick insertion for otitis externa, are potential aerosol generating procedures, and appropriate precautions must be observed. cerumen extraction is a common out-patient office procedure for many orl specialists, and curette-extraction or syringing can both induce a cough reflex.160   even insertion of an ear wick for better delivery of otic medications in the setting of acute otitis externa may stimulate the ear-cough reflex.155, 156, 160 when performing these procedures, the appropriate ppe should be donned by the physician (and any assisting staff ) and the patient should maintain a surgical mask (at least), preferably covered by a face shield (see section on personal protection).  ear canal foreign bodies may also require emergent or urgent office intervention in the setting of retained button batteries, animate foreign bodies, or obstructive otitis externa. a retained button battery in the external auditory canal should be treated emergently with appropriate ppe if any office intervention is to be considered. animate foreign bodies (e.g., insects, etc.) or other foreign bodies with a marked inflammatory reaction causing obstructive otitis externa also require operative intervention. if the child (or other patient) is unable to tolerate the procedure awake, conscious sedation may be preferred to general anesthesia, which requires positive pressure ventilation.161 as such, this may cease to be an out-patient procedure and require ambulatory hospital care. middle ear procedures should be performed only for absolute indications with complete ppe. respiratory viral pathogens (rhinovirus, respiratory syncytial virus, coronavirus) have been found in the middle ear during episodes of acute otitis media.162  while sars-cov-2 has not been specifically identified, it may be reasonable to assume that it may also be found in the middle ear. this is the context wherein the clinician may be review article philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 1918 philippine journal of otolaryngology-head and neck surgery exposed to the virus when suctioning the middle ear and performing aural toilette for otitis media.  the use of non-fenestrated microsuction is recommended for ear procedures.  significant aerosolization of biological materials may occur during ear microsuctioning, particularly with fenestrated suction. although the risk of covid-19 transmission with microsuction is low particularly for wax clearance in the absence of inflammation, the use of non-fenestrated suction tips probably reduces the risk of aerosolization.163   myringotomy with or without tympanostomy tube insertion should only be performed for urgent and emergent conditions. the same applies during myringotomy with or without tympanostomy tube insertion. the aao-hns161, 164 has recommended performing these procedures only for urgent or emergent conditions (e.g., complicated acute otitis media) with the patient under general anesthesia with endotracheal intubation. however, philippine otolaryngologists may opt to perform outpatient myringotomy with or without tympanostomy tube insertion under local or topical anesthesia. in such cases, it is strongly recommended that the same ppe requirements as previously discussed in the preceding sections of this document be applied. the patient should also be wearing a surgical mask while undergoing the procedure.  for patients with unknown, suspected, or positive covid-19 status, myringotomy and tympanostomy tube insertion is preferred to cortical mastoidectomy for uncomplicated acute mastoditis refractory to medical therapy, as the risk of exposure is less.161 non-endoscopic routine examination of the nasal cavity, oral cavity, and the naso-, oro-, and hypopharynx are high-risk agps and should only be performed if absolutely necessary.  routine examination of these mucosa-lined structures are considered high-risk agps and must be avoided unless an absolute indication exists (e.g., retained foreign body, intractable bleeding, etc.).136, 138, 142  when absolutely indicated, it is recommended that as much as possible, these procedures be performed in a negative-pressure room, the ent surgeon wears complete ppe, and the use of barriers and endoscopes with camera systems are employed to mitigate the risks of aerosolization and infection.  a detailed discussion on negative-pressure rooms, hepa filters and ppe are in other sections of this review.  epistaxis should initially be managed in the out-patient setting as conservatively as possible with digital nasal pressure and medications, while ensuring the safety of patients and staff.  patients presenting with epistaxis should be treated in the outpatient setting by applying digital nasal pressure for 15 minutes, administering tranexamic acid,  and control of risk factors (blood pressure, aspirin, anticoagulants) and insertion of a nasal pack.165,166 routine anterior rhinoscopy and endoscopy, applying topical decongestants and suctioning may have to give way to “blind” outpatient epistaxis management, especially when the physician and patient are not adequately protected by ppe, and/or when the ideal situation – transfer to a nearby hospital emergency room – is not feasible or possible. the highest possible score should be assigned for tonsillar inflammation physical finding scoring systems in children with a clinical history consistent with streptococcal pharyngitis. adults presenting as acute tonsillopharyngitis should be treated by history alone without an examination of the mouth and throat unless airway compromise or sepsis is suspected. a guideline from the royal college of paediatrics and child health and the british paediatric allergy immunity and infection group167 recommends assigning the highest possible score for tonsillar inflammation physical finding scoring systems in children >3 years of age complaining of sore throat and a history consistent with streptococcal pharyngitis.  this is to decrease the risk of infection of the ent surgeon and to conserve scarce ppe.167   while this recommendation was used for children using the feverpain clinical scoring system,168 it may reasonably be extrapolated to adults when using the m-centor scoring system for streptococcal pharyngitis.169 however, the ent uk covid-19 tonsillitis and quinsy guidelines recommend that adults presenting as acute tonsillopharyngitis should be treated by history alone if possible, and without an examination of the mouth and throat unless airway compromise or sepsis is suspected.170 moreover, it should be reiterated that patients complaining of fever and sore throat should be managed as a suspect case of covid-19, and referred to the government-mandated screening process. nasal and laryngeal endoscopies should only be performed for absolute indications and with complete ppe for agps. absolute indications include those that are necessary to prevent morbidity or mortality in the next 30 days,138 e.g., airway obstruction, review article philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery malignancy, foreign body, persistent epistaxis.  complete ppe for agp entails an n99 or n100 mask (or n95 mask with a 3-ply surgical mask over it), or use of a powered air-purifying respirator (papr) if available, surgical cap, goggles and face shield, waterproof gown, gloves, and shoe covers or booties.138, 142, 171  flexible fiberoptic endoscopies using the smallest diameter scope are preferred over rigid endoscopes, and the use of a video monitor is recommended to increase the distance between the physician’s face and the patient.138 alternatives to laryngoscopy should be considered (e.g. ct scanning, laryngeal ultrasound, etc.) for other cases such as work-ups of head and neck masses, lymphadenopathy and mild airway stenosis.172 decongestants and anesthetics should be applied with cottonoid strips or instilled by drops or gel and should not be sprayed. topical decongestants with anesthesia (1:100,000 epinephrine + 2% lidocaine carpules; or oxymetazoline 0.05% adult spray / 0.025% pediatric solution plus 2% lidocaine) should be applied with cottonoid strips or instilled in drops or gel form to blunt the cough and sneeze reflexes. these should not be sprayed to lessen the risk of aerosolizing the virus.  barrier methods may be employed during endoscopies to reduce the risk of droplet transmission and infection. multiple methods of creating a barrier between the patient (and the patient’s possible secretions) and the physician are in varying stages of development, and may be found in traditional (e.g., published literature) and non-traditional sources of scientific information (e.g., social media).  adapting the aerosol box173, 174 for outpatient procedures may be considered in addition to complete ppe precautions as another strategy to decrease contamination and risk of spreading the aerosolized virus.  a plastic sheet draped over a pvc frame originally intended for intubations and patient transport may also be adapted for outpatient procedures.175, 176   a study by workman et al. using cadavers and atomizers showed that the use of surgical masks and valved endoscopy of the nose and throat ( vent ) masks prevent the spread of aerosols during simulated sneezing.149 figure 4 shows vent modification with a double one-way  valve similar to a double septum secundum by our co-author dr. ryner jose c. carrillo. another example is an innovation where otolaryngologists in thailand used seats and hair dryers in salons, a pacifier and a plastic film to create a barrier between the patient and the examiner that still enabled endoscopic examination.177  the zamboanga city medical center department of orl-hns under our co-author dr. justin elfred lan b. paber has developed figure 4. surgical mask with endoscopy valve. a. modification of the valved endoscopy of the nose and throat (vent) mask:149 a double one-way valve is fabricated (like a double septum secundum). b. a vertical cut in the upper mid portion of the mask is made, creating a slit 2.5 to 10 mm in height depending on the intended scope or instrument to be inserted. one or two valves can be created. c. plastic flaps are stapled superior to the hole in front of the mask. d. inferior to the hole behind the mask. the flaps cover the hole and minimize droplets and aerosols from entering and exiting. taping the mask to the patient’s face and chin is an option for added seal. e. the scope can enter the valve with the mask acting as an aerosol shield. a b c d e review article figure 5. covid-19: efforts & innovations of zamboanga city medical center department of orl-hns: a. 3d printed frame for a diy face shield; b., c. makeshift negative pressure booth; d., e. endoscope splash guard. (photos published with permission) a ed cb philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 2120 philippine journal of otolaryngology-head and neck surgery portable endoscope splash guards from acetate and 3d-printed frames, as well as makeshift examination booths with negative pressure.62 (figure 5) camera-based procedures increase physical distance and may decrease exposure. camera-based ear, nose and oral cavity examination and laryngoscopy may increase the distance between patient and examiner, and possibly lessen exposure to infectious material. (figure 6)  a 2.7 mm hopkins scope mounted on a portable camera can be used for otoscopy, oral and nasal examination while the patient is wearing a surgical mask. the scope is passed through small puncture holes in the mask. nasopharyngeal and laryngeal endoscopy are optional using flexible or rigid scopes. the patient is asked to pull out their tongue and an additional puncture is placed in the mask if needed for access (e.g., for forceps during extraction of readily accessible foreign bodies such as fish bone embedded in the tonsil or tonsillar  pillar).  this set-up may lessen aerosolization while performing routine simple examinations, with the face of the patient covered all throughout the procedure.  foreign bodies located deeper in the oroand hypopharyngeal areas may require an operating room set-up.149, 172 observance of proper ppe donning and doffing with a trained observer is still recommended for all these high risk procedures, regardless of the presence of a physical barrier. the standard practice of using fda-approved chemicals for instrument disinfection and sterilization, per recommendations of cdc disinfection guidelines, can be applied to eradicate the presence of coronavirus in medical equipment. standard instrument disinfection applies as recommended by the us cdc guideline for disinfection and sterilization in healthcare facilities.178 varying degrees of minor outpatient procedures utilizing facilities and instruments will require different levels of housekeeping. accessible and affordable cleaning materials should be used for sustainable outpatient service or office-based procedures. some us fda recommended instrument sterilants or disinfectants that are readily available for philippine use include: high level disinfectants such as 2.4% glutaraldehyde (cidex®) which can be used for a 45 minute soak with the solution reusable for 14 days; and 3.4% glutaraldehyde (cidexplus®) which can be used for a 20 minute soak with the solution reusable for 28 days.68   readily accessible hand and instrument surface disinfectants consisting of alcohol-based solutions range from 70% isopropyl or ethyl alcohol to propanol-based solutions (cutasept® and sterillium®).   other methods of sterilization include autoclaving and ultraviolet light type c.71, 179 caution is advised with using ultraviolet light as this may injure skin and eyes.  strict observance of proper ppe use (see section on personal protection) must be followed while performing disinfection procedures. it is also recommended to use an isolation screen while performing reprocessing, involving the minimum number of highly trained staff.178 prevention and health promotion a balanced diet, appropriate exercise, and adequate rest are essential to wellness, disease-prevention, and health promotion. while no vaccines or cures for covid-19 yet exist, there is insufficient or no evidence for the use of topical solutions, vitamins, supplements, antibiotics, antimalarials or vaccines as prophylaxis for or prevention of covid-19. good health and a healthy lifestyle help prevent illness, while poor health and an unhealthy lifestyle predispose people to various diseases including chronic lifestyle-diseases, infections, and neoplasms.90,101-103,180 these maxims are not any different as far as the covid-19 pandemic is concerned. conventional wisdom and numerous studies support a well-balanced diet, appropriate exercise and adequate rest as essential to wellness, disease-prevention and health promotion.181, 182 aside from healthy diet, exercise and rest, disease-prevention and health promotion may involve such strategies as decreasing viral load, or increasing host immunity.    there is currently no clear evidence for  the use of topical preparations of povidone iodine, saline solution, vitamin c, or virgin coconut oil (vco), in decreasing viral load in covid-19.  povidone iodine solution has been proposed to potentially decrease viral load. studies by eggers and kariwa show the lowest concentration of povidone-iodine to be effective in vitro was 0.23%, review article figure 6. camera-based ent examination. a. otoscopy using a scope attached to a camera. b. oral, nasal, laryngeal examination may be performed through a hole in the mask. removal of oropharyngeal foreign bodies (not shown), may be facilitated by creating another hole in the mask to introduce a forceps. (photos published in full, with permission) a b philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery leading to reduction of viral activity to undetectable levels.183, 184 a recent study by kampf et al. showed that sars-cov-2 should behave similarly.185 a 1% povidone iodine solution is locally available and is marketed to be used as 15ml to be gargled for 30 seconds, repeated 2 to 4 times daily.  another locally available solution is marketed as a 0.45% throat spray, to be used 3-4 times daily.186  mady et al. proposed the use of povidone-iodine as a form of personal protection for hcws, with the following dilution, mode of delivery, and dosing:187 a. nasal irrigation: 240 ml of 0.4% pvp-i solution (dilution of 10 ml of commercially available 10% aqueous pvp-i in 240 ml of normal saline with a sinus rinse delivery bottle); and  b. oral/oropharyngeal wash: 10 ml of 0.5% aqueous pvp-i solution (1:20 dilution in sterile or distilled water).  they proposed that healthcare providers apply the nasal and oral pvp-i before and after each patient contact (or every 2–3 hours, up to 4×/day for repeated patient contact). however, there is no evidence that this actually decreases viral load in covid-19.  an experimental sodium chloride – sodium bicarbonate buffered solution with 1.5 mg/ml sodium ascorbate has been proposed for intranasal (1-3 drops per nostril) and transoral (4-6 drops on tongue) prophylaxis (every 4-6 hours) by retired professor gisela concepcion of up in collaboration with other orl specialists.188 saline solution has long been used for nasal douches and oral gargles with most preparations using a range between hypertonic (3%) to isotonic (0.9%) and hypotonic (0.65%) sodium chloride and has been associated with reduction in microbial antigens and a related decline of microbial burden.189,190 in particular, saline inhibits rna viral replication191,192 and hypertonic saline denatures viral structures, preventing viral replication and synthesis193 although it may affect mucociliary flow.194  because vitamin c has been claimed to inactivate influenza viruses (in an animal study)195 and because it has long been advocated as a remedy for colds and influenza, it might hypothetically exert protective effects when applied directly to nasal mucosa in combination with saline solution.196-198  as this combination was developed during the present covid-19 pandemic, no formal studies have been conducted, and no therapeutic claims are made for its use. virgin coconut oil has also been proposed as prophylaxis against sars-cov-2 because vco and lauric acid derivatives have in-vitro antiviral effects, possibly through destroying virus envelopes, inhibiting late stage virus maturation, and preventing the binding of the viral proteins to the host’s cell membranes.199, 200 although people have anecdotally applied vco topically in their nostrils and swished it in their mouths as topical prophylaxis (instead of ingesting it) to inhibit sars-cov-2 particles, there is currently no evidence to support this practice, or the use of vco in the adjunctive treatment of covid-19.201   there is insufficient evidence for the use of oral supplements like vitamin c and d, zinc, and melatonin as prophylactics against covid-19. there are relatively low risk, oral prophylactic supplements currently being advertised such as thiamine, vitamins c and d, zinc202, 203 and melatonin.204 although rapid evidence reviews of the up institute of clinical epidemiology and asia-pacific center for evidence-based healthcare found “no direct evidence available ... for efficacy of intravenous vitamin c as an adjunctive treatment in preventing mortality or shortening disease course among adults with covid-19,”205 vitamin c has long been used to prevent the common cold and as a cold and flu remedy, and has shown a “possible increased benefit in patients subjected to cold stress.”198, 206 zinc “may possess a protective effect” against sars-cov-2 and be used as a supplement for “preventive ... therapy of covid-19” by “reducing inflammation,” improving “mucociliary clearance,” and modulating “antiviral and antibacterial immunity.”207 although there are two ongoing clinical trials investigating zinc supplements combined with other medications as prevention for covid-19, there is currently “no clinical evidence that zinc supplementation should be used for the prevention of covid-19.”208 a pre-print reporting that the mean level of vitamin d in each of 20 european countries was strongly associated with the number of cases/1m and with the mortality/1m, and was especially low in spain, italy, and switzerland advises vitamin d supplementation to protect against sars-cov2 infection.209 vitamin d3 supplementation at 10,000 iu/day was also recommended by grant et al., although this recommendation was based on indirect evidence, observational, and ecological studies only.182  melatonin shows anti-inflammatory and antioxidant properties in vitro and may have an indirect antiviral effect, but because “there are no published clinical trials nor ongoing trials found,” there is currently “no sufficient evidence to support” its “use as prophylaxis for  covid-19.”210 while each of these oral supplements may have its own relative merits, there is no sufficient evidence for their actual benefit vis-avis the novel coronavirus. thus, we recommend prudence in utilizing any of these for prevention, prophylaxis or as immune boosters, particularly cautioning against mega-dosing and the complications that ensue from such practices.211-21 review article philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 2322 philippine journal of otolaryngology-head and neck surgery there is currently no evidence to support the use of chloroquine or hydroxychloroquine (hcq), with or without azithromycin as chemoprophylaxis against covid-19. there is much debate and controversy on the use of various antimicrobials for the treatment of sars-cov-2, more so for their use as prophylactics.214 in particular, the widespread use of hcq was propounded by us president donald trump,215 used alone or in combination with azithromycin.216 however, subsequent reports of serious complications, including several deaths217 resulted in warnings being issued by such agencies as the who and philippine doh and philippine society for microbiology and infectious diseases (psmid).218, 219 there is currently no evidence to support chemoprophylaxis using chloroquine or hcq against covid-19.219 moreover, there is no high-quality evidence proving the efficacy and safety of hcq with azithromycin for the treatment of covid-19.220 there is insufficient evidence for the use of the bacillus calmetteguerin (bcg) vaccine as prophylaxis for covid-19, but clinical trials are ongoing to determine its efficacy and safety in preventing covid-19 and its severe symptoms. the us cdc has issued guidelines for prophylactic use of seasonal influenza vaccine in special settings.  the bcg vaccine has been getting attention for its possible immunomodulatory effects, primarily through the innate immune system, as prophylaxis for covid-19.221 current evidence does not support this at present222, 223 but five clinical trials are underway among hcws to determine the efficacy and safety of bcg vaccine in preventing covid-19 and its severe symptoms.223, 224 meanwhile, the us cdc has guidelines for prophylactic seasonal influenza vaccine use in long-term care facilities, and while the influenza vaccine is not effective against covid-19 virus, it is highly recommended for vulnerable persons to get vaccinated each year to prevent seasonal influenza infection.225; 226  only an effective vaccine against the sars-cov-2 will be the gold standard for prophylaxis against covid-19. until such time that one is available, all persons encountered should be considered as potentially covid-19 positive.  ultimately, an effective vaccine against the novel coronavirus would be the gold standard for prophylaxis if and when one should finally be developed. to date, there are several vaccines at various stages of development around the world.227, 228 a covid-19 vaccine & therapeutics tracker with  the latest updates for vaccine and therapeutic drug developments for covid-19 is available from:229 https://biorender.com/covid-vaccine-tracker?utm_campaign =vaccine+tracker%3a+announce&utm_content=covid-19+vaccin e+tracker%3a+announcement&utm_medium=email_action&utm_ source=customer.io  in the meantime, until such time that one is available (or until widespread herd immunity has been achieved), all persons encountered should be considered as potentially covid-19 positive.    peer support is necessary to ensure wellness among hcws and enable them to provide high quality care. as the “response to the covid-19 pandemic is a marathon, not a sprint …  planning should begin for a longer, disillusionment phase during which emotional needs among hcws will grow.”230 peer support at institutional or organizational levels should “provide leadership focused on resilience,” “structure crisis communications to provide information and empowerment,” and “create a continuum of staff support within the organization.”230 the johns hopkins 24/7 “confidential peer support program … resilience in stressful events (rise)…” provides in-person psychological first aid and emotional support to hcws.230 the american medical association (ama) has a “free program” peerrxmed (peerrx) “that uses a ‘buddy system’ to provide support and guidance for physicians and other health professionals.”231 the american college of physicians (acp) encourages “sharing challenges and successes” to “help meet urgent needs during the evolving pandemic” through its “physician well-being and discussion forum”232 while the aao-hns has a special podcast on “managing your wellness.”233 closer to home, rappler.com provides “a list of institutions and organizations offering free online counseling for people affected by the coronavirus pandemic.”234 practice implications the bottom-line question we asked ourselves as co-authors as well as our reviewers was: “would you (and could you) implement these recommendations in your practice?” a unanimous “yes” is the answer of all co-authors and reviewers representing diverse practice settings in different classes of provinces, cities and municipalities from various geographic regions in the philippines. we believe these recommendations are consistent with the best available evidence to date, and are globally acceptable while being locally applicable. we particularly address the concerns of orl specialists, hns, and facial plastic and craniomaxillofacial surgeons about resuming their out-patient clinical office practices during the “post”-covid-19 period when strict quarantines are gradually lifted and a transition to the review article https://biorender.com/covid-vaccine-tracker?utm_campaign=vaccine+tracker%3a+announce&utm_content=covid-19+vaccine+tracker%3a+announcement&utm_medium=email_action&utm_source=customer.io https://biorender.com/covid-vaccine-tracker?utm_campaign=vaccine+tracker%3a+announce&utm_content=covid-19+vaccine+tracker%3a+announcement&utm_medium=email_action&utm_source=customer.io https://biorender.com/covid-vaccine-tracker?utm_campaign=vaccine+tracker%3a+announce&utm_content=covid-19+vaccine+tracker%3a+announcement&utm_medium=email_action&utm_source=customer.io https://biorender.com/covid-vaccine-tracker?utm_campaign=vaccine+tracker%3a+announce&utm_content=covid-19+vaccine+tracker%3a+announcement&utm_medium=email_action&utm_source=customer.io philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery review article references 1. world health organization (who). coronavirus disease 2019 (covid-19) situation report – 51. data as reported by national authorities by 10am cet 11 march 2020 [cited 2020 april 11]. available from: https://www.who.int/docs/default-source/coronaviruse/situationreports/20200311-sitrep-51-covid-19.pdf 2. zhu n, zhang d, wang w, li x, yang b, song j, et al., china novel coronavirus investigating and research team. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med 2020 feb 20;382(8):727–733. doi:10.1056/nejmoa2001017. pubmed pmid:31978945; pubmed central pmcid: pmc7092803. 3. zhou p, yang xl, wang xg, hu b, zhang l, zhang w, et al. a pneumonia outbreak associated with a new coronavirus of probable bat origin. nature. 2020 mar;579(7798):270-273. doi: 10.1038/s41586-020-2012-7. pubmed pmid:32015507 pubmed central pmcid: pmc7095418. 4. li q, guan x, wu p, wang x, zhou l, tong y, et al. early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia. n engl j med. 2020 mar 26;382(13):11991207. doi:10.1056/nejmoa2001316. pubmed pmid: 31995857; pubmed central pmcid: pmc7121484. 5. yeager a. coronavirus’s genetics hint at its cryptic spread in communities – contact tracing and genetic testing reveal how sars-cov-2 circulated among individuals for weeks, especially in the us, before being detected. the scientist, 2020 mar 6 [cited 2020 april 12]. available from: https://www.the-scientist.com/news-opinion/coronaviruss-genetics-hint-at-its-crypticspread-in-communities-67233 6. johns hopkins resource center. johns hopkins coronavirus resource center [internet]. covid-19 dashboard by the center for systems science and engineering (csse) at johns hopkins university (jhu). 2020 [cited 2020 apr 15]. available from: https://coronavirus.jhu. edu/map.html 7. wu z, mcgoogan jm. characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention. jama. 2020 feb 24;323(13):1239-1242. doi: 10.1001/jama.2020.2648. pubmed pmid: 32091533. 8. wilder-smith a, freedman do. isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019ncov) outbreak. j travel med. 2020 mar 13;27(2). pii: taaa020. doi: 10.1093/jtm/taaa020. pubmed pmid: 32052841; pubmed central pmcid: pmc7107565. 9. thanh le t, andreadakis z, kumar a, gómez román r, tollefsen s, saville m, mayhew s. the covid-19 vaccine development landscape. nat rev drug discov. 2020 may;19(5):305-306. doi: 10.1038/d41573-020-00073-5. pubmed pmid: 32273591. 10. ahn d-g, shin h-j, kim m-h, lee s, kim h-s, myoung j, et al. current status of epidemiology, diagnosis, therapeutics, and vaccines for novel coronavirus disease 2019 (covid-19). j microbiol biotechnol. 2020 mar 28;30(3):313–24. doi: 10.4014/jmb.2003.03011. pubmed pmid: 32238757. 11. godin m. sweden’s relaxed approach to the coronavirus could already be backfiring. time. 2020 apr 9 [cited 2020 april 21]. available from: https://time.com/5817412/swedencoronavirus/ 12. meyerowitz-katz g. here’s why herd immunity won’t save us from the covid-19 pandemic. science alert. 2020 march 30 [cited 2020 apr 22]. available from: https://www.sciencealert. com/why-herd-immunity-will-not-save-us-from-the-covid-19-pandemic 13. an j, liao x, xiao t, qian s, yuan j, ye h, et al. clinical characteristics of the recovered covid-19 patients with re-detectable positive rna test. (preprint) medrxiv doi: https://doi.org/10.1101 /2020.03.26.20044222. [cited 2020 april 20]. available from: https://www.medrxiv.org/conte nt/10.1101/2020.03.26.20044222v1 14. leung h. can you be re-infected after recovering from coronavirus? here’s what we know about covid-19 immunity. time. 2020 april 3, 2020; updated 2020 april 13 [cited 2020 april 20]. available from: https://time.com/5810454/coronavirus-immunity-reinfection/ 15. hancocks p, seo y, hollingsworth j. recovered coronavirus patients are testing positive again. can you get reinfected? cnn health. 2020 april 18 [cited 2020 april 20]. available from:   https://edition.cnn.com/2020/04/17/health/south-korea-coronavirus-retestingpositive-intl-hnk/index.html 16. xia j, tong j, liu m, shen y, guo d. evaluation of coronavirus in tears and conjunctival secretions of patients with sars‐cov‐2 infection. j med virol. 2020 feb 26;92(6):589-594. doi:10.1002/jmv.25725. pubmed pmid: 32100876. 17. li jo, lam dsc, chen y, ting dsw. novel coronavirus disease 2019 (covid-19): the importance of recognising possible early ocular manifestation and using protective eyewear. br j ophthalmol. 2020 mar;104(3):297–8.  doi: 10.1136/bjophthalmol-2020-315994. pubmed pmid: 32086236. 18. xu r, cui b, duan x, zhang p, zhou x, yuan q. saliva: potential diagnostic value and transmission of 2019-ncov. int j oral sci. 2020 apr 17;12(1): 11. doi: 10.1038/s41368-0200080-z. pubmed pmid: 32300101; pubmed central pmcid: pmc7162686. 19. wang w, xu y, gao r, lu r, han k, wu g, tan w. detection of sars-cov-2 in different types of clinical specimens. jama. 2020 mar 11. doi: 10.1001/jama.2020.3786. [epub ahead of print] pubmed pmid: 32159775; pubmed central pmcid: pmc7066521. 20. xu k, lai x, liu z. suggestions on the prevention of covid-19 for health care workers in department of  otorhinolaryngology head and neck surgery. world j otorhinolaryngol head neck surg. 2020 apr 2. doi: 10.1016/j.wjorl.2020.03.002. pubmed pmid: 32292630; pubmed central pmcid: pmc7128200.  21. medema g, heijnen l, elsinga g, italiaander r, brouwer a. presence of sarscoronavirus-2 in sewage, medrix. 2020 mar 30 [cited 2020 april 6]. available from: https://www.medrxiv.org/ content/10.1101/2020.03.29.20045880v1. doi: 10.1101/2020.03.29.20045880. 22. world health organization (who) [internet]. scientific brief: modes of transmission of “new” normal is made despite the unavailability of a specific vaccine for sars-cov-2. while these specifically target practice settings in the philippines, we believe they will be useful to our colleagues in other countries as well. our recommendations cover the range of office practice, from physical office set-up to processing of patients, through personal protection and procedures, to prevention, prophylaxis and health promotion. we hope that they will be as helpful, relevant and practical for you as they are for us and that we all will be able to ensure a balance between service and safety as we continue to serve our patients during these challenging times. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf https://www.the-scientist.com/news-opinion/coronaviruss-genetics-hint-at-its-cryptic-spread-in-communities-67233 https://www.the-scientist.com/news-opinion/coronaviruss-genetics-hint-at-its-cryptic-spread-in-communities-67233 https://coronavirus.jhu.edu/map.html https://coronavirus.jhu.edu/map.html https://time.com/5817412/sweden-coronavirus/ https://time.com/5817412/sweden-coronavirus/ https://www.sciencealert.com/why-herd-immunity-will-not-save-us-from-the-covid-19-pandemic https://www.sciencealert.com/why-herd-immunity-will-not-save-us-from-the-covid-19-pandemic https://www.medrxiv.org/content/10.1101/2020.03.26.20044222v1 https://www.medrxiv.org/content/10.1101/2020.03.26.20044222v1 https://time.com/5810454/coronavirus-immunity-reinfection/ https://edition.cnn.com/2020/04/17/health/south-korea-coronavirus-retesting-positive-intl-hnk/index.html https://edition.cnn.com/2020/04/17/health/south-korea-coronavirus-retesting-positive-intl-hnk/index.html https://doi.org/10.1136/bjophthalmol-2020-315994 https://www.medrxiv.org/content/10.1101/2020.03.29.20045880v1 https://www.medrxiv.org/content/10.1101/2020.03.29.20045880v1 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 2524 philippine journal of otolaryngology-head and neck surgery review article fpm journal blog. 2020 mar 30 [cited 2020 apr 29]. available from: https://www.aafp.org/ journals/fpm/blogs/inpractice/entry/covid19_home.html 43. khunti k, chan x-h, ross l, et al. what is the evidence that covid-19 personal protective equipment should include shoe covers? [internet].  oxford: the centre for evidence-based medicine 2020 apr 7 [cited 2020 apr 7]. available from: https://www.cebm.net/covid-19/ what-is-the-evidence-that-covid-19-personal-protective-equipment-should-include-shoecovers/ 44. sweetmat disinfection mats [internet]. new zealand: disinfectant options. [cited 2020 may 5]. available from: http://disinfectionmat.com/how-to-use-a-disinfection-mat/ 45. republic of the philippines: department of health. [internet] department of health memorandum 2020-0157: guidelines on cleaning and disinfection in various settings as an infection prevention and control measure against covid-19. 2020 april 10 [cited 2020 may 5]. available from: https://www.doh.gov.ph/sites/default/files/health-update/dm2020-0157.pdf 46. us centers for disease control and prevention [internet]. atlanta: guideline for disinfection and sterilization in healthcare facilities. 2008 (updated 2016 september 18) [cited 2020 may 5]. available from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/ disinfection-methods/chemical.html 47. world health organization (who) [internet]. geneva: is wearing rubber gloves while out in public effective in preventing the new coronavirus infection? 2020 mar 17 [cited 2020 apr 29]. available from:   https://www.facebook.com/who/posts/q-is-wearing-rubber-gloves-whileout-in-the-public-effective-in-preventing-the-n/2988790457832984/ 48. world health organization (who) [internet]. geneva: management of ill travellers at points of entry—international airports, seaports and ground crossings—in the context of covid-19 outbreak. 2020 feb 16 [cited 2020 apr 29]. available from: https://www.who.int/publicationsdetail/management-of-ill-travellers-at-points-of-entry-international-airports-seaports-andground-crossings-in-the-context-of-covid--19-outbreak 49. republic of the philippines: department of health. [internet] reiteration of the interim guidelines on 2019 novel coronavirus acute respiratory disease (2019-ncov ard) response in the workplace. 2020 feb 5 [cited 2020 apr 29].  available from: https://www.doh.gov. ph/sites/default/files/health-update/dc2020-0039-reiteration-of-dm2020-056-interimguidelines-on-2019-ncov-ard-response-in-the-workplace.pdf   50. united states department of labor occupational safety and health agency [internet]. united states of america: guidance on preparing workplaces for covid-19   2020 mar [cited 2020 apr 29]. available from: https://www.osha.gov/publications/osha3990.pdf 51. dudalski n., mohamed a., mubareka s, bi r, zhang c, savory e. experimental investigation of far field human cough airflows from healthy and influenza-infected subjects. wiley online library. 2019 nov 8. [cited 2020 apr 30]. available from: https://onlinelibrary.wiley.com/doi/ epdf/10.1111/ina.12680 doi: 10.1111/ina.12680. pubmed pmid: 32304605. 52. morawska l, cao j.  airborne transmission of sars-cov-2: the world should face the reality.  environ int. 2020 jun 10. [cited 2020 apr 30]. available from: https://doi.org/10.1016/j. envint.2020.105730. pubmed pmid: 32294574; pubmed central pmcid: pmc7151430. 53. bahl p, doolan c, de silva c, chughtai aa, bourouiba l, macintyre cr.  airborne or droplet precautions for health workers treating coronavirus disease 2019? j infect dis. april 16, 2020; doi: 10.1093/infdis/jiaa189. pubmed pmid: 32301491; pubmed central pmcid: pmc7184471. 54. tay j, lim ws, loh ws, loh ks. sustaining otolaryngology services for the long haul during the covid-19 pandemic: experience from a tertiary health system. otolaryngol head neck surg. 2020 may 5. [cited 2020 may 5]. available from: https://doi.org/10.1177%2f0194599820922983 doi: 10.1177/0194599820922983. pubmed pmid: 32366174. 55. world health organization (who) [internet]. geneva: standard precautions in health care. 2007 oct [cited 2020 apr 29]. available from: https://www.who.int/csr/resources/ publications/standardprecthc.pdf 56. us centers for disease control and prevention [internet]. atlanta: respiratory hygiene/cough etiquette in healthcare settings seasonal influenza (flu). 2009 aug 1 [cited apr 29]. available from: https://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm 57. lifshitz e. practical healthcare epidemiology, 4th edition. emerg infect dis. 2019 nov;25(11):2161. doi: 10.3201/eid2511.190464 58. united states department of labor occupational safety and health agency [internet]. united states of america: healthcare workplaces classified as very high or high exposure risk for pandemic influenza. 2006 may [cited 2020 apr 30]. available from: https://www.osha.gov/ publications/exposure-risk-classification-factsheet.html 59. us centers for disease control and prevention [internet]. atlanta: interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings coronavirus disease 2019 (covid-19). 2020 apr 13 [cited 2020 may 5]. available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ infection-control-recommendations.html 60. us centers for disease control and prevention [internet]. atlanta: guidelines for environmental infection control in health-care facilities environmental infection control guidelines. 2003 [cited 2020 may 5]. available from: https://www.cdc.gov/infectioncontrol/ guidelines/environmental/background/air.html 61. minnesota department of health [internet]. minnesota: airborne infectious disease management – methods for temporary negative pressure isolation. 2007 [cited 2020 may 5]. available from: https://www.health.state.mn.us/communities/ep/surge/infectious/ airbornenegative.pdf 62.    enthnszcmc. paving the way towards a “new normal.” covid-19: efforts and innovations.  march to april [internet]. 2020 apr 23 [cited 2020 april 23]. available from:  https://www. facebook.com/enthnszcmc/ 63.    lu j, gu j, li k, xu c, su w, lai z, et al. covid-19 outbreak associated with air conditioning in restaurant, guangzhou, china. emerg infect dis. 2020 july [cited 2020 apr 30]. available from:  https://doi.org/10.3201/eid2607.200764. pubmed pmid: 32240078. virus causing covid-19: implications for ipc precaution recommendations. 2020 march 29 [cited 2020 april 21]. available from: https://www.who.int/news-room/commentaries/ detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precautionrecommendations 23. lewis d. is the coronavirus airborne? experts can’t agree. nature. 2020 april 9;580(7802):175. [cited 2020 april 22]. available from: https://www.nature.com/articles/d41586-020-00974-w doi: 10.1038/d41586-020-00974-w. pmid: 32242113. 24. american academy of otolaryngology head and neck surgery (aao-hns). position statement: otolaryngologists and the covid-19 pandemic. march 23, 2020 [cited 2020 april 12]. available from: https://www.entnet.org/content/otolaryngologists-and-covid-19pandemic 25 chan jyk, wong ewy, lam w. practical aspects of otolaryngologic clinical services during the 2019 novel coronavirus epidemic: an experience in hong kong. jama otolaryngol head neck surg. 2020 mar 20. doi: 10.1001/jamaoto.2020.0488. pubmed pmid: 32196070. 26. centers for medicare & medicaid services (cms) recommendations: re-opening facilities to provide non-emergent non-covid-19 healthcare: phase i. 2020 april 19. [cited 2020 april 22]. available from: https://www.cms.gov/files/document/covid-flexibility-reopen-essentialnon-covid-services.pdf 27. american college of surgeons (acs): covid-19 guidelines for triage of otolaryngology patients. 2020 mar 24 [cited 2020 april 22]. available from: https://www.facs.org/covid-19/ clinical-guidance/elective-case/otolaryngology 28. the royal college of surgeons: guidance for ent during the covid-19 pandemic. 2020 mar 16 [cited 2020 april 22]. available from: https://www.entuk.org/guidance-ent-during-covid19-pandemic 29. givi b, schiff ba, chinn sb, clayburgh d, iyer ng, jalisi s, et al. safety recommendations for evaluation and surgery of the head and neck during the covid-19 pandemic. jama otolaryngol neck surg. 2020 mar 31. doi: 10.1001/jamaoto.2020.0780. pubmed pmid: 32232423. 30. lai c-c, liu yh, wang c-y, wang y-h, hsueh s-c, yen m-y, et al. asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (sars-cov-2): facts and myths. j microbiol immunol infect. 2020 mar 4; pii: s1684-1182(20)30040-2. doi: 10.1016/j.jmii.2020.02.012. pubmed pmid: 32173241; pubmed central pmcid: pmc7128959. 31. li r, pei s, chen b, song y, zhang t, yang w, et al. substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2). science 2020 may 1;368(6490):489-493. doi: 10.1126/science.abb3221. pubmed pmid: 32179701; pubmed central pmcid: pmc7164387. 32. world health organization (who) [internet]. “immunity passports” in the context of covid-19. 2020 april 24 [cited 2020 april 30]. available from: https://www.who.int/newsroom/commentaries/detail/immunity-passports-in-the-context-of-covid-19 33. american academy of family physicians [internet]. kansas: checklist to prepare physician offices for covid-19. c2020 [cited 2020 apr 29]. available from: https://www.aafp.org/dam/ aafp/documents/patient_care/public_health/covid-19%20office%20prep%20checklist. pdf 34.  republic of the philippines: department of health and department of the interior and local government. [internet]. guidelines on local isolation and general treatment areas for covid-19 cases and the community-based management of mild covid-19 cases. 2020 apr 15 [cited 2020 apr 29]. available from: https://www.doh.gov.ph/sites/default/files/healthupdate/jao2020-0001_0.pdf 35. world health organization (who) [internet]. geneva: coronavirus disease (covid-19) advice for the public: when and how to use masks. c2020 [cited 2020 apr 29]. available from: https:// www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-andhow-to-use-masks 36. us centers for disease control and prevention [internet]. recommendation regarding the use of cloth face coverings, especially in areas of significant community-based transmission. coronavirus disease 2019 (covid-19). c2020 [cited 2020 apr 29]. available from: https://www. cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html 37. singapore ministry of health [internet]. singapore: continued stringent implementation & enforcement of circuit breaker measures. 2020 apr 14 [cited 2020 apr 29]. available from: https://www.moh.gov.sg/news-highlights/details/continued-stringent-implementationenforcement-of-circuit-breaker-measures 38. republic of the philippines: inter-agency task force for the management of emerging infectious diseases.  [internet] recommendations relative to the management of the coronavirus disease 2019 (covid-19) situation, iatf resolution no. 18 series of 2020. 2020 april 1 [cited 2020 apr 29].  available from: https://www.doh.gov.ph/sites/default/files/ health-update/iatf-reso-18.pdf 39. city government of makati. resolutions and ordinances 2020-089: an ordinance requiring all persons within the territorial jurisdiction of the city of makati to wear face masks or other similar protective equipment outside their home premises.  2020 apr 8 [cited 2020 apr 29]. available from: . https://www.makati.gov.ph/content/resolutions-and-ordinances/ search?query=2020-089 40. san francisco department of public health [internet]. san francisco: preparing your office or clinic for potential covid-19 (novel coronavirus) patients. 2020 february 14 [cited 2020 april 29]. available from: https://www.sfcdcp.org/wp-content/uploads/2020/02/preparing-clinicfor-covid19-14feb2020.pdf  41. guo z-d, wang z-y, zhang s-f, li x, li l, li c, et al. aerosol and surface distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards, wuhan, china. emerg infect dis. 2020 apr 10;26(7). doi: 10.3201/eid2607.200885. pubmed pmid: 32275497. 42. allen-ehrhart t. how to leave coronavirus behind when you come home [internet]. kansan: https://www.aafp.org/journals/fpm/blogs/inpractice/entry/covid19_home.html https://www.aafp.org/journals/fpm/blogs/inpractice/entry/covid19_home.html file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.cebm.net/covid-19/what-is-the-evidence-that-covid-19-personal-protective-equipment-should-include-shoe-covers file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.cebm.net/covid-19/what-is-the-evidence-that-covid-19-personal-protective-equipment-should-include-shoe-covers file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.cebm.net/covid-19/what-is-the-evidence-that-covid-19-personal-protective-equipment-should-include-shoe-covers http://disinfectionmat.com/how-to-use-a-disinfection-mat/ https://www.doh.gov.ph/sites/default/files/health-update/dm2020-0157.pdf https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-methods/chemical.html https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-methods/chemical.html https://www.facebook.com/who/posts/q-is-wearing-rubber-gloves-while-out-in-the-public-effective-in-preventing-the-n/2988790457832984/ https://www.facebook.com/who/posts/q-is-wearing-rubber-gloves-while-out-in-the-public-effective-in-preventing-the-n/2988790457832984/ file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.who.int/publications-detail/management-of-ill-travellers-at-points-of-entry-international-airports-seaports-and-ground-crossings-in-the-context-of-covid--19-outbreak file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.who.int/publications-detail/management-of-ill-travellers-at-points-of-entry-international-airports-seaports-and-ground-crossings-in-the-context-of-covid--19-outbreak file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.who.int/publications-detail/management-of-ill-travellers-at-points-of-entry-international-airports-seaports-and-ground-crossings-in-the-context-of-covid--19-outbreak https://www.doh.gov.ph/sites/default/files/health-update/dc2020-0039-reiteration-of-dm2020-056-interim-guidelines-on-2019-ncov-ard-response-in-the-workplace.pdf https://www.doh.gov.ph/sites/default/files/health-update/dc2020-0039-reiteration-of-dm2020-056-interim-guidelines-on-2019-ncov-ard-response-in-the-workplace.pdf https://www.doh.gov.ph/sites/default/files/health-update/dc2020-0039-reiteration-of-dm2020-056-interim-guidelines-on-2019-ncov-ard-response-in-the-workplace.pdf file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.osha.gov/publications/osha3990.pdf file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/onlinelibrary.wiley.com/doi/epdf/10.1111/ina.12680 file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/onlinelibrary.wiley.com/doi/epdf/10.1111/ina.12680 https://doi.org/10.1111/ina.12680 file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/doi.org/10.1016/j.envint.2020.105730 file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/doi.org/10.1016/j.envint.2020.105730 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc7151430/ https://doi.org/10.1093/infdis/jiaa189 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc7184471/ https://doi.org/10.1177%2f0194599820922983 https://doi.org/10.1177/0194599820922983 https://www.who.int/csr/resources/publications/standardprecthc.pdf https://www.who.int/csr/resources/publications/standardprecthc.pdf https://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm https://dx.doi.org/10.3201/eid2511.190464 https://www.osha.gov/publications/osha3990.pdf file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/ https:/www.osha.gov/publications/exposure-risk-classification-factsheet.html file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/ https:/www.osha.gov/publications/exposure-risk-classification-factsheet.html https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.cdc.gov/infectioncontrol/guidelines/environmental/background/air.html file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.cdc.gov/infectioncontrol/guidelines/environmental/background/air.html https://www.health.state.mn.us/communities/ep/surge/infectious/airbornenegative.pdf https://www.health.state.mn.us/communities/ep/surge/infectious/airbornenegative.pdf https://www.facebook.com/enthnszcmc/ https://www.facebook.com/enthnszcmc/ https://doi.org/10.3201/eid2607.200764 https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations https://www.nature.com/articles/d41586-020-00974-w https://www.entnet.org/content/otolaryngologists-and-covid-19-pandemic https://www.entnet.org/content/otolaryngologists-and-covid-19-pandemic https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf https://www.facs.org/covid-19/clinical-guidance/elective-case/otolaryngology https://www.facs.org/covid-19/clinical-guidance/elective-case/otolaryngology https://www.entuk.org/guidance-ent-during-covid-19-pandemic https://www.entuk.org/guidance-ent-during-covid-19-pandemic https://www.who.int/news-room/commentaries/detail/immunity-passports-in-the-context-of-covid-19 https://www.who.int/news-room/commentaries/detail/immunity-passports-in-the-context-of-covid-19 https://www.aafp.org/dam/aafp/documents/patient_care/public_health/covid-19%20office%20prep%20checklist.pdf file:///users/vergie/desktop/2020%20folder/pso%202020/journal%20jan-june%202020/pjohnsreviewarticlereferences/%20https://www.aafp.org/dam/aafp/documents/patient_care/public_health/covid-19%20office%20prep%20checklist.pdf https://www.doh.gov.ph/sites/default/files/health-update/jao2020-0001_0.pdf https://www.doh.gov.ph/sites/default/files/health-update/jao2020-0001_0.pdf https://www.aafp.org/dam/aafp/documents/patient_care/public_health/covid-19%20office%20prep%20checklist.pdf https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html https://www.moh.gov.sg/news-highlights/details/continued-stringent-implementation-enforcement-of-circuit-breaker-measures https://www.moh.gov.sg/news-highlights/details/continued-stringent-implementation-enforcement-of-circuit-breaker-measures https://www.moh.gov.sg/news-highlights/details/continued-stringent-implementation-enforcement-of-circuit-breaker-measures https://www.doh.gov.ph/sites/default/files/health-update/iatf-reso-18.pdf https://www.doh.gov.ph/sites/default/files/health-update/iatf-reso-18.pdf https://www.makati.gov.ph/content/resolutions-and-ordinances/search?query=2020-089 https://www.makati.gov.ph/content/resolutions-and-ordinances/search?query=2020-089 https://www.sfcdcp.org/wp-content/uploads/2020/02/preparing-clinic-for-covid19-14feb2020.pdf https://www.sfcdcp.org/wp-content/uploads/2020/02/preparing-clinic-for-covid19-14feb2020.pdf philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery 64. van doremalen n, morris d, holbrook m, gamble a, williamson bn, tamin a, et al. aerosol and surface stability of sars-cov-2 as compared with sars-cov-1. n engl j med. 2020 apr 16 [cited 2020 apr 29]. available from: https://www.nejm.org/doi/full/10.1056/nejmc2004973 doi: 10.1056/nejmc2004973. pubmed pmid: 32182409; pubmed central  pmcid: pmc7121658. 65. us centers for disease control and prevention [internet]. atlanta: interim recommendations for u.s. community facilities with suspected/confirmed coronavirus disease 2019 (covid-19). 2020 apr 1 [cited 2020 may 5]. available from: https://www.cdc.gov/coronavirus/2019-ncov/ community/organizations/cleaning-disinfection.html 66. united states environmental protection agency [internet]. united states of america: list n: disinfectants for use against sars-cov-2 updated 2020 apr 30 [cited 2020 may 6]. available from: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 67. chang cwd, brenner mj, shuman ek, kokoska ms. reprocessing standards for medical devices and equipment in otolaryngology: safe practices for scopes, speculums, and single-use devices. otolaryngol clin north am. 2019 feb;52(1):173-183. doi: 10.1016/j. otc.2018.08.014. pubmed pmid: 30262168. 68. us food and drug authority [internet]. united states of america: fda-cleared sterilants and high level disinfectants with general claims for processing reusable medical and dental devices. 2015 sep. [cited 2020 apr 29]. available from: https://www.fda.gov/medical-devices/ reprocessing-reusable-medical-devices-information-manufacturers/fda-cleared-sterilantsand-high-level-disinfectants-general-claims-processing-reusable-medical-and 69. us centers for disease control and prevention [internet]. atlanta: miscellaneous inactivating agents guideline for disinfection and sterilization in healthcare facilities (updated 2016 sep 18) [cited 2020 may 5]. available from: https://www.cdc.gov/infectioncontrol/guidelines/ disinfection/disinfection-methods/miscellaneous.html 70. knox rw, demons st, cunningham cw. a novel method to decontaminate surgical instruments for operational and austere environments. wilderness environ med. 2015 dec;26(4):509-13. doi: 10.1016/j.wem.2015.03.030. pubmed pmid: 26165581. 71. martin sb, dunn c, freihaut jd, bahnfleth wp, lau j, nedeljkovic-davidovic a. ultraviolet germicidal irradiation – current best practices. ashrae j. 2008 aug; 50(8):28-36. available from: https://nebraska.pure.elsevier.com/en/publications/ultraviolet-germicidal-irradiationcurrent-best-practices 72. storz the world of endoscopy [internet]. hygiene: maintenance, sterilization, storage techniques. 2nd edition. 2013 jan [cited 2020 apr 30]. available from: https://www.karlstorz. com/cps/rde/xbcr/karlstorz_assets/assets/3331303.pdf 73. aeran h, sharma s, kumar v, gupta n. use of clinical uv chamber to disinfect dental impressions: a comparative study. j clin diagn res. 2015 aug; 9(8): zc67–zc70. published online 2015 aug 1. doi: 10.7860/jcdr/2015/14025.6353. pubmed pmid: 26436051; pubmed central pmcid: pmc4576645. 74. health quality ontario. portable ultraviolet light surface-disinfecting devices for prevention of hospital-acquired infections: a health technology assessment. ont health technol assess ser [internet]. 2018 feb;18(1):1-73 [cited 2020 apr 3]. available from: http://www.hqontario. ca/portals/0/documents/evidence/reports/hta-uv-light-1802-en.pdf 75. united states of america: u.s. department of health and human services food and drug administration center for devices and radiological health. enforcement policy for sterilizers, disinfectant devices, and air purifiers during the coronavirus disease 2019 (covid-19) public health emergency: guidance for industry and food and drug administration staff. march 2020 [cited 2020 may 5]. available from: https://www.fda.gov/media/136533/download 76. walker rw, markillie lm, colotelo ah, gay me, woodley cm, brown rs. the efficacy of ultraviolet radiation for sterilizing tools used for surgically implanting transmitters into fish. draft final report. pacific northwest national laboratory, prepared for the u.s. army corps of engineers, portland district, under an interagency agreement with the u.s. department of energy contract de-ac05-76rl01830. 2012 feb [cited 2020 may 5]. available from: https:// waterpower.pnnl.gov/jsats/pdf/pnnl-21126.pdf  77. xu y, li x, zhu b, liang h, fang c, gong y, et al. characteristics of pediatric sars-cov-2 infection and potential evidence for persistent fecal viral shedding. nat med. 2020 apr;26(4):502-505. doi: 10.1038/s41591-‎020-0817-4. pubmed pmid: 32284613; pubmed central pmcid: pmc7095102. 78. occhipinti v, pastorelli l. challenges in the care of ibd patients during the covid-19 pandemic: report from a “red zone” area in northern italy. inflamm bowel dis. 2020 apr 21; pii: izaa084. doi: 10.1093/ibd/izaa084. pubmed pmid: 32314792; pubmed central pmcid: pmc7188155. 79. johnson da. toilets may pose risk for spreading covid 19. medscape commentary. 2020 apr 09 [cited 2020 may 6]. available from: https://www.medscape.com/viewarticle/928234 80. kurnitski j, boerstra a, franchimon f, mazzarella l, hogeling j, hovorka f, et al. how to operate and use building services in order to prevent the spread of the coronavirus disease (covid-19) virus (sars-cov-2) in workplaces [internet]. brussels: federation of heating, ventilation and air conditioning associations.  updated 2020 apr  3 [cited 2020 may 5]. available from: https://www.rehva.eu/fileadmin/user_upload/rehva_covid-19_guidance_document_ ver2_20200403_1.pdf 81. singapore ministry of health and national environment agency [internet]. interim guidelines for environmental cleaning and disinfection of areas exposed to confirmed case(s) of covid-19 in non-healthcare premises. 2020 jan 25, revised 2020 apr 29 [cited 2020 may 5]. available from: https://www.nea.gov.sg/our-services/public-cleanliness/environmentalcleaning-guidelines/guidelines/guidelines-for-environmental-cleaning-and-disinfection 82. us centers for disease control and prevention [internet]. atlanta: interim laboratory biosafety guidelines for handling and processing specimens associated with coronavirus disease 2019 (covid-19). 2020 mar 31 [cited 2020 may 7].  available from: https://www.cdc. gov/coronavirus/2019-ncov/lab/lab-biosafety-guidelines.html) 83. asian development bank [internet]. mandaluyong: managing infectious medical waste during the covid-19 pandemic. 2020 [cited 2020 may 07]. available from: https://www.adb. org/sites/default/files/publication/578771/managing-medical-waste-covid19.pdf  84. siwicki b. telemedicine during covid-19: benefits, limitations, burdens, adaptation. in healthcareitnews.com [internet] 2020 march 19 [cited 2020 may 10].  available from: https:// www.healthcareitnews.com/news/telemedicine-during-covid-19-benefits-limitationsburdens-adaptation 85. mccool rr, davies l. where does telemedicine fit into otolaryngology? an assessment of telemedicine eligibility among otolaryngology diagnoses. otolaryngol head neck surg. 2018  feb 13; 158 (4):641-644 doi: 10.1177/0194599818757724. pubmed pmid 29436270. 86. american academy of otolaryngology head and neck surgery.  prioritizing novel approaches to telehealth for all practitioners from the aao-hns telemedicine committee douglas m. hildrew, md. 2020 march 18  [cited 2020 may 6]. available from: https://www. entnet.org/content/prioritizing-novel-approaches-telehealth-all-practitioners 87. department of health philippines. [internet] doh boosts telemedicine services for ncr; service to expand to other regions soon. press release 2020 april 07 [cited 2020 may 10]. available from: https://www.doh.gov.ph/doh-press-release/doh-boost-telemedicineservices-for-ncr-service-to-expand-to-other-regions-soon 88. university of the philippines padayon public service office. [internet] up-pgh covid-19 operations center bayanihan na website. [cited 2020 may 10].  available from: https:// publicservice.up.edu.ph/uppgh-bayanihan-na/ 89. centers for disease control and prevention. [internet] outpatient and ambulatory care settings: responding to community transmission of covid-19 in the united states. cdc. last reviewed 2020 april [cited 2020 may 10]. available from: https://www.cdc.gov/ coronavirus/2019-ncov/hcp/ambulatory-care-settings.html 90. world health organization (who) [internet]. atlanta: infection prevention and control during health care when covid-19 is suspected. 2020 [cited 2020 may 10]. available from: https:// apps.who.int/iris/rest/bitstreams/1272420/retrieve 91. philippine society of otolaryngology head and neck surgery [internet]. philippines: psohns covid-19 advisory: aerosol generating procedures in orl-hns pso-hns. 2020 [cited 2020 may 8]. available from: https://www.facebook.com/psohns.org/photos/rpp.151490160539 4714/2616827178535479/?type=3&theater 92. american healthcare association national center for assisted living [internet]. covid-19: screening checklist – for visitors and staff 2020 [cited 2020 may 5]. available from: https:// www.ahcancal.org/facility_operations/disaster_planning/documents/covid19-screeningchecklist-snf-visitors.pdf 93. couzin-frankel j. why don’t some coronavirus patients sense their alarmingly low oxygen levels? [internet]. american association for the advancement of science. 2020 [cited 2020 may 5]. available from: https://www.sciencemag.org/news/2020/04/why-don-t-somecoronavirus-patients-sense-their-alarmingly-low-oxygen-levels# 94. khalid a. pulse oximeters are selling out because of the pandemic. most people don’t need them [internet]. quartz. 2020 [cited 2020 may 5]. available from: https://qz.com/1832464/ pulse-oximeters-for-coronavirus-unnecessary-but-selling-strong/ 95. groth l. pulse oximeters may be helpful for people with covid-19—here’s what to know before you buy one. in health.com [internet] 2020 april 28 [cited 2020 may 10]. available from: https://www.health.com/condition/infectious-diseases/coronavirus/pulse-oximeter 96. department of business energy and industrial strategy, public health england [internet]. london: guidance for employers and businesses on coronavirus (covid-19). 2020 [cited 2020 may 5]. available from: https://www.gov.uk/government/publications/guidance-toemployers-and-businesses-about-covid-19/guidance-for-employers-and-businesses-oncoronavirus-covid-19 97. centers for disease control and prevention. [internet] cleaning and disinfection for households. cdc. last reviewed 2020 may 7 [cited 20 may 10]. available from: https://www. cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cleaning-disinfection.html 98. world health organization [internet]. geneva: q&a on coronaviruses (covid-19). 2020 april 17 [cited 2020 may 10]. available from: https://www.who.int/emergencies/diseases/novelcoronavirus-2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses 99. king r, shen a. will cash survive covid-19? [internet]. infopro digital services limited. 2020 [cited 2020 may 5]. available from: https://www.centralbanking.com/central-banks/ currency/7509046/will-cash-survive-covid-19 100. world health organization [internet]. geneva: health topics: can covid-19 be spread through coins and banknotes? (infographic on the web). 2020 april 17 [cited 2020 may 9]. available from: https://www.who.int/images/default-source/health-topics/coronavirus/engmythbusting-ncov-(23).tmb-1920v.png 101. centers for medicare & me. cms adult elective surgery and procedures recommendations [internet]. 2020 [cited 2020 may 8]. available from: https://www.cms.gov/files/document/ covid-elective-surgery-recommendations.pdf 102. tantuco vl. explainer: the ppe keeping our healthcare workers safe [internet]. manila: rappler inc.; c2020-21 (updated 2020 april 5) [cited 2020 may 8]. available from: https://www.rappler. com/newsbreak/iq/256806-explainer-personal-protective-equipment-keeping-healthcareworkers-safe-coronavirus 103. dofitas r, say a, lahoz e, de leon j, inso r, aison d, et al. recommendations for the rational and effective use personal protective equipment [internet]. philippine college of surgeons. 2020 [cited 2020 may 13]. available from: http://pcs.org.ph/assets/images/pcs-covid-10rationale-use-of-ppe.pdf 104. health protection scotland. best practice aide memoire for levels of personal protective equipment (ppe) for healthcare workers when providing patient care [internet]. 2020 feb [cited 2020 mar 25]. available from: http://www.nipcm.hps.scot.nhs.uk/appendices/ appendix-16-best-practice-aide-memoire-for-levels-of-personal-protective-equipment-ppefor-healthcare-workers-when-providing-patient-care/   105. wang j, zhou m, liu f. reasons for healthcare workers becoming infected with novel review article https://www.nejm.org/doi/full/10.1056/nejmc2004973 https://doi.org/10.1056/nejmc2004973 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc7121658/ https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/cleaning-disinfection.html https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/cleaning-disinfection.html https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 https://doi.org/10.1016/j.otc.2018.08.014 https://doi.org/10.1016/j.otc.2018.08.014 file:////users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.fda.gov/medical-devices/reprocessing-reusable-medical-devices-information-manufacturers/fda-cleared-sterilants-and-high-level-disinfectants-general-claims-processing-reusable-medical-and file:////users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.fda.gov/medical-devices/reprocessing-reusable-medical-devices-information-manufacturers/fda-cleared-sterilants-and-high-level-disinfectants-general-claims-processing-reusable-medical-and file:////users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.fda.gov/medical-devices/reprocessing-reusable-medical-devices-information-manufacturers/fda-cleared-sterilants-and-high-level-disinfectants-general-claims-processing-reusable-medical-and https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-methods/miscellaneous.html https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-methods/miscellaneous.html https://nebraska.pure.elsevier.com/en/publications/ultraviolet-germicidal-irradiation-current-best-practices https://nebraska.pure.elsevier.com/en/publications/ultraviolet-germicidal-irradiation-current-best-practices https://www.karlstorz.com/cps/rde/xbcr/karlstorz_assets/assets/3331303.pdf https://www.karlstorz.com/cps/rde/xbcr/karlstorz_assets/assets/3331303.pdf http://www.hqontario.ca/portals/0/documents/evidence/reports/hta-uv-light-1802-en.pdf http://www.hqontario.ca/portals/0/documents/evidence/reports/hta-uv-light-1802-en.pdf https://www.fda.gov/media/136533/download https://waterpower.pnnl.gov/jsats/pdf/pnnl-21126.pdf https://waterpower.pnnl.gov/jsats/pdf/pnnl-21126.pdf https://dx.doi.org/10.1093%2fibd%2fizaa084 https://www.ncbi.nlm.nih.gov/pubmed/32314792 https://www.medscape.com/viewarticle/928234 https://www.rehva.eu/fileadmin/user_upload/rehva_covid-19_guidance_document_ver2_20200403_1.pdf https://www.rehva.eu/fileadmin/user_upload/rehva_covid-19_guidance_document_ver2_20200403_1.pdf https://www.rehva.eu/fileadmin/user_upload/rehva_covid-19_guidance_document_ver2_20200403_1.pdf file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.nea.gov.sg/our-services/public-cleanliness/environmental-cleaning-guidelines/guidelines/guidelines-for-environmental-cleaning-and-disinfectio file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.nea.gov.sg/our-services/public-cleanliness/environmental-cleaning-guidelines/guidelines/guidelines-for-environmental-cleaning-and-disinfectio https://www.cdc.gov/coronavirus/2019-ncov/lab/lab-biosafety-guidelines.html https://www.cdc.gov/coronavirus/2019-ncov/lab/lab-biosafety-guidelines.html file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.adb.org/sites/default/files/publication/578771/managing-medical-waste-covid19.pdf file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.adb.org/sites/default/files/publication/578771/managing-medical-waste-covid19.pdf https://www.healthcareitnews.com/news/telemedicine-during-covid-19-benefits-limitations-burdens-adaptation https://www.healthcareitnews.com/news/telemedicine-during-covid-19-benefits-limitations-burdens-adaptation https://www.healthcareitnews.com/news/telemedicine-during-covid-19-benefits-limitations-burdens-adaptation https://doi.org/10.1177/0194599818757724 https://www.entnet.org/content/prioritizing-novel-approaches-telehealth-all-practitioners https://www.entnet.org/content/prioritizing-novel-approaches-telehealth-all-practitioners https://www.doh.gov.ph/doh-press-release/doh-boost-telemedicine-services-for-ncr-service-to-expand-to-other-regions-soon https://www.doh.gov.ph/doh-press-release/doh-boost-telemedicine-services-for-ncr-service-to-expand-to-other-regions-soon https://publicservice.up.edu.ph/uppgh-bayanihan-na/ https://publicservice.up.edu.ph/uppgh-bayanihan-na/ https://www.cdc.gov/coronavirus/2019-ncov/hcp/ambulatory-care-settings.html https://www.cdc.gov/coronavirus/2019-ncov/hcp/ambulatory-care-settings.html https://apps.who.int/iris/rest/bitstreams/1272420/retrieve https://apps.who.int/iris/rest/bitstreams/1272420/retrieve https://www.facebook.com/psohns.org/photos/rpp.1514901605394714/2616827178535479/?type=3&theater https://www.facebook.com/psohns.org/photos/rpp.1514901605394714/2616827178535479/?type=3&theater https://www.ahcancal.org/facility_operations/disaster_planning/documents/covid19-screening-checklist-snf-visitors.pdf https://www.ahcancal.org/facility_operations/disaster_planning/documents/covid19-screening-checklist-snf-visitors.pdf https://www.ahcancal.org/facility_operations/disaster_planning/documents/covid19-screening-checklist-snf-visitors.pdf https://www.sciencemag.org/news/2020/04/why-don-t-some-coronavirus-patients-sense-their-alarmingly-low-oxygen-levels# https://www.sciencemag.org/news/2020/04/why-don-t-some-coronavirus-patients-sense-their-alarmingly-low-oxygen-levels# https://qz.com/1832464/pulse-oximeters-for-coronavirus-unnecessary-but-selling-strong/ https://qz.com/1832464/pulse-oximeters-for-coronavirus-unnecessary-but-selling-strong/ https://www.health.com/condition/infectious-diseases/coronavirus/pulse-oximeter https://www.gov.uk/government/publications/guidance-to-employers-and-businesses-about-covid-19/guidance-for-employers-and-businesses-on-coronavirus-covid-19 https://www.gov.uk/government/publications/guidance-to-employers-and-businesses-about-covid-19/guidance-for-employers-and-businesses-on-coronavirus-covid-19 https://www.gov.uk/government/publications/guidance-to-employers-and-businesses-about-covid-19/guidance-for-employers-and-businesses-on-coronavirus-covid-19 https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cleaning-disinfection.html https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cleaning-disinfection.html https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses https://www.centralbanking.com/central-banks/currency/7509046/will-cash-survive-covid-19 https://www.centralbanking.com/central-banks/currency/7509046/will-cash-survive-covid-19 https://www.who.int/images/default-source/health-topics/coronavirus/eng-mythbusting-ncov-(23).tmb-1920v.png https://www.who.int/images/default-source/health-topics/coronavirus/eng-mythbusting-ncov-(23).tmb-1920v.png https://www.cms.gov/files/document/covid-elective-surgery-recommendations.pdf https://www.cms.gov/files/document/covid-elective-surgery-recommendations.pdf https://www.rappler.com/newsbreak/iq/256806-explainer-personal-protective-equipment-keeping-healthcare-workers-safe-coronavirus https://www.rappler.com/newsbreak/iq/256806-explainer-personal-protective-equipment-keeping-healthcare-workers-safe-coronavirus https://www.rappler.com/newsbreak/iq/256806-explainer-personal-protective-equipment-keeping-healthcare-workers-safe-coronavirus http://pcs.org.ph/assets/images/pcs-covid-10-rationale-use-of-ppe.pdf http://pcs.org.ph/assets/images/pcs-covid-10-rationale-use-of-ppe.pdf http://www.nipcm.hps.scot.nhs.uk/appendices/appendix-16-best-practice-aide-memoire-for-levels-of-personal-protective-equipment-ppe-for-healthcare-workers-when-providing-patient-care/ http://www.nipcm.hps.scot.nhs.uk/appendices/appendix-16-best-practice-aide-memoire-for-levels-of-personal-protective-equipment-ppe-for-healthcare-workers-when-providing-patient-care/ http://www.nipcm.hps.scot.nhs.uk/appendices/appendix-16-best-practice-aide-memoire-for-levels-of-personal-protective-equipment-ppe-for-healthcare-workers-when-providing-patient-care/ philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 2726 philippine journal of otolaryngology-head and neck surgery coronavirus disease 2019 (covid-19) in china. j hosp infect. 2020 mar 6. doi: 10.1016/j. jhin.2020.03.002. pubmed pmid: 32147406; pubmed central pmcid: pmc7134479. 106. remuzzi a, remuzzi g. covid-19 and italy: what next? lancet. 2020 mar 12 [cited 2020 apr 12]; 5(10231):1225–8. doi: https://doi.org/10.1016/s0140-6736(20)30627-9. pubmed pmid: 32178769; pubmed central pmcid: pmc7102589. 107. minder r, peltier e. virus knocks thousands of health workers out of action in europe. in: the new york times. [internet] 2020 march 24 [cited 2020 may 8]. available from: https://www. nytimes.com/2020/03/24/world/europe/coronavirus-europe-covid-19.html 108. royal college of psychiatrists. [internet] covid-19: personal protective equipment (ppe). royal college of psychiatrists. [cited 2020 may 11]. available from: https://www.rcpsych.ac.uk/ about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians/personalprotective-equipment-ppe 109. cheng x, liu j, li n, nisenbaum e, sun q, chen b, et al. otolaryngology providers must be alert for patients with mild and asymptomatic covid-19. otolaryngol head neck surg. 2020 apr 14 [epub ahead of print]. doi: 10.1177/0194599820920649. pubmed pmid: 32286913. 110. public health england, academy of medical royal colleges, public health wales, health protection scotland, hsc public health agency, nhs. recommended ppe for primary, outpatient, community and social care by setting, nhs and independent sector. 2020 april 4 [cited 2020 may 11]. available from: https://assets.publishing.service.gov.uk/government/ uploads/system/uploads/attachment_data/file/878750/t2_poster_recommended_ppe_ for_primary__outpatient__community_and_social_care_by_setting.pdf 111. world health organization. [internet] coronavirus disease 2019 (covid-19) situation report – 66 2020 [cited 2020 may 8]. available from: https://www.who.int/docs/default-source/ coronaviruse/situation-reports/20200326-sitrep-66-covid-19.pdf?sfvrsn=81b94e61_2 112. world health organization. [internet]. rational use of personal protective equipment for coronavirus disease (covid-19) and considerations during severe shortages. 2020 [cited 2020 may 8]. available from: https://apps.who.int/iris/bitstream/handle/10665/331695/who2019-ncov-ipc_ppe_use-2020.3-eng.pdf 113. health and safety executive uk. research: review of personal protective equipment provided in health care settings to manage risk during the coronavirus outbreak [internet]. hse. 2020 [cited 2020 may 8]. available from: https://www.hse.gov.uk/news/face-mask-equivalenceaprons-gowns-eye-protection-coronavirus.htm 114. us centers for disease control and prevention. strategies for optimizing the supply of n95 respirators [internet]. cdc. 2020 [cited 2020 may 8]. available from: https://www.cdc.gov/ coronavirus/2019-ncov/hcp/respirators-strategy/index.html 115. 3m personal safety division. technical bulletin: comparison of ffp2, kn95, and n95 and other filtering facepiece respirator classes. revision 3, 2020 may [cited 2020 may 11]. available from: https://multimedia.3m.com/mws/media/1791500o/comparison-ffp2-kn95-n95filtering-facepiece-respirator-classes-tb.pdf 116. health and safety executive uk. fit testing face masks to avoid transmission during the coronavirus outbreak [internet]. hse. 2020 [cited 2020 may 8]. available from: https://www. hse.gov.uk/news/face-mask-ppe-rpe-coronavirus.htm 117. us centers for disease control and prevention. [internet] healthcare respiratory protection resources. updated 2020 may 5 [cited 2020 may 11]. available from: https://www.cdc.gov/ niosh/npptl/hospresptoolkit/programeval.html 118. us centers for disease control and prevention. [internet] national personal protective technology laboratory, national institute for occupational safety and health. ancillary respirator information. reviewed 2018 jan 29 [cited 2020 may 11]. available from: https:// www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3.html 119. institute of medicine. preventing transmission of pandemic influenza and other viral respiratory diseases: personal protective equipment for healthcare personnel: update 2010 (2011). larson el, liverman ct (editors). washington, dc: the national academies press; 2011. doi: https://doi.org/10.17226/13027. 120. magennis p, kumar n, british association of oral and maxillofacial surgeons, ent uk [internet]. guidance ppe for patients with emergency oropharyngeal and nasopharyngeal conditions whose covid status is unknown. ent uk. 2020 march 25 [cited 2020 may 11]. available from: https://www.entuk.org/guidance-ppe-patients-emergency-oropharyngeal-andnasopharyngeal-conditions-whose-covid-status 121. royal college of surgeons. [internet]. aerosol-generating procedures in ent. ent uk. 2020 [cited 2020 may 8]. available from: https://www.entuk.org/aerosol-generating-proceduresent 122. national institute for occupational safety and health. [internet]. recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings niosh workplace safety and health topic. pandemic planning. 2020 [cited 2020 apr 14]. available from: https://www.cdc.gov/niosh/topics/hcwcontrols/ recommendedguidanceextuse.html 123. patel zm, fernandez-miranda j, hwang ph, nayak jv, dodd ri, sajjadi h, et al. precautions for endoscopic transnasal skull base surgery during the covid-19 pandemic. neurosurgery. 2020 apr 23. pii: nyaa156. doi: 10.1093/neuros/nyaa156. pubmed pmid: 32323725; pubmed central pmcid: pmc7188177. 124. ent today.org [internet] otolaryngologists may contract covid-19 during surgery 2020 march 20 [cited 2020 may 8]. available from: https://www.enttoday.org/article/ otolaryngologists-may-contract-covid-19-during-surgery/ 125. kowalski lp, sanabria a, ridge ja, ng wt, de bree r, rinaldo a, et al. covid-19 pandemic: effects and evidence-based recommendations for otolaryngology and head and neck surgery practice. head neck. 2020 apr 9 [epub ahead of print] doi: 10.1002/hed.26164. pubmed pmid: 32270581. 126. world health organization. [internet] advice on the use of masks in the community, during home care and in health care settings in the context of the novel coronavirus (2019-ncov) outbreak. 2020 january 29 [cited 2020 apr 30]. available from: https://www.who.int/docs/ default-source/documents/advice-on-the-use-of-masks-2019-ncov.pdf 127. philippine general hospital. guide to donning personal protective equipment. [internet] 2020 march 27 [cited 2020 may 12]. available from: http://www.pgh.gov.ph/static/media/uploads/ covid19filesemployees/donning3272020.jpg 128. philippine general hospital. guide to doffing personal protective equipment. [internet] 2020 march 27 [cited 2020 may 12]. available from: http://www.pgh.gov.ph/static/media/uploads/ covid19filesemployees/doffing3272020.jpg 129. department of surgery. pgh surgery donning and doffing of ppe (enhanced version 6.1) [internet]. philippine general hospital; 2020 april 4 [cited 2020 may 12]. available from: https://www.youtube.com/watch?v=rvq63c5lync 130. us centers for disease control and prevention. [internet] protecting healthcare personnel 2014 august 18 [cited 2020 april 30]. available from: https://www.cdc.gov/hai/prevent/ppe. html 131. department of health philippines. [internet]. interim guidelines on the management of health care waste in health facilities, community quarantine units, and temporary treatment and monitoring facilities with cases of coronavirus disease 2019 (covid-19). 2020 april 2 [cited 2020 may 8]. available from: https://www.doh.gov.ph/sites/default/files/healthupdate/dm2020-0170.pdf 132.  bauchner h, fontanarosa pb, livingston eh. conserving supply of personal protective equipment—a call for ideas. jama 2020 mar 20 [epub ahead of print] doi: 10.1001/ jama.2020.4770. pubmed pmid: 32196543. 133.   united states national institutes of health. [internet]. supplemental covid face shield instructions for use. c2020 [cited 2020 april 25]. available from: https://3dprint.nih. gov/sites/default/files/models/supplemental_documentation/ifu_face_shield%20_ rev.1.1_03_30.20_0.pdf  134.   national science teaching association. [internet]. eye protection and safer practice faq 2020 [cited 2020 may 8]. available from: http://static.nsta.org/pdfs/ eyeprotectionandsaferpracticesfaq.pdf 135. united states food and drug administration. [internet]. questions about personal protective equipment (ppe). 2020 mar 11 [cited 2020 april 15]. available from: https://www.fda.gov/ medical-devices/personal-protective -equipment-infection-control/questions-aboutpersonal-protective-equipment-ppe  136. american academy of otolaryngology-head and neck surgery [internet]. academy supports cms, offers specific nasal policy. 2020 march 18 [updated 2020 march 26; cited 2020 april 20]. available from: https://www.entnet.org/content/academy-supports-cms-offers-specificnasal-policy 137. bloomberg news [internet]. europe’s doctors repeat errors made in wuhan, china medics say. 2020 march 17 [cited 2020 april 20]. available from: https://www.bloomberg.com/news/ articles/2020-03-17/europe-s-doctors-getting-sick-like-in-wuhan-chinese-doctors-say 138. lu d, wang h, yu r, yang h, zhao y. integrated infection control strategy to minimize nosocomial infection of coronavirus disease 2019 among ent healthcare workers. j hosp infect. 2020 apr;104(4):454–455. doi: 10.1016/j.jhin.2020.02.018. pubmed pmid: 32114056; pubmed central pmcid: pmc7124261. 139. rothe c, schunk m, sothmann p, bretzel g, froeschl g, wallrauch c, et al. transmission of 2019ncov infection from an asymptomatic contact in germany. n engl j med. 2020;382(10):970– 971. doi: 10.1056/nejmc2001468. pubmed pmid: 32003551; pubmed central pmcid: pmc7120970. 140. xu j, li y, gan f, du y, yao y. salivary glands: potential reservoirs for covid-19 asymptomatic infection. j dent res. 2020 apr 9;22034520918518. doi:10.1177/0022034520918518. pubmed pmid: 32271653. 141. hu z, song c, xu c, jin g, chen y, xu x, et al. clinical characteristics of 24 asymptomatic infections with covid-19 screened among close contacts in nanjing, china. sci china life sci. 2020;63(5):706–711. doi:10.1007/s11427-020-1661-4. pubmed pmid: 32146694; pubmed central pmcid: pmc7088568. 142. philippine society of otolaryngology-head and neck surgery and philippine academy of rhinology [internet]. a friendly reminder to fellow ents & residents. 2020 march 22 [cited 2020 april 20]. available from https://pso-hns.org/wp-content/uploads/2020/03/paradvisory-re-covid-no.-1.pdf 143. lan l, xu d, ye g, xia c, wang s, li y, et al. positive rt-pcr test results in patients recovered from covid-19 [published online ahead of print, 2020 feb 27]. jama. 2020 feb 27;323(15):1502–1503. doi: 10.1001/jama.2020.2783. pubmed pmid: 32105304; pubmed central pmcid: pmc7047852. 144. zou l, ruan f, huang m, liang l, huang h, hong z, et al. sars-cov-2 viral load in upper respiratory specimens of infected patients. n engl j med. 2020 mar 19;382(12):1177– 1179. doi:10.1056/nejmc2001737. pubmed pmid: 32074444; pubmed central pmcid: pmc7121626. 145. leung, h. what we know about coronavirus immunity and reinfection.  time  [internet]. 2020 april 3 (updated 2020 april 13) [cited 2020 april 20]. available from: https://time. com/5810454/coronavirus-immunity-reinfection/. 146. yu p, zhu j, zhang z, han y, huang l. a familial cluster of infection associated with the 2019 novel coronavirus indicating potential person-to-person transmission during the incubation period. j infect dis. 2020 may 11;221(11):1757-1761. doi:10.1093/infdis/jiaa077. pubmed pmid: 32067043; pubmed central pmcid: pmc7107453. 147. philippine society of otolaryngology – head and neck surgery [internet]. endoscopy guidelines during the covid-19 pandemic. 2020 march 22 [cited 2020 april 20]. available from https://pso-hns.org/2020/03/22/endoscopy-guidelines-during-covid-19-pandemic/.  148. jones rm, brosseau lm. aerosol transmission of infectious disease. j occup environ med. 2015 review article https://dx.doi.org/10.1016%2fj.jhin.2020.03.002 https://dx.doi.org/10.1016%2fj.jhin.2020.03.002 https://www.ncbi.nlm.nih.gov/pubmed/32147406 https://doi.org/10.1016/s0140-6736(20)30627-9 https://www.nytimes.com/2020/03/24/world/europe/coronavirus-europe-covid-19.html https://www.nytimes.com/2020/03/24/world/europe/coronavirus-europe-covid-19.html https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians/personal-protective-equipment-ppe https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians/personal-protective-equipment-ppe https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians/personal-protective-equipment-ppe https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878750/t2_poster_recommended_ppe_for_primary__outpatient__community_and_social_care_by_setting.pdf https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878750/t2_poster_recommended_ppe_for_primary__outpatient__community_and_social_care_by_setting.pdf https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878750/t2_poster_recommended_ppe_for_primary__outpatient__community_and_social_care_by_setting.pdf https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200326-sitrep-66-covid-19.pdf?sfvrsn=81b94e61_2 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200326-sitrep-66-covid-19.pdf?sfvrsn=81b94e61_2 https://apps.who.int/iris/bitstream/handle/10665/331695/who-2019-ncov-ipc_ppe_use-2020.3-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331695/who-2019-ncov-ipc_ppe_use-2020.3-eng.pdf https://www.hse.gov.uk/news/face-mask-equivalence-aprons-gowns-eye-protection-coronavirus.htm https://www.hse.gov.uk/news/face-mask-equivalence-aprons-gowns-eye-protection-coronavirus.htm https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html https://multimedia.3m.com/mws/media/1791500o/comparison-ffp2-kn95-n95-filtering-facepiece-respirator-classes-tb.pdf https://multimedia.3m.com/mws/media/1791500o/comparison-ffp2-kn95-n95-filtering-facepiece-respirator-classes-tb.pdf https://www.hse.gov.uk/news/face-mask-ppe-rpe-coronavirus.htm https://www.hse.gov.uk/news/face-mask-ppe-rpe-coronavirus.htm https://www.cdc.gov/niosh/npptl/hospresptoolkit/programeval.html https://www.cdc.gov/niosh/npptl/hospresptoolkit/programeval.html https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3.html https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3.html https://doi.org/10.17226/13027 https://www.entuk.org/guidance-ppe-patients-emergency-oropharyngeal-and-nasopharyngeal-conditions-whose-covid-status https://www.entuk.org/guidance-ppe-patients-emergency-oropharyngeal-and-nasopharyngeal-conditions-whose-covid-status https://www.entuk.org/aerosol-generating-procedures-ent https://www.entuk.org/aerosol-generating-procedures-ent https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html https://www.enttoday.org/article/otolaryngologists-may-contract-covid-19-during-surgery/ https://www.enttoday.org/article/otolaryngologists-may-contract-covid-19-during-surgery/ https://www.who.int/docs/default-source/documents/advice-on-the-use-of-masks-2019-ncov.pdf https://www.who.int/docs/default-source/documents/advice-on-the-use-of-masks-2019-ncov.pdf http://www.pgh.gov.ph/static/media/uploads/covid19filesemployees/donning3272020.jpg http://www.pgh.gov.ph/static/media/uploads/covid19filesemployees/donning3272020.jpg http://www.pgh.gov.ph/static/media/uploads/covid19filesemployees/donning3272020.jpg https://www.youtube.com/watch?v=rvq63c5lync https://www.youtube.com/watch?v=rvq63c5lync https://www.cdc.gov/hai/prevent/ppe.html https://www.cdc.gov/hai/prevent/ppe.html https://www.doh.gov.ph/sites/default/files/health-update/dm2020-0170.pdf https://www.doh.gov.ph/sites/default/files/health-update/dm2020-0170.pdf file:///users/vergie/desktop/2020%20folder/pso%202020/journal%20jan-june%202020/pjohnsreviewarticlereferences/%20https://3dprint.nih.gov/sites/default/files/models/supplemental_documentation/ifu_face_shield%20_rev.1.1_03_30.20_0.pdf file:///users/vergie/desktop/2020%20folder/pso%202020/journal%20jan-june%202020/pjohnsreviewarticlereferences/%20https://3dprint.nih.gov/sites/default/files/models/supplemental_documentation/ifu_face_shield%20_rev.1.1_03_30.20_0.pdf file:///users/vergie/desktop/2020%20folder/pso%202020/journal%20jan-june%202020/pjohnsreviewarticlereferences/%20https://3dprint.nih.gov/sites/default/files/models/supplemental_documentation/ifu_face_shield%20_rev.1.1_03_30.20_0.pdf http://static.nsta.org/pdfs/eyeprotectionandsaferpracticesfaq.pdf http://static.nsta.org/pdfs/eyeprotectionandsaferpracticesfaq.pdf file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.fda.gov/medical-devices/personal-protective-equipment-infection-control/questions-about-personal-protective-equipment-ppe file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.fda.gov/medical-devices/personal-protective-equipment-infection-control/questions-about-personal-protective-equipment-ppe file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.fda.gov/medical-devices/personal-protective-equipment-infection-control/questions-about-personal-protective-equipment-ppe https://www.entnet.org/content/academy-supports-cms-offers-specific-nasal-policy https://www.entnet.org/content/academy-supports-cms-offers-specific-nasal-policy https://www.bloomberg.com/news/articles/2020-03-17/europe-s-doctors-getting-sick-like-in-wuhan-chinese-doctors-say https://www.bloomberg.com/news/articles/2020-03-17/europe-s-doctors-getting-sick-like-in-wuhan-chinese-doctors-say https://pso-hns.org/wp-content/uploads/2020/03/par-advisory-re-covid-no.-1.pdf https://pso-hns.org/wp-content/uploads/2020/03/par-advisory-re-covid-no.-1.pdf https://time.com/5810454/coronavirus-immunity-reinfection/ https://time.com/5810454/coronavirus-immunity-reinfection/ https://pso-hns.org/2020/03/22/endoscopy-guidelines-during-covid-19-pandemic/ philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery may;57(5):501–508. doi:10.1097/jom.0000000000000448. pubmed pmid: 25816216. 149. workman ad, welling db, carter bs, curry wt, holbrook eh, gray st, et al. endonasal instrumentation and aerosolization risk in the era of covid-19: simulation, literature review, and proposed mitigation strategies. int forum allergy rhinol. 2020 apr 3;10.1002/alr.22577. doi: 10.1002/alr.22577. pubmed pmid: 32243678. 150. asadi s, wexler as, cappa cd, barreda s, bouvier nm, ristenpart wd. aerosol emission and superemission during human speech increase with voice loudness. sci rep. 2019 feb 20;9(1):2348. published 2019 feb 20. doi: 10.1038/s41598-019-38808-z. pubmed pmid: 30787335; pubmed central pmcid: pmc6382806. 151. tateda, k. coronavirus: new facts about infection mechanisms nhk documentary [internet]. 2020 april 3 [cited 2020 april 24]. available from: https://www.youtube.com/ watch?v=h2azcn7mqou 152. lanese, n.  covid-19 may spread through breathing and talking — but we don’t know how much [internet]. 2020 april 7 [cited 2020 april 7]. available from: https://www.livescience. com/covid19-coronavirus-transmission-through-speech.html  153. wang j, du g. covid-19 may transmit through aerosol. ir j med sci. 2020 mar 24;1–2. doi:10.1007/s11845-020-02218-2. pubmed pmid 32212099; pubmed central pmcid: pmc7094991. 154. asadi s, bouvier n, wexler as, ristenpart wd.  the coronavirus pandemic and aerosols: does covid-19 transmit via expiratory particles? aerosol sci technol. 2020 apr 3; 54:6, 635-638. doi: 10.1080/02786826.2020.1749229. pubmed pmid: 32308568; pubmed central: pmc7157964. 155. bloustine s, langston l, miller t. ear-cough (arnold’s) reflex. ann otol rhinol laryngol. 1976 may 1;85(3 pt 1):406–407. doi: 10.1177/000348947608500315. pubmed pmid: 937970. 156. gupta d, verma s, vishwakarma sk. anatomic basis of arnold’s ear-cough reflex. surg radiol anat. 1986;8(4):217–220. doi: 10.1007/bf02425070. pubmed pmid: 3107144. 157. world health organization (who) [internet].  atlanta: coronavirus disease (covid-19) advice for the public. 2020 march 31 [cited 2020 april 29]. available from: https://www.who.int/ emergencies/diseases/novel-coronavirus-2019/advice-for-public  158.  national center for immunization and respiratory diseases (ncird), division of viral diseases, us centers for disease control and prevention [internet]. united states of america: social distancing, quarantine, and isolation. 2020 april 4 [cited 2020 april 29]. available from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html  159. shaw s, wherton j, vijayaraghavan s, morris j, bhattacharya s, hanson p, et al. advantages and limitations of virtual online consultations in an nhs acute trust: the vocal mixed-methods study. health serv deliv res 2018;6(21).  doi: 10.3310/hsdr06210. pubmed pmid: 29939519. 160. jegoux f, legent f, beauvillain de montreuil c. chronic cough and ear wax [published correction appears in lancet 2002 oct 19;360(9341):1256]. lancet. 2002 aug 24;360(9333):618. doi: 10.1016/s0140-6736(02)09786-6. pubmed pmid: 12241935. 161. saadi ra, bann dv, patel va, goldenberg d, may j, isildak h. a commentary on safety precautions for otologic surgery during the covid-19 pandemic. otolaryngol head neck surg. 2020 april 14:019459982091974. doi:10.1177/0194599820919741. pubmed pmid: 32286916. 162. pitkäranta a, jero j, arruda e, virolainen a, hayden fg. polymerase chain reaction-based detection of rhinovirus, respiratory syncytial virus, and coronavirus in otitis media with effusion. j pediatr. 1998 sep;133(3):390–394. doi: 10.1016/s0022-3476(98)70276-8. pubmed pmid: 9738723; pubmed central pmcid: pmc7095025. 163. rea p, lloyd s, jenkins d. guidance for undertaking otological procedures during covid-19 pandemic [internet]. ent uk.  2020 [cited 2020 april 13]. available from: https://www.entuk. org/guidance-undertaking-otological-procedures-during-covid-19-pandemic  164. jackler rk. commentary: covid-19 and ear surgery [internet]. ent uk. 2020  [cited 2020 april 13]  available from: https://www.entnet.org/sites/default/files/uploads/covid-19_and_ear_ surgery_rk_jackler_stanford.pdf 165. davies e, hopkins c, harries p, walker a, heward e. ent-uk covid-19 epistaxis management [internet]. ent uk. 2020 [cited 2020 may 9]. available from: https://www.entuk.org/sites/ default/files/files/covid%2019%20epistaxis%20management.pdf  166. philippine society of otolaryngology head and neck surgery [internet]. advisory no. 4: algorithm for ent-hns covid-19 epistaxis management from the philippine academy of rhinology (par). 2020 april 14 [cited 2020 may 10]. available from: https://pso-hns. org/2020/04/14/par-advisory-no-2-on-epistaxis/.  167. royal college of paediatrics and child health and british paediatric allergy immunity & infection group [internet].  covid-19 guidance for paediatric services. 2020 march 13 (updated 2020 april 9) [cited 2020 april 22].  available from: https://www.rcpch.ac.uk/sites/ default/files/generated-pdf/document/covid-19---guidance-for-paediatric-services.pdf 168. primary care critical trials unit [internet]. fever pain clinical score. [cited 2020 april 29]. available from: https://ctu1.phc.ox.ac.uk/feverpain/index.php  169. tang yc.  modified centor score for streptococcal pharyngitis (m-centor) [internet]. [cited 2020 april 29] available from: https://canadiem.org/tiny-tips-modified-centor-score/. 170. mcnally g, burgess a, agrawal s, ismail koch h, elgan-davies j, paul j. ent uk covid-19 tonsillitis and quinsy guidelines [internet]. ent uk. 2020 [cited 2020 may 9]. available from: https://www.entuk.org/sites/default/files/files/ent_uk_covid_19_tonsillitis_and_quinsy_ guidelines.pdf  171. davies e, roland n. nasal endoscopy and laryngoscopy examination of ent patients [internet]. 2020 march 23  [cited 2020 april 13]. available from:  https://www.entuk.org/sites/ default/files/files/nasal%20endoscopy%20and%20laryngoscopy%20examination%20of%20 ent%20patients_compressed.pdf 172. rameau a, young vn, amin mr, sulica l. flexible laryngoscopy and covid-19. otolaryngol head neck surg. 2020 april 21:194599820921395.  doi: 10.1177/0194599820921395. pubmed: pmid: 32312166. 173. everington, k. taiwanese doctor invents device to protect us doctors against coronavirus. taiwan news [internet].  2020 march 23 [cited 2020 april 23] available from: https://www. taiwannews.com.tw/en/news/3902435 174. canelli r, connor cw, gonzalez m, nozari a, ortega r. barrier enclosure during endotracheal intubation. n engl j med. 2020 apr 3; nejmc2007589. doi:10.1056/nejmc2007589. pubmed pmid: 32243118; pubmed central pmcid: pmc7151333. 175. your design medical. [website] creating a biohazard space for covid19 intubation: a covid intubation tent / box. 2020 march 23 [cited 2020 april 26]. available from: https:// yourdesignmedical.com/blogs/making-a-safe-intubation-space-for-covid19/creating-abiohazard-space 176. under the scope. in face of covid-19, ent resident develops new devices, facebook page to help healthcare workers [internet]. 2020 april 9 [cited 2020 april 26]. available from: https:// oto.wustl.edu/in-face-of-covid-19-ent-resident-develops-new-devices-facebook-page-tohelp-healthcare-workers/. 177. vatanasapt p. necessity is the mother of invention!!  diy: “endoscopy salon” [internet].  2020 april 1 [cited 2020 april 23].  available from: https://www.facebook.com/patravoot/ videos/3399277473422865/.   178. us centers for disease control and prevention [internet].  disinfection and sterilization. 2008 [cited 2020 april 28].  available from: https://www.cdc.gov/infectioncontrol/guidelines/ disinfection/. 179. the national academies of sciences [internet]. does ultraviolet light kill the coronavirus 2020 april 22  [cited 2020 april 30]. available from: https://sites.nationalacademies.org/ basedonscience/covid-19-does-ultraviolet-light-kill-the-coronavirus/index.htm 180. american college of surgeons [internet]. covid-19: guidance for triage of non-emergent surgical procedures. 2020 [cited 2020 may 8]. available from: https://www.facs.org/covid-19/ clinical-guidance/triage 181. vilag l, vilag v. healthy diet to combat covid19 [internet]. 2020 [cited 2020 may 1]. available from: http://www.paase.org/downloads/paase bulletin 7.pdf 182. grosso g, bella f, godos j, sciacca s, del rio d, ray s, et al. possible role of diet in cancer: systematic review and multiple meta-analyses of dietary patterns, lifestyle factors, and cancer risk. nutr rev. 2017 jun 1;75(6):405–419.  doi: 10.1093/nutrit/nux012. pubmed pmid: 28969358. 183.   eggers m. infectious disease management and control with povidone iodine. infect dis ther. 2019 dec;8(4):581-593. doi: 10.1007/s40121-019-00260-x. pubmed pmid:31414403; pubmed central pmcid: pmc6956232 [correction to: infectious disease management and control with povidone iodine. infect dis ther. 2019 dec;8(4):595. doi: 10.1007/s40121-019-00263-8. pubmed pmid: 31440901; pubmed central pmcid: pmc6856231.] 184. kariwa h, fujii n, takahima i. inactivation of sars coronavirus by means of povidone-iodine, physical conditions and chemical agents. dermatology. 2006; 212 suppl1: 119-23. doi: 10.1159/000089211. pubmed pmid: 16490989; pubmed central pmcid: pmc7179540. 185. kampf g, todt d, pfaender s, steinmann e. persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. j hosp infect. 2020 mar;104(3):246-251. doi: 10.1016/j.jhin.2020.01.022. pubmed pmid: 32035997; pubmed central pmcid: pmc7132493. 186. monthly index of medical specialties [internet]. betadine gargle & paint/betadine throat spray [cited 2020 apr 20]. available from: https://www.mims.com/philippines/drug/info/ betadine%20gargle%20and%20paint-betadine%20throat%20spray 187.   mady lj, kubik mw, baddour k, snyderman ch, rowan nr. consideration of povidone-iodine as a public health intervention for covid-19: utilization as “personal protective equipment” for frontline providers exposed in high-risk head and neck and skull base oncology care. oral oncol. 2020 apr 16;104724. doi: 10.1016/j.oraloncology.2020.104724. pubmed pmid: 32317139; pubmed central pmcid: pmc7161480. 188. concepcion g. (personal communication, with permission). vit-c protecttm naso-oral drops with 1.5mg/ml vitamin c. biogeninstm 2020 may 2 [cited 2020 may 2]. 189.  talbot ar, herr tm, parsons ds. mucociliary clearance and buffered hypertonic saline solution. laryngoscope. 1997 apr;107(4):500–3.  doi: 10.1097/00005537-1997040000-00013. pubmed pmid: 9111380. 190. kaliner m. medical management of sinusitis. am j med sci. 1998 jul;316(1):21–8.  doi: 10.1097/00000441-199807000-00004. 191. bishop jm, maldonado rl, garry rf, allen pt, bose hr, waite mr. effect of medium of lowered nacl concentration on virus release and protein synthesis in cells infected with reticuloendotheliosis virus. j virol. 1976 feb;17(2):446–52. pubmed pmid: 176425; pubmed central pmcid: pmc515436. 192. tsurumi t, aoki h, nishiyama y, shibata m, maeno k, seo h. effect of high salt treatment on influenza b viral protein synthesis in mdck cells. microbiol immunol. 1983;27(6):519–29. doi: 10.1111/j.1348-0421.1983.tb00613.x. pubmed pmid: 6195511. 193. ramalingam s, graham c, dove j, morrice l, sheikh a. a pilot, open labelled, randomised controlled trial of hypertonic saline nasal irrigation and gargling for the common cold. sci rep. 2019 jan 31;9(1):1015. doi: 10.1038/s41598-018-37703-3. pubmed pmid: 30705369; pubmed central pmcid: pmc6355924. 194. min yg, lee ks, yun jb, rhee cs, rhyoo c, koh yy, et al. hypertonic saline decreases ciliary movement in human nasal epithelium in vitro. otolaryngol head neck surg. 2001 mar;124(3):313–6. doi: 10.1067/mhn.20001.113145. pubmed pmid: 11240998. 195. hennet t, peterhans e, stocker r. alterations in antioxidant defences in lung and liver of mice infected with influenza a virus. j gen virol. 1992 jan;73(pt1):39–46. doi: 10.1099/0022-131773-1-39. pubmed pmid: 1530963. 196. jiao j, meng n, wang h, zhang l. the effects of vitamins c and b12 on human nasal ciliary beat frequency. bmc complement altern med. 2013 may 20;13(110). doi: 10.1186/1472-6882-13110. pubmed pmid: 23688196; pubmed central pmcid: pmc3663725. 197. gorton hc, jarvis k. the effectiveness of vitamin c in preventing and relieving the symptoms of virus-induced respiratory infections. j manipulative physiol ther. 1999 oct;22(8):530–3. doi: 10.1016/s0161-4754(99)70005-9. pubmed pmid: 10543583. review article https://www.youtube.com/watch?v=h2azcn7mqou https://www.youtube.com/watch?v=h2azcn7mqou https://www.livescience.com/covid19-coronavirus-transmission-through-speech.html https://www.livescience.com/covid19-coronavirus-transmission-through-speech.html https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html https://www.entuk.org/guidance-undertaking-otological-procedures-during-covid-19-pandemic https://www.entuk.org/guidance-undertaking-otological-procedures-during-covid-19-pandemic file:///users/vergie/desktop/2020%20folder/pso%202020/journal%20jan-june%202020/pjohnsreviewarticlereferences/%20https://www.entnet.org/sites/default/files/uploads/covid-19_and_ear_surgery_rk_jackler_stanford.pdf file:///users/vergie/desktop/2020%20folder/pso%202020/journal%20jan-june%202020/pjohnsreviewarticlereferences/%20https://www.entnet.org/sites/default/files/uploads/covid-19_and_ear_surgery_rk_jackler_stanford.pdf https://www.entuk.org/sites/default/files/files/covid%2019%20epistaxis%20management.pdf https://www.entuk.org/sites/default/files/files/covid%2019%20epistaxis%20management.pdf https://pso-hns.org/2020/04/14/par-advisory-no-2-on-epistaxis/ https://pso-hns.org/2020/04/14/par-advisory-no-2-on-epistaxis/ https://www.rcpch.ac.uk/sites/default/files/generated-pdf/document/covid-19---guidance-for-paediatric-services.pdf https://www.rcpch.ac.uk/sites/default/files/generated-pdf/document/covid-19---guidance-for-paediatric-services.pdf https://ctu1.phc.ox.ac.uk/feverpain/index.php https://canadiem.org/tiny-tips-modified-centor-score/ file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.entuk.org/sites/default/files/files/ent_uk_covid_19_tonsillitis_and_quinsy_guidelines.pdf file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.entuk.org/sites/default/files/files/ent_uk_covid_19_tonsillitis_and_quinsy_guidelines.pdf file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.entuk.org/sites/default/files/files/ent_uk_covid_19_tonsillitis_and_quinsy_guidelines.pdf https://www.entuk.org/sites/default/files/files/nasal%20endoscopy%20and%20laryngoscopy%20examination%20of%20ent%20patients_compressed.pdf https://www.entuk.org/sites/default/files/files/nasal%20endoscopy%20and%20laryngoscopy%20examination%20of%20ent%20patients_compressed.pdf https://www.entuk.org/sites/default/files/files/nasal%20endoscopy%20and%20laryngoscopy%20examination%20of%20ent%20patients_compressed.pdf https://www.taiwannews.com.tw/en/news/3902435 https://www.taiwannews.com.tw/en/news/3902435 https://yourdesignmedical.com/blogs/making-a-safe-intubation-space-for-covid19/creating-a-biohazard-space https://yourdesignmedical.com/blogs/making-a-safe-intubation-space-for-covid19/creating-a-biohazard-space https://yourdesignmedical.com/blogs/making-a-safe-intubation-space-for-covid19/creating-a-biohazard-space https://oto.wustl.edu/in-face-of-covid-19-ent-resident-develops-new-devices-facebook-page-to-help-healthcare-workers/ https://oto.wustl.edu/in-face-of-covid-19-ent-resident-develops-new-devices-facebook-page-to-help-healthcare-workers/ https://oto.wustl.edu/in-face-of-covid-19-ent-resident-develops-new-devices-facebook-page-to-help-healthcare-workers/ https://www.facebook.com/patravoot/videos/3399277473422865/ https://www.facebook.com/patravoot/videos/3399277473422865/ https://www.cdc.gov/infectioncontrol/guidelines/disinfection/ https://www.cdc.gov/infectioncontrol/guidelines/disinfection/ https://sites.nationalacademies.org/basedonscience/covid-19-does-ultraviolet-light-kill-the-coronavirus/index.htm https://sites.nationalacademies.org/basedonscience/covid-19-does-ultraviolet-light-kill-the-coronavirus/index.htm https://www.facs.org/covid-19/clinical-guidance/triage https://www.facs.org/covid-19/clinical-guidance/triage http://www.paase.org/downloads/paase%20bulletin%207.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6856231/ https://www.mims.com/philippines/drug/info/betadine%20gargle%20and%20paint-betadine%20throat%20spray https://www.mims.com/philippines/drug/info/betadine%20gargle%20and%20paint-betadine%20throat%20spray philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery vol. 35 no. 1 january – june 2020 philippine journal of otolaryngology-head and neck surgery 2928 philippine journal of otolaryngology-head and neck surgery 198. nahas r, balla a. complementary and alternative medicine for prevention and treatment of the common cold. can fam physician. 2011 jan;57(1):31–6. pubmed pmid: 21322286; pubmed central pmcid: pmc3024156. 199. dayrit f, newport m. the potential of coconut oil and its derivatives as effective and safe antiviral agents against the novel coronavirus (ncov-2019). [internet]. ateneo de manila university school of science and engineering. 2020. available from: http://ateneo.edu/ ls/sose/sose/news/research/potential-coconut-oil-and-its-derivatives-effective-and-safeantiviral 200. sands ja, auperin ld, reinhardt a. enveloped virus inactivation by fatty acid derivatives. antimicrob agents chemother. 1979 jan;15(1):134–6.  doi: 10.1128/aac.15.1.134. pubmed pmid: 218498; pubmed central pmcid: pmc352613. 201. tan-lim cs, martinez cv. should virgin coconut oil be used in the adjunctive treatment of covid-19? [internet]. asia pacific center for evidence based healthcare. 2020 [cited 2020 may 11]. available from: https://www.psmid.org/should-virgin-coconut-oil-be-used-in-theadjunctive-treatment-of-covid-19/ 202. lin p-h, sermersheim m, li h, lee phu, steinberg sm, ma j. zinc in wound healing modulation. nutrients. 2017 dec 24;10(1):16. doi: 10.3390/nu10010016. pubmed pmid: 29295546; pubmed central pmcid: pmc5793244. 203. healthline [internet]. the 10 best foods that are high in zinc. 2018 [cited 2018 apr 30]. available from: https://www.healthline.com/nutrition/best-foods-high-in-zinc 204. zhang y, li x, grailer jj, wang n, wang m, yao j, et al. melatonin alleviates acute lung injury through inhibiting the nlrp3 inflammasome. j pineal res. 2016 may;60(4):405–14.  doi: 10.1111/jpi.12322. pubmed pmid: 26888116. 205. abat me, larracas c, cabaluna it. should vitamin c/ ascorbic acid be used in the treatment of covid-19? 2020 april 1, updated 2020 may 6. up institute of clinical epidemiology and asia-pacific center for evidence-based healthcare rapid evidence reviews on covid-19 management: treatment [internet] hosted by the philippine society for microbiology and infectious diseases (psmid). university of the philippines asia pacific center for evidence based medicine. [cited 2020 may 10]. available from: https://www.psmid.org/rapid-reviewvitamin-c/ 206. hemilä h, chalker e. vitamin c for preventing and treating the common cold. cochrane database syst rev. 2013 jan 31;(1):cd000980.  doi: 10.10002/14651858.cd000980.pub4. pubmed pmid: 23440782. 207. skalny a v, rink l, ajsuvakova op, aschner m, gritsenko va, alekseenko si, et al. zinc and respiratory tract infections: perspectives for covid19 (review). int j mol med. 2020 apr 14. doi: 10.3892/ijmm.2020.4575. pubmed pmid: 32319538. 208. eubanas gs. should zinc be used in the treatment of covid-19? [internet]. asia pacific center for evidence based healthcare. 30 march 2020, updated 2020 april 2. up institute of clinical epidemiology and asia-pacific center for evidence-based healthcare rapid evidence reviews on covid-19 management: treatment [internet] hosted by the philippine society for microbiology and infectious diseases (psmid). university of the philippines asia pacific center for evidence based medicine. [cited 2020 may 11]. available from: https://www.psmid.org/ rapid-review-zinc/ 209.   ilie pc, stefanescu s, smith l. the role of vitamin d in the prevention of coronavirus disease 2019 infection and mortality. aging clin exp res. 2020 may 6;1-4 doi: 10.1007/s40520-02001570-8. pubmed pmid: 32377965; pubmed central pmcid: pmc7202265. 210.    garcia amvp, cabaluna i. should melatonin be used as prophylaxis for covid19? 2020 april 2, updated 2020 april 2. up institute of clinical epidemiology and asia-pacific center for evidence-based healthcare rapid evidence reviews on covid-19 management: prophylaxis [internet] hosted by the philippine society for microbiology and infectious diseases (psmid). university of the philippines asia pacific center for evidence based medicine. [cited 2020 may 10] available from: https://www.psmid.org/rapid-review-melatonin/ 211. lam hs, chow cm, poon wt, lai ck, chan kca, yeung wl, et al. risk of vitamin a toxicity from candy-like chewable vitamin supplements for children. pediatrics. 2006 aug 1;118(2):820-4. doi: 10.1542/peds.2006-0167. pubmed pmid: 16882846. 212. urivetzky m, kessaris d, smith ad. ascorbic acid overdosing: a risk factor for calcium oxalate nephrolithiasis. j urol. 1992 may 1;147(5):1215–8. doi: 10.1016/s0022-5347(17)37521-3. pubmed pmid: 1569652. 213. shively rm, harding sa, hoffman rs, hill ad, astua aj, manini af. rebound metabolic acidosis following intentional amygdalin supplement overdose. clin toxicol (phila). 2020 apr 2;58(4):290–293. doi: 10.1080/15563650.2019.1640369. pubmed pmid: 31322009. 214. lee k. covid-19 prophylaxis in healthcare workers [internet]. 2020 [cited 2020 apr 30]. available from: https://keleefitness.com/covid-19-prophylaxis-in-healthcare-workers/ 215. glenza j. online demand for hydroxychloroquine surged 1,000% after trump backed it, study finds [internet]. the guardian. 2020 [cited 2020 may 5]. available from: https://www. theguardian.com/world/2020/apr/29/online-demand-for-hydroxychloroquine-surged-1000after-trump-backed-it-study-finds 216. gautret p, lagier j-c, parola p, hoang vt, meddeb l, mailhe m, et al. hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial. int j antimicrob agents. 2020 mar 20;105949. doi: 10.1016/j.ijantimicag.2020.105949. pubmed pmid: 32205204; pubmed central pmcid: pmc7102549. 217.  marchionne m. nationwide study finds malaria drug touted by president trump led to more deaths, no benefits in coronavirus patients. [internet] time. 2020 [cited 2020 may 8]. available from: https://time.com/5825398/hydroxychloroquine-study-coronavirus/ 218. us food and drug administration [internet]. united states of america: fda cautions against use of hydroxychloroquine or chloroquine for covid-19 outside of the hospital setting or a clinical trial due to risk of heart rhythm problems. 2020 [cited 2020 may 5]. available from: https://www.fda.gov/drugs/drug-safety-and-availability/fda-cautions-against-usehydroxychloroquine-or-chloroquine-covid-19-outside-hospital-setting-or review article 219. palileo-villanueva lm, villanueva ca, uy e. should hydroxychloroquine (hcq) or cholroquine (cq) be used in the treatment of covid-19? 2020 march 31, updated 2020 april 10. up institute of clinical epidemiology and asia-pacific center for evidence-based healthcare rapid evidence reviews on covid-19 management: treatment [internet] hosted by the philippine society for microbiology and infectious diseases (psmid). university of the philippines asia pacific center for evidence based medicine. [cited 2020 may 10] available from: https://www. psmid.org/rapid-review-hydroxychloroquine-hcq-or-chloroquine-cq-treatment/ 220. tolosa mt. should hydroxychloroquine with azithromycin be used in the treatment of covid-19? 2020 march 31, updated 2020 march 31. up institute of clinical epidemiology and asia-pacific center for evidence-based healthcare rapid evidence reviews on covid-19 management: treatment [internet] hosted by the philippine society for microbiology and infectious diseases (psmid). university of the philippines asia pacific center for evidence based medicine. [cited 2020 may 10] available from: https://www.psmid.org/rapid-reviewhydroxychloroquine-with-azithromycin/ 221. branswell h. why a decades-old tb vaccine is getting attention in the fight against covid-19? [internet]. massachusetts: stat. 2020 april 14 [cited 2020 may 10, 2020]. available from: https://www.statnews.com/2020/04/14/decades-old-tb-vaccine-attracts-attention-andskepticism-as-a-potential-weapon-against-covid-19/ 222. soliman r, brassey j, plüddemann a, heneghan c. does bcg vaccination protect against acute respiratory infections and covid-19? a rapid review of current evidence [internet]. cebm. 2020 [cited 2020 may 5]. available from: https://www.cebm.net/covid-19/does-bcgvaccination-protect-against-acute-respiratory-infections-and-covid-19-a-rapid-review-ofcurrent-evidence/ 223. sanchez-mostiero d, melicor a. should bacillus calmette-guerin (bcg) vaccine be used as prophylaxis for covid-19? asia pacific center for evidence based healthcare [internet]. university of the philippines asia pacific center for evidence based medicine. 2020 [cited 2020 may 5]. available from: https://www.psmid.org/rapid-review-bcg-vaccine/ 224.  murdoch children’s research institute [internet]. bcg vaccination to protect healthcare workers against covid-19. 2020. [cited 2020 may 10]. available from: https://clinicaltrials. gov/ct2/show/nct04327206 225. centers for disease control and prevention [internet]. atlanta: influenza (flu) guidance: outbreak management in long-term care facilities; [updated 2019 november 18; cited 2020 may 10]. available from: https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facilityguidance.htm 226. world health organization [internet]. geneva: q&a: similarities and differences covid-19 and influenza. 2020 march 17 [cited 2020 april 30]. available from: https://www.who.int/ emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-asimilarities-and-differences-covid-19-and-influenza 227. world health organization [internet]. geneva: update on who solidarity trial – accelerating a safe and effective covid-19 vaccine. 2020 [cited 2020 may 5]. available from: https:// www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novelcoronavirus-2019-ncov/solidarity-trial-accelerating-a-safe-and-effective-covid-19-vaccine 228. callaway e. the race for coronavirus vaccines: a graphical guide [internet]. nature. 2020 apr;580(7805):567-577. [cited 2020 may 11]. available from: https://www.nature.com/ articles/d41586-020-01221-y doi: 10.1038/d41586-020-01221-y. pubmed pmid: 32346146. 229. biorender [internet]. toronto: covid-19 vaccine & therapeutics tracker [cited 2020 may 11]. available from: https://biorender.com/covid-vaccine-tracker?utm_campaign=vaccine+tra cker%3a+announce&utm_content=covid-19+vaccine+tracker%3a+announcement&u tm_medium=email_action&utm_source=customer.io 230.  wu a, connors c, everly g jr. covid-19 peer support and crisis communication strategies to promote institutional resilience. ann intern med. 2020 apr 6; m20-1236 [epub ahead of print] doi:10.7326/m20-1236. pubmed pmid: 32251512; pubmed central pmcid: pmc7146593. 231. berg s. peer support program strives to ease distress during pandemic. american medical association practice management: physician health. 2020 apr 14 [cited 2020 april 16]. available from: https://www.ama-assn.org/practice-management/physician-health/peersupport-program-strives-ease-distress-during-pandemic 232. dewey c, hingle s, goelz e, linzer m. supporting clinicians during the covid-19 pandemic. ann intern med. 2020 mar 20; m20--1033 doi: 10.7326/m20-1033. pubmed pmid:32196544; pubmed central pmcid: pmc7106065. 233. blythe wr, shapiro ja, wei jl. aao-hns coronavirus disease (covid-19) podcast series episode 6: ents personal covid-19 experiences: managing your wellness. [internet] american academy of otolaryngology head and neck surgery. 2020 apr 3. [cited 2020 april 16]. available from: https://www.entnet.org/content/covid-19-podcast-series 234. rappler.com [internet]. list: groups providing free online counseling during the pandemic. 2020 april 11 [cited 2020 april 23]. available from: https://www.rappler.com/moveph/257641-list-groups-providing-free-online-counseling-during-the-pandemic http://ateneo.edu/ls/sose/sose/news/research/potential-coconut-oil-and-its-derivatives-effective-and-safe-antiviral http://ateneo.edu/ls/sose/sose/news/research/potential-coconut-oil-and-its-derivatives-effective-and-safe-antiviral http://ateneo.edu/ls/sose/sose/news/research/potential-coconut-oil-and-its-derivatives-effective-and-safe-antiviral https://www.psmid.org/should-virgin-coconut-oil-be-used-in-the-adjunctive-treatment-of-covid-19/ https://www.psmid.org/should-virgin-coconut-oil-be-used-in-the-adjunctive-treatment-of-covid-19/ https://www.healthline.com/nutrition/best-foods-high-in-zinc https://www.psmid.org/rapid-review-vitamin-c/ https://www.psmid.org/rapid-review-vitamin-c/ https://www.psmid.org/rapid-review-zinc/ https://www.psmid.org/rapid-review-zinc/ https://www.psmid.org/rapid-review-melatonin/ https://keleefitness.com/covid-19-prophylaxis-in-healthcare-workers/ https://www.theguardian.com/world/2020/apr/29/online-demand-for-hydroxychloroquine-surged-1000-after-trump-backed-it-study-finds https://www.theguardian.com/world/2020/apr/29/online-demand-for-hydroxychloroquine-surged-1000-after-trump-backed-it-study-finds https://www.theguardian.com/world/2020/apr/29/online-demand-for-hydroxychloroquine-surged-1000-after-trump-backed-it-study-finds https://time.com/5825398/hydroxychloroquine-study-coronavirus/ https://www.fda.gov/drugs/drug-safety-and-availability/fda-cautions-against-use-hydroxychloroquine-or-chloroquine-covid-19-outside-hospital-setting-or https://www.fda.gov/drugs/drug-safety-and-availability/fda-cautions-against-use-hydroxychloroquine-or-chloroquine-covid-19-outside-hospital-setting-or https://www.psmid.org/rapid-review-hydroxychloroquine-hcq-or-chloroquine-cq-treatment/ https://www.psmid.org/rapid-review-hydroxychloroquine-hcq-or-chloroquine-cq-treatment/ file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.psmid.org/rapid-review-hydroxychloroquine-with-azithromycin file:///users/joseflorenciolapena/library/containers/com.microsoft.word/data/downloads/%20https:/www.psmid.org/rapid-review-hydroxychloroquine-with-azithromycin https://www.statnews.com/2020/04/14/decades-old-tb-vaccine-attracts-attention-and-skepticism-as-a-potential-weapon-against-covid-19/ https://www.statnews.com/2020/04/14/decades-old-tb-vaccine-attracts-attention-and-skepticism-as-a-potential-weapon-against-covid-19/ https://www.cebm.net/covid-19/does-bcg-vaccination-protect-against-acute-respiratory-infections-and-covid-19-a-rapid-review-of-current-evidence/ 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https://www.rappler.com/move-ph/257641-list-groups-providing-free-online-counseling-during-the-pandemic https://www.rappler.com/move-ph/257641-list-groups-providing-free-online-counseling-during-the-pandemic philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 13 abstract objective: to determine the value of the 6-hour postoperative ionized calcium (ica) slope versus 6-hour postoperative calcium alone in predicting the occurrence of hypocalcemia in patients who underwent thyroid surgery in a tertiary hospital in metro manila. methods: design: retrospective cross-sectional study setting: tertiary private hospital subjects: pre-operative and 6-hour postoperative ionized calcium determinations were analyzed in 59 patients of the ent-hns department in a tertiary hospital in metro manila who underwent thyroid surgery from january 2009 to december 2013. results: the 6-hour postoperative ica slope (difference between the pre-operative and 6-hour postoperative ica levels) of ≥0.18 mmol/l correctly predicted 57.1% of patients who eventually developed hypocalcemia, with a specificity of 81.6% and a positive predictive value of 63.2%. in contrast, the 6-hour postoperative ica measurement identified only 23.8% (5 out of 21) patients who developed hypocalcemia. conclusion: the 6-hour postoperative ica slope increased the probability of identifying patients who developed hypocalcemia from 23.8% to 57.1%. however, as a single determination, this may not suffice to take the place of serial ica measurements after thyroid surgery. keywords: ionized calcium (ica), hypocalcemia, thyroidectomy hypocalcemia is the most common complication of thyroid surgery and has a higher incidence in total and near-total thyroidectomy than other types of thyroid surgery such as total thyroid lobectomy and near-total thyroidectomy.1 to our knowledge, there is no standard as to when the levels of ionized calcium should first be measured following thyroid surgery, nor are value of the 6-hour postoperative ionized calcium slope in predicting postthyroidectomy occurrence of hypocalcemia ryan e. cabance, md1 emmanuel tadeus s. cruz, md1,2 1department of otolaryngology head & neck surgery manila central university filemon d. tanchoco medical foundation hospital 2department of otolaryngology – head & neck surgery quezon city general hospital correspondence: dr. emmanuel tadeus s. cruz department of otolaryngology – head & neck surgery mcu fdtmf hospital edsa, caloocan city 1400 philippines phone: (632) 367 2031 local 1212 opd 1144 fax: (632) 367 2249 email: orlhns_mcu@yahoo.com reprints will not be available from the authors. the authors declare that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the requirements for authorship have been met by the author, and that the author believes that the manuscript represents honest work. disclosures: the authors signed a disclosure that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. philipp j otolaryngol head neck surg 2015; 30 (2): 13-18 c philippine society of otolaryngology – head and neck surgery, inc. philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles 14 philippine journal of otolaryngology-head and neck surgery there accepted guidelines on when calcium supplementation should be started in the absence of symptoms of hypocalcemia regardless of ionized calcium levels. indiscriminate calcium supplementation after thyroid surgery is unnecessary and puts patients at risk for hypercalcemia. in our institution, a 6-hour postoperative ionized calcium determination is often requested after total thyroidectomy. however, it is only requested after a thyroid lobectomy or near-total thyroidectomy when the patient shows symptoms and signs of hypocalcemia. calcium supplementation is started once symptoms and signs of hypocalcemia appear. in cases of asymptomatic hypocalcemia, it is often left to the discretion of the attending physician if and when supplementation will be started. the 1-hour postoperative parathyroid hormone level has shown high sensitivity and specificity in predicting patients who will develop hypocalcemia after thyroid surgery avoiding potentially dangerous clinical consequences and lessening the need for multiple calcium measurements.2-4 unfortunately, this test is expensive and not available in our institution. serial determinations of postoperative ionized calcium would be ideal in identifying patients with hypocalcemia but each determination poses an additional financial burden. if the test is not available, ionized calcium levels (the biologically active form) can better assess calcium homeostasis than serum calcium which, even when corrected for albumin levels has been shown to be only 53% sensitive and 85% specific in evaluating hypocalcemia.5 the slope or drop in calcium levels postoperatively may be predictive of hypocalcemia but multiple measurements are required in 24 hours; this slope (or difference) between pre-operative and 24-hour postoperative serum calcium levels can help differentiate between temporary or permanent hypocalcemia.6 previous studies showed that 8-hour postoperative ionized calcium levels accurately detected 40% of patients who required calcium supplementation after total/ near-total thyroidectomy and/or parathyroidectomy7 while a 12to 18 hour slope (decrease) in serum calcium of ≥1.1 mg/dl predicted the occurrence of hypocalcemia in 76% of patients who underwent total thyroidectomy and reduced the number of calcium measurements from a mean of 13 tests/patient to a mean of 3 tests/patient.8 if the 6-hour postoperative ionized calcium slope could accurately predict patients who would develop hypocalcemia, it would be of significant value in the postoperative care of patients undergoing thyroid surgery. this paper seeks to determine the value of the 6-hour postoperative ionized calcium (ica) slope, versus 6-hour postoperative calcium alone, in predicting the occurrence of hypocalcemia in patients who underwent thyroid surgery in a tertiary hospital in metro manila. methods a. research design: retrospective cross sectional b. sample population the research protocol was approved by the institution’s irb. private and clinical division patients who underwent thyroid surgery from january 2009 to december 2013 under the service of the department of ent-hns of our institution, with preoperative and 6-hour postoperative ionized calcium determinations were included. excluded from the study were those without pre-operative and/or 6-hr postoperative ica determinations, history of hypocalcemia / hypoparathyroidism, history of hypercalcemia / hyper-parathyroidism, diabetes, renal disease, and the use of maintenance medications such as diuretics and anticonvulsants. c. variables the following variables were recorded and tabulated: preoperative ionized calcium, 6-hr postoperative ionized calcium, 6-hr postoperative ica slope (difference between pre-operative and 6-hr postoperative ica levels), age, sex, type of thyroid surgery (total/completion, near-total, lobectomy), histopathological findings (benign or malignant), number of parathyroid glands identified and preserved and the presence of signs and symptoms of hypocalcemia. d. sample size using the 95% confidence level, the ideal sample size was computed to be n=40 where: zα = 1.96 at 95% confidence level zβ = 1.28 at 80%power of the study sd = 0.098 (a qari, 2005) e = 0.05 (error of 5%) e. statistical analysis the gathered data was grouped into two: the normocalcemic group (group 1) consisted of patients who did not have any postoperative calcium result below 1.10 mmol/l and did not develop any of signs or symptoms of hypocalcemia such as perioral numbness, tingling sense or paresthesia of hands and/or feet, chvostek sign, trousseau sign, muscle n = x 2 (z α +z β )2 + (sd)2 e2 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 15 cramps, or tetany during their hospital stay; the hypocalcemic group (group 2) composed of patients who developed the above mentioned signs or symptoms and/or had a postoperative ionized calcium level <1.10 mmol/l during their hospital stay. the signs and symptoms noted by patients in the hypocalcemic group were tallied to determine the frequency of occurrence. the variables of the 2 groups such as the difference (slope) between preoperative and postoperative ionized calcium levels, the type of thyroid surgery, the number of parathyroid glands identified and preserved, mean age, sex and final histopath results were analyzed statistically using the t-test, paired t-test and mann whitney u test, kruskal wallis and bonferroni test using spss for windows version 20 (ibm corporation, ny, usa). results a total of 59 out of 76 patients who underwent thyroid surgery in our department between january 2009 and december 2013 were included in this study. seventeen patients were excluded because of the absence of either a pre-operative or 6-hr postoperative ica result. there were 55 (93.2%) females and 4 (6.8%) males with ages ranging from 20 to 82 years old with an average age of 41.96 years. all were euthyroid and normocalcemic at the time of surgery. there was no significant difference in the sex and age distribution among the patients between the two groups. (table 1) thirty-six out of 38 patients in the normocalcemic group had a drop in their ica levels 6-hrs postoperatively while the remaining 2 had an increase in their postoperative ica levels. all patients in the normocalcemic group had 6-hr postoperative ica levels within normal range. only 5 patients in the hypocalcemic group had ica levels less than 1.10 mmol/l at 6-hrs postoperatively. none of the 21 patients were symptomatic at 6-hrs postop. at 18-hrs postop, 1 patient developed symptoms of hypocalcemia despite a normal ica level. at 24 hours postop, 5 patients had below normal ica levels and signs and symptoms of hypocalcemia; and 1 patient developed signs/symptoms but had normal ica levels. table 3 summarizes the findings in the hypoglycemic group. calcium supplementation was started for all the patients once clinical signs and symptoms were observed. supplementation for patients with only biochemical hypocalcemia was given according to the discretion of the attending physician. table 1. age and sex of patients grouped according to presence of postoperative hypocalcemia # normocalcemic (%) (n=38) # of patients (%) (n=59) # hypocalcemic (%) (n=21) p-value* female male age in yrs ± sd 55 (93.2%) 4 (6.8%) 41.96 ± 13.92 35 (92.1%) 3 (7.9%) 41.55 ± 13.85 20 (95.2%) 1 (4.8%) 42.71 ± 14.34 1.00 (ns) 0.76 (ns) * p-values >0.05not significant; p-values ≤0.05-significant table 2. comparison of preand post-operative ica levels between normocalcemic and hypocalcemic groups normocalcemic (n=38) hypocalcemic (n=21) n=59 p-value pre-op mean (n=38) postop mean (n=21) mean slope ± sd (median) 1.37 1.26 0.10 ± 0.30 (0.10) 1.27 1.09 0.18 ± 0.09 (0.19) 0.07 (ns) 0.00 (s) 0.006 (s) * p-values >0.05not significant; p-values ≤0.05-significant there was no significant difference between the pre-operative ica levels of the normocalcemic and hypocalcemic groups (p=0.07). however, a significant difference was noted in the 6-hr postoperative ica levels of the 2 groups (p=0.00) with the hypocalcemic group having lower ica levels. comparing the 6-hr postoperative ica slope, there was a significant difference (p=0.006) between the 2 groups with the hypocalcemic group having a larger drop (mean=0.18) in ica levels. (table 2) table 3. presence of biochemical and/or clinical hypocalcemia among patients in the hypocalcemic group (n=21) ica < 1.10 mmol/l no signs/ symptoms ica < 1.10 mmol/l with signs/ symptoms ica ≥ 1.10 mmol/l with signs/ symptoms hours postop 6 hrs 18 hrs 24 hrs 36 hrs 48 hrs total 5 0 5 0 2 12 0 0 5 1 0 6 0 1 1 0 1 3 the mean 6-hr postoperative ica slope (difference between the pre-operative and 6-hr postoperative ica levels) of 0.18mmol/l of the hypocalcemic group correctly identified 12 out of the 21 patients who developed hypocalcemia while the other 9 patients had a slope of philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles 16 philippine journal of otolaryngology-head and neck surgery table 5. comparison of the mean 6-hr postoperative ica slope between and within normocalcemic and hypocalcemic groups according type of thyroid surgery. normocalcemic (%) (n=38) hypocalcemic (%) (n=21) n=59 thyroid lobectomy ± isthmusectomy (n=21) near total thyroidectomy (n=18) total thyroidectomy (n=20) p-value* 1.32 1.19 1.29 1.20 1.54 1.35 16 (42.1%) 5 (23.8%) 13 (34.2%) 5 (23.8%) 9 (23.7%) 11 (52.4%) pre-op mean pre-op mean p-value*postop mean postop mean mean slope ± sd (median) mean slope ± sd (median) 1.25 1.08 1.29 1.05 1.23 1.12 0.07 ± 0.15 (0.09) 0.11 ± 0.06 (0.1) 0.74 (ns) 0.003 ± 0.32 (0.09) 0.14 ± 0.07 (0.13) 0.17 (ns) 0.31 ± 0.42 (0.18) 0.23 ± 0.08 (0.22) 0.38 (ns) 0.03 (s) 0.01 (s) * p-values >0.05not significant; p-values ≤0.05-significant table 6. comparison of the mean 6-hr postoperative ica slope benign and malignant findings in the hypocalcemic group. malignant benign hypocalcemic group (n=21) 1.29 1.27 6 (28.6%) 15 (71.4%) pre-op mean pre-op mean p-value*postop mean postop mean mean slope ± sd mean slope ± sd 1.11 1.090.18 ± 0.09 0.18 ± 0.09 0.95 (ns) * p-values >0.05not significant; p-values ≤0.05-significant <0.18mmol/l. the sensitivity was 57.1% and specificity of 81.6% with a positive predictive value of 63.2%. (table 4) out of the 38 patients in the normocalcemic group, 9 (23.7%) underwent total thyroidectomy, 13 (34.2%) near total thyroidectomy and 16 (42.1%) thyroid lobectomies. of the 21 patients in the hypocalcemic group 11 (55%) underwent total thyroidectomy, 5 table 4. comparison of preand post-operative ica levels between the normocalcemic and hypocalcemic groups normocalcemic # of patients (n=38) hypocalcemic # of patients (n=21) total6-hr postop ica slope (mmol/l) ≥0.18 <0.18 7 31 sensitivity = 57.1% specificity = 81.6% positive predictive value = 63.2% negative predictive value = 77.5% 12 9 19 40 (23.8%) near total thyroidectomy and 5 (23.8%) total lobectomy. the 6-hr postoperative ica slope between the 2 groups according to the type of thyroid surgery done showed no significant difference. however, in both groups, the patients who underwent total/ completion thyroidectomy had a significantly larger drop in ica 6-hours postoperatively when compared to near-total thyroidectomy and lobectomy within the same group. ( table 5) comparison of the 6-hr ica slope in the patients with hypocalcemia showed no significant difference between those with malignant and benign tumors. (table 6) a minimum of 2 parathyroid glands were identified and preserved in all of the cases. there was no significant difference in the slope of the 2 groups according to the number of parathyroid glands preserved. hypocalcemia developed in 14 out of 21 (29.8%) patients despite having 4 parathyroid glands preserved. (table 7) among the 21 patients in the hypocalcemic group, 9 (42.9%) developed signs and symptoms of hypocalcemia during their hospital stay. the most common complaint was tingling / numbness in the philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles philippine journal of otolaryngology-head and neck surgery 17 normocalcemic (%) (n=38) hypocalcemic (%) (n=21) n=59 0 (n=0) 1 (n=0) 2 (n=4) 3 (n=8) 4 (n=47) 1.33 1.37 1.37 1.29 1.27 1.27 0 0 0 0 3 (75%) 2 (25%) 33 (70.2%) 1 (25%) 6 (75%) 14 (29.8%) pre-op mean pre-op mean p-value*postop mean postop mean mean slope ± sd mean slope ± sd 1.37 1.22 1.22 1.11 1.09 1.09 n/a n/a 0.13 ± 0.04 0.07 ± 0.05 0.10 ± 0.33 0.22 ± 0 0.21 ± 0.08 0.16 ± 0.09 0.18 (ns) 0.10 (ns) 0.08 (ns) table 7. comparison of the mean 6-hr postoperative ica slope between normocalcemic and hypocalcemic groups according to the # of parathyroid glands preserved. * p-values >0.05not significant; p-values ≤0.05-significant table 8. frequency of signs and symptoms of hypocalcemia frequencysigns / symptoms tingling / numbness upper extremities tingling / numbness lower extremities circumoral numbness positive trosseau positive chvosteks 7 1 3 4 1 upper extremities which was reported by 7 patients. the most common sign was a positive trosseau sign which was elicited in 4 patients. all the 21 patients in the hypocalcemic group were asymptomatic at 6-hours postop. the initial appearance of signs and symptoms occurred at an earliest of approximately 18 hours to a latest of 48 hours postoperatively with some lasting up to 72 hours despite calcium supplementation. one patient required oral calcium supplementation up to 2 weeks postoperatively. (table 8) discussion calcium plays a major role in many physiologic processes such as contraction of skeletal, cardiac and smooth muscles; blood clotting; and nerve impulse transmission. neurons are sensitive to changes in calcium ion concentrations and elevation of calcium ion concentration above normal (hypercalcemia) causes depression of the nervous system while decreases in calcium concentration (hypocalcemia) cause the nervous system to become more excitable.9 parathyroid hormone plays a major role in controlling extracellular calcium and phosphate concentrations by various mechanisms. hypofunction, ischemia or injury of the parathyroid glands causes hypocalcemia which may lead to tetany if not corrected. removal of 3 of the 4 normal glands causes temporary hypoparathyroidism. but even a small amount of parathyroid tissue is capable of hypertrophying to perform the function of all the glands.4 hypocalcemia, although often transient, is the most common cause of morbidity following thyroid surgery. in this study, hypocalcemia occurred in 35.6% (21 out of 59) of patients. the incidence of hypocalcemia in patients who underwent total thyroidectomy was 55%, higher than the results of other studies10, 11 and may be attributed to the different levels of expertise of the surgeons. based on the 6-hr postoperative ica measurement, only 5 (23.8%) patients were identified as hypocalcemic. sixteen patients who were normocalcemic at 6-hrs postop eventually developed hypocalcemia during their hospital stay. three out of the 17 patients who were excluded had a normal 6-hr postop ica result and eventually developed hypocalcemia during the course of their hospitalization. in contrast, when the pre-operative and 6-hour postoperative ica difference (slope) was determined, 12 out of the 21 (57.1%) patients were correctly predicted to develop hypocalcemia. a significant difference was seen between the ica slopes of the normocalcemic and hypocalcemic groups with the hypocalcemic group having a larger drop in ica levels at 6-hours postop. this study showed that the mean 6-hr postoperative slope of ica (≥0.18 mmol/l) correctly predicted 57.1% (12 out of 21) of patients who developed hypocalcemia with a positive predictive value of 63.2%. this is in contrast to the study of bentrem et al. that showed that 8-hr postoperative ica levels identified 40% of patients who would need supplementation. this study, however, utilized lower biochemical criteria (ica<1.0mmol/l).7 the results of this study are lower than the 76% (42 out of 65) correctly predicted cases of hypocalcemia following total thyroidectomy in the study of tredici, et al. that utilized the 12to 18-hour postoperative serum calcium slope.8 philippine journal of otolaryngology-head and neck surgery vol. 30 no. 2 july – december 2015 original articles 18 philippine journal of otolaryngology-head and neck surgery references 1. qari fa. estimation of ionized calcium levels after thyroidectomy at king abdul aziz university hospital (jeddah). kuwait med j. 2005 sep; 37 (3): 169-172. [editor: duplicate publication of qari fa. estimation of ionized calcium levels after thyroidectomy at king abdul aziz university hospital (jeddah). pak j med sci. 2004 oct-dec; 20 (4): 325-330.] 2. le tn, kerr pd, sutherland de, lambert p. validation of 1-hour post-thyroidectomy parathyroid hormone level in predicting hypocalcemia. j otolaryngol head neck surg. 2014 jan 29: 43(1):5. 3. venderlei f, vieira j, hojaij fc, cervantes o, kunii i, ohe mn, et al. parathyroid hormone: an early predictor of symptomatic hypocalcemia after total thyroidectomy. arq bras endocrinol metabol. 2012 apr; 56 (3): 168-172. 4. lam a, kerr pd. parathyroid hormone: an early predictor of post-thyroidectomy hypocalcaemia. laryngoscope. 2003 dec; 113 (12), 2196-2200. 5. byrnes mc, huynh k, helmer sd, stevens c, dort jm, smith rs. a comparison of corrected serum calcium levels to ionized calcium levels among critically ill surgical patients. am j surg. 2005 mar; 189 (3): 310-314. 6. pfleiderer a, ahmad n, draper mr, vrostsou k, smith wk. the timing of calcium measurements in helping to predict temporary and permanent hypocalcemia in patients having completion and total thyroidectomies. ann r col surg engl. 2009 mar; 91(2): 140-146. 7. bentrem dj, rademaker a, angelos p. evaluation of serum calcium levels in predicting hypoparathyroidism after total / near-total thyroidectomy or parathyroidectomy. am surg.2001 mar; 67 (3): 251-252. 8. tredici p, grosso e, gibelli b, massaro ma, arrigoni c, tradati n. identification of patients at high risk for hypocalcemia after total thyroidectomy. acta otorhinolaryngol ital. 2011 jun; 31(3): 144148. 9. hall je, guyton ac. guyton and hall textbook of medical physiology.12th ed. philadelphia. saunders elsevier. 2010 jun. 1388-1391. 10. asari r., passler c., kaczirek k, scheuba c, niederle b. hypoparathyroidism after total thyroidectomy: aprospective study. arch surg. 2008 feb; 143 (2): 132-137. 11. leahu a, carroni v, g.b. calcium level, a predictive factor of hypocalcemia following total thyroidectomy. jurnalul de chirurgie, iasi. 2009; 5 (2): 148-152. 12. kim jh, chungmk, sonyi. reliable early prediction for different types of post-thyroidectomy hypocalcemia. clin exp otorhinolaryngol. 2011 jun; 4 (2): 95-100. it is also worth mentioning that 3 out of the 21 (14.3%) patients in the hypocalcemic group developed signs and symptoms of hypocalcemia but their ica levels were normal. this occurrence may be explained by a rapid decline in ica levels following thyroid surgery without necessarily falling below normal levels.12 the type of thyroid surgery, age, sex, histopathologic findings and the number of parathyroid glands preserved were not found to be associated with the occurrence of hypocalcemia. however, patients who underwent total thyroidectomy had a significantly larger drop in ica levels at 6 hours after the surgery. the most common sign of hypocalcemia was numbness of the upper extremities and the most common sign was a positive trosseau sign. all cases of hypocalcemia in this study were transient with the earliest onset at 18 hours postoperatively. none of the patients required calcium supplementation for more than 2 weeks after surgery. additional studies on postoperative ica determinations may identify which may be the most beneficial as a single determination in predicting the development of hypocalcemia when serial determinations are not feasible.